Correspondence: David M. Ndetei, Director, Africa Mental Health Foundation, Lower Hill Road, PO Box 48423, 00100 Nairobi, Kenya. Tel/Fax: �254 020 2716315. E-mail: dmndetei@uonbi.ac.ke

(Received 15 April 2013 ; accepted 4 July 2013 )

Factors that infl uence the choice of psychiatry as a career by medical students at the School of Medicine, College of Health Sciences, University of Nairobi

DAVID M. NDETEI 1,2 , ZIPPORAH W. NGUMI 1 , VICTORIA N. MUTISO 2 , CHRISTINE W. MUSYIMI 2 & LUCY W. KAMAU 2

1 Department of Psychiatry, University of Nairobi, Kenya, and 2 Africa Mental Health Foundation, Nairobi, Kenya

Abstract The aim of this paper is to assess the particular factors facilitating and those hampering the choice of psychiatry as a career by medical students at the University of Nairobi in a cross-sectional population study of medical students at the University of Nairobi, College of Health Sciences, School of Medicine using self-administered questionnaires. A total of 31 students (13%) said they would like to be psychiatrists while 44 (18%) were neutral and 170 (69%) did not want to become psychiatrists. The factors that made psychiatry interesting for the students included the view that the problems presented by psychiatric patients were often particularly interesting and challenging and the fact that mental illness presented the fi eld of medicine with one of the greatest challenges. Discouraging factors articulated by the students included views that psychiatry was a vague and speculative speciality, psychiatry was not an important part of the curriculum in medical schools, and psychiatric patients tend to make more emotional demands on their doctors than other patients. There was a negative view of psychiatric patients who most of the students thought were strange, dangerous and incurable, although they were curious to know more about them. Most of the negative infl uence in psychiatry is due to the misconceptions that students have about its prestige and scope, the rewards it offers in terms of job satisfaction and opportunities and the negative views towards psychiatric patients. Integration of psychiatry into the curriculum may address these misunderstandings.

Introduction

The World Health Organization has long recognized that mental health is an important component of health universally. Mental health problems are now recognized as causes of serious morbidity and disabil-ity internationally. The availability of psychiatrists, however, has been continuously documented to lag behind other medical specialities. This is particularly true of developing countries. The WHO continues to record marked differences in the availability of psy-chiatrists between developing and developed countries with a distribution across regions ranging from 9.8 per 100,000 in Europe to 0.04 per 100,000 in Africa. This disparity has increased since 2001 (WHO, 2005).

As a regional example, Kenya has been training psychiatrists since 1983. However, rather than increasing, the ratio of psychiatrists to population has remained fairly stable in the last 10 years at 1: 514,200 in 1997; 1: 543,396 in 2004 and 1: 528,571 in 2006 (Ndetei et al., 2007). Other coun-tries in the region have much worse ratios.

The provision of adequate health cannot be addressed without addressing the provision of mental health services and consequently the availability of psychiatrists and other mental health workers in the communities.

The University of Nairobi School of Medicine is the only institution in Kenya that has been training psychiatrists. While some of the students trained here may come from other institutions or countries, the bulk are graduate doctors of the same college. By looking at the current crop of medical students, this study intends to establish factors intrinsic and extrin-sic that could infl uence students in choosing psy-chiatry as a future career.

Background information and literature review

A number of studies, both in developing and devel-oped countries, have indicated low interest in psychiatry as a career option among medical stu-dents in different parts of the world and even lower

International Review of Psychiatry, August 2013; 25(4): 406–412

ISSN 0954–0261 print/ISSN 1369–1627 online © 2013 Institute of PsychiatryDOI: 10.3109/09540261.2013.823383

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Attitudes towards psychiatry 407

recruitment into psychiatry at postgraduate levels compared to other medical specialities (Davydow et al., 2008; Fischel et al., 2008; Niaz et al., 2003; Rajagopal et al., 2004; Rao et al., 1998; Sierles & Taylor, 1995). The choice of a career, any career, is a multidimensional process and no single factor can be said to hold the key to recruitment to psychiatry. Several studies have tried to look at factors thought to infl uence the choice of psychiatry as career. Sierles et al. (2003) described two main categories of fac-tors: cultural factors and national trends, and intrin-sic factors such as the training institutions and the programmes offered (Sierles & Taylor, 1995).

Some of the factors that have been cited as nega-tively infl uencing the recruitment of psychiatrists include perceptions about low fi nancial reward, poor scientifi c foundation, poor effectiveness of treatments and extent to which patients are helped, potential stresses and frustrations, and relatively lower prestige both within and outside medical cir-cles (Abramowitz & Bentov-Gofrit, 2005; Rajagopal et al., 2004). Some studies have also reported pos-itive attributes including an attractive work – life bal-ance, interesting subject matter, and an intellectually challenging fi eld (Syed et al., 2008; Wigney & Parker, 2008).

Although extrinsic factors are important (Abramowitz & Bentov-Gofrit, 2005; Garryfallos et al., 1998; Sierles & Taylor, 1995), it is the intrin-sic factors, within medical school that are thought to have a major impact on students. Medical schools ’ attitudes towards psychiatry, the views of non-psychiatric faculties about psychiatry and psychia-trists, undergraduate psychiatric education and clerkship in psychiatry are all thought to be factors impacting upon students (Garryfallos et al., 1998; Sierles et al., 2003).

A reported trend towards a positive attitude, par-ticularly as students are exposed to more intensive training in psychiatry, has been increasingly reported. It is, however, to be noted that positive attitudes did not always translate into a choice of a career in psy-chiatry (Ndetei et al., 2008; Rao et al., 1998). In Israel it was found that although psychiatry scored as highly as gynaecology and internal medicine as a potential career choice (in 33% of respondents), only 6% of medical graduates eventually entered into residency in psychiatry (Abramowitz & Bentov-Gofrit, 2005).

Other studies though have also shown that clerk-ship in training had little impact on students ’ atti-tudes towards psychiatry (Fischel et al., 2008), and that students in the lower years (before experience of psychiatry) had a more positive attitude towards psy-chiatry than the upper years (Ndetei et al., 2008; Niaz et al., 2003). An assumption here would be that there are situations where, as students ’ exposure to

mental illnesses and patients increases during clerk-ship, the perceptions of mental illnesses impact on their attitudes towards psychiatry.

What infl uences or hinders the choice of psychia-try as a career is a complex interplay of factors that need to be assessed from several dimensions. This study proposes to explore some of these dimensions by assessing and measuring both medical students ’ attitudes to psychiatry, and perceptions of mental illness.

Problem statement

By including mental healthcare as a component of primary healthcare, Kenya has shown its commit-ment to making mental health an important priority in the delivery of health. However, this commitment hinges on the ability to train and retain mental health workers, including, critically, psychiatrists. The number of doctors graduating from the University of Nairobi has more than doubled in the last 20 years. However, the number of psychiatrists trained within the same time has more or less remained static. Although Kenya is superior to neighbouring coun-tries in numbers of practising psychiatrists, the ratio of psychiatrists to population has remained fairly stable in the last 10 years (Ndetei et al., 2007). How does the medical student experience in Kenya impact on a choice of a career in psychiatry? This study expects to fi nd out by studying attitudes, career intentions, and the impact of role models in senior medical students at one university.

Aims and objectives of study

The main objective of this study is to assess the par-ticular factors facilitating and those hampering the choice of psychiatry as a career by fi nal year medical students at the University of Nairobi, Kenya.

The specifi c objectives were:

to determine the attitudes towards psychiatry 1. among fi nal year medical students at the School of medicine, to determine the attractiveness of psychiatry as 2. a future career, to determine opinions of mental illness among 3. medical students at different levels of training, to determine the impact of role models in the 4. choice of psychiatry as a career.

Methodology

A cross-sectional population study was made of an estimated student population of 1,500 at the College of Health Sciences of the University of Nairobi School of Medicine. The study focused on 300 fi nal

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408 D. M. Ndetei et al.

year students who had passed through the Depart-ment of Psychiatry.

Data collection instruments

1. A researcher-designed personal data questionnaire – age, sex, marital status, year of study and religion.

2. Attitudes Towards Psychiatry (ATP)-30 instru-ment used by other researchers to assess attitudes of medical students towards psychiatry as a career (Burra et al., 1982; Ndetei et al., 2008).

3. A 10-question researcher-designed role model questionnaire (Table 1) (http://informahealthcare.com/doi/abs/10.1080/08039480310000932) using a Likert scale to assess the impact of lectur-ers and other professionals in psychiatry on stu-dents who have rotated through the department.

4. The Standardized Assessment of Personality (SAP), Abbreviated Scale – an eight-question questionnaire to assess personality traits (Kessler, 1994, 1996).

5. A 14-question Attitude Towards Psychiatric Patients questionnaire (Mistik & Turan, 2005; Vezzoli et al., 2001).

6. A 7-question Opinions Regarding Mental Illness Questionnaire (Crisp et al., 2000).

Data collection procedure

In collaboration with the class representatives and student representatives, the principal investigator (PI) (D.M.N.) arranged for a convenient time during normal lecture hours (to maximize on response) to introduce the study and hand the self-administered questionnaires to the students. All students were required to sign a consent form before fi lling the questionnaires.

Ethical considerations

Ethical approval for conducting the study was sought and approved by the Institutional Review Board in Kenya through the Kenyatta National Hospital Review Board. Students signed informed consent with the options not to participate and to withdraw the participation any time without prejudice. Confi -dentiality was achieved through anonymous comple-tion of the questionnaires. The students were not required to write their names, admission number or any personal identifi cation data. Some questions may have been emotionally stressful (e.g. personal experience of mental illness). There was a provision for the individual participants to get in touch with the PI through a mobile number. Those who needed help were channelled through the University Health Services and those who did not want to be seen there were directed to the PI at no cost.

Data analysis

Data was entered by two data entry clerks, cleaned and compared for accuracy. Differences were recon-ciled. Data was then analysed quantitatively using SPSS version 17. Simple statistics were used.

Results

Response rate

The study focused on the 300 fi nal year students. There was a very high response rate of 254 (85%).

Socio-demographics

The majority of respondents (55%) were female with a mean age of 25 years. A large majority (82%) of

Table 1. Role Model Questionnaire.

If you have not had a lecturer from the psychiatry department indicate N/A

1 � agree, 2 � neutral (no opinion), 3 � disagree

1. Most of the lecturers are warm and friendly2. Most of the lecturers are cold and unfriendly3. The lecturers in this speciality have on average been excellent role models4. There is at least one lecturer who has been an encouraging role model5. There is at least one lecturer who has been a discouraging role model6. The single most important infl uence on my attitude to this speciality is the role

model provided by a lecturer7. The single most positive infl uence of my attitude to this speciality has been

provided by other professionals in the speciality who are not lecturers8. The single most negative infl uence on my attitude to this speciality has been

provided by professional in this speciality who are not my lecturers9. The single most positive infl uence on my attitude to this speciality has to do with

other things BUT NOT the role model provided by a professional or a lecturer in the speciality

10. The single most negative infl uence on my attitude to this speciality has to do with other things BUT NOT the role model provided by a professional or a lecturer in the speciality

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Attitudes towards psychiatry 409

students were Kenyan, and most students (90%) were enrolled in the 5-year medical degree (Table 2).

In relation to parents ’ occupation, 69 (38%) said their mothers were skilled workers while 71 (40%) said their fathers were professionals (Table 3).

Career choices (ATP-30)

When ranking speciality careers, psychiatry was the eighth out of 10 listed Kenyan specialities. However, 22% of students reported that psychiatry fell within their top three choices for specialization (Table 4).

A total of 31 (13%) of fi nal year medical students endorsed the statement ‘ I would like to be a psy-chiatrist ’ ; 188 (87%) of students were either neutral or disagreed with the statement. Conversely, two thirds of respondents endorsed the statement that psychiatry would be excluded as one of the three most exciting medical specialties (Table 5).

Views towards psychiatry (Attitude towards Mentally Ill Patients questionnaire)

Table 5 also reports views towards psychiatry among fi nal year medical students.

Comparison with other careers

When asked how psychiatry compared to other fi elds, students said that psychiatry was better than other fi elds in terms of work – life balance (21, 57%), aca-demic opportunities (19, 50%) and fl exible working

(18, 50%). In terms of competition for training, 14 students (38%) felt that it was more competitive than other fi elds. A total of 19 (51%) thought work – life balance was an important comparison to other fi elds, 16 (43%) thought competition for training was an important comparison to other fi elds and 15 (40%) thought psychiatry compared importantly in terms of prestige as compared to other fi elds; 15 students (40%) did not think it was important to compare psychiatry with other fi elds in relation to job prospects.

Infl uence in undertaking medical training and experience of role models (Role Model Questionnaire)

Portrayal of doctors in books, television and the media and personal/family experience of physical illness were considered important factors in the decision to study medicine in 160 (89%) and 145 (81%) of respondents respectively. Personal/family experience of mental illness and work experience were not considered important factors by 124 (72%) and 90 (50%) of students respec-tively. Other highly endorsed factors that infl uenced choice of medicine were contact with books on employment, personal conviction and the many possibilities that were associated with being a doctor.

A total of 142 (77%) students were infl uenced in their career by people who were in recovery from illness, 124 (67%) people with symptoms that were chronic and 120 (65%) acutely unwell patients. According to the responses, there was at least one lecturer who had been an encouraging role model 113 (56%) and the lecturers in psychiatry had, on average, been excellent role models to 94 (47%). Nearly half the students (100, 49%) did not agree that the single most important infl uence on their attitude to psychiatry was the role model provided by a lecturer. Slightly more (106, 52%) considered that the most positive infl uence had come from other professionals who were not psychiatrists.

Students rated psychiatric clinical placement and small group teaching as ‘ above average ’ in 87 (58%) and 78 (55%) of respondents respec-tively. The lecturers, on the other hand, were rated by 74 (50%) of the students as above average. During medical school, the most important learn-ing was from lecturers and tutorials (123, 67%) and the least important form of learning was

Table 2. Demographic characteristics of Nairobi Medical School fi nal year medical students.

Characteristic N (%)

GenderMale 75 (45)Female 92 (55)

Age (Mean 25 years)Country of origin

Kenya 128 (82)Other countries 28 (18)

Duration of medical school training5-year degree 162 (90)6-year degree 17 (7)

Year of main psychiatry placement5th year 154 (85)6th year 27 (15)

Table 3. Profession of parents of Nairobi Medical School students.

Full-time parent

Managerial/Clerical Professional

Semi-skilled worker

Skilled Worker Unskilled Total

N (%) N (%) N (%) N (%) N (%) N (%) N (%)

Mother’s occupation 7 (4) 47 (26) 39 (21) 12 (7) 69 (38) 7 (4) 181 (100)Father’s occupation 1 (1) 32 (18) 71 (40) 26 (15) 42 (24) 5 (3) 177 (100)

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410 D. M. Ndetei et al.

research experience in psychiatry (3, 2%). Other important forms of learning were special study modules in psychiatry and specialist service place-ments which were undertaken by nearly two thirds (114, 63%) of students.

Views towards mentally ill patients (Opinion Regarding Mental Illness questionnaire)

Of the students, 113 (70%) agreed that the prob-lems presented by psychiatric patients were often particularly interesting and challenging. Two thirds (108, 66%) agreed that mental illness presented as one of the great challenges within the fi eld of medicine and 94 (62%) agreed that psychiatric patients tend to make more emotional demands on their doctors than other patients. Similar numbers (106, 65%) disagreed that psychiatry is one of the least important specialities within the fi eld of medicine.

A total of 144 (80%) of the students said they had worked with a psychiatric patient, 93 (68%) said that one could recognize a psychiatric patient by observation and 38 (28%) by the way they talk; 76 (53%) said they were hesitant before examining

a psychiatric patient. A total of 108 (79%) students said they thought psychiatric patients were strange, 21 (15%) that they were like everyone else and 7 (5%) that they were dangerous; 158 (77%) thought that psychiatric patients can hurt people and 59 (42%) are curious when they see a psychiatric patient. Examining views on aetiology, students thought that mental illness is caused by: 71 (52%) life experiences, 38 (28%) genetic infl uences, and 10 (7%) by organic causes.

The students viewed psychiatric patients with a range of diagnoses including substance use disorders and epilepsy as people who were unpredictable, hard to communicate with, and dangerous to themselves and others (Table 6). Table 6 shows that the majority felt these disorders were not curable with treatment (with substance use disorders achieving highest scores for incurability).

Personality traits (SAP)

Because different questions received different response rates, denominators differed. Popular self-endorsed personality traits among the students were: creativity 53 (53%); intelligence 52 (63%); 188 (78%) easily made friends, 182 (74%) did not depend on others, 166 (68%) did not lose their temper easily, and 160 (66%) did not consider themselves as worriers. The most popular negative self-appraisals among the students were lack of imagination 63 (61%) and shyness 54 (48%). A large number of students (148, 60%) said they were perfectionists.

Discussion

There was a high response rate of 254 respondents out of 300 fi nal year medical students. The most popu lar personality traits self-reported among medical students were creativity and intelligence, perfection-ism, ease in making friends, not depending on others, not losing their tempers easily and not normally

Table 4. Comparison of the choice of psychiatry with other specialities.

‘ At this stage in your training please state whether or not you would choose each of the following specialties ’

YesN (%)

NoN (%)

General (internal) medicine 112 (66) 58 (34)Obstetrics and gynaecology 143 (84) 28 (16)Anaesthetics 149 (91) 15 (9)Radiology 108 (66) 56 (34)Psychiatry 94 (58) 67 (42)Accident and emergency medicine 63 (41) 89 (58)Clinical laboratory sciences 66 (42) 90 (58)General practice 114 (67) 55 (32)Paediatrics 133 (78) 38 (22)Surgery 122 (72) 47 (28)

Table 5. View towards the profession of psychiatry by Nairobi Medical School students.

AgreeN (%)

NeutralN (%)

DisagreeN (%)

I would like to be a psychiatrist 31 (13) 44 (18) 170 (69)It is interesting to try to unravel the cause of a psychiatric illness 126 (52) 34 (14) 83 (34)Psychiatric hospitals have a specifi c contribution to make to the treatment of the mentally ill 178 (74) 25 (10) 37 (15)If I were asked what I considered to be the three most exciting medical specialities, psychiatry

would be excluded146 (61) 39 (16) 54 (23)

The practice of psychiatry allows the development of really rewarding relationships with people 147 (61) 45 (19) 23 (20)Psychiatry is unappealing because it makes so little use of medical training 55 (22) 55 (24) 133 (54)Most of the so-called facts in psychiatry are really just vague speculations 122 (51) 52 (22) 64 (27)If we listen to them, psychiatric patients are just as human as other people 74% (178) 40 (17) 9% (23)Doctors taking up psychiatric training are running away from the participation in real medicine 44 (18) 31 (13) 170 (69)Psychiatry is the most important part of the curriculum in medical schools 30 (12) 80 (34) 128 (54)

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Attitudes towards psychiatry 411

beings worriers. Psychiatry in general was not a top choice for most of them. Slightly over half of the students, however, said they were interested in psy-chiatry. The factors that made psychiatry interesting included the view that the problems presented by psychiatric patients were often particularly interest-ing and challenging. Mental illness presented the fi eld of medicine with one of the greatest challenges. The students noted that it was interesting to try to unravel the cause of a psychiatric illness, and that psychiatric hospitals have a specifi c contribution to make to the treatment of the mentally ill. The prac-tice of psychiatry allowed the development of really rewarding relationships with people (Syed et al., 2008; Wigney & Parker, 2008).

Their greatest positive infl uences in choosing a career in medicine included people who were in recovery from illness, people with symptoms that were chronic, and acutely unwell patients. Other sources of infl uence were from people who wanted to seek help from addictions, university tutors, and fam-ily and friends. Other factors that presented medicine as a possible career were the general view of doctors through media and books, as well as the experience they had. Some were also motivated by their own conviction of being doctors, and from the view of the many possibilities that were present in being a doctor. The students also thought that psychiatry was better than other fi elds in work – life balance, academic opportunities and fl exible working; psychiatry com-pared importantly in terms of prestige to other fi elds (Garryfallos et al., 1998; Sierles et al., 2003).

The most common forms of learning in the Uni-versity of Nairobi Medical School were lectures and tutorials, as well as study modules in psychiatry and placement in a specialist mental health service. The skills acquired in psychiatry were considered as important in general practice. Too little time was devoted to psychiatry in the medical curriculum and was rated as of average performance. Clinical psy-chiatry placements were seen to be of above average performance. The lecturers were rated as ‘ very good ’ role models on average and this is why they were the most important infl uences for the students who intended to specialize in psychiatry.

There were several challenges presented by the Nairobi students to trainers in psychiatry: students held views that the speciality consisted of just ‘ vague speculations ’ , psychiatry was considered an unimportant part of the curriculum in medical school, and psychiatric patients were seen as making more emotional demands on their doctors than other patients, there was a stigmatized view of psychiatric patients as ‘ strange ’ , although students were also curious to know more about them, (Abramowitz & Bentov-Gofrit, 2005; Rajagopal et al., 2004). The students, although having a strong perception that psychiatric patients were not dangerous, believed that they could hurt people. They considered patients who suffered severe and enduring mental illnesses, including substance use disorders, as dangerous. Mental health patients were also thought of as unpre-dictable, hard to communicate with, and having the ability to harm themselves and others. Students thought that psychiatric diseases were ‘ not curable ’ . This study reports the fi rst fi ndings of such attitudes among students.

Conclusion

A total of 13% of fi nal year medical students at Nai-robi Medical School, Kenya, reported that they would like to be psychiatrists. The main infl uences of choice of psychiatry in Nairobi are intrinsic and depend on the student experience of psychiatry in medical school. Most of the negative infl uence in psychiatry is due to misconceptions that students have about its prestige and scope, the rewards it offers in terms of job satisfaction and opportunities, and the view that psychiatric patients may be emotionally demanding, and dangerous to them-selves and others. It is challenging for a student to choose a fi eld where healing is perhaps not as visible and where patients are identifi ed as risky and strange. With the integration of psychiatry into the curri-culum, it will be possible for students to learn about the scientifi c basis of modern psychiatry, to experi-ence clinical recovery, and perhaps reduce stigma and misinformation on which they may base their choice in specialization.

Table 6. View of Psychiatric patients by Nairobi Medical School students.

Opinions regarding mental illness. Answer on a scale of never, sometimes, often/always.

Psychiatric patients with:

Severe depression

N (%)

Manic episodeN (%)

SchizophreniaN (%)

Severe anxietyN (%)

DementiaN (%)

Alcohol use disorders

N (%)

Substance use disorders

N (%)EpilepsyN (%)

Are dangerous 159 (75) 185 (89) 168 (84) 139 (72) 129 (69) 183 (91) 180 (92) 104 (53)Are unpredictable 195 (91) 165 (91) 160 (84) 148 (81) 162 (84) 162 (86) 119 (63)Cannot be cured with treatment 135 (68) 113 (61) 120 (69) 112 (62) 106 (61) 141 (75) 142 (78) 111 (60)Are hard to communicate with 192 (92) 110 (57) 121 (67) 160 (83) 106 (60) 143 (71) 143 (77) 96 (36)Can harm themselves 185 (90) 152 (80) 134 (74) 112 (60) 142 (79) 174 (91) 127 (68) 64 (68)

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412 D. M. Ndetei et al.

Acknowledgement

Our sincere gratitude goes to the Africa Mental Health foundation for providing research support. We also thank the Principal of the College of Health Sciences, University of Nairobi, for granting us per-mission to collect data, the students who participated in the study, the Royal College of Psychiatrists for their input, and Dinesh Bughra of the Institute of Psychiatry, London.

Declaration of interest: The authors report no confl ict of interest. The authors are alone responsible for the content and writing of the paper.

References

Abramowitz , M.Z. & Bentov-Gofrit , D . (2005) . The making of a psychiatrist: An Israeli perspective . International Psychiatry , 10 , 3 – 9 .

Burra , P. , Kalin , R. , Leichner , P. , Waldron , J.J. , Handforth , J.R. , Jarrett , F.J. & Amara , I.B . (1982) . The ATP 30 – A scale for measuring medical students ’ attitudes to psychiatry . Medical Education , 16 , 31 – 38 .

Crisp , A. , Gelder , M.G. , Rix , S. & Meltzer , H . (2000) . Stigmatisation of people with mental illness . British Journal of Psychiatry , 177 , 4 – 7 .

Davydow , D. , Bienvenu , J. , Lipsey J. & Swartz , K . (2008) . Factors infl uencing the choice of a psychiatric residency program: A survey of applicants to the John Hopkins residency program in psychiatry . Academic Psychiatry , 32 , 143 – 146 .

Fischel , T. , Manna , H. , Krivoy , A. , Mathew , L. & Weizman , A . (2008) . Does clerkship in psychiatry contribute to changing medical students ’ attitudes towards psychiatry? Academic Psychiatry , 32 , 147 – 150 .

Garryfallos , G. , Adamopoulou , A. , Lavrentiadis , G. , Giouzepas , J. , Parashos , A. & Dimitriou , E . (1998) . Medical students ’ attitudes towards psychiatry in Greece: An eight year comparison . Academic Psychiatry , 22 , 92 – 97 .

Kessler , R.C . (1994) . The World Health Organization International Consortium in Psychiatric Epidemiology (ICPE): Initial work

and future directions – the NAPE lecture 1998 . Acta Psychiatrica Scandinavica , 1999 , 99 , 2 – 9 .

Kessler , R.C. & Ustiin , T.B . (1996) . The World Health Organization World Mental Health 2000 Initiative . Hospital Management International 2000, 195 – 196 .

Mistik , S. & Turan T . (2005) . Change in medical students ’ opinions and attitudes towards mental illness . Middle East Journal of Family Medicine , 3 , 19 – 24 .

Ndetei , D.M. , Khasakhala , L. , Ongecha-Owuor , F. , Kuria , M. , Mutiso , V. , Syanda , J & Kokonya , D . (2008) . Attitudes towards psychiatry: A survey of medical students at the University of Nairobi, Kenya . Academic Psychiatry , 32 , 154 – 159 .

Ndetei , D.M. , Ongecha , F.A. , Mutiso , V. , Kuria , M. , Khasakhala , L.I. & Kokonya , D.A . (2007) . The challenges of human resources in mental health in Kenya . South African Psychiatry Review, 10 , 33 – 36 .

Niaz , U. , Hassan S. , Hussain , H. & Saeed , S . (2003) . Attitudes towards psychiatry in pre-clinical and post-clinical clerkships in different medical colleges of Karachi . Pakistan Journal of Medical Sciences , 19 , 253 – 263 .

Rajagopal , S. , Rehill , K.S. & Godfrey , M . (2004) . Psychiatry as a career choice compared with other specialities: A survey of medical students . Psychiatric Bulletin , 28 , 444 – 446 .

Rao , N.R. , Meinzer , A.E. , Manley , M. & Chagwedera , I . (1998) . International medical students ’ career choice, attitudes towards psychiatry, and emigration to the United States . Academic Psychiatry , 22 , 117 – 126 .

Sierles , F.S. , Dinwiddie , S.H. , Patroi , D. , Atre-Vaidya , N. , Schrift , J.M. & Woodard , J.L . (2003) . Factors affecting medical students career choice of psychiatry from 1999 to 2001 . Academic Psychiatry , 27 , 260 – 268 .

Sierles , F.S. & Taylor , M.A . (1995) . Decline of U. S. medical students ’ career choice of psychiatry and what to do about it . American Journal of Psychiatry , 152 , 1416 – 1426 .

Syed , E.U. , Siddiqi , M.N. , Dogar , I. , Hamrani , M.M. , Yousafzai , A.W. & Zuberi , S . (2008) . Attitudes of Pakistani medical students towards psychiatry as a prospective career: A survey . Academic Psychiatry , 32 , 160 – 164 .

Vezzoli , R. , Archiati L. , Buizza , C. , Pasqualett,i P., Rossi , G. & Pioli , R . (2001) . Attitude towards psychiatric patients: A pilot study in a northern Italian town . European Psychiatry , 16 , 451 – 458 .

WHO . (2005) . Mental Health Atlas . Geneva: World Health Organization. http://www.who.int/mental_health/evidence/atlas/

Wigney , T. & Parker , G . (2008) . Factors encouraging medical students to a career in psychiatry: qualitative analysis . Australia and New Zealand Journal of Psychiatry , 42 , 520 – 525 .

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