Mental illness is one of the major contributors to global disease burden.^[1] They are common and affect more than 25% of all people at some time during their lifetime.^[2] The knowledge of health professionals and their attitude and awareness about mental health and psychiatric disorders is of great importance, as they are often involved in the care of these patients either directly or indirectly.^[2] Negative attitudes of physicians and other healthcare professionals towards mental illness affects treatment.^[3] Positive attitudes of health professionals influence positively on the person with mental illness.^[3] Patients with mental illness are often ignored and have to wait longer than other patients. They feel that they are stigmatized. Even health professionals including doctors tend to attribute patient’s physical complaints to mental illness.^[4] The Medical Council of India recommends obligatory two weeks of psychiatric training during undergraduate course however, doctors have multiple lacunae in their knowledge of psychiatric disorders, patients and treatment. The reason could be neglect of psychiatry training, insufficient number of allotted lectures, inadequate clinical postings and fewer hours allotted to psychiatry.^[5] Similarly for nurses, inadequate exposure to psychiatric nursing could be the reason for poor knowledge about psychiatry. Past research studies have focused more on students and interns but this study focuses on practicing health care workers; doctors and nurses.^[6-8] The objective of this study was to assess the attitude of various non-mental health professionals towards mental illness.

It is a crosssectional study, conducted in the Department of Psychiatry at Yenepoya Medical College Hospital, Deralakatte, Mangalore, India. The study period was for two months from July 2019 to August 2019. 76 non-mental health professionals consisting of interns, doctors, and nurses were enrolled in the study. Those who underwent specialized training courses in psychiatry or who were on treatment for any psychiatric disorders either psychological or pharmacological were excluded from the study. The study was initiated after obtaining Institutional ethical committee clearance. Informed written consent was obtained from all study participants. The proforma included two parts. First part contained a semi-structured demographic profile and the second part was the ‘Mental Illness: Clinicians Attitude Scale’ Version 4 (MICA-4). This questionnaire contains 16 questions, with each questions scored on a six point Likert scale (1=strongly agree, 2= agree, 3 = somewhat agree, 4 = somewhat disagree, 5 = disagree and 6 = strongly disagree).

The total number of subjects included was 76 among which doctors constituted 57 and nurses 19. The majority of the participants were in the age group of 20-25 years (32, 42.1%), followed by the age group of 26-30 years (28, 36.8%). The mean age was found to be 27.09 (± 3.66) years. Most of the study participants were males 43 (56.6%), whereas females were 33(43.4%). The study sample had 59.2 % (45) MBBS graduates, 15.8% specialist doctors and 25 % (19) participants were nursing staffs. Among MBBS graduates, 34 (44.7%) were interns, 10 (13.2%) were postgraduate residents. (Table 1)

Spearman correlation tests were run to determine the relationship between various socio-demographic variables like age, experience and various questions in the questionnaire. We found a positive correlation between Age and Questions 1, 2, 4, 5, 7, 8, 13, 14 and 15. There was a positive correlation observed between Experience and Questions 1, 2, 4, 5, 7, 13 and 14. There was a negative correlation between Age and Questions 3, 9, 10, 11 and 16. Also there was a negative correlation between Experience and Questions 3, 9, 10 and 16. (Table 2)

Sixteen questions in the Questionnaire were broken into four domains of Stigma towards psychiatric illness (Questions 2,4,5,7,13,15), Seeking knowledge (Question 1), Stigma towards professionals (Questions 8,14) and Positive attitude (Questions 3,6,9,10,11,12,16). Two domains (stigma towards psychiatric illness and stigma towards professionals) were considered to be more favorable with increase in scores in the Likert scale. The fourth domain (Positive attitude and seeking knowledge) was more favorable when there was a decrease in scores in the Likert scale.

Pearson correlation test were run to determine the relationship between various socio-demographic variables like age, experience and four domains such as stigma towards psychiatric illness, seeking knowledge, stigma towards professionals and positive attitude. It was noted that with advancing age and experience, stigma related to psychiatric illness and professionals decreased and a more positive attitude towards mental health professionals developed. Also, when age and experiences increased the participants had more positive attitude towards mental illness and exhibited more interest to know about the psychiatric illness in detail. All these findings were statistically highly significant. (Table 3)

Spearman’s tests were run to determine the relationship between different socio-demographic variables such as gender, qualification, occupation and four domains such as stigma towards psychiatric illness and professionals, seeking knowledge and positive attitude. (Table 4)

Positive approaches towards patients with psychiatric illness can accelerate recovery in them. The approach towards mental illness is determined by the depth of knowledge one has about it.^[9,10] This helps indirectly by helping the patient to voice out the problem, hence aiding in diagnosis and treatment. Most often the patients with psychiatric illness are judged based on their behavioral symptoms and are usually ignored. This is of concern including to family and treating psychiatric professionals jeopardizing the patient’s care.^[11] Aggressive and offensive behavior of a BPD (Borderline personality disorder) patient or sensitive demeanor of a suicide attempter could be a contributor to such considerations.^[1] Also, their unpredictable behavior creates fear in others thinking that they can be dangerous.^[11]

In our study we tried to assess the attitude of non-mental health professionals towards mentally ill patients. Questionnaire had 16 questions; these items were broken into four domains for our convenience which includes,

Most of the participants were interested in seeking knowledge about mental illness, especially the specialist doctors were keen on learning more about mental illness, while people doing internship did not show as much interest in learning more about mental illness. A statistically significant majority believed that the patient will not recover. Greater number of participants admitted that they will not reveal about psychiatric illness to their family or friends. Among them most of them were females. Moreover, 2/3rd of the participants in the study considered psychiatric patients were dangerous and they believed that the public had to be protected from them. Most of the participants agreed that they label patients with psychiatric illness as mad, crazy, nutter, etc. However, specialists had a more positive opinion towards psychiatric conditions.

Stigma was not only limited to psychiatric illness, perhaps it was extended towards mental health professionals too. Most of the nurses were unaware of mental health being a part of the health care system. Nevertheless, most of the participants agreed mental health field is just as respectable as other field of health care. MBBS graduates reported that they would not be happy to work with colleagues suffering from mental illness, while consultants and nursing staff expressed no hesitation in working with them.

In a study done by Alshahrani W et al., showed that the age of the professional had a positive influence on their attitude towards mental illness.^[3] Our study also found a similar finding with older and experienced professionals having a more positive attitude towards psychiatric illness than younger professionals, especially in a chronic patient with multiple or prolonged admissions like a patient with schizophrenia. Our study also showed similar findings with participants of increased age having less hesitation to work with people having a mental disorder and being more comfortable to talk and evaluate a patient with mental illness. It could be attributed to the increased number of years of experience in the field of medicine and more exposure to the patient with mental illness. Chikaodiri et al; and Yadav et al; found that greater exposure and contact with psychiatric patients help in generating more positive stance for them. Moreover, the presence of psychiatric patients in the family helps in understanding them better and providing proper care.^{[12, 13}] Professionals with >10 years of experience were found to have a positive attitude toward them.^[14]

Challapallisri et al; noted that female gender was seen to have a more negative perception towards mental illness.^[14] Likewise in our study, females admitted that they would never reveal to their friends and family if they have any psychiatric problems. The reason could be stigma and cultural beliefs. Certain members in the society believed psychiatric illness occurs due to evil spirits.^[15] Stigma appears to be one of the major factors contributing to negative attitudes. In this study, professionals believed that they will not recover and are harmful to society. Media portrayal of the perilous nature of mentally ill persons has also contributed to the burden of stigma. These negative approaches rooted in stigma, false beliefs and lack of knowledge can have an adverse effect on the treatment.^[16] Stigma destroys a person’s dignity and makes him disabled in his daily activities.^[17]

Also, the presence of comorbidities in these patients attracts only less attention and they receive delayed and lesser care as their symptoms are attributed to the mental illness. This can be fatal to the patients.^[18-20] In our study the majority of nursing and few interns believed that physical illnesses were due to mental illness. Different methods that can be undertaken to change the negative attitude as explained by Corrigon et al; are educating the public and correcting their misconceptions, conciliating through contact with diseased persons and protesting against the stigma. More positive changes were brought about by the second one, through contact.^[21]

The strength of the study is the inclusion of nurses and doctors of different cadre. A larger sample size would have made the study more comprehensive. In the future, including a larger sample with the inclusion of a wide range of health workers such as a pharmacists, physiotherapists and technicians from other settings as in government hospitals, primary and secondary care health facilities could make the study more generalizable. Furthermore, the effect of short course of training in psychiatry in health professionals to aid in removing the stigma associated with mental illness needs evaluation. Such an evaluation of the changing attitude of subjects after undergoing a short course training in psychiatry could help us in predicting how effectively we can remove stigma across a wide range of modern-day medical professionals.

As the experience and age of the individual increases, a shift to a positive attitude was noticed from our study. This positive approach may be attributed to their exposure to such patients and mingling with them. Hence, it is high time to bring a change in the medical curriculum with an extended period of posting and training in psychiatry. It is the need of the hour to create awareness among health care workers to eradicate the stigma associated with mentally ill and mental illness.