Participant Demographic Table
Table 2: Participant demographic data split via year group, gender, sexuality, ethnicity, and previous mental illness.
Participant Demographics
The questionnaire was disseminated to all students within the medical schools at Imperial (N=2200) and NTU (N=732). 352 students completed the survey (Imperial: n=211; NTU: n=141). Participant demographics are shown in Table 2. 20 students were interviewed in total [Imperial: n=12 (Years 1-6); NTU: n=8 (Years 1-4)]. NTU Year 5 students contributed to the survey data but were unable to participate in the interview stage due to their upcoming examinations.
Quantitative Results
Score Distributions Between Schools
Figure 1: a) Box and whisker plot showing the total score distribution between the two schools (Imperial: n=211, Median (M)=30, Interquartile Range (IQR)=10; NTU: n=141, M=32, IQR=7). “X” represents mean (Imperial = 31.5; NTU = 32.0). No significant differences identified between schools when Mann-Whitney U test applied). b) Bar chart showing M±IQR. Subscale 1 scores (Imperial: n=211, 11.5±4.25; NTU: n=141, 13±5). Error bars represent IQR. Significant difference identified when Mann-Whitney U test applied (p=0.003). c) Bar chart showing M±IQR. Subscale 2 scores (Imperial: n=211, 12±4; NTU: n=141, 12±4). Error bars represent IQR. No significant difference identified when Mann-Whitney test applied. d) Bar chart showing M±IQR. Subscale 3 scores (Imperial: n=211, 7±4; NTU: n=141, 8±3). Error bars represent IQR. Significant difference identified when Mann-Whitney U test applied (p<0.00001).
Overall:
Total scores ranged from 19-51 for Imperial (n=211) and 16-53 for NTU (n=141); means and standard deviations are shown in Table 2. No significant difference in total scores were identified between the schools (p=0.242).
Small statistically significant differences were found in subscale analysis whereby NTU had higher stigma scores than Imperial for Subscales 1 (Attitudes of healthcare providers towards people with mental illness) (p=0.003) and 3 (Attitudes of healthcare providers towards social distance) (p<0.00001). No statistically significant differences were identified for Subscale 2 (Attitudes of healthcare providers towards disclosure and help-seeking) (p=0.078)(Figure 1).
Average Scores Spread by Institution and Year Group
Table 3: Table representing means, standard deviations (SD) (shown as mean±standard deviation) and p-values for each school and year group comparison (p<0.05)
*Year 4 NTU maps to Year 5 Imperial; Year 5 NTU maps to Year 6 Imperial
Year Group Analysis
Years 1–3 at Imperial and NTU were compared directly with each other. However, Year 5 Imperial was compared with Year 4 NTU students and Year 6 Imperial was compared with Year 5 NTU students to account for intercalation at Imperial in Year 4. This ensured cohorts with similar amounts of clinically based education were compared to each other. No significant difference in total scores was observed between the medical schools for any single year group; distribution of year group scores can be compared in Figure 2. Interestingly, Subscale 1 (Attitudes of healthcare providers towards people with mental illness) showed significant differences between the penultimate (p=0.004) and final year (p=0.011) medical student groups when comparing the two schools; Subscale 2 (Attitudes of healthcare providers towards disclosure and help-seeking) showed statistical differences between the Year 3 groups (p=0.044) and Subscale 3 (Attitudes of healthcare providers towards social distance) showed statistical differences between each year group (Year 2: p=0.019; Year 3: p=0.012; Year 5/4: p=0.016; Year 6/5: p=0.078), except Year 1 (p=0.226). Overall and subscale analyses are shown in Table 3.
Kruskal-Wallis tests were performed to explore differences between year groups within the same medical school, for overall score and each subscale. No significant differences were found between year groups, suggesting stigma levels are unchanged throughout each individual medical school.
Year Group Score Distributions
Figure 2: Box and whisker plots showing the distribution of total scores across year groups for both NTU and Imperial. “X” represents the mean. There was no significant difference for Year 1 (Imperial: n=50, median (M)=29, IQR=7; NTU: n=25, M=32, IQR=11), Year 2 (Imperial: n=51, M=30, IQR=10.5; NTU: n=49, M=32, IQR=6),Year 3 (Imperial: n=29, M=31.5, IQR=9.5; NTU: n=19, M=33, IQR=7.5), Year 4/5 (Imperial Year 5: n=29, M=31, IQR=10; NTU Year 4: n=28, M=33.5, IQR=5.5), or Year 5/6 (Imperial Year 6: n=30, M=26, IQR=11; NTU Year 5: n=20, M=27.5, IQR=9) when Mann-Whitney U tests were performed, with p>0.05 in all instances.
Qualitative Results
A total of four major themes were identified from the interview analysis:
- Perceptions of Medical Students Towards Mental Illness
- Impact of Medical School Culture on Mental Health
- University Support for Mental Health
- Impact of Curriculum on Perceptions Towards Mental Health
Perceptions of Medical Students Towards Mental Illness
Students reported that mental illnesses were prevalent, particularly amongst themselves.
“It's not uncommon that some students develop some psychiatric issues” – Student 7 (Year 4), NTU
Interviewees felt that the general population, including themselves and peers, viewed those with a mental illness negatively, suggesting students’ perceptions are not meeting expectations.
“To have some of these really problematic viewpoints still prevalent is really disheartening.” – Student 1 (Year 1), Imperial
Varying opinions were seen regarding openness about mental health from those with mental illnesses, some suggesting that medical students tended to hide their mental illnesses.
“I know that some people do seek help by themselves, but they do not involve any of their friends.” – Student 6 (Year 3), NTU
Students also believed that mental illnesses were viewed more negatively compared to physical illnesses.
“It also stems from a more Asian mindset. It's not a physical illness, right? Mental is all in your head.” – Student 8 (Year 4), NTU
Impact of Medical School Culture on Mental Health
Students believe the high-stress environment of medical school leads to poor mental health, considering factors such as competitiveness, general and academic culture.
“Because of the competition, people’s depression and anxiety can get very bad.” – Student 10 (Year 5), Imperial
There were fears of repercussions from being open with mental health experiences, particularly amongst those students from NTU, suggesting that it would stifle career progression.
“[…] people don't seek help because of the fear of loss of employment in the future […] And that's not something that a school can fix.” – Student 6 (Year 3), NTU
University Support for Mental Health
Students believed mental health support from universities was important, suggesting the positive impact faculty can have.
“Faculty do a lot to show people that it's okay to come forward. They always signpost in newsletters […] they tried to de-stigmatise it.” – Student 9 (Year 5), Imperial
“Knowing that there's a house system and house tutor that we can talk to was very encouraging.” – Student 3 (Year 2), NTU
They felt that universities considered mental health, however perceptions on support varied considerably. Those who believed the current support offered was sufficient complimented tutoring schemes, faculty attitudes, openness towards the topic and welfare and counselling support.
“I feel like the college does well in providing support. So, we have counsellors, for example.” – Student 3 (Year 2), Imperial
“I will say that the people [Faculty] more on the ground are very well in tune with us.” – Student 6 (Year 3), NTU
Those with negative perceptions commented on poor faculty and placement staff attitudes, the necessity for more skilled and representative tutors, and support groups.
“Having personal tutors, or designated proper professionals, because our welfare team […] they’re not trained in anything.” – Student 12 (Year 6), Imperial
“The tutors are from a different generation.” – Student 6 (Year 3), NTU
“If there was improvement […] they could create peer support groups.”– Student 7 (Year 4), NTU
They commented on a requirement for more regular meetings with their tutors to improve relationships and ability to share mental health problems.
“If I speak to you once every 12 weeks over the phone for 10 minutes, I'm probably not going to confess that I'm depressed or anxious or whatever.” – Student 12 (Year 6), Imperial
“The tutors and faculty members can check on the students more frequently.” – Student 7 (Year 4), NTU
Students agreed that sharing of mental health success stories from peers and faculty could be beneficial in opening talks around mental illness and enabling reduction in stigmatising attitudes throughout.
“…Maybe open communication and open sharing from students and faculty?” – Student 1 (Year 1), NTU
“If they could find ways of getting people to come forward and talk about their experiences, I think that would allow people to feel more able talk about it.” – Student 9 (Year 5), Imperial
Impact of Curriculum on Perceptions Towards Mental Health
Some students did not perceive much teaching on mental health within their curriculum.
“From my experience of it, it's barely ever mentioned.” – Student 4 (Year 2), Imperial
“They haven't touched on mental illnesses at all in our curriculum.” – Student 2 (Year 1), NTU
Other students felt that mental health was covered well within the curriculum, particularly in psychiatry-based placements.
“I have a whole module in psychiatry. So, there is a lot of information that I get from there and a lot of knowledge that I draw upon.” – Student 2 (Year 1), Imperial
These students complimented the curriculum, suggesting it exposed medical students to certain mental illnesses and in doing so helped shape perceptions and raise awareness, increasing empathy and understanding.
“They have someone come in, […] saying what they've been through and explaining it and letting us ask questions, which I think was really good.” – Student 8 (Year 4), NTU
“I've been taught a lot more about […] what things you should be looking out for in people with mental health problems.” – Student 7 (Year 4), Imperial
Students identified a need to improve the curriculum for its inability to address negative perceptions, suggesting requirements for earlier inclusion and increased teaching, particularly within holistic care.
“They could emphasise […] there are genetic components, stressor components, more than just telling you about the criteria in the DSM-5.” – Student 6 (Year 3), NTU
“It would be quite useful to have people who speak about how their religion has helped or this culture has helped […] Rather than it still being quite so blanket treatment.” – Student 5 (Year 3), Imperial
“I think it does need to be addressed earlier.” – Student 3 (Year 2), Imperial
There was also acknowledgement that curricular changes would be hard to initiate, due to the dense nature of the syllabus.
“I also understand that the curriculum is quite intensive. And that it is already quite packed as it is, even with the normal schedule, there's not much time in-between.” – Student 7 (Year 4), NTU