Mind-Body dualism and medical student attitudes toward mental illness in Saudi Arabia

Abstract

Background

Philosophical beliefs regarding the origin of mental illness may underlie resistance to psychiatric treatment and affect attitudes toward the mentally ill.

Aim

The present study sought to: (1) identify characteristics of medical students who hold mind-brain dualism (MBD) beliefs and (2) determine relationships between MBD beliefs and perceptions of mental illnesses.

Methods

This was a cross-sectional study that asked medical students questions about mind-brain beliefs and religiosity. Three fictitious vignettes (schizophrenia, antisocial personality disorder [APD], and depression) were presented and then students asked about how much participants felt the patients in these scenarios bore responsibility for their illness. A MBD score was calculated to measure MBD beliefs, and a total responsibility score (RS) was used to measure patient blameworthiness. Mediation analysis was used to examine whether MBD beliefs explained the relationship between religiosity and perceived patient responsibility for their illness, and whether this was moderated by gender.

Results

The questionnaire was completed by 106 Saudi medical students. The average RS was highest for the APD scenario and lowest for schizophrenia, whereas depression fell intermediate between those two (ANOVA F (1.82, 219.83) = 27.21, P < .001). Religiosity was positively correlated with RS, a relationship that was mediated by MBD in all three vignettes.

Conclusion

Mind-brain dualism beliefs among medical students in Saudi Arabia were associated with greater perceptions of self-infliction, preventability, controllability, and blameworthiness for patients with mental illness, moderated by gender. Greater emphasis on the neurobiological aspects of psychiatric disorders might help to change this attitude.

Keywords

mind-brain dualism religiosity medical student training psychiatric disorder patient responsibility

Introduction

The biopsychosocial model of mental illness is the predominant paradigm through which mental illnesses are viewed in modern mental health care. This integrated model emphasizes the role of neurobiological causation for mental disorders without neglecting the roles of psychological, social, and environmental factors.^1,2 This view of mental disorders embraces mind-brain monism, the philosophical stance that all mental phenomena are ultimately brain-based. The opposite philosophical stance is mind-brain dualism (MBD). As articulated by Rene Descartes,³ Mind-body dualism claims that mental phenomena are separate and independent of physical ones.³ This view is largely incompatible with modern neuroscience in an era where great advancements in neuroimaging and other techniques has bolstered a cerebro-centric approach to explaining mental disease.

Mind-body dualism beliefs are also potentially harmful in the clinical context as previous research has shown that such beliefs are associated with undue blame and stigmatization of patients with mental illness.⁴ Nevertheless, some mental health professionals and trainees continue to use MBD as a framework for understanding mental illnesses, which may lead them to conceptualize some disorders as “more biological” than others.^4,5 Practitioners’ clinical decision-making may be affected by non-biological beliefs about mental disorders.⁶ This can be stigmatizing to patients and lead to non-adherence, prevention of access to treatment, or interfere with the therapeutic relationship due to decreased empathy by clinicians.

It is not yet completely understood why MBD beliefs seem to persist among mental healthcare professionals and trainees in certain areas of the world. Cultural beliefs related to mental illnesses are prevalent and likely play a role in such beliefs, as the beliefs of practitioners tend to parallel those among lay persons in the culture.^7-9 Ethnicity, religion, and sociodemographic variables may also influence how mental illnesses are perceived and treated.⁶ This influence may be affected by the manner in which a given ethnic or religious group deals with the mind-brain problem.^8,10 This is particularly true in the context of non-Western cultures where the topic has received only limited attention.¹⁰

Saudi Arabia (94% Muslim) is a deeply religious country with 93% of the populace indicating that religion is important in their lives.¹¹ As the birthplace of Islam, millions of faithful followers come to this country during the Hajj, the pilgrimage to Mecca that takes place during the last month of the Islamic calendar (Dhul-Hijjah) 2 months and 10 days after the Ramadan fast ends. Religious beliefs and long-standing cultural traditions affect virtually every aspect of life in this country, including beliefs about and attitudes toward psychiatric illnesses. Consequently, these conditions are often thought to have religious explanations, being due either to possession by supernatural entities called Jinn, or alternatively, to wrong beliefs, attitudes, or bad behavior. Thus, psychiatric conditions are considered to be quite distinct from physical illnesses with biological causes, e.g., inherited, that are not under the individual’s control.¹¹

The present study sought to determine the frequency and correlates of MBD among Saudi medical students, and explore whether MBD beliefs are associated with the belief that patients with mental illness are responsible and blameworthy for their illnesses. Specifically, we sought to examine how MBD beliefs and religiosity might shape attitudes toward 3 fictitious vignettes of patients with mental illness (depression, schizophrenia, and antisocial personality disorder (APD)). The hypothesis is that there will be a difference in attitudes and perceptions towards mental illness based on the degree of MBD beliefs, with this being at least partially explained by religious and cultural factors and moderated by gender.

Methods

A convenience sample of medical students recruited for this observational study. Sample selection criteria were (1) students in their fifth or sixth years of a 6-years bachelor’s degree program in medicine at King Abdulaziz University; (2) completion of their psychiatry training consisting of a 3-week clinical rotation during the fifth year; and (3) agreement to complete the study questionnaire. A link to the study questionnaire was distributed through class email lists and social media platforms with the intent of reaching as many as possible out of the 800 students in the 2 psychiatry clinical rotations. They were asked to complete the questionnaire unassisted at a time convenient to them, and privacy was assured using a secure survey platform. The purpose of the study was explained on the online platform, including that completion of the survey was voluntary and indicative of informed consent. A total of 106 medical students of the 800 students agreed to participate in the study and completed the study questionnaire.

Of the 106 medical students who completed the study, mean age of participants was 23.8 ± 1.9 years. All students were Muslim and of Arab ethnicity. Table 1 describes the sample demographics. Slightly over half of participants were female (53.8%). Two-thirds of participants did not have a family history of psychiatric illness (67%). Most were in their sixth year of medical school (60.4%) and had completed their psychiatry rotation within 12 months of completing the study questionnaire.

Table 1.

Demographic Characteristics of the Sample.

	Overall (n = 106)
Gender
Male	49 (46.2%)
Female	57 (53.8%)
School type
General	73 (68.9%)
Private	33 (31.1%)
Family history of psychiatric disorder
No	71 (67.0%)
Yes	35 (33.0%)
Medical school year
5	42 (39.6%)
6	64 (60.4%)
Time since psychiatry
less than 3 months	39 (36.8%)
less than 6 months	13 (12.3%)
less than 12 months	18 (17.0%)
more than 12 months	36 (34.0%)

Case Vignettes

Three brief fictious but realistic case vignettes were described, with the first involving a 30-years-old female with major depression, neurovegetative symptoms, and suicidal ideation in the setting of multiple life stressors. The second vignette described a 25-years-old male who was diagnosed with schizophrenia after presenting with auditory hallucinations of evil spirits commanding him to become pious and punish others. He also had delusions that a sorcerer could read his mind and control his actions. The third case described a 35-year-old male with a childhood history of oppositional-defiant disorder who presented in adulthood with callousness towards others, opportunistic behavior, significant marital problems, and sexual harassment of a colleague at work, behaviors often found in those with anti-social personality disorder.

The disorders portrayed in the case vignettes were common ones that varied with regards to how “strongly biological” they might be perceived, with schizophrenia expected to be the most biological, antisocial personality to be the least biological, and depression in between.^4,5

Measures

Patient Responsibility (Primary Dependent Variable)

After each vignette, participants were asked 4 questions about their perception of the patient’s responsibility for their illness, following the framework described by Weiner.¹² Participants were asked to rate on a Likert scale from 1 to 5 how much they thought the patients’ disorders were self-inflicted, within their control, could be prevented by patients’ efforts, and extent to which they were culpable for having the disorder. The total responsibility scale score (RS) was considered to be an indication of patient blameworthiness. The RS was calculated for each case vignette by adding the scores for each question and dividing by the number of items (4), producing a score ranging from 1 to 5. The Cronbach’s alpha for the RS in each of the 3 vignettes range from .83 to .90 (see Table 2).

Table 2.

Means, Standard Deviations (SD), and Distributions of Participant Responsibility, Dualism, and Religiosity Scores.

Variable	No. of Items	M	SD	Skewness	Kurtosis	Cronbach'sAlpha
RS - depression	4	2.92	1.05	.09	−.75	.831
RS - schizophrenia	4	2.58	1.12	.35	−.68	.853
RS - ASPD	4	3.29	1.1	−0.4	−.74	.901
DS	4	3.08	.87	.05	−.14	.687
BRS	10	4.13	1.4	.35	−.41	.764

Maximum possible scores noted are divided by number of items.

RS = responsibility score; ASPD = antisocial personality disorder; DS = mind-body dualism score; BRS = BIAC religiosity score.

Mind-Body Dualism

To measure MBD beliefs, we reviewed previously developed dualism scales. These scales consisted of statements about MBD to which participants were asked to provide their level of agreement on a 5-point Likert scale. To capture the essence of the concept of MBD, we chose 4 questions that were easy to understand by participants and culturally compatible.^13,14 The questions were translated into Arabic, and were modified for clarity in a pilot study involving 10 participants. The statements were: (1) “the human mind and brain are independent”; (2) “the human brain controls the human mind”; (3) “the human brain has a minor role in controlling the mind and behavior”; and (4) “humans have immaterial powers that govern thought and behavior”. Question 3 was reverse coded. The total dualism score (DS) was calculated by adding the sum of the individual scale scores and dividing the sum by the number of items. The DS ranged from 1 to 5, with higher scores indicating a more dualistic way of thinking. The Cronbach’s alpha for the DS was .69 (see Table 2).

Religiosity

Religiosity was measured using the 10-item Belief into Action (BIAC) Scale. A Muslim version of the BIAC has been validated in Arabic.¹⁵ The Arabic Muslim BIAC in the original study had acceptable internal reliability (Cronbach α = .80, 95% CI = .76-.84), test-retest reliability (ICC = .88, 95% CI = .77-.94), and convergent, discriminant, and factor analytic validity. Items are rated on a visual analogue scale with response options ranging from 1 to 10. Responses to individual items are summed to create a total score ranging from 10 to 100. The total score on the BIAC was divided by the number of items (10) to create the BIAC religiosity score (BRS), which ranged from 1 to 10. The Cronbach’s alpha for the BIAC in the present study was .76 (see Table 2).

Statistical Analyses

Sample characteristics were examined using percentages for categorical variables and means (with standard deviations) for continuous variables. Pearson correlations and analysis of variance (ANOVA) were used to examine bivariate associations. Moderated mediation analysis was used to examine direct, indirect, and total associations. To evaluate the indirect association between the BRS and RS, we evaluated the association between BRS and DS and whether or not it was moderated by gender. Next, the association between DS and RS was examined and whether this was moderated by gender. Also evaluated was the direct association between BRS and RS and its moderation by gender. These analyses were performed using 3 models, 1 for each vignette. Figure 1 visually describes the proposed mediation analysis concerning how religiosity might influence perceptions of patient responsibility through dualism. Statistical significance was set at an alpha of .05 or less. SPSS version 20.0 was used in all analyses.

Figure 1.

Mediation and moderated mediation model emphasizing the direct and indirect associations between religiosity and belief in patient responsibility for illness acting through dualistic thinking (causal arrows hypothesized). Applicable to depression, schizophrenia, and antisocial personality disorder.

Results

Table 3 displays the frequencies for categorical variables that reflect students’ attitudes toward patient responsibility for their mental illness. A similar proportion of the sample agreed or strongly agreed that depression and schizophrenia were self-inflicted (35% of the sample in the case of depression, and 33% for schizophrenia). A larger proportion (more than half) agreed or strongly agreed that the patient with ASPD inflicted the illness on him or herself. With regard to preventability, the proportion of patients that agreed or strongly agreed was highest for ASPD (>50%), followed by depression (about 44%) and schizophrenia (26%). The proportion that agreed or strongly agreed that the patient should be able to control their symptoms was highest for ASPD (57%), followed by depression (53%) and schizophrenia (27%). The proportion of patients that agreed or strongly agreed that the patient in the vignette was blameworthy for the illness was highest for ASPD (50%), followed by schizophrenia (23%) and depression (18%).

Table 3.

Responses for Scenarios Indicating Patient Responsibility for their Illness.

		Responsibility
		Depression (V1)		Schizophrenia (V2)		Anti-social personality (V3)
		n	%	n	%	n	%
Self-infliction	Strongly disagree	28	26.4	31	29.2	14	13.2
	Disagree	19	17.9	23	21.7	17	16.0
	Neutral	22	20.8	17	16.0	21	19.8
	Agree	21	19.8	18	17.0	39	36.8
	Strongly agree	16	15.0	17	16.0	15	14.1
Preventability	Strongly disagree	11	10.4	31	29.2	13	12.3
	Disagree	21	19.8	24	22.6	14	13.2
	Neutral	27	25.5	23	21.7	24	22.6
	Agree	27	25.5	15	14.2	37	34.9
	Strongly agree	20	18.9	13	12.3	18	17.0
Controllability	Strongly disagree	12	11.3	22	20.8	9	8.5
	Disagree	10	9.4	26	24.5	10	9.4
	Neutral	27	25.5	29	27.4	26	24.5
	Agree	40	37.7	20	18.9	45	42.5
	Strongly agree	17	16.0	9	8.5	16	15.0
Blame	Strongly disagree	39	36.8	40	37.7	18	17.0
	Disagree	25	23.6	21	19.8	14	13.2
	Neutral	22	20.8	20	18.9	24	22.6
	Agree	12	11.3	17	16.0	31	29.2
	Strongly agree	8	7.5	8	7.5	19	20.8

Note. Due to rounding errors, percentages may not equal 100%.

V = vignette.

Table 2 display the means, standard deviations, and internal consistencies (Cronbach’s alpha) of the study variables and scales for measuring patient responsibility, dualism (MBD), and religiosity. As hypothesized, the average responsibility scores (RS) were highest for APD and lowest for schizophrenia, whereas depression fell in between (ANOVA F (1.82, 219.83) = 27.21, P < .001), indicating that there were significant differences between the degree to which students perceived that patients were responsible for their illness. Table 4 provides bivariate correlations between DS, RS, and BRS scores, indicating significant correlations.

Table 4.

Correlations between Patient Responsibility Scores in the 3 Vignettes, Religiosity, and Dualism.


		RS - Schizophrenia	RS - ASPD	DS	BRS
RS - depression	Pearson correlation	.522	.662	.516	.313
	p (2-tailed)	.000	.000	.000	.000
	N	106	106	106	106
RS - schizophrenia	Pearson correlation		.464	.385	.026
	p (2-tailed)		.000	.000	.777
	N		106	106	106
RS - ASPD	Pearson correlation			.510	.203
	p (2-tailed)			.000	.025
	N			106	106
DS	Pearson correlation				.314
	p (2-tailed)				.000
	N				106

RS = responsibility score; ASPD = antisocial personality disorder; DS = mind-body dualism score; BRS = BIAC religiosity score.

The moderated mediation analysis for the depression vignette (Table 5) yielded the following. Overall, BRS (religiosity) was significantly related to RS (patient responsibility for their illness) (total effect, β = .25, SE = .07, P < .00). There was a direct effect of BRS on RS scores (β = .13, SE = .06, P = .04). Results also indicated that the BRS was significantly related to the DS (dualistic thinking) (β = .18, SE = .06, P = .002), and that the DS was in turn significantly related to RS (β = .59, SE = .10, P <.001). The indirect effect of the BRS on RS through DS was also positive and significant (β = .11, SE = .04, P=.006). Gender significantly moderated only the association between religiosity and dualism (β = - .26, SE = .11, P = .02), such that the association between religiosity and dualism was significant only in males (β = .23, SE = .06, P < .001), not in females (β = .02, SE = .04, P = .57).

Table 5.

Moderation and Moderated Mediation Analysis for Depression Scenario (V1).

Moderation by Gender
Interaction	Estimate	SE	Lower	Upper	β	z	P
Religiosity: Gender1 ⇒ Dualism	−.26	.11	−.48	−.03	−.21	−2.26	.0241
Religiosity: Gender1 ⇒ V1_Responsibility	.17	.13	−.09	.42	.11	1.29	.1956
Gender1: Dualism ⇒ V1_Responsibility	−.30	.21	−.71	.11	−.46	−1.44	.1487

Moderated Mediation
Moderator Levels					95% C.I. (a)
Gender	Type	Effect	Estimate	SE	Lower	Upper	β	z	P
Overall	Indirect	Religiosity ⇒ Dualism ⇒ V1_Responsibility	.11	.04	.03	.18	.14	2.74	.0062
Overall	Component	Religiosity ⇒ Dualism	.18	.06	.07	.29	.28	3.12	.0018
Overall		Dualism ⇒ V1_Responsibility	.59	.10	.39	.80	.49	5.74	<.0001
Overall	Direct	Religiosity ⇒ V1_Responsibility	.13	.06	.00	.26	.17	2.02	.0435
Overall	Total	Religiosity ⇒ V1_Responsibility	.25	.07	.12	.39	.34	3.64	.0003
Male	Indirect	Religiosity ⇒ Dualism ⇒ V1_Responsibility	.23	.06	.10	.35	.28	3.50	.0005
Male	Component	Religiosity ⇒ Dualism	.30	.08	.16	.45	.49	4.01	<.0001
Male		Dualism ⇒ V1_Responsibility	.74	.10	.54	.95	.58	7.19	<.0001
Male	Direct	Religiosity ⇒ V1_Responsibility	.05	.09	−.12	.22	.06	.54	.5906
Male	Total	Religiosity ⇒ V1_Responsibility	.27	.09	.09	.46	.36	2.92	.0035
Female	Indirect	Religiosity ⇒ Dualism ⇒ V1_Responsibility	.02	.04	−.05	.10	.03	.57	.5657
Female	Component	Religiosity ⇒ Dualism	.05	.08	−.12	.21	.08	.58	.5622
Female		Dualism ⇒ V1_Responsibility	.45	.10	.24	.65	.38	4.30	<.0001
Female	Direct	Religiosity ⇒ V1_Responsibility	.21	.09	.04	.39	.29	2.38	.0175
Female	Total	Religiosity ⇒ V1_Responsibility	.24	.10	.03	.44	.31	2.27	.0233

For the schizophrenia vignette (Table 6), total and direct associations between BRS and RS were not significant (β = - .01, SE = .08, P = .91, and β = - .11, SE = .08, P = .15, respectively). However, there was a significant indirect association between the BRS and RS scores (indirect association β = .10, SE = .04, P = .01). BRS was associated with DS (β = .18, SE = .06, P = .002), which was associated with RS score (β = .55, SE = .12, P <.001). Similar to the depression vignette, gender moderated the association between religiosity and dualism (i.e., significant in males only; β = - .26, SE = .11, P = .02).

Table 6.

Moderation and Moderated Mediation Analysis for Schizophrenia Scenario (V2).

Moderation by Gender
Interaction	Estimate	SE	Lower	Upper	β	z	P
Religiosity: Gender1 ⇒ Dualism	−.26	.11	−.48	−.03	−.21	−2.26	.0241
Religiosity: Gender1 ⇒ V2_Responsibility	.21	.15	−.09	.51	.13	1.40	.163
Gender1: Dualism ⇒ V2_Responsibility	−.07	.25	−.56	.41	−.10	−.30	.7664

Moderated Mediation
Moderator Levels					95% C.I. (a)
Gender	Type	Effect	Estimate	SE	Lower	Upper	β	z	P
Overall	Indirect	Religiosity ⇒ Dualism ⇒ V2_Responsibility	.10	.04	.02	.17	.12	2.56	.0104
Overall	Component	Religiosity ⇒ Dualism	.18	.06	.07	.29	.28	3.12	.0018
Overall		Dualism ⇒ V2_Responsibility	.55	.12	.31	.80	.43	4.50	<.0001
Overall	Direct	Religiosity ⇒ V2_Responsibility	−.11	.08	−.26	.04	−.14	−1.45	.1473
Overall	Total	Religiosity ⇒ V2_Responsibility	−.01	.08	−.16	.15	−.01	−.11	.9134
Male	Indirect	Religiosity ⇒ Dualism ⇒ V2_Responsibility	.18	.06	.07	.29	.22	3.08	.0021
Male	Component	Religiosity ⇒ Dualism	.30	.08	.16	.45	.49	4.01	<.0001
Male		Dualism ⇒ V2_Responsibility	.59	.12	.35	.83	.45	4.80	<.0001
Male	Direct	Religiosity ⇒ V2_Responsibility	−.22	.10	−.42	−.02	−.27	−2.11	.0346
Male	Total	Religiosity ⇒ V2_Responsibility	−.04	.11	−.24	.17	−.05	−.36	.7168
Female	Indirect	Religiosity ⇒ Dualism ⇒ V2_Responsibility	.03	.04	−.06	.11	.03	.57	.5658
Female	Component	Religiosity ⇒ Dualism	.05	.08	−.12	.21	.08	.58	.5622
Female		Dualism ⇒ V2_Responsibility	.52	.12	.28	.76	.40	4.21	<.0001
Female	Direct	Religiosity ⇒ V2_Responsibility	.00	.11	−.21	.21	−.01	−.04	.9691
Female	Total	Religiosity ⇒ V2_Responsibility	.02	.12	−.21	.25	.03	.18	.8567

Results for the ASPD vignette (Table 7) were similar to those for schizophrenia. BRS was associated overall with the RS (total association β = .18, SE = .07, P = .02), but there was no direct association (β = .06, SE = .07, P = .41). There was a significant indirect association through the DS (β = .11, SE = .04, P = .006) such that religiosity was significantly associated with dualism (β = .18, SE = .06, P = .002), which in turn was significantly associated with RS scores (β = .62, SE = .10, P <.001). As with depression and schizophrenia vignettes, gender moderated the association between religiosity and dualism (significant only in males; β = - .26, SE = .11, P = .02).

Table 7.

Moderation and Moderated Mediation Analysis for Anti-Social Personality Disorder Scenario (V3).

Moderation by Gender
Interaction	Estimate	SE	Lower	Upper	β	z	P
Religiosity: Gender1 ⇒ Dualism	−.26	.11	−.48	−.03	−.21	−2.26	.0241
Religiosity: Gender1 ⇒ V3_Responsibility	−.11	.14	−.37	.16	−.07	−.79	.4313
Gender1: Dualism ⇒ V3_Responsibility	−.15	.22	−.58	.28	−.21	−.67	.5039

Moderated Mediation
Moderator Levels					95% C.I. (a)
Gender	Type	Effect	Estimate	SE	Lower	Upper	β	z	P
Overall	Indirect	Religiosity ⇒ Dualism ⇒ V3_Responsibility	.11	.04	.03	.19	.14	2.73	.0063
Overall	Component	Religiosity ⇒ Dualism	.18	.06	.07	.29	.28	3.12	.0018
Overall		Dualism ⇒ V3_Responsibility	.62	.11	.41	.84	.49	5.69	<.0001
Overall	Direct	Religiosity ⇒ V3_Responsibility	.06	.07	−.08	.19	.07	.83	.4061
Overall	Total	Religiosity ⇒ V3_Responsibility	.18	.07	.03	.32	.22	2.40	.0164
Male	Indirect	Religiosity ⇒ Dualism ⇒ V3_Responsibility	.21	.06	.09	.33	.26	3.39	.0007
Male	Component	Religiosity ⇒ Dualism	.30	.08	.16	.45	.49	4.01	<.0001
Male		Dualism ⇒ V3_Responsibility	.70	.11	.48	.91	.54	6.36	<.0001
Male	Direct	Religiosity ⇒ V3_Responsibility	.11	.09	−.07	.29	.14	1.20	.2295
Male	Total	Religiosity ⇒ V3_Responsibility	.32	.10	.13	.51	.41	3.28	.001
Female	Indirect	Religiosity ⇒ Dualism ⇒ V3_Responsibility	.03	.05	−.06	.12	.04	.58	.5647
Female	Component	Religiosity ⇒ Dualism	.05	.08	−.12	.21	.08	.58	.5622
Female		Dualism ⇒ V3_Responsibility	.55	.11	.34	.76	.44	5.02	<.0001
Female	Direct	Religiosity ⇒ V3_Responsibility	.00	.10	−.18	.19	.00	.03	.9749
Female	Total	Religiosity ⇒ V3_Responsibility	.03	.11	−.18	.24	.04	.27	.7844

Discussion

To our knowledge, this is the first study to examine the root philosophical beliefs related to attribution of personal responsibility for psychiatric illness (mental illness stigma) to mentally-ill patients. Overall, there was a relatively high degree of attribution of responsibility and blame on patients. Significant proportions of medical students felt, to varying degrees across the vignettes, that the patients in the vignettes inflicted some of their illness on themselves, should have been able to prevent it, could control it, and were to blame for it.

Both systematic research and clinical experience have demonstrated the importance of empathy and compassion when treating mental illnesses.^16,17 Critical judgement breeds coldness and dismissal of the patient concerns, suggesting that patients’ suffering may be under their own control. Such attitudes are associated with negative outcomes and mental illness stigma.^18-21

Recent research suggests that mental illness stigma in Saudi Arabia continues to be a concern and has effects on access to and quality of care.^22,23 The findings of this study argue that sufficient focus on the biological aspects of mental disorders and mental phenomena in general may help to improve these attitudes and combat stigma. The present study found a relationship between how much a disorder is viewed as biological and how much patients with the disorder are viewed as responsible for their illness. This was most evident for ASPD and least evident for schizophrenia, whereas depression fell in between (mean RS scores of 3.29, 2.58 and 2.92, respectively). These findings are consistent with those of other researchers who have examined the topic,⁴ suggesting that there may be a spectrum of attitudes towards different mental illnesses. Moreover, we argue that addressing the philosophical beliefs underlying the extent to which a disorder is viewed as biological may be important. The more that medical students were dualistic in their view of the mind and brain (and hence presumably less inclined to view mental illnesses as biological in origin), the more they were likely to attribute responsibility and blame for mental illnesses. Mind-body dualism has previously been linked to stigma, not only for mental illness,^4,24 but also for epilepsy, a neurological disorder with behavioral manifestations.²⁵ Thus, it may be helpful to target mind body monism in psychiatric training and research, which could lead to a greater acceptance of mental illnesses as having a biological basis.²⁶ On the other hand, an exclusive focus on biological aspects may decrease clinician empathy, promoting the idea that patients are abnormal, unchangeable, different from others and thus deserving of exclusion.²⁷ Thus, an integrated explanation for mental disorders, i.e., that these disorders result from both biological, psychological, social, and behavioral factors working in concert, corresponds more to reality. Such an attitude may help to preserve clinician empathy for patients with these disorders, and motivate clinicians to provide a range of treatments that are both biological and psychosocial-spiritual.^28-30 This may be especially important in Saudi Arabia and other Middle Eastern countries, deeply religious regions of the world that are strongly influenced by culture and tradition, where judgements about the moral basis for certain disorders may be particularly influential.^31-33

This study explored whether religiosity, an important variable in shaping discourse in Saudi Arabia, is associated with MBD and with negative perceptions of patients with mental illness. We found that religiosity was directly associated with a negative perception of people with depression but not directly associated with negative perceptions of those with schizophrenia or ASPD, outside of the effect mediated by MBD.

Islamic theology describes the concept of the soul (rouh) as an elusive entity within human nature.³⁴ Islamic thinkers like Gazali and Avicenna to some extent argued for dualistic views of the human mind, whereas more recent thinkers have challenged this view.³⁵ Dialogue between psychiatrists, neuroscientists, theologians and medical educators may be necessary to further explore the nature of the human mind in Islam and how it relates to the practice of psychiatry.

We also found that religious males were more likely to have dualistic thinking and, thus, more likely to harbor negative attitudes toward these illnesses. A possible cause for these gender differences in dualistic thinking may be due to more conservative cultural/religious influences on males than on females, given the latter’s more progressive attitudes toward many issues within Saudi society in recent years (driving, voting, reduced need for consent from a guardian, etc., perhaps even the role of biological influences in mental health problems).

Limitations and Strengths of the Study

First, this was a convenience sample of medical students who had not yet completed their training, and thus, arguably are more representative of the general population than of experienced clinicians. Second, participants in this study were from a single university located in the metropolitan progressive port-city of Jeddah, which may not be representative of other areas of Saudi Arabia or the Middle East. Finally, the cross-sectional nature of these findings prevents causal inference, thus limiting the findings to associations only.

Nevertheless, this study also has numerous strengths, including the use of reliable and valid measures of the constructs examined, and the fact that students were in their last years of training and had completed their rotations in psychiatry (and so perhaps should have been familiar with the biopsychosocial model of mental disorders). Finally, as noted above, this is 1 of the few studies from the Middle East to examine how beliefs about mind-body dualism, religious involvement, and demographic factors interact to influence the attitudes of future doctors towards the responsibility that patients have for their mental disorders.

Conclusions

Fifth and sixth-year medical students at a university hospital in Saudi Arabia who scored high on MBD beliefs were more likely to attribute responsibility (and blame) for mental illnesses to patients themselves. Religiosity was associated with this negative view for depression, but not for schizophrenia or APD unless acting through MBD beliefs. These findings were particularly strong for male students. Belief that patients are to blame for their condition (rather than neurobiological dysfunctions) is likely to affect healthcare professionals’ empathy towards patients with these mental illnesses. Teaching on mind-brain monism in medical school may positively impact students’ and later clinicians’ attitudes toward mental illness and reduce mental illness stigma.

What is Known and What has Been Learnt

1. Philosophical beliefs regarding the causes of mental illness may underlie resistance to psychiatric treatment and affect attitudes toward the mentally ill by healthcare professionals.

2. This is the first study, to our knowledge, to examine characteristics of medical students who hold MBD beliefs, determine relationships between MBD beliefs and perceptions of patient responsibility (RS) for their mental illness, determine whether MBD mediates the relationship between religious beliefs and perceptions of patient responsibility, and examine the moderating effects of gender on the relationship between MBD and RS.

3. Medical students’ perceptions of patient responsibility for their mental illness was highest for APD, lowest for schizophrenia, and intermediate for depression. Religiosity was positively correlated with perceptions of patient responsibility for their mental illnesses, a relationship that was mediated by MBD in all 3 vignettes. The relationship between MBD and RS was particularly strong in male medical students.

4. Greater emphasis on the neurobiological aspects of psychiatric disorders may help to change medical students’ perceptions of self-infliction, preventability, controllability, and blameworthiness for patients with mental illness.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Ethical Considerations

This study was approved by the Institutional Review Board of King Abdulaziz University, Jeddah, Saudi Arabia (#19-16).

ORCID iDs

Yousef Alsawwaf

Harold G. Koenig

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