In the late 1970s, when Academic Psychiatry was known as the Journal of Psychiatric Education, the first article on medical student attitudes toward psychiatry was published [1]. Since that time, both within and beyond this journal, there has been a consistent flow of research related to the topic. Although not an exhaustive list, different authors have explored many factors that impact students’ attitudes toward psychiatry: student demographic variables, medical school admission processes, the formal curriculum in preclinical and clerkship experiences, the influence of attitudes and opinions of others, enrichment activities, exposure to patients with psychiatric illness, and cultural and societal beliefs, including stigma. While the exploration of attitudes toward psychiatry began in the USA, there are now studies from across the globe, in both developed and developing countries.

Given the breadth of available literature, clearly, academic psychiatrists have a keen interest in how medical students perceive the specialty. For the most part, this interest is related to concerns about recruitment into the field. Many articles on student attitudes begin with dire statistics that reflect the gap between the population’s mental health care needs and the number of both existing psychiatrists and newly graduating physicians who choose a residency in psychiatry. Through the evaluation of attitudes, researchers are attempting to understand what draws learners into the field and what might discourage them. By understanding these factors, the hope is that interventions can be developed to increase recruitment.

Attitudes toward psychiatry are not, however, only important for those students who decide to specialize in psychiatry. For example, in the USA, approximately half of the 8 million visits for depression yearly occur in primary care clinics, and in the UK, 90% of mental health care takes place solely in this setting [2]. Given the emigration of specialists from developing to developed countries, this relative shortage of specialists is likely even more of a concern in other areas of the world [3, 4]. Gauging medical student attitudes toward psychiatry provides not only a glimpse of how future physicians feel about patients with psychiatric disease but also information about their perceptions of psychiatrists and the field in general. Through this knowledge, psychiatrists may be able to effect change through targeted curricular efforts.

Two scales are commonly utilized to measure medical student attitudes toward psychiatry. The Attitudes to Psychiatry 30 (ATP-30), developed in 1982 by Burra et al. [5], is a 30-item assessment divided into eight categories: psychiatric patients, psychiatric illness, psychiatrists, psychiatric knowledge, psychiatric career choice, psychiatric treatment, psychiatric institutions, and psychiatric teaching. The questions in the ATP-30 are equally divided into negative and positive statements; for example, “It is quite easy for me to accept the efficacy of psychotherapy” versus “There is very little that psychiatrists can do for their patients.” All questions are answered via Likert scale (strongly agree to strongly disagree), and a total score is calculated by adding all items, with a high number indicating a more positive attitude. The Attitudes to Psychiatry Scale (APS), developed in 1999 by Balon et al. [6], is a 29-item questionnaire with a similar Likert scale and balanced positive and negative approach. Items in this assessment are divided into five dimensions, including overall merits of psychiatry, efficacy, role definition and functioning of psychiatrists, possible abuse and social criticism, and career and personal award and specific medical school factors.

Four articles in the December 2021 issue of Academic Psychiatry [3, 4, 7, 8] add to the existing literature on medical student attitudes toward psychiatry worldwide. “Revisiting the ATP 30: The Factor Structure of a Scale Measuring Medical Students’ Attitudes Towards Psychiatry” [4] reexamines the ATP-30 [5], which was originally found to have no meaningful subscales. Baminiwatta et al. [4] analyze secondary data from a survey of over 700 medical students across nine schools in Sri Lanka and derive six subscales from the original domains: the image of psychiatrists, psychiatric patients and mental illness, the efficacy of treatment, psychiatric teaching, career choice, and psychiatry as an evidenced-based discipline. The authors note the similarity to an analysis of the factor structure of the APS, which provides additional evidence that attitudes toward psychiatry are multidimensional in nature [9]. The authors propose that this multidimensionality will allow educators “to identify the areas where the students’ attitudes are relatively more stigmatized so that greater attention can be directed to these aspects.” Interestingly, the domain “image of psychiatrists,” which included questions pertaining to students’ perceptions of psychiatrists, emerged as the most prominent underlying dimension, which suggests that efforts should focus on this area in the population studied.

“Attitudes of Medical Students Towards Psychiatry in Venezuela: A 6-year Longitudinal Study” [7] used a modified version of the APS to evaluate changes in students’ attitudes from the first to the sixth year of education in one medical school. Medical students in this institution have both limited didactic and clinical exposure, with only 12 h of lectures integrated into the internal medicine curriculum and 4 h total of psychiatric care, specific to psychotic disorders. Although students had a positive attitude toward most of the statements in the APS, the number seriously considering psychiatry as a career choice fell from 15.8 to 1.4% during the period of study. Reflective of the importance of image noted by Baminiwatta et al. [4], several related items changed in a concerning manner. For example, there was a statistically significant increase in agreement to the statements “If a student expresses interest in psychiatry, he or she risks being associated with a group of other would-be-psychiatrists who are often seen by others as odd, peculiar and neurotic” and “Psychiatrists are too often apologetic when teaching psychiatry” and a significant decrease in agreement with both “Most psychiatrists are clear, logical thinkers” and “Psychiatry has a high status among other disciplines.”

In “Attitudes Towards Psychiatry in Lebanese Medical Students: What Are the Factors that Could Lead to a More Favorable Outlook?” [3], El Hage et al. completed a cross-sectional study on a sample of pre-medical and medical students across the country using the ATP-30. Interestingly, in an area of the world that the authors describe as still “surrounded by stigma,” student attitudes toward psychiatry were like that of several European nations. Among students who participated, 95.1% had a positive attitude toward the field, and 26.5% reported psychiatry as a potential career choice. Perhaps more surprising was the fact that almost 35% of student participants agreed or strongly agreed with the statement “These days psychiatry is the most important part of the curriculum in medical schools.” These findings should be interpreted carefully, however, as pre-medical students were included in the data, and the actual number of students who ultimately specialized in psychiatry was not calculated. As far as the impact these results might have on the care of patients within Lebanon, additional caution is warranted, as 40% of physicians decide to leave the country upon completion of training [3].

Finally, in “Stigma in Psychiatry: Impact of a Virtual and Traditional Psychiatry Clerkship in Medical Student Attitudes” [8], the ATP-30 is utilized to examine changes in attitudes toward psychiatry in a virtual versus in-person clerkship experience. Although the authors admit that existing literature has not revealed a consensus on the “influential nature clerkships have on students and their attitudes toward psychiatry as a specialty,” they hypothesized that the virtual model would have a detrimental impact on attitudes. Interestingly, even though students in the virtual experience had a reduced amount of overall clinical time and less subspecialty exposure and only engaged with patients via video and telephone consultation with a preceptor, there was no difference in the magnitude of improved attitudes when compared to the in-person clerkship.

Taken together, the collection of papers in this issue offer valuable new information about assessment measures and student attitudes both in the USA and developing countries. As researchers continue to gather data from both the USA and abroad, psychiatrists can hopefully modify existing curricula and develop creative interventions to address deficiencies discovered. Although increased recruitment may be the main goal of these collective efforts, positively influencing medical students who choose to serve patients in non-psychiatric specialties and who share influence on how future health care resources are allocated is likely of equal importance.