Cinema has been a source of entertainment and recreation for decades, and usually the themes depicted in films have roots in society itself, portraying several issues regarding culture, religion, health, and mankind. The combination of images, dialog, sound effects, and music in a film makes it particularly well suited for depicting psychological states and mental illnesses. Thus, psychiatry has a long and deep history in cinema^1,2.

Films featuring psychiatrists and the mentally ill abound. Over the decades, movies have portrayed a wide range of psychiatric conditions, being the most popular: suicide, substance use disorders, multiple personality disorder, and schizophrenia^1,3. The depiction of psychiatry-related subjects in cinema has evolved over the years. The first portrayal of a psychiatric hospital was in 1020 on the German film Das cabinet des Dr. Caligari, directed by Robert Wiene and written by Hans Janowitz and Carl Mayer. Nonetheless, if any film has become the prototype representation of asylums, it must be One Flew Over the Cuckoo's Nest (1975), directed by Milos Forman and based on the novel by Ken Kesey. The film was a blockbuster and received recognition in the form of 5 Academy Awards^1,3,4.

Since the beginning of cinema, psychiatric hospitals have caught the attention of directors, producers, and the general public, as clearly shown in the amount of films whose plot develops in such place; one could even state that the hospital plays a role as important as the protagonists in the telling of the story^3,4,5,6. Bedlam (1946) by Mark Robson, The Snake Pit (1948) by Anatole Litvak, La tête contre les murs (1958) by Georges Franju, Shock Corridor (1963) by Samuel Fuller, Shock Treatment (1964) by Denis Sanders, Hombre Mirando al Sudeste (1986) by Eliseo Subiela, Twelve Monkeys (1995) by Terry Gilliam, Girl, Interrupted (1999) by James Mangold, Quills (2000) by Philip Kaufman, Shutter Island (2010) by Martin Scorsese, and others, are among the list of the most popular and representative films portraying asylums and psychiatric hospitals from a dramatic point of view^3,6,7.

Most early interpretations of hospitals were rather negative, showing sadistic psychiatrists who used emotional or psychological manipulation by hypnosis or deception. Horror films have a tendency to portray mental institutions as dark, tenebrous places, with cold, high walls, harboring diabolical nurses and demented directors. This is the case of Das cabinet des Dr. Caligari, which is arguably the first true horror film and it is known for setting a brilliantly high bar for the genre, remaining terrifying nearly a century after it first appeared on the screen^2,3,6. However, it is not only horror movies that have used this formula; in general, the majority of movies based on such institutions tended to present them in such a light. Psychopathic psychiatrists who inflict emotional wounds were depicted in films such as A Fine Madness (1966) by Irvin Kershner and Bad Timing (1980) by Nicolas Roeg. The use of cruel and aver- sive behavioral techniques is seen in A Clockwork Orange (1971) by Stanley Kubrick, where they attempt to condition a sadistic murderer against violence, and two brutal procedures are depicted in One Flew Over the Cuckoo's Nest (1975), where they use unmodified electro-convulsive therapy and lobotomy as treatment for the main character's illness^{3,8,9,10,11,12,13}.

One of the downsides of using psychiatry-related topics in films has been the fact that the majority of depictions tended to be negative and to perpetuate myths and stereotypes, thus contributing to the stigmatization of mental illness. On the other hand, portrayals too could be overly positive, suggesting that a mental illness can be easily cured, thus furthering misinformation among the general public. There was a lack of detailed studies into film techniques used in the representation of mental illness. As said by M. Anderson, «contemporary cinema has a difficult task on its hands in attempting to depict the experience of mental illness»^{4,8,9,10,11,12,13,14}.

Fortunately, times are changing from the films being criticized for the negative portrayal of psychiatrics and psychiatric conditions to the current times when an increasing number of them are able to provide realistic depictions of character styles and psychopathologic disorders, as well as personal and family dynamics, being reasonably accurate and therefore suitable for psychiatric teaching purposes. Cinema constitutes not only an important source of entertainment, but also an educational tool and a significant influence on people's attitude towards mental illness^7,8,16.

Over the last three decades, psychiatry trainers have attempted to use films as an educational tool for teaching medical students and psychiatry residents for a number of mental health conditions and scenarios, that range among personality disorders, assessment of mental state, response of others to the mentally ill, and the relationship between the therapist and the patient; especially on issues of transference and counter-transference^7,8,10.

Although such depictions may not always be completely accurate, they may however be good enough to use as an example to understand and analyze some aspects of a mental disorder. Even negative images can be used to generate discussion and promote critical thinking. It is unavoidable that films are made for entertainment, different from documentaries which are meant for education, nonetheless commercial films have an artistic richness that is rarely matched by documentaries. Films are well produced, interesting, entertaining, accessible, well-liked by students, and there are no concerns over patient confidentiality, all of which constitutes an advantage when using them for teaching^7,8.

In films, characters experience their symptoms in the context of their lives, not in an isolated clinical encounter, which offers multiple perspectives on illness not usually seen in short psychiatry placements. Likewise, they can offer an opportunity to observe the long-term course of an illness, which is no usually possible in short training posts^8,12,17.

From a practical perspective, another advantage is the fact that films can be paused to deal with a discussion point. This allows students to express their honest opinions and feelings about film characters in situations when they may feel inhibited to do so about patients^8,9. Also, films can be viewed repeatedly to emphasize specific learning objectives, being particularly helpful when learning about clinical examination, given that it offers an opportunity for the students to notice things they may have overlooked the first time, such as behaviors, mannerisms, expressions or any other information useful to determine the proper diagnosis, prognosis and treatment of an illness.

Psychiatry practice requires skills such as critical and reflective thinking, clinical ethical reasoning, values-based practice and narrative skills, which can be aided by cinemeducation since it offers trainees a vicarious experience of mental illness and the opportunity for reflective observation, thus a deeper understanding of the subject^8,9,14,15,16.

An example of the use of cinemeducation is the introductory lecture in psychiatry for students at the University of Nottingham, UK, which provides an overview of the ICD-10 classification with the diagnostic criteria of the major psychiatric disorders by using a range of films that include As Good as It Gets (1997) by James L. Brooks, The Madness of King George (1994) by Nicholas Hytner, Some Voices (2000) by Simon Cellan-Jones, Mr. Jones (1993) by Mike Figgis, Rainman (1988) by Barry Levinson, The Lost Weekend (1945) by Billy Wilder, among others^{8,17,18,19,20,21}.

According to particular learning objectives, entire films or selective clips can be used. The clips can be watched before and after discussing the diagnostic criteria, which enables students to correlate the criteria with the audio-visual representation. Zazulak²⁴ recommends asking the following questions after presenting a film clip: «what did you see? What did you hear? What did you feel? What did you think? What impact might this have on your clinical practice?», thus creating starting points for guided discussion^{8,21,22,23,24,25}.

Films can be used to engage students' attention, emphasize learning points in lectures and illustrate symptoms of a disorder, being particularly helpful when learning about mental state examination, how to reach a diagnosis, doctor-patient interactions, and treatment formulation skills. Trainers should encourage students to discuss a character's appearance, behavior, abnormal experiences and perceptions, which they can consider in the context of the other characters in the film. One of the difficulties of using films to illustrate psychopathology is that the diagnoses are not always clear, therefore it is important to consider ICD-10 or DSM-5 categories, as well as differential diagnosis^9,21,26.

Additionally, film clips can be useful in prompting role-play by providing a set of ready-made characters and circumstances for students to incorporate into their enactment. The Psychiatry Teaching Programme at Derby Medical School, UK, uses this method regularly to teach aptitudes such as interviewing, diagnostic and therapeutic skills^1,8,17.

Trainees can learn as well about doctor-patient relationships, transference and countertransference, therapeutic boundaries, and professionalism. One of the strategies is to ask trainees to look at the reasons why doctor behaves in an arrogant manner, so introducing them to the notion that insensitivity to the patient is created by the doctor's defense mechanism. M.A.S.H. (1970) by Robert Altman offers a terrific setting for looking at how doctors deal with working under stress. Ordinary People (1980) by Robert Redford displays an overly involved patient, which can encourage discussion about the boundaries of therapeutic relationships^1,8,9,17.

Films can help illustrate the course of a disorder, for example, the features of substance misuse may be clearer in a film than in a patient interview and it may be easier to identify different personality disorders or more subtle psychological impairments thanks to the longitudinal perspective of some films^1,8.

There are hundreds of films available as teaching materials. There are many resources that trainers can use to identify films suitable for teaching psychiatry, some authors have compiled lists of movies that meet the criteria. Alexander et al.²⁶ list film clips with questions related to some psychiatric disorders and treatments. Wedding et al.²⁷ provide a detailed bibliography of films illustrating psychopathology. Robinson²⁸ compiles film portrayals of many conditions, usefully cross-referenced with DMS-IV or ICD-10 diagnostic criteria. And the Association of Directors of Medical Student Education in Psychiatry has listed a summary of more than 100 feature films depicting various psychiatric disorders²⁹.

The author's personal choice of films for teaching the topics mentioned above is shown in Table 1 and Table 2. The list is not comprehensive, and readers may have their own preferences.

One of the main challenges of cinemeducation is managing to integrate films into the existing curriculums. The first step is to identify the learning objectives, then to determine the purpose of the film or clip and how it aids to achieve those goals. Films are an additional tool to help facilitate learning rather than replacing any other learning activity. The material should be used selectively, and the educational context should be explicit. Trainers should prepare lead-in questions for active watching, such as those suggested by Zazulak²⁵ which are mentioned above. As well as follow-up questions as resources to further motive active discussion among trainees^8,22,23.

Cinema and psychiatry interact in many ways and have a complex relationship though history. Films represent an entertaining and informative device in the current clinical educator's set of teaching tools, as they can be easily integrated with existing formats of teaching such as lectures, role-play or small group discussions.

Thus, cinema constitutes not only an important source of entertainment, but also an educational tool and a significant influence on people's attitude towards mental illness.