Attitudes towards prescribing psychiatric medicines: Do the views of psychology and medical students differ?

doi:10.4236/ojpsych.2011.13017

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Open Journal of Psychiatry, 2011, 1, 115-121

doi:10.4236/ojpsych.2011.13017 Published Online October 2011 (http://www.SciRP.org/journal/OJPsych/

OJPsych

Published Online October 2011 in SciRes. http://www.scirp. org/journal/OJPsych

Attitudes towards prescribing psychiatric medicines: do the

views of psychology and medical students differ?

Carlos De las Cuevas1,2*, Wenceslao Peñate3, Lilisbeth Perestelo2,4, Amado Rivero5, Jeanette Pérez5,

Marien González5, Alia Pérez-W ehbe5

1Department of Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Canary Islands, Spain;

2CIBER en Epidemiología y Salud Pública (CIBERESP), Santa Cruz de Tenerife, Spain;

3Department of Personality, Assessment and Psychological Treatments, University of La Laguna, Canary Islands, Spain;

4Evaluation Unit of the Canary Islands Health Service (SESCS), Santa Cruz de Tenerife, Spain;

5Fundación Canaria de Investigación y Salud (FUNCIS), Santa Cruz de Tenerife, Spain.

Email: *[email protected]

Received 1 July 2011; revised 12 August 2011; accepted 22 August 2011.

ABSTRACT

Concordance has been suggested as a process of the

consultation in which prescribing process is based on

partnership. The aim of this cross-sectional study was

to compare attitudes towards psychiatric medication

and concordance in medicine taking between medical

and psychology students, as they represent future

members of mental health teams. Two hundred and

sixteen medical students and 222 psychology students

completed the Leeds Attitudes toward Concordance

scale (LATCon) and the Beliefs about Medication

Questionnaire (BMQ) (both adapted for psychiatric

medication). Psychology students saw psychiatric

medicines as more harmful and were also most likely

to believe that psychiatrists overprescribed these

medicines. They also scored higher than medical stu-

dents on attitudes towards concordance, although

this difference remained at the limit of statistical sig-

nificance.

Keywords: Leeds Attitude toward Concordance Scale

(LATCon); Beliefs about Medication Questionnaire

(BMQ); Medical Students; Psychology Students

1. INTRODUCTION

Although there are slight variations in the structure and

composition, multidisciplinary Community Mental Health

Teams are considered to provide the core of Specialist

Mental Health Services in Spain. They are responsible for

delivering and for coordinating a specialized level of

community-based care for defined populations [1]. In this

context, psychiatrists and psychologists have to work

together sharing approaches and objectives although they

have obvious different skills arising from different pro-

fessional backgrounds and different basic training.

Even though psychological treatments of proven effi-

cacy are available for the management of many psycho-

pathological disorders, the prescription of psychoactive

medication is one of the most common interventions in

mental healthcare. However, the gap between best care

and usual care is large for psychiatric disorders. In parti-

cular, poor adherence to treatment of psychiatric disor-

ders is a worldwide problem of striking magnitude that

contributes to the gap care [2]. Poor adherence to long-

term therapies compromises severely the effectiveness of

treatment, making this a critical issue in population

health from the perspective of both quality of life and

health economics [3]. This lack of adherence is not only

a problem of pharmacotherapy, but also a problem in

psychological treatments [4].

The ability of patients to follow treatment plans in an

optimal manner is frequently compromised by diverse

barriers, usually related to different aspects of the

problem that include: social and economic factors, the

health care team/system, the characteristics of the dis-

ease, disease therapies and patient-related factors. Sol-

ving the problems related to each of these factors is

necessary if patients’ adherence to therapies is to be im-

proved. In this sense, experts recommended, especially,

to devote time in treatment specifically in addressing

medication adherence, assess patients’ motivation to take

prescribed medications, and to focus on strengthening

the therapeutic alliance [2]. This implies some changes

in the traditional model of the health service delivery.

The traditional model of the practitioner-patient inter-

action incorporates a practitioner-centred approach, foc-

using on the disease rather than on the patient. The “the-

C. De las Cuevas et al. / Open Journal of Psychiatry 1 (2011) 115-121

116

rapeutic alliance” represents another point of view, and it

is based on the philosophy of “concordance” (or “par-

tnership in medicine-taking”). Concordance is a psych-

ological interaction process that puts the patient at the

centre of the relationship, interacting reciprocally with

the practitioner. In the concordance model, patients are

viewed as active participants who manage their own

health care. Practitioners and patients are encouraged to

forge partnerships to work together as equals. Practi-

tioners bring their professional expertise to the table,

whilst patients draw on their own experiences, beliefs

and wishes [5]. Concordance is viewed as a strategy to

improve medication adherence, among other complex

interventions [6].

The problem of treatment adherence is especially

relevant in mental health services, since psychiatric

patients are more likely than others to refuse medication

[7], and are more likely to participate in therapeutic

decisions [8]. The importance of (non)adherence in men-

tal health practice has dealed to the creation of a expert

panel to afford potential solutions for adherence [9]. A

prior consensus among healthcare practitioners is the

basic target to get those potential solutions.

Psychiatrists and clinical psychologists are part of the

healthcare team that has daily contact with patients to

discuss medication. If they have different respective

beliefs about psychoactive medication, what treatment a

patient should receive and the consequent provision of

different information to the patient about the treatment,

the patient could then have difficulties evaluating the

treatment [10]. Thus, agreement between mental health

professionals is a pre-requisite in treatment election and

patient’s commitment. This includes agreement in psy-

chiatric medication and concordance. This is a relevant

aim, since there are different perceptions about medicine

depending on the different educational background of

practitioners [11]. Psychiatrists and clinical psycholo-

gists have different formative curricula in both their

theoretical and practical formation, and it can be part of

a lack of consensus about mental health intervention.

The objective of the present paper is to investigate the

beliefs of medical and psychology students about psych-

iatric medication and their attitudes towards concordance

in medicine taking, as they potentially represent future

mental health care providers. Potential differences in at-

titudes towards prescribing psychiatric medicines bet-

ween psychiatrists and clinical psychologists could ori-

ginate from their different academic formation which

could favor a biological perspective in the case of medical

students and a more psychosocial view for psychology

students. Therefore, we assume that medical students will

show more positive beliefs about psychiatric medicines,

while psychology student will show a better attitude

towards concordance.

2. METHODS

2.1. Participants

216 medical students and 222 psychology students parti-

cipated in the study. According to their level degrees,

medicine students were 63 third degree, 57 fourth degree,

56 fifth degree, and 40 sixth degree. Psychology students:

85 third degree, 69 fourth degree, 46 fifth degree, and 22

master degree. Medicine students mean age was 22,62;

psychology students mean age was 22.2. Based on sex,

medical students: 64 were males, and 152 females; psy-

chology students: 41 males, and 181 females.

Students were recruited during class lessons. They were

asked whether they want to voluntarily participate in a

study about mental health treatment. There was not any

credit nor specific remuneration for their participation.

2.2. Instruments and Measures

In order to measure students’ beliefs about psychiatric

medication, the Spanish version of BMQ-General ques-

tionnaire was used. The scale assesses general beliefs or

social representations of pharmaceuticals as a type of

treatment: beliefs that medicines in general are overused

by doctors and beliefs that medicines in general are

harmful, addictive, poisons that should not be taken con-

tinuously. BMQ have shown to be a valid and reliable

measure [12-14] and it is able to discriminate between

different groups of patients and students [11-14]. The

BMQ-General scale includes eight items in two sub-

scales, the Overuse subscale and the Harm subscale. The

degree of agreement with each statement is indicated on

a five point Likert scale, ranging from (1) strongly dis-

agree to (5) strongly agree. For this study, items were

modified to specifically refer to psychiatric medication.

In order to investigate the attitudes of medical and

psychology students towards concordance, the Leeds

Attitude toward Concordance Scale (LATCon) was used

[15,16]. It consists of a 12-item scale. The respondent

scores each item on a four point Likert scale: (0)

strongly disagree, (1) disagree, (2) agree, (3) strongly

agree. The total maximum score is therefore 36. An av-

erage item score between 2 and 3 indicates that the re-

spondent tends to ‘agree’ with the concept of concor-

dance, while an average score below 2 suggests that he/

she does not.

The original English version of the questionnaire was

translated into Spanish by two members of the research

team and then translated back into English by a native

English speaker to check whether or not the Spanish

translations conveyed the original meaning intended by

the authors. As with the BMQ, items were modified to

specifically refer to psychiatric medication.

C. De las Cuevas et al. / Open Journal of Psychiatry 1 (2011) 115-121

117

OJPsych

The questionnaire that the medical and psychology un-

dergraduate students completed also included some so-

ciodemographic variables and information about present

or past use of psychoactive drugs by the interviewee or

their relatives.

2.3. Study Design

According to Montero and León [17], a post-facto design

was used. This was a cross-sectional, self-administered

questionnaire survey of an opportunistic sample of medi-

cal and psychology students registered in the last courses

of their respective degrees as undergraduates at the Uni-

versity of La Laguna, in the Canary Islands, Spain.

2.4. Data Collection

The data collection for this cross-sectional study was

performed in May 2010, during class lessons. At the

time of the data collection students were informed both

orally and in writing about the aim of the study and that

participation was voluntary and anonymous. They also

received information on how to complete the question-

naires.

2.5. Data Analysis

Mean differences between medical and psychology stu-

dents were calculated using one way MANOVA (BMQ

subscales) and t-test (LATCon). For BMQ subscales, the

effect of having personal or vicarious experience with

psychiatric drugs, as well as its interaction with type of

studies, were analyzed.

Apart from total and factor-scores comparisons, an

item-level analysis was also carried out, by means of two

additional MANOVAs with BMQ and LATCon items,

respectively, as dependent variables. Finally, a forward

stepwise logistic regression was conducted with both the

BMQ-General and LATCon items as independent vari-

ables, and type of studies as dependent variable.

3. RESULTS

3.1. Sample

There was no significant difference in both age and level

degree between student groups. Psychology students

included significantly more women (81.5% vs. 70.4%;



2 = 7.483, p < 0.006).

3.2. Beliefs about Medications

Scores for the BMQ Overuse and Harm subscales were

normally distributed in both samples. No significant

differences in general beliefs about medication were

found due to age or sex for any student category consid-

ered. According to BMQ subscales scores, psychology

students saw psychiatric medicines as more harmful

compared to medical students (BMQ-Harm: 2.68 ± 0.58

vs. 2.38 ± 0.62; p < 0.001) and were also most likely to

believe that psychiatrists overprescribed these medicines

(BMQ-Overuse: 3.67 ± 0.66 vs. 3.18 ± 0.7; p < 0.001).

Table 1 shows the mean scores in the BMQ items for

medical and psychology students. Taking as a criterion a

theoretical intermediate score of 3 for each item (neither

agree nor disagree), both medical and psychology stu-

dents surpassed this score on items related to the addic-

tive nature of the psychiatric medication and the con-

sid-eration that spending more time with patients would

result in less prescribed medication. There are two other

Table 1. Differences in BMQ items for medical and psychology students (MANOVA).

Beliefs About Medicines Questionnaire—General Items

Overuse subscale Medicine Mean

(SD) Psychology

Mean (SD) F p η2

1. Psychiatrists use too many medicines 2.98 (0.85) 3.67 (0.85) 70.635 0.0000.139

7. Psychiatrists place too much trust on medicines 2.98 (1.01) 3.70 (0.75) 71.132 0.0000.140

8. If psychiatrists had more time with patients they would prescribe fewer medicines 3.61 (1.09) 3.65 (0.98) 0.181 0.6700.000

Harm subscale

2. People who take psychiatric medicines should stop their treatment for a while every

now and again 2.64 (1.12) 2.95 (1.02) 9.473 0.0020.021

3. Most psychiatric medicines are addictive 3.15 (1.13) 3.47 (0.98) 9.804 0.0020.022

4. Natural remedies are safer than psychotropic medicines* 2.36 (1.02) 2.72 (0.99) 13.650 0.0000.030

5. Psychiatric medicines do more harm than good 1.96 (0.79) 2.30 (0.77) 20.695 0.0000.045

6. All psychiatric medicines are poisons 1.81 (0.98) 1.96 (0.96) 2.601 0.1080.006

*In the Spanish validation of BMQ, item 4 loads on Harm subscale, contrary to the original questionnaire.

C. De las Cuevas et al. / Open Journal of Psychiatry 1 (2011) 115-121

118

items in which psychology students scored above this

term: the facts that psychiatrists use too many medicines

and that they place too much trust on their prescriptions.

These data indicate that, overall, the two samples tend to

disagree more than to agree with the contents of the

items of BMQ-General scale.

As shown in Table 1, six out of the eight items Regis-

tered significant differences with the psychology stu-

dents scoring higher than the medical students: they

were most likely to believe that patients should discon-

tinue the use of drug from time to time, that psychiatric

drugs are addictive, and that these compounds do more

harm than good or that natural remedies are more useful.

However, considering the effect size (η2), the differ-

ences are really low. Only the differences found in the

items about overuse and excessive reliance on psychiat-

ric drugs seem to have reached a certain consistency. On

the other hand, no significant differences were registered

in the item that considers psychiatric medications as

poisons and the already mentioned that if psychiatrists

had more time with patients they would prescribe fewer

medicines.

Having in mind that a greater knowledge of psy-

choactive drugs might influence the student’s beliefs, the

sample was divided into two groups: those who have

been treated with such compounds or that have a relative

or close friend under this treatment (n = 240) and those

who have no experience on these drugs (n = 198). The

only significant item was the one corresponding to “all

psychiatric medications are poisons” (F1, 436 = 5.52; p

≤ 0.019;

2 = 0.013) with the group without experience

about (M = 2.01; SD = 0.95) considering the psychoac-

tive drugs more toxic than the group who knew them (M

= 1.79; SD = 0.97). The interaction between this variable

and the type of studies only found in one item and it was

marginally significant (F1, 434 = 3.83; p ≤ 0.051;

2 =

0.01), suggesting that psychology students have a greater

tendency to disregard toxic psychotropic drugs when

they know them.

3.3. Attitude to Concordance

Considering the results of the Leeds Attitude to Concor-

dance Scale (LATCon), the mean item score of the

global sample was 2.00 ± 0.35, median score 2 (Table 2).

These values indicate that the respondents tend to “agree”

with the concept of concordance. There was no difference

in the attitudes towards concordance of the medical and

psychology students (mean item score: medicine = 1.97

± 0.33; psychology = 2.03 ± 0.37; p = 0.07).

In the comparison of items means across the two sam-

ples, five items allow to appreciate differences between

medical and psychology students. In four of the items

Table 2. Differences in LATCon items for medical and psychology students (MANOVA).

Leeds Attitude to Concordance Scale—items Medicine Mean

(SD) Psychology Mean

(SD) F p η2

1. The consultation between the psychiatrist and patient should be viewed as a

negotiation between equals 1.52 (0.71) 1.71 (0.75) 7.631 0.0060.017

2. Psychiatrists should respect their patients’ personal beliefs & how they cope 2.22 (0.61) 2.19 (0.64) 0.228 0.6330.001

3. The best use of medicine is when it is what the patient wants and is able to

achieve 2.13 (0.62) 2.11 (0.65) 0.126 0.7230.000

4. Just as prescribing is an experiment carried out by the psychiatrist, so too is

medication taking an experiment carried out by the patient 1.51 (0.93) 1.42 (0.86) 1.122 0.2900.003

5. Psychiatrists should give patients the opportunity to talk about their thoughts

about their illness and negotiate how it is treated 2.08 (0.72) 2.07 (0.72) 0.052 0.8200.000

6. Better health would follow from co-operation between psychiatrists and patients2.56 (0.58) 2.50 (0.52) 1.323 0.2510.003

7. A high priority in the consultation between psychiatrist and patients is to estab-

lish agreement about the need for medicine 2.18 (0.70) 2.05 (0.67) 4.265 0.0390.010

8. Psychiatrists should be sensitive to patient desires, needs and abilities 2.07 (0.65) 2.23 (0.64) 6.842 0.009 0.015

9. Psychiatrists should try to help patients to make as informed a choice as possible

about benefits and risks of alternative treatments 2.46 (0.60) 2.49 (0.59) 0.244 0.6220.001

10. During the psychiatrist-patient consultation, it is the patient’s decision that is

most important 1.10 (0.76) 1.48 (0.77) 26.605 0.0000.058

11. Psychiatrists should be more sensitive to how patients react to the information

they give 1.89 (0.59) 2.22 (0.54) 36.835 0.0000.078

12. Psychiatrists should try to learn about the beliefs their patients hold about their

meicines d1.94 (0.60) 1.94 (0.68) 0.001 0.9770.000

C. De las Cuevas et al. / Open Journal of Psychiatry 1 (2011) 115-121 119

(the consultation is a negotiation between equals; doc-

tors should be sensitive to patients desires, needs, abili-

ties and how patients react to the information they give;

and the patient decision is the most important), psychol-

ogy students scored significantly higher than those of

medicine. However, with regard to the priority to estab-

lish agreement about the need for medicines, the medical

students were the ones who scored higher. In eight out of

12 items composing the scale, both groups scored above

2 (indicating agreement rather than disagreement). In

four of the items both samples disagree with the asser-

tion. They included the consideration that the consulta-

tion between doctor and patient should be viewed as a

negotiation between equals, the fact that the patients’

decision is the most important one, the experimental

nature of prescribing and using psychoactive drugs, and

the need for psychiatrists to learn about the beliefs their

patients hold about their medication.

Finally, stepwise logistic regression (Wald forward

method) was carried out to try to identify which items of

the BMQ and LATCon scales differ for medical and

psychology students. The final resulting model included

10 items, with a Nagelkerke R2 = 0.43, highly significant

(x2 = 171.72; p ≤ 0.001). The Table 3 summarizes the

model. As it can be seen, the variables that best predict

are the BMQ items pertaining to the Overuse subscale.

Six items about concordance become part of the equa-

tion with secondary importance, with significant coeffi-

cients, but with a low incremental weight (with the ex-

ception of the consideration that psychiatrists should be

more sensitive to information provided by the patient).

4. DISCUSSION

The improvement of health services includes the need of

an agreement among health teams about therapeutic

process. Attitudes about medicines, and about the con-

cordance between patients and practitioners, are parts of

that agreement. This is especially relevant in mental

health services, because of there are different practitio-

ners with different curricula (i.e., psychiatrics, psycholo-

gists…), and because mental patients are more sensitive

about their treatments. Additionally, despite some social

changes, a stigma of mental disorders still prevents pa-

tients from seeking help [18].

According to our results, the first consideration to

highlight is that, in general, medical and psychology

students agree in that medication is not always the best

choice and that concordance between patient and thera-

pist is a value to keep in mind within the therapeutic

relationship. Somehow this information indicates that

both groups are more in agreement rather than in dis-

agreement. The necessary coordination between these

two professional groups in the attention they pay to

mental health seems to have certain guarantees, though

some differences persist. The reason for this does not

seem to be justified by the academic curriculum or the

Table 3 . Forward stepwise logistic regression with BMQ and LATCon items as independent variables and type of student as de-

pendent variable (medical students categorized as 0).

Variables B Standard errorWald Sig R2 (Nagelkerke)

(Constant) –5.598 0.840 44.46 0.000

(BMQ-1) Psychiatrists use too many medicines 0.855 0.170 25.38 0.000 0.186

(BMQ-4)Natural remedies are safer than psychotropic medicines 0.339 0.127 7.13 0.008 0.261

(BMQ-7) Psychiatrists place too much trust on medicines 0.696 0.162 18.36 0.000 0.301

(BMQ-8) If psychiatrists had more time with patients they would prescribe

fewer medicines –0.435 0.140 9.64 0.002 0.342

(LAT-1) The consultation between the doctor & patient should be viewed

as a negotiation between equals 0.363 0.168 4.67 0.031 0.365

(LAT-4) Just as prescribing is an experiment carried out by the doctor. so

too is medication taking an experiment carried out by the patient –0.425 0.152 7.80 0.005 0.387

(LAT-7) A high priority in the consultation between doctor and patients is

to establish agreement about the need for medicine –0.550 0.187 8.60 0.003 0.398

(LAT-10) During the doctor-patient consultation. it is the patient’s decision

that is most important 0.441 0.168 6.86 0.009 0.414

(LAT-11) Psychiatrists should be more sensitive to how patients react to

the information they give 1.260 0.243 26.80 0.000 0.423

(LAT-12) Psychiatrists should try to learn about the beliefs their patients

hold about their medicines –0.436 0.205 4.54 0.033 0.432

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120

training reasons, as the academic contents of these studies

are uneven. It is possible that other factors are influ-

encing this, such as the social and human values (the less

medication the better, a good patient-therapist relation-

ship is better than a bad relation), or the social desirability

(“politically correct”). This is especially relevant in the

case of the LATCon, provided that both students groups

highly agree in two thirds of the items.

Analyzing the differences and differential profile

found, it is striking that the major weight rests on medi-

cation rather than on conformity. In this case, it can be

due to the training curriculum, because of the fact that in

psychology the functional factors are accentuated as the

pathology’s determinant elements, opposite to the more

prominent biological component in medicine. On the

other hand, culture favors a vision of the medication as

an unquestionable healer (and as such it is a ‘profes-

sional’ decision). This element would be more deeply

rooted in medicine students that in those of psychology

due to the proximity to this cultural tradition. Our data

point out that the modulating function of knowing the

psychoactive drugs’ effects does not seem to play a

relevant role. Nevertheless, the necessary patient-thera-

pist relationship passes to be of secondary importance,

possibly because both student groups have a similar so-

cial value on mutual commitment, and on the need of

empathy between patient and physician. In any case,

some differences could be observed, showing overall

that psychology students showed a higher agreement on

the importance of concordance.

These differences can be justified by the epistemo-

logical diversity in the medical and psychological treat-

ments’ nature. In psychotherapy there is an assertion

which calls for an active patients’ participation in health

change. On the other hand, in medicine this assertion is

mediated by the intrinsic treatments’ effects (especially

medication taken). In other words, concordance is part of

an active principle of psychological treatments, but in

medicine it is part of a better procedure (better adher-

ence, better commitment). In this sense, psychologists

encourage patient-therapist concordance as an intrinsic

element of treatment efficacy, whereas physicians con-

sider it as a modulator variable, via adherence, of treat-

ment efficacy.

Definitively, medical and psychology students seem to

show a raising agreement in the need of concordance

within the therapist-patient relationship. Taking into ac-

count the training differences [19] the fact that the

agreement is major for both professional groups it might

be indicating the need of new contents that trace these

training differences in relation with concordance. In this

respect, new versions of the LATCon could favor this

point of view [20]. In any case, beyond new versions of

the LATCon could improve its differential and dis-

criminant validity, it might be more appropriate to bear

in mind the major impact that the levels of social desir-

ability have on concordance when it is always seen as

“what it should be”.

The most notable differences were found in the role of

medication and its management. Beyond the modulating

paper of social and personal values of every students

group, the training curriculum could be modulating these

results; for this reason it would be necessary to consider

the role of the curricular development [21] and that of

the professional practice (clinical psychology and psy-

chiatry) as elements that could go eliminating these dif-

ferences. This does not mean that both curricula must

share more equivalent contents between them, and more

equivalent professional responsibilities, as the polemic

of prescription privileges for clinical psychologists

seems to point out [22]. We do not find reasons to con-

fuse both the functional and biological perspectives in

mental health. But we find reasons for a better comple-

mentary formation in clinical practice. As it has been

mentioned, the necessary complementarity and confor-

mity among mental health professionals makes it neces-

sary that the elimination of these differences is tackled

explicitly. The agreement between professionals who

shared a common task is a prerequisite of its efficacy

and efficiency.

It is important to point out, as a main limitation of this

study, that only a small proportion of medical and psy-

chology undergraduates go on to work in the area of

mental health, so these results are not directly gener-

alizable to future psychiatrists and clinical psychologists.

Nevertheless, they offer a general view of differences in

attitude towards psychiatrist medicines and concordance

between these student samples, differences that therefore

could be present independently of the eventual academic

education and training in mental health area.

5. ACKNOWLEDGEMENTS

This work was supported by the Instituto de Salud Carlos III, FEDER

Unión Europea (PI10/00955).

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