PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of amjpharmedLink to Publisher's site
 
Am J Pharm Educ. 2010 June 15; 74(5): 89.
PMCID: PMC2907854

Nepalese Pharmacy Students' Perceptions Regarding Mental Disorders and Pharmacy Education

Suresh Panthee, MPharm,a,b Bimala Panthee, BN,c Sabin Raj Shakya, BPharm,d Nirmal Panthee, MBBS,e Dhaka Ram Bhandari, BPharm,d and J Simon Bell, PhDcorresponding authorf,g,h

Abstract

Objective

To determine Nepalese pharmacy students' perceptions of whether mental disorders impact performance in pharmacy school.

Method

All first- and third-year undergraduate pharmacy students (n=226) in Nepal were invited to complete a modified version of the Mental Illness Performance Scale.

Results

Among the 200 respondents (response rate 88.5%), 14% reported that they had a mental disorder. The majority (92%) of third-year students agreed or strongly agreed that depression would interfere with a student's academic performance. Almost half of first-year students agreed or strongly agreed that alcohol or drug abuse would be grounds for both rejecting an applicant from pharmacy school (49%) and dismissal of a student from pharmacy school (46%).

Conclusions

Students perceived a high level of academic impairment associated with mental disorders, but the majority did not perceive that mental disorders were grounds for dismissal from or rejection of entry to pharmacy school. Students' attitudes may discourage them from seeking help or providing mental health support to others.

Keywords: attitude of health personnel, mental disorders, pharmacy students, mental health

INTRODUCTION

Psychological morbidity and burn-out has been reported among pharmacy,1,2 medical,3-6 and dental students.7 Between 23% and 39% of medical students exhibit depressive symptoms.8,9 Healthcare professionals and students enrolled in health schools frequently use and abuse illicit and prescription drugs.7,10,11 Eighty-eight percent of pharmacists in the United States who admit abusing potentially addictive prescription drugs began this practice during their time in college.12

As part of their training, pharmacy students are usually taught to recognize the signs and symptoms of physical health problems but not those of mental health problems. Seventy-five percent of colleges and schools of pharmacy in the United States employ a psychiatric pharmacist.13 In comparison, just 37% of European universities employ or contract a mental health pharmacist, and only 31% include course content about sufferers' experiences with depression, schizophrenia, and substance abuse.14 Ignorance about mental health problems may lead pharmacy students to develop stigmatizing attitudes15-17 and this may discourage them from seeking help for themselves or providing support for their peers18 and later, professional colleagues with mental health problems. Lack of adequate training has been described as the main barrier to the provision of pharmaceutical services to people with depression.19 The need to provide appropriate training may be particularly important as pharmacists develop and provide new patient care services for people with mental disorders.20,21

The attitudes of pharmacists and pharmacy students towards people with mental disorders have been investigated,15-17,22-24 but no studies have assessed how pharmacy students perceive how their own mental disorders interfere with academic performance, or whether mental disorders should be grounds for reject admission to or dismissal from pharmacy schools. This knowledge is important to better understand the help-seeking behavior and mental health needs of pharmacy students. Understanding how pharmacy students perceive mental disorders is also important to inform the possible need for curriculum reform. The objective of this study was to investigate how Nepalese pharmacy students' perceive that mental disorders impact students' performance in pharmacy education. The specific objectives were to determine how students perceive the impact of mental disorders on students' academic performance, and whether having a mental disorder should be grounds for rejecting an applicant to pharmacy school or dismissing a student from pharmacy school.

METHODS

A cross-sectional census survey of all first- and third-year undergraduate pharmacy students in Nepal was conducted from April 2008 through February 2009. All 4 universities that provide pharmacy education in Nepal participated in the study: Tribhuvan University, Kathmandu University, Pokhara University, and Purbanchal University. Pharmacy education in Nepal consists of a 4-year bachelor of pharmacy (BPharm) degree followed by a 2-year master of pharmacy (MPharm) degree. At the master's degree level, students can choose to specialize in industrial pharmacy or pharmaceutical care. Though no university curriculum has special focus on mental disorders, students are given a brief overview of depression, mania, psychosis, drug abuse, and dependence during their undergraduate studies. The majority of pharmacy graduates in Nepal work in the pharmaceutical industry (48%), academia (11%), and community and hospital pharmacies (8%).25

Data were collected using a modified version of the Mental Illness Performance Scale (MIPS),26 which comprises a list of 17 mental disorders. Respondents were asked to indicate their level of agreement about whether each disorder would (1) interfere with academic performance, (2) be grounds for dismissal from pharmacy school, and (3) be grounds for rejecting a pharmacy school applicant. All responses were rated using a 5-point Likert scale ranging from 1 = strongly agree to 5 = strongly disagree. The survey instrument also included additional items related to respondents' age, gender, university, personal experience of mental disorders, family experience of mental disorders, and previous visits to a mental health institution. The survey instrument was pilot tested for face-validity by a group of 5 second-year pharmacy students from Tribhuvan University with similar backgrounds to the sample population. The 5 students checked the survey instrument for any items that might be considered ambiguous or lead to inaccurate responses. Based on the comments they provided, minor changes were made to the layout and wording of the survey instrument.

All potential respondents were provided with a participant information sheet about the study. Students were asked to voluntarily and anonymously complete the survey instrument in a lecture or tutorial held at their respective university. The study was approved by the Ethical Review Board of Nobel College, Pokhara University, Kathmandu, Nepal.

All data were analyzed using the Statistical Package for the Social Sciences (SPSS, Version 15.0, Chicago, IL). The numbers of students who agreed or strongly agreed with each of the survey items were tabulated. Cases with missing data were excluded from the statistical analyses (there was a maximum of 3 missing responses for each item of the survey). Students who reported personal experience of a mental disorder, family experience of a mental disorder, and/or a previous visit to a mental health institution were considered to be familiar with mental disorders. Independent samples t tests were used to compare the mean Likert-scale ratings on each of the items for students who were familiar and unfamiliar with mental disorders.

RESULTS

Completed survey instruments were received from 200 of 226 pharmacy students (88.5% response rate). This included 117 first-year students and 83 third-year students. The mean age of first-year students who responded was 19.6 ± 1.2 years (range 18-24 years) compared to 21.7 ± 2.0 years (range 19-35 years) for third-year students. Eighty-one (69.2%) of the first-year students were male compared to 46 (55.4%) of the third-year students. Twenty-eight respondents (14.0%) reported that they had a mental disorder, 31 students (15.5%) reported that they had family experience with a mental disorder, and 36 students (18.0%) reported that they had visited a mental health institution.

Overall 173 students (86.5%) agreed or strongly agreed that depression would likely interfere with academic performance, whereas 152 students (76.8%) agreed or strongly agreed that schizophrenia would impact academic performance. Tobacco use was the disorder least frequently rated as impacting academic performance. There was no overall relationship between students' year of study and the extent to which they perceived various mental disorders would impact students' academic performance (Table (Table1).1). Third-year students perceived a higher impact for 9 of the 17 disorders and first year students a higher impact for 8 of the 17 disorders.

Table 1
Percentage of Students Who Agreed or Strongly Agreed That a Mental Disorder Would Interfere With a Student's Academic Performance

There were 9 students (4.5%) who agreed or strongly agreed that depression should be grounds for dismissal from pharmacy school, and 71 students (36.0%) who agreed or strongly agreed schizophrenia should be grounds for dismissal from pharmacy school. Third-year students were less likely to agree that mental disorders were grounds for dismissal from pharmacy school for 13 of the 17 disorders listed (Table (Table2).2). However, third-year students were more likely to perceive depression as grounds for dismissal from pharmacy school than first-year students (8.4% versus 1.7%).

Table 2
Percentage of Students Who Agreed or Strongly Agreed That a Mental Disorder Would Be Grounds for Dismissal from Pharmacy School

Twenty-five students (12.6%) agreed or strongly agreed that depression should be grounds for rejecting a pharmacy school applicant, and 72 students (36.5%) agreed or strongly agreed that schizophrenia should be grounds for rejecting a pharmacy school applicant. Third-year students were less likely to agree that having a mental disorder was grounds for rejecting a pharmacy school applicant for 14 of the 17 disorders (Table (Table33).

Table 3
Percentage of Students Who Agreed or Strongly Agreed That a Mental Disorder Would Be Grounds for Rejecting a Pharmacy School Applicant

Seventy-four (37.8%) students were considered to be familiar with mental disorders. There was no significant relationship between students' familiarity with mental disorders and their attitudes towards a student's performance in (p = 0.65) or rejection from (p = 0.07) pharmacy school. However, those students who were familiar with mental disorders were more likely to agree or strongly agree that mental disorders are grounds for dismissal from pharmacy school (p = 0.01).

DISCUSSION

To our knowledge this was the first study to investigate students' perception of mental disorders in relation to academic performance and acceptance to and dismissal from pharmacy school. Both first- and third-year students perceived a high level of academic impairment associated with mental disorders. However, the majority of students did not perceive that mental disorders were grounds for rejection of entry to or dismissal from pharmacy school.

Third-year students were less likely to agree or strongly agree that 13 out of the 17 disorders were grounds for dismissal and that 14 out of the 17 disorders were grounds for rejection than their first-year peers. The pharmacy curriculum in the second and third years may have provided third-year students with greater information about mental disorders, or third-year students' slight age difference may have resulted in more work and life experiences in which they encountered people with mental disorders. Previous studies have found that people with greater familiarity with mental disorders have less-stigmatizing attitudes.27,28 In a previous study, mental health professionals had more positive attitudes towards medical students with mental disorders than health professionals not specialized in mental health.26 Paradoxically, in our study, students with personal or family experience of a mental disorder and those who had visited a mental health institution were more likely to agree or strongly agree that mental disorders were grounds for dismissal from pharmacy school. Attitudes of health professionals may be biased by greater contact with patients with chronic or recurrent disorders.29 Another explanation is that experience with a mental disorder may have led to a better understanding of how mental disorders affect thought and behavior, making these students more cautious about allowing individuals with mental disorders to pursue a pharmacy career.30

While the majority of students exhibited favorable attitudes towards mental disorders, lack of awareness and suboptimal attitudes were common. More than 35% of students perceived that schizophrenia should be grounds for dismissal and rejection from pharmacy school, and greater than 10% perceived that depression should be grounds for rejection. This was consistent with findings of pharmacy student attitudinal surveys conducted in Australia, Belgium, Estonia, Finland, India and Latvia.15 A range of strategies have been used to improve students' attitudes towards people with mental disorders.31 Utilizing trained consumer educators with personal experience with mental disorders to provide university-based instruction has been successful in pharmacy schools in Australia and the United States, resulting in students having improved attitudes and greater confidence to provide patient care services.32,33

Alcohol, drug abuse, or occasional illegal drug use was not seen by a majority of students as grounds for dismissal from pharmacy school, or for a pharmacy school application to be rejected. Criminal acts and being under the influence of drugs or alcohol while undertaking a patient care activity are often considered grounds for dismissal from pharmacy education. Four United Kingdom schools of pharmacy have fitness to practice procedures specific to pharmacy and health care.34 US colleges and schools of pharmacy often have an academic integrity code and drug-related offenses may lead to suspension or dismissal from the university. However, the American Association of Colleges of Pharmacy recommends that students who are not legally restricted and are no longer chemically impaired be given the opportunity to continue their pharmacy education without stigma or penalty.35

The belief that mental disorders should be grounds for dismissal from or rejection of entry to pharmacy education may discourage students from seeking or providing mental health support.18 Recent attention has focused on educating members of the public and allied healthcare professionals about how to support someone developing a mental disorder.36,37 Referred to as mental health first aid, this training has been recommended for people who have increased contact with people experiencing mental disorders. Mental health first aid is now being taught as part of continuing professional development programs for pharmacists in Australia.38 Given that many respondents demonstrated a lack of awareness about mental disorders, mental health first aid training may be valuable to include in degree programs for pharmacy students in Nepal and elsewhere.

Like their international colleagues, pharmacists in Nepal also are adopting new patient care roles in clinics and mental health wards of hospitals. Patient care services provided by pharmacists also constitute an essential part of the health care team in community settings.39 This is particularly the case in developing countries, including Nepal, where access to physicians is limited and prohibitively expensive for many people.40 Curriculum reform may be required to support these new pharmaceutical care roles performed by pharmacists. The results of our study highlight areas where the pharmacy curriculum in Nepal may need to be reformed and expanded; however, further research is needed to determine whether greater coverage of the pharmacotherapy of mental disorders would translate into improved understanding of mental disorders among pharmacy students.

There are a number of methodological strengths and limitations of our study. An important strength was that we conducted a national census survey of all first- and third-year pharmacy students in Nepal. In light of the high response rate, our results may be reasonably generalized to the pharmacy student population in Nepal. However, further research is needed to determine how Nepalese students' perceptions compare to those of students in other countries. Suboptimal attitudes are common among pharmacy students in different countries; however, the determinants of stigma among pharmacy students may be different in each country.15,41 Future research also should investigate the extent to which specific mental disorders impact performance in pharmacy school.

CONCLUSION

Pharmacy students in Nepal perceived a high level of academic impairment associated with mental disorders. Although the majority of students did not perceive mental disorders were grounds for dismissal from or rejection of entry to pharmacy school, suboptimal attitudes toward mental disorders and lack of awareness was common, which may discourage students from seeking or providing mental health support.

ACKNOWLEDGMENTS

The authors thank Professor Martin M Antony, Department of Psychology, Ryerson University, Canada, for supplying a copy of the Mental Illness Performance Scale that was modified for use in this study.

REFERENCES

1. Ried LD, Motycka C, Mobley C, Meldrum M. Comparing self-reported burnout of pharmacy students on the founding campus with those at distance campuses. Am J Pharm Educ. 2006;70(5) Article 114. [PMC free article] [PubMed]
2. Marshall LL, Allison A, Nykamp D, Lanke S. Perceived stress and quality of life among doctor of pharmacy students. Am J Pharm Educ. 2008;72(6) Article 136. [PMC free article] [PubMed]
3. Sreeramareddy CT, Shankar PR, Binu VS, Mukhopadhyay C, Ray B, Menezes RG. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Med Educ. 2007;7 Article 26. [PMC free article] [PubMed]
4. Moffat KJ, McConnachie A, Ross S, Morrison JM. First year medical student stress and coping in a problem-based learning medical curriculum. Med Educ. 2004;38(5):482–491. [PubMed]
5. Chandler RA, Wang PW, Ketter TA, Goodwin GM. A new US-UK diagnostic project: mood elevation and depression in first-year undergraduates at Oxford and Stanford universities. Acta Psychiatr Scand. 2008;118(1):81–85. [PubMed]
6. Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005;165(22):2595–2600. [PubMed]
7. Lennon MA. Drink, drugs and depression in dental students. Br Dent J. 2002;192(11):636.
8. Mikolajczyk RT, Maxwell AE, Naydenova V, Meier S, El Ansari W. Depressive symptoms and perceived burdens related to being a student: Survey in three European countries. Clin Pract Epidemiol Ment Health. 2008;4 Article 19. [PMC free article] [PubMed]
9. Baldassin S, Alves TC, de Andrade AG, Nogueira Martins LA. The characteristics of depressive symptoms in medical students during medical education and training: a cross-sectional study. BMC Med Educ. 2008;8 Article 60. [PMC free article] [PubMed]
10. Kenna GA, Wood MD. Prevalence of substance use by pharmacists and other health professionals. J Am Pharm Assoc. 2004;44(6):684–693. [PubMed]
11. Kenna GA, Wood MD. Substance use by pharmacy and nursing practitioners and students in a northeastern state. Am J Health-Syst Pharm. 2004;61(6):921–930. [PubMed]
12. Dabney DA. Onset of illegal use of mind-altering or potentially addictive prescription drugs among pharmacists. J Am Pharm Assoc (Wash). 2001;41(3):392–400. [PubMed]
13. Cates ME, Monk-Tutor MR, Drummond SO. Mental health and psychiatric pharmacy instruction in US colleges and schools of pharmacy. Am J Pharm Educ. 2007;71(1):4. [PMC free article] [PubMed]
14. Koski I, Heikkila A, Bell JS. Mental health pharmacy education at 16 European universities. Am J Pharm Educ. 2009;73(8):139. [PMC free article] [PubMed]
15. Bell JS, Aaltonen SE, Bronstein E, et al. Attitudes of pharmacy students toward people with mental disorders, a six country study. Pharm World Sci. 2008;30(5):595–599. [PubMed]
16. Bell JS, Johns R, Chen TF. Pharmacy students' and graduates' attitudes towards people with schizophrenia and severe depression. Am J Pharm Educ. 2006;70(4) Article 77. [PMC free article] [PubMed]
17. Volmer D, Mäesalu M, Bell JS. Pharmacy students' attitudes toward and professional interactions with people with mental disorders. Int J Soc Psychiatry. 2008;54(5):402–413. [PubMed]
18. Rickwood DJ, Deane FP, Wilson CJ. When and how do young people seek professional help for mental health problems? Med J Aust. 2007;187(Suppl 7):S35–S39. [PubMed]
19. Scheerder G, De Coster I, Van Audenhove C. Pharmacists' role in depression care: a survey of attitudes, current practices, and barriers. Psychiatr Serv. 2008;59(10):1155–1160. [PubMed]
20. Bell JS, Rosen A, Aslani P, Whitehead P, Chen TF. Developing the role of pharmacists as members of community mental health teams: perspectives of pharmacists and mental health professionals. Res Soc Adm Pharm. 2007;3(4):392–409. [PubMed]
21. Bell S, McLachlan AJ, Aslani P, Whitehead P, Chen TF. Community pharmacy services to optimise the use of medications for mental illness: a systematic review. Aust New Zealand Health Policy. 2005;2:29. [PMC free article] [PubMed]
22. Jermain DM, Crismon ML. Students' attitudes toward the mentally ill before and after clinical rotations. Am J Pharm Educ. 1991;55(1):45–48.
23. Scheerder G, De Coster I, Van Audenhove C. Community pharmacists' attitude toward depression: a pilot study. Res Soc Adm Pharm. 2009;5(3):242–252. [PubMed]
24. Phokeo V, Sproule B, Raman-Wilms L. Community pharmacists' attitudes toward and professional interactions with users of psychiatric medication. Psychiatr Serv. 2004;55(12):1434–1436. [PubMed]
25. Nepal Pharmacy Council. Pharmacy Human Resource Status in Nepal. http://www.nepalpharmacycouncil.org.np/downloads/Newsletter_V2_2007.pdf. Accessed May 11, 2010.
26. Roth D, Antony M, Kerr K, Downie F. Attitudes toward mental illness in medical students: does personal and professional experience with mental illness make a difference? Med Educ. 2000;34(3):234–236. [PubMed]
27. Couture SM, Penn DL. Interpersonal contact and the stigma of mental illness: a review of the literature. J Ment Health. 2003;12(3):291–305.
28. Corrigan PW, Green A, Lundin RK, Kubiak MA, Penn DL. Familiarity with and social distance from people who have serious mental illness. Psychiatr Serv. 2001;52(7):953–958. [PubMed]
29. Jorm AF, Korten AE, Jacomb PA, Christensen H, Henderson S. Attitudes towards people with a mental disorder: a survey of the Australian public and health professionals. Aust N Z J Psychiatry. 1999;33(1):77–83. [PubMed]
30. Green B. Attitudes towards mental illness in medical students. Med Educ. 2000;34(3):166–167. [PubMed]
31. Jorm AF, Oh E. Desire for social distance from people with mental disorders. Aust N Z J Psychiatry. 2009;43(3):183–200. [PubMed]
32. Bell JS, Johns R, Rose G, Chen TF. A comparative study of consumer participation in mental health pharmacy education. Ann Pharmacother. 2006;40(10):1759–1765. [PubMed]
33. Buhler AV, Karimi RM. Peer-level patient presenters decrease pharmacy students' social distance from patients with schizophrenia and clinical depression. Am J Pharm Educ. 2008;72(5) Article 106. [PMC free article] [PubMed]
34. Schafheutle EI, Silverthorne J, Hall J, Tully MP, Noyce PR, David TJ. Fitness to practise procedures for pharmacy students in UK universities: a literature review. School of Pharmacy and Pharmaceutical Sciences. University of Manchester. http://www.rpsgb.org/pdfs/studftpsoplitrev.pdf. Accessed May 11, 2010.
35. American Association of Colleges of Pharmacy. American Association of Colleges of Pharmacy Guidelines for the Development of Psychoactive Substance Use Disorder Policies for Colleges of Pharmacy. http://www.ajpe.org/legacy/pdfs/aj6304S11.pdf. Accessed May 11, 2010.
36. Jorm AF, Morgan AJ, Wright A. First aid strategies that are helpful to young people developing a mental disorder: beliefs of health professionals compared to young people and parents. BMC Psychiatry. 2008;8 Article 42. [PMC free article] [PubMed]
37. Langlands RL, Jorm AF, Kelly CM, Kitchener BA. First aid for depression: a Delphi consensus study with consumers, carers and clinicians. J Affect Disord. 2008;105(1–3):157–165. [PubMed]
38. Pharmaceutical Society of Australia. Mental Health First Aid Training. http://www.psa.org.au/site.php?id=5840. Accessed May 28, 2010.
39. Puspitasari HP, Aslani P, Krass I. A review of counseling practice on prescription medicines in community pharmacies. Res Soc Adm Pharm. 2009;5(3):197–210. [PubMed]
40. Smith F. The quality of private pharmacy services in low and middle-income countries: a systematic review. Pharm World Sci. 2009;31(3):351–361. [PubMed]
41. Bell JS, Aaltonen SE, Airaksinen MS, et al. Determinants of mental health stigma among pharmacy students in Australia, Belgium, Estonia, India, Finland and Latvia. Int J Soc Psychiatry. 2010;56(1):3–14. [PubMed]

Articles from American Journal of Pharmaceutical Education are provided here courtesy of American Association of Colleges of Pharmacy