Background

Psychotropic medications are widely prescribed by general practitioners in Europe as a whole, and the highest levels of prescription are seen in France [1, 2]. Increasing consumption among adolescents is a major public health problem [3], regardless of whether the medication is prescribed or obtained informally (from a family member, for example). Several epidemiological studies have reported increases in their prescription [4, 5]. The potential consequences of psychotropic drug use include morbidity, mortality, deleterious effects on quality of life, and the cost of remedial treatments [6, 7]. More specifically with regard to adolescent health, psychotropic medication carries a risk of undesirable side-effects, the development of dependency, and delayed initiation of adequate management of the underlying problem. Furthermore, relief of symptoms may result in the patient neglecting to follow appropriate health-related advice or failing to modify dangerous habits. Rapid progress in medicine has reinforced this trend, as have advertising and the greater availability of certain drugs – putting the younger generation at an increasing risk [8].

Providing GPs – and other relevant non-specialist health professionals – with training in psychiatry would be expected to reduce inappropriate administration. According to some authors [9, 10], medical students are more likely than members of the general public to be aware of the benefits of psychotropic treatment. One survey [11] found that the general population in Germany has more faith in psychotherapy than in pharmacological approaches, due to concerns about potential dependency. For them, psychotropic medications and drug abuse had comparable negative images. An investigation in the USA reported similar, but even less favorable, attitudes [12]. Other German surveys, and some conducted in Australia, indicate that the general public equate the use of psychotropic medication with having a weak personality[13, 14].

A survey carried out among 4545 adolescent patients reported that five different treatment components (individual psychotherapy with the patient, functional therapies, parent-and family-oriented interventions, other environmental interventions and psychotropic medication) were used in various combinations to treat a range of disorders in diverse settings [15]. It found that although psychotherapy has traditionally been the principal treatment for depression in adolescents, there has recently been an increase in the prescription of antidepressants to this age group. Approximately three quarters (79%) of treated adolescents received psychotherapy and more than half (60%) were prescribed psychotropic medications. Antidepressant medications appear to be used far more commonly than would be expected on the basis of published treatment recommendations [16]. A review of the literature concerning "juvenile maladaptive aggression" published in 2006 shows that "therapeutic nihilism" in the treatment of aggressive children and adolescents with conduct problems is no longer warranted. The best evidence for effectiveness is in multifocused psychosocial interventions given early in life to at-risk children and adolescents [17].

Observations of this kind prompted the present authors to consider factors that might influence attitudes towards counseling about the use of psychotropic drugs and their administration. University students completing courses in medicine or psychology were chosen in the light of the recommendation by numerous authors that a two-pronged approach (medication and psychotherapy) can be taken to manage psychosocial problems in adolescents [18].

Because of heavy workloads, improvements in this area are likely to focus on the quality of interactions between young people and health professionals, rather than on increasing the length of consultations. However, the first contact should be sufficiently long to establish a worthwhile relationship, and help close the gap between what we really know about mental health difficulties, and the messages that society gives. It may be that visits of that kind should be given priority status and funding.

Although the international literature contains no investigations about the relationship between prescription of psychotropic medication and professional personality traits, a link is plausible.

The objective here was to obtain answers to the following questions: what advice would students of medicine and psychology give adolescents concerning the use of psychotropic drugs in coping with difficult life events? Is there a statistically significant difference between the two groups? Is it possible to identify aspects of personality that discriminate between students with different attitudes towards advising adolescents with psychosocial problems about the use of psychotropic medication?

Methods

Subjects

Two groups of future healthcare professionals studying at French universities were recruited for this cross-sectional survey. Participants ranged in age from 19 to 30 years. The first group comprised 41 fourth-year medical students (MS) who had completed their psychiatry course; their average age was 22.6 years (SD = 2.3), and 61% were female. The second group were 76 third-year psychology students (PS) of whom 89% were female; the average age was 22.7 years (SD = 1.8) (t = 0.39; p = 0.69).

Data collection

Respondents completed a two-part self-administered instrument at the end of a lecture given at each university. Participation was voluntary and unpaid.

The first part of the questionnaire was designed to elicit the attitudes of respondents to the administration of psychotropic drugs to adolescents. It comprised 20 case studies of young people (10 males and 10 females) going through difficult life events. The situations described were reported by general practitioners and psychiatrists [19]. Each case study was accompanied by the following question: 'In your opinion, does this adolescent need psychotropic drugs?'. The possible answers were "Yes" and "No". The second part of the instrument measured facets of personality using a selection of the 240 assertions in the Costa & McCrae revised NEO Personality Inventory (NEO PI-R) [20]. A panel comprising the steering group plus a sociologist and three psychologists selected 112 assertions exploring the fields of: neuroticism (anxiety, hostility, depression, self-consciousness, impulsiveness, vulnerability to stress), extraversion (warmth), agreeableness (trust, altruism), conscientiousness (competence, dutifulness, deliberation) and openness to experience (feelings, openness), all of which were considered to have a potential effect on attitudes towards advice on taking psychotropic drugs.

Subjects responded to each of the 112 assertions by circling a letter that best described their opinion (in French), as follows: FD (strongly disagree), D (disagree), N (neutral), A (agree), FA (strongly agree).

Statistical analysis

The chi2 test was used to compare the proportions of each group (MS and PS) with favourable attitudes towards the prescription of psychotropic drugs. Two linear regressions were carried out (type III Anova tests). We have used the computer program SPSS. An 'advising medication score' was calculated for each student by multiplying the number of positive responses to the case studies question (n = 20) by 5, to give a percentage. This was adopted as the dependent variable. The sex of respondents was considered.

Results

As Table 1 shows, the difference between the two student groups was significant in seven of the 20 cases (35%), but did not reach significance in the majority (65%). No statistically significant difference was observed between female and male students in their responses to the case studies. Men would prescribe psychotropic drugs in 36% of the cases, and women in 30.6 % (x2 = 1.33; df = 1; p = 0.25).

Table 1 Frequency of students advising psychotropic medication
Full size table

Overall, mean case-study scores were statistically significantly higher (x2 = 4.46; df = 1; p = 0.035) among MS (40, 5%) than in the group studying psychology (27, 3%). In other words, MS would prescribe psychotropic drugs in 40% of cases, compared with 27% among PS.

MS were more likely than PS to favour psychotropic medications when the case described behaviour that might put the adolescent's life at risk. In two cases, more than 80% of MS, but 40–50% of PS would prescribe psychotropic drugs (2: Patrick; 17: Valérie, both of whom exhibit behaviour putting them at risk, and impulsivity). Mental disorders (tantrums and destabilising overexcitement) are present in these cases.

MS would recommend psychotropic medication significantly more often than would PS. Significant differences between the two groups were marked in five cases: (3: Nadia who presents with depressive affect's 10: Mathieu, who is afraid of panic attacks, 12: Frédéric, who is tired and has sleep disorder, 15: Christelle, who claims to no longer have a goal in life, and 16: Kevin, who suffers from anxiety). They have in common a lack of aims in life, and feelings of oppression.

In just one case more than 73% of both groups would prescribe psychotropic drugs (14: Michel, whose brother died 5 months previously and who showed behavior disorders).

In six other cases, 20–40% of both groups favored psychotropic drugs (6: Emmanuel; 7: Claudine; 8: Azzedine; 9: Francesca; 19: Laetitia; 20: Jérôme). They were all distressed, irritable, and felt rejected by others.

In six cases, fewer than 20% of the MS and PS would prescribe (or recommend) psychotropic drugs (1: Julie; 4: Philippe; 5: Claire; 11: Natacha; 13: Elodie; 18: Franck). The common elements are disinterest, tiredness and, particularly, loss of self-confidence.

Table 2. By retaining the most significant variables, we obtain two separate linear models for the MS and the PS. Parameter estimates are shown in table 2. The models explain 23% (MS) and 21% (PS) of the variance in the proportions advising medication. The predicted means of the percentages advising medication (0.40 [0.37; 0.44], 0.27 [0.24; 0.31], respectively) are essentially identical to the crude percentages, showing that the MS are more likely to advise medication.

Table 2 Regression analyses to explain psychotropic drug prescription according to aspects of personality among medical students and psychology students.
Full size table

Table 2 shows that MS who favour prescribing psychotropic medication differ in personality profile from the psychology students. MS who have a tendency to experience anger and related states such as frustration and bitterness, and do not consider fulfilling moral obligations as important are more likely to prescribe psychotropic drugs.

PS likely to favour medication tend to be susceptible to stress, and to panic when they are in problematic situations. However, they are not shy or socially anxious, not disturbed by embarrassing social circumstances, often speak and act without considering the consequences and lack distance in their decisions.

Discussion

The major findings in this study are: first that, overall (considering all the cases) the majority of – respondents (PS+MS) do not tend to prescribe psychotropic medication; second, certain personality traits relate to willingness to prescribe/recommend psychotropic medication.

In all cases, the MS who had been taught psychiatry tended to have more favorable attitudes towards psychotropic medications than did PS (who would never have the opportunity to prescribe them). It is plausible that PS, are less likely to favor medication because they have learned that psychotherapy is a good way to deal with some problems. This assumption is in accord with the results of German studies [10, 11].

The most important differences between the answers of the MS and PS relate to cases where symptoms described include "tantrums", "mood of exultation", and "oppression". These words come from the vocabulary of mental disorders and may be familiar to MS from their training in psychiatry. However, some German investigators [10] administered questionnaires to different groups of students at different stages of their medical education. Among those just starting, attitudes towards pharmacotherapy in this context were broadly comparable with those seen in a general population. However, the similarity diminished as training progressed. It appeared that the more knowledge students acquired about psychiatry and pharmacology, the more favourable their attitudes became towards psychotropic drugs and other treatments (psychotherapy, etc.).

Although the difference was particularly pronounced in cases involving male adolescents, the available data do not allow the gender influence of the person described to be differentiated from that of other factors. One way to learn more about this, and to determine the content validity of the case reports, would be to repeat the survey having changed the forenames from male to female and vice versa.

Importantly, in only one case (Michel whose brother died 5 months previously) did the majority of both groups favour prescription. They considered Michel to be going through a period of mourning that was exhausting him and putting him at risk of suicide.

This study demonstrates that certain aspects of personality influence the advice a person gives concerning psychotropic medication. The findings here refer only to students, but they raise the question of whether personality traits have a similar influence on attitudes among practicing health professionals.

Interpretation of the NEO PI-R personality inventory data [20] indicates that those MS who have a tendency to feel anger, frustration and bitterness, and who show no misgivings in fulfilling moral duties would be more likely to prescribe psychotropic medication. Would that not be a quick and effective way to respond to a person in need?

PS who had difficulty facing up to stress, but were not shy, who were not unfriendly but showed interest in the well-being of others and had difficulty with social contact and tended not to think before acting would prescribe more psychotropic drugs. Someone quite vulnerable to stress himself and wanting to help others, might, without feeling an ounce of human warmth towards his peers, see prescribing psychotropic drugs as the most appropriate solution.

Limitations to be borne in mind include the difference in the numbers of PS and MS who volunteered. PS controls may have had a special interest in psychotherapeutic approaches given that they would never have the opportunity to prescribe; however, they would act as advisers and healthcare providers. Only students present on campus on the day of the investigation and who volunteered to participate were enrolled; they may not be representative of all the students registered in the respective faculties. The lack of reference to the type of medication (anti-depressants, anxiolytics, etc.) was intentional. With hindsight, data concerning respondents' own history of adverse life events and their management would have been of interest. But for ethical and confidentiality reasons, the researchers did not want the professors who authorized the study (see acknowledgements) to be able to identify responses from students in their classes.

Health promotion is not simply a matter of educating those young people who take psychotropic drugs – health professionals must also question the criteria that inform their decisions. It is as important to investigate the attitudes of the future health professionals (advisers or prescribers) as it is to focus on consumer-related issues.