Download MJP 2008, Vol.17 No - Malaysian Journal of Psychiatry

MJP 2008, Vol.17 No.1
June 2008
Vol. 17 No. 1
CONTENTS
Editorial
Women’s Mental Health – Our Future
Direction
1-2
Nor Zuraida Z
Original Paper
Parasuicide And Suicide: Demographic
Features And Changing Trend Among
Cases In Hospital Sungai Bakap 20012005
3 - 12
Teo GS, Teh LC
Lim JH
Binge Eating And Lifestyle Factors In
Relation To Obesity In Schizophrenia
13 -22
Ainsah O,
Salmi R
Osman CB
Validation Of The Malay Version Of
Children Depression Inventory (CDI)
Among Children And Adolescents
Attending Outpatient Clinics In Kota
Bharu, Kelantan
23 - 29
Rosliwati MY
Rohayah H
Jamil BYM
Zaharah S
Psychiatric Morbidity And Attitudes
Towards Mental Illness Among Patients
Attending Primary Care Clinic Of Hospital
Universiti Kebangsaan Malaysia
30 - 43
Riana AR
Osman CB
Ainsah O
Satisfactory and Achievement in Basic
Sciences
Among
Postgraduate
Candidates
Attending
Universiti
Kebangsaan Malaysia’s Revision Course
– A Short Report
44 - 50
Hatta Sidi
Exploratory and confirmatory factor
validation and psychometric properties of
the Beck Depression Inventory for Malays
(BDI-Malay) in Malaysia.
51 - 64
Mukhtar F
Tian PS Oei
Factors Affecting Readmission in A
Teaching Hospital in Malaysia
65 - 72
Amer Siddiq AN
Ng CG
Aida SA
Zuraida NZ
Abdul Kadir R
MJP 2008, Vol.17 No.1
Review Paper
Case Report
Assertive Community Treatment (Act) For
Patients With Severe Mental Illness:
Experience In Malaysia
73 - 78
Voyeurism With Sexual Fantasy On
Female Body Parts: A Subtype Of
Obsessive-Compulsive Disorder? - A
Case Report
94 - 99
Ruzanna ZZ
Marhani M
A
Review
of
Neurobehavioural
Hatta Sidi
Marhani M
ECT
Practices:
79 - 85
Prem Kumar C
Theory of Minds for the Psychiatrists
86 - 93
Ang GK
Pridmore S
Bridging a Malay Mystical Belief and
Psychiatry: A Case of Fetus “Stolen” by
Orang Bunian in Advanced Pregnancy
100 -103
Ruzanna ZZ
Marhani M
MJP 2008, Vol.17 No.1
Editorial
Women’ Mental Health – Our Future Direction
Nor Zuraida Z
Department of Psychological Medicine, Faculty of Medicine, University of Malaya,
Kuala Lumpur
Globally women’s mental health issues have been emphasized since many decades ago.
World Health Organization (WHO) has highlighted the importance of justice and equality
in term of social context related to gender in order to achieve good mental well-being.
Gender differences in the prevalence of psychiatric disorders have been recognized long
ago where women commonly exceeds the men for a number of psychiatric illnesses (1).
Women are more likely to suffer from depression, anxiety, somatic problems and being
victims of sexual or physical violence. At least 1 in 5 women suffer rape in their lifetime
but the rate differ from various country (2). pppppppppppppppppppppppppppppppppppp
Much work has been done to look into the general well-being and psychological distress
in women as well as to understand the reason for women become more vulnerable to
stress as compared to men. Multiple factors such as biological determinants and
psychosocial issues have been found to be correlated to depression. Women with chronic
major depression tend to have a younger age at the onset of her illness, a more extensive
family history of mood disorder, poorer social adjustment, and poorer quality of life
compared to chronically depressed men (3).
Women are also known to be more likely to seek help for their mental health problem
from primary care physician. Furthermore, across socio-economic levels many women
nowdays are doing multiple roles in the society. They are not only wives and mothers in
their family, but women also go out to earn for living. Some women are holding a higher
position at workplace or in any organization. These multitasking roles may cause stress to
women especially if she has to handle family-work or work-family conflicts.
Biological differences related to gender have been increasingly explored. Differences
exist in brain anatomy and that male and female reproductive hormones i.e. estrogen and
progesterone produce psychoactive effects (4). Estrogen’s antidopaminergic (5) and
serotonin-enhancing (6) effects may play a role in psychiatric disorders in women. These
are the areas that need more research investigations.
However, WHO (2) is focusing on various issues in relation to women’s mental health.
• Build evidence on the prevalence and causes of mental health problems in women as
well as on the mediating and protective factors.
• Promote the formulation and implementation of health policies that address women's
needs and concerns from childhood to old age.
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MJP 2008, Vol.17 No.1
• Enhance the competence of primary health care providers to recognize and treat mental
health consequences of domestic violence, sexual abuse, and acute and chronic stress in
women.
Malaysia is also moving forward together with other parts of the world to promote and to
improve women’s mental health. Networking between professionals, government and
non-government agencies, and international women societies would help to enhance
mental health services for women. In addition, more research on women should be
encouraged through collaboration at national and international levels.
References
1. Andrade L, Caraveo-Anduaga J, Berglund P. The epidemiologyy of major depressive
episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE)
Surveys. Int J Methods Psychiatr Res. 2003;12:3-12.mmmmmmmmmmmmmmmmm
2. WHO. Women's Mental Health: An Evidence Based Review. Geneva; 2000 Contract
No.: Document Number|.mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
3. Kornstein S, Schatzberg A, Thase M. Gender differences in chronic major and double
depression. J Affect Disord. 2000;60:1-11.
4. Steiner M, Dunn E, Born L. Hormones and mood: from menarche to menopause and
beyond. J Affect Disord. 2003;74:67-83.
5. Rao M, Kolsch H. Effects of estrogen on brain development and neuroprotection implications for negative symptoms in schizophrenia. Psychoneuroendocrinology.
2003;28 (suppl 2):83-96.
6. Soares CN, Poitras JR, Prouty J. Effects of reproductive hormones and selective
estrogen receptors modulators on mood during menopause. Drug Aging. 2003;20:85-100.
Professor Dr Nor Zuraida Zainal
Consultant Psychiatrist
Editor-in-Chief MJP
2
MJP 2008, Vol.17 No.1
ORIGINAL PAPER
PARASUICIDE AND SUICIDE: DEMOGRAPHIC FEATURES
AND CHANGING TREND AMONG CASES IN HOSPITAL
SUNGAI BAKAP 2001-2005.
Teo GS*, Teh LC* & Lim JH**
ABSTRACT
Parasuicide has become an increasingly common response to
emotional distress in young adults. The general pattern of parasuicide
shows variations among the developing countries. The objectives of
this study were to determine the pattern of parasuicide and suicide
beside comparing the characteristics between different ethnic groups.
The study was a retrospective case review of all parasuicide cases
treated in Hospital Sungai Bakap and all suicides from the hospital
mortuary from January 2001 to December 2005. We collected data
concerning demographic data, information on method used and the
circumstances. A total of 189 cases of parasuicide were analysed.
There was a significant increase of parasuicide from 26.5 per 100,000
persons in 2001 to 32.1 per 100,000 persons in 2005. Seventy two
percent of the cases were female. Indians constituted 64 % of the
cases, followed by the Chinese (19 %), Malays (13 %) and foreigners
(4 %). The age group 18-30 years ranked at the top, constituting
59.7% of the cases. Majority of the cases were by intentional
poisoning and only 2 cases (1.1 %) were intentional injuries by sharp
objects. In the past 5 years, the agents implicated were drugs (43.9
%), pesticides (23.5 %), household products (11.8 %), and others
(20.8 %). Intentional Paracetamol poisoning had doubled from 11.7
% in 2001 to 23.4 % in 2005 while the use of pesticides had decreased
from 32 % in 2001 to 17 % in 2005. Only 2 % of the cases had history
of underlying disorders like schizophrenia and personalities
disorders. As for suicide, the rates remained relatively unchanged at 5
per 100,000 populations. In this study, the demographic
characteristics of suicide differ from parasuicide as suicides were
associated with higher percentage of males and Chinese. There were 2
peaks in the age group of 31-40 and above 60 years old. The highest
mode of suicide was hanging (53.5 %), followed by pesticide poisoning
(25.6 %) and inhaled carbon monoxide (9.3 %).There is a need to
improve on prevention and interventions for parasuicide and decrease
suicide prevalence. oooooooooooooooooooooooooooooooooooooooo
Keywords : parasuicide, suicide, self-harm, Penang
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MJP 2008, Vol.17 No.1
INTRODUCTION
Intentional self-harm has become an
increasingly common response to
emotional distress in young adults.
Parasuicide is a term to describe all nonfatal self-injurious behaviour with clear
intent to cause bodily harm or death (1).
The clinical diagnosis of suicide as
defined
by
the
World
Health
Organisation through its ICD-10 (2)
refers to suicide as “Intentional Selfharm (fatal)”.
The general pattern of parasuicide shows
variations among the developing
countries. A review of 20 studies on the
rates of parasuicide in the general
population from the year 1970 to 2000,
reported that annual rates range from 2.6
to 1,1000 per 10,000 population and
lifetime prevalence rates range from 720
to 5,930 per 100,000 (1). The most
important risk factors identified were
younger age and female gender. In
Malaysia, annual data on parasuicide and
suicide pattern are scarce and
incomplete. The Ministry of Health
Malaysia estimate of suicide rate was 912 per 100,000 populations in 2004 (3).
To determine the pattern of intentional
self-harm (parasuicide and suicide) and
to evaluate the associated demographic
factors, reasons for parasuicide and
method implicated.
METHODOLOGY
The study was a retrospective case
review of all parasuicide admissions and
suicide cases in Hospital Sungai Bakap
from January 2001 to December 2005.
A computer generated list according to
diagnostic codes X60-X84 of ICD-10
was obtained from the record office.
Subsequently, patients’ records were
traced. During the same period, postmortems records from the mortuary were
reviewed. Diagnosis of suicide was
based on clinical diagnosis instead of a
legal diagnosis which may takes up to 3
years to be determined by the court. We
collected data concerning demography,
information on method used and the
circumstances. Descriptive analysis was
carried out.
RESULTS
Hospital Sungai Bakap is the only
hospital in the district of Seberang Prai
Selatan. There are 36 private medical
clinics and 5 government health clinics
in the district. In 2005, the population
was estimated to be 146,400 and the
ethnic distribution was 38.6 % Malay,
37.1 % Chinese, 19.7 % Indian, 0.3 %
others and 4.3 % non-Malaysian.
Percentage of employed persons by
industry is the highest in manufacturing
sector followed by wholesales and retail
trade, public administration, agriculture
and fishing (4).
According to the medical record list,
there were 189 discharges with the
diagnosis of intentional self-harm
between
the
years
2001-2005,
representing 180 patients. Three had 2
admissions and one had 3 admissions in
the 5-year period. During the same
period, post-mortems were done for 43
cases of suicides. Majority of the cases
were brought in dead and only 8 cases
(18%) were admitted and died after
several hours to 4 days.
OBJECTIVES
Based on the population in the Seberang
Perai Selatan District, the annual
a)
Parasuicide and Suicide rates
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MJP 2008, Vol.17 No.1
admission rates were shown in Fig.1.
There was a significant increase of
parasuicide from 26.5 per 100,000
populations to 32.1 per 100,000
populations in 2005.The annual rates of
suicides remained relatively unchanged
from 2001-2005.
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MJP 2008, Vol.17 No.1
b) Demographic features
Sex
Majority of the parasuicide cases were females but for suicides, majority were males (χ2:
p<0.05)
Fig.2 Parasuicides In Sungai
Bakap (2001-2005) : By Gender
Fig.3 Suicides In Sungai Bakap
(2001-2005) : By Gender
Males
52
28%
Males
35
81%
Female
8
19%
Female
137
72%
Ethnic Groups
Indians constituted 64 % of the parasuicide cases (Fig.4), followed by the Chinese,
Malays and foreigners (χ2: p<0.05). However for suicides, as shown in Fig.5, nearly half
were Chinese followed by the Indians, foreigners and Malays (χ2: p<0.05).
Fig.4 Parasuicides In Sungai Bakap
(2001-2005) : By Ethnic Group
Fig. 5 Suicides In Sungai Bakap
(2001-2005) : By Ethnic Groups
Chinese
35
19%
Indian
18
42%
Indian
122
64%
Chinese
21
49%
malay
25
13%
Foreigner
7
4%
Foreigner malay
3
1
7%
2%
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MJP 2008, Vol.17 No.1
Age Groups
Majority (72.5 %) of parasuicide cases were from 14 to 30 years age groups.
The number of parasuicides decreased with age. However, for suicides, the age
group 31-40 years ranked at the top and there was another smaller peak at age
above 60 years old.
Fig. 6 Parasuicides in SPS (2001-2005): By Age Groups
80
60
No. 40
20
0
<=20
21-30
31-40
41-50
51-60
>60
68
69
35
9
5
3
No.
Age groups
Fig. 7 Suicides in SPS (2001-2005):By Age Groups
16
14
12
10
No.
8
6
4
2
0 <=20
No.
1
21-30
31-40
41-50
51-60
>60
unknow n
6
15
7
4
7
3
Age groups
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MJP 2008, Vol.17 No.1
c) Methods implicated
Methods implicated for parasuicide
About 99 % of parasuicides were intentional self-inflicted poisoning and only 1%
were intentional self-harm by sharp objects (Table 1). Intentional Paracetamol
poisoning had doubled from 11.7 % in 2001 to 23.4 % in 2005 while the use of
pesticides had decreased from 32 % in 2001 to 17 % in 2005. The agents implicated
in intentional poisoning included drugs, household products, pesticides and others.
Table 1: Methods Implicated For Parasuicide Treated In Hospital Sungai Bakap
Year 2001- 2005
YEAR
Injuries
Intentional poisoning
Drugs
Household products Pesticides Others by
sharps
Paracetamol Sedatives Others Detergent Petroleum
based
2001
4
1
4
7
1
11
6
0
2002
4
0
3
5
1
8
7
0
2003
9
1
9
1
0
8
8
1
2004
4
2
15
2
0
9
8
0
2005
11
2
12
4
1
8
7
1
Subtotal
32
7
12
19
3
44
36
2
Total
82
22
44
39
2
(%)
(43.4%)
(11.7%)
(23.3%) (20.6%) (1%)
Methods implicated for suicide
The most common method was by hanging (53.5 %), followed by intentional
ingestion of pesticides, carbon monoxide poisoning and drowning.
Table 2: Methods Implicated For Suicide, Hospital Sungai Bakap
METHODS
TOTAL
YEAR
(%)
2001 2002 2003 2004 2005
Hanging
2
5
1
5
10
Pesticides
4
1
3
1
2
23
(53.5%)
11(25.6%)
Carbon
monoxides
Drowning
0
1
2
0
1
4 (9.3%)
0
0
1
2
1
4(9.3%)
Drug
(sedatives)
1
0
0
0
0
1(2.3%)
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MJP 2008, Vol.17 No.1
d) Reasons for parasuicide
The most common reason cited as to why they wanted to die, was problems mainly with
spouses, family members or boy/girlfriends. There were 4 cases of previous history of
mental disorders (schizophrenia, depression and personality disorder) and 14 cases with
chronic illnesses and pain.
Table 3: Reasons for parasuicide, Hospital Sungai Bakap
YEAR
Reasons
TOTAL
2001
2002
2003
2004
2005
NO.
%
Relationship problems
(spouse, family, friend etc)
Health problems
(chronic illness)
Financial problems
26
11
21
24
26
108
57.2
0
0
4
7
7
18
9.5
0
2
3
0
1
6
3.2
Problems at work
0
1
0
1
0
2
1.0
Problems at school/exams
0
0
0
1
0
1
0.5
Not recorded
TOTAL
8
34
15
29
10
38
8
41
13
47
54
189
28.6
100
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MJP 2008, Vol.17 No.1
DISCUSSION
Little epidemiological information about
parasuicidal and suicidal individuals is
available in Malaysia. National data on
suicide are not collected prior to this
study. Between the year 2001 and 2005,
parasuicide rates in Sungai Bakap,
Penang had increased from 26.5 to 32.1
per 100,000 populations. The World
Health Organisation Multicentre Study
on parasuicide reported that the rates of
parasuicide varied substantially across
16 different sites (5). In other
registration studies, the rates varied
widely from 2.6 to 542 per 100,000
populations (1). However the process of
data collection also varied among the
sites which could have influenced the
rate.
Similar to the WHO study, the limitation
of this study is its focus on medically
treated parasuicide. This approach may
not
have
been
necessary
methodologically but registration study
may miss people who never seek
treatment, went to other hospitals or
private practitioner. The few population
studies in the United States and Australia
had shown rates similar or higher than
those of registration studies (300 – 1000
per 100,000 populations) (6,7).
In line with those of many previous
studies, our results indicate that the
demographic
characteristics
of
parasuicide admissions were associated
with a higher percentage of female,
Indian, aged 21-30 years old (1,8,9).
About 57.2 % of the parasuicide cases
cited interpersonal conflict especially in
relationship to a partner or close family
member as the reason for intentional self
harm. This would be consonant with the
evidence in several previous studies
(8,10). About 2 % of the cases had
history of mental illnesses and 7.5 % had
chronic pain and illnesses. Problems at
school or examination stress stood as
low as 0.5 % compared to Singapore
where there is a peak during examination
months (9)
Previous parasuicide is
highly predictive of future parasuicide.
In the WHO study, 42 % of males and
45 % of females had a previous attempt
of parasuicide (5). In this study, only 4
cases (2.1 %) had a previous attempt of
parasuicide. Longitudinal research is the
next step to assess accurately parasuicide
repetitive rates.
The increasing trend of parasuicide
could reflect an increasing response to
emotional distress in young adults. The
method implicated commonly involved
drug ingestion followed by household
products and pesticides. Similar to other
studies, the drugs and household
products they took were relatively nontoxic and in small amounts (11).
However, There was an increasing rate
of Paracetamol poisoning which require
urgent attention from the health
authority. Paracetamol poisoning was
responsible for 28 % poisoning cases
admitted to Hospital Pulau Pinang (11)
which was similar to those reported in
the Western and some Asian Countries
(12,13). In Hospital Sungai Bakap,
pesticide poisoning represents 23.3 % of
all parasuicide cases compared to only
3.3 % of all poisoning cases admitted to
Hospital Pulau Pinang (11). This could
be due to relatively low agricultural
activities on the Penang Island compared
to the mainland. Only 2 % were nonfatal intentional self-harm by sharp
objects.
The annual rates of suicide remained
relatively unchanged from 2001-2004
and increased slightly in 2005. Our
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MJP 2008, Vol.17 No.1
figures are lower than the Ministry of
Health, Malaysia estimate for suicide
rates in 2004 which was 9-12 per
100,000. For comparison the suicide rate
in the United States has averaged 12.5
out of 100,000 populations in past
decades and the Irish suicide rate stands
at 13.7 per 100,000 populations (10).
Because of the stigma of suicide, it is
thought that the under-reported figures
of suicide could be many times that of
official figures. In this study, the
demographic characteristics of suicide
differ from parasuicide as suicides were
associated with higher percentage of
males and Chinese. There were 2 peaks
in the age group of 31-40 and above 60
years old.
Poisoning with pesticides had been
identified as the agent responsible for
death in a majority of parasuicide in
developing countries. Pesticides account
for high proportion of suicides in rural
China (60 %), Sri Lanka (71 %) and
Malaysia (90 %) (14). in this study, it
was the second highest mode of suicide
(25.6 %) after hanging (53.5 %).
However the admission rates for
pesticides poisoning is declining,
probably due to industralisation and
declining agriculture activities.
The Health Ministry has set up a
national suicide database in January
2007 to better identify suicide trends and
contributory factors and from there,
tailor its prevention and intervention
strategies. Definitely, there is a need to
intensify health education in promoting
healthy lifestyles and good mental health
besides creating awareness on the
hazards of pesticides and drug
overdoses.
CONCLUSIONS
Suicide and parasuicide rates are
important markers of the mental health
of a population. Both pose a tremendous
burden to individuals, families and
society. Beside the current newly
launched Ministry of Health Suicide
Registry, a national study on parasuicide
would be very useful to increase our
understanding of these phenomena. By
identifying the common modes of self
harm and the changing trends,
intervention program can be planned and
instituted according.ooooooooooooooo
ACKNOWLEDGEMENT
The authors would like to thank the
Director General of Health Malaysia for
permission to publish this paper. We
also would like to thank Dr Nor Hayati
bt Arif, Consultant and Head of
Psychiatry Department, Hospital Pulau
Pinang and Dr Umadevi Vasudevan,
Head of Psychiatry Department,
Hospital Bukit Mertajam for their
support and helpful comments.
REFERENCES
1.
Welch SS. A review of literature
on epidemiology of parasuicide in the
general population. Psychiatr Serv,
2001:52:368-375.
2.
WHO: International Statistical
Classification of Diseases-10th revision
(ICD-10). Geneva, 1992.
3.
Ministry of Health Malaysia:
Suicide Prevention in Malaysia, 2004
(unpublished).
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MJP 2008, Vol.17 No.1
4.
Socioeconomic
and
Environmental
Research
Institute:
Penang Statistic Bulletin. Georgetown,
2006.
12.
Wai BHK, Hong C, Heok KE.
Suicidal behavior among young people
in Singapore. Gen Hosp Pschy, 1999:
21:2 :128-133.
5.
Schmidtke A, Bille-Brahne U,
De Leo et al. Attempted suicide in
Europe:
rates,
trends
and
sociodemographic characteristics of
suicide
attempters:
result
of
WHO/EURO Multicenter Study on
Parasuicide.
Acta
Psychiatrica
Scandinavica, 1992:93:327-338.
13.
Hanssen Y, Deleu D, Taqi A.
Etiologic
and
demographic
characteristics
of
poisoning:
a
prospective hospital based study in
Oman. Clin Toxicol, 2001:39:4: 371380.
6.
Crosby AE, Cheltenham MP,
Sacks JJ. Incidence of suicide ideation
and behavior in the United States.
Suicide and Life-threatening Behavior,
1999:29:131-140.
14.
Gunnell D & Eddleston. Suicide
by intentional ingestion of pesticides: a
continuing tragedy in developing
countries. Int. J. of Epidimiol,
2003:32:902-909.
7.
Pirkis J, Burgess P, Dunt D.
Suicide ideation and suicide attempts
among Australian adults. Crisis, 2000:
21:1:16-25.
8.
Maniam
T.
Suicide
and
parasuicide in a hill resort in Malaysia.
Br J Psychiatry, 1988: 153:222-25.
9.
Ung EK. Youth suicide and
parasuicide in Singapore. Ann Acad
Med Singapore, 2003: 32:12-8.
10.
Cryan EMJ. Parasuicide and
suicide in the south-west of Ireland. Irish
J of Medical Sciences, 2003: 172 :3:105106.
11.
Ahmed Ibrahim F, Ab Fatah AR,
Zaininah MZ. Demographic features of
drug and chemical poisoning in Northern
Malaysia. Clin Toxicol, 2005: 43:2:8994.
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MJP 2008, Vol.17 No.1
ORIGINAL PAPER
BINGE EATING AND LIFESTYLE FACTORS IN RELATION TO
OBESITY IN SCHIZOPHRENIA.
Ainsah O* Salmi R** Osman CB*
ABSTRACT
Obesity is highly prevalent among patient with schizophrenia. It is
therefore important to know whether lifestyle factors could contribute
to obesity. The objective of this paper is to study the prevalence of
overweight, obesity and high waist circumference (WC) in relation to
Binge eating and lifestyle factors among patients with schizophrenia.
This is a cross sectional study for a period of three and a half months
which systematically selected patients with schizophrenia who fulfilled
the inclusion criteria. The diagnosis of schizophrenia was made using
Structured Clinical Interview for DSM-IV (SCID). The diagnosis of
Binge Eating Disorder (BED) and the assessment of lifestyle factors
were made using Eating Disorder, Module H of SCID and Health
Promoting Lifestyle Profile II (HPLP II) respectively. The prevalence
of overweight was 39.2%, obesity was 35.1% and high waist
circumference was 63.9%. The difference between presence of BED
among patients who had normal and either overweight or obese was
not significant (χ2 with Yates correction 3.34, p=0.06). BED was found
to be more in patients with high WC (n=11, 78.6%) than those with
normal WC (n=3, 21.4%) but the difference was not significant
(χ2=1.88, p=0.21). In term of lifestyle factors, no significant different
found between those who smoke and those who did not smoke in
relation to BMI (χ2=0.00, p=0.98) and WC (χ2=0.15, p=0.90). There
was no difference between total score of diet and exercise among
patients who had normal weight and those who were either
overweight or obese in relation to BMI (t=1.30, p=0.20) and WC
(t=0.91, p=0.36) and BMI (t=0.80, p=0.43) and WC (t=0.02, p=0.98)
respectively. There were also no differences between total score of all
four domains of psychological lifestyle i.e. stress management, health
responsibility, spiritual growth and interpersonal relationship among
patients who had normal weight and those who were overweight and
obese in relation to BMI and WC (p>0.05). Presence of Binge eating
disorder and the lifestyle factors did not contribute to obesity among
patients with schizophrenia.
Keywords: Schizophrenia, obesity, lifestyle, binge eating disorder
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MJP 2008, Vol.17 No.1
INTRODUCTION
Obesity is a chronic health problem
affecting large numbers of people
worldwide. There was a study which
reported a high prevalence of obesity
among schizophrenic patients (1). Both
men and women with schizophrenia had
a higher prevalence of obesity than their
counterparts without schizophrenia (2,3).
Recent review suggested that 40-80% of
patients treated with antipsychotic
medications experienced weight gain
that exceeds ideal body weight by 20%
or greater (4). However it is unclear
whether schizophrenia per se causes
obesity. In Malaysia, studies related to
this problem are sparse (5). It is a wellknown
fact
that
people
with
schizophrenia were also found to have
poor lifestyle compared to general
population (6).
Patients with
Schizophrenia not only had poor eating
habits but also had limited physical
activity and exercise (7,8,9). It was also
found that sugar consumption was high
among Schizophrenia (10). Walker and
Hill-Polerecky 1996 had reviewed
several dimension of health promoting
lifestyles (11). Apart from diet and
eating habit, the lifestyle factors which
include
physical
activity,
stress
management, health responsibilities,
interpersonal relationship/support and
spirit growth are also important for
physical and mental health as well as
have effects on body weight (11).
Substantial studies have been done to
examine the relationship between pattern
of eating habit and obesity (12,13,14).
Binge eating disorder and night eating
syndrome are two type of eating disorder
that mostly studied and have significant
relationship with obesity (15). However
little attention has been paid to explore
more on the co-morbidity of binge eating
disorders and schizophrenia (16).
This study aimed to determine the
prevalence of overweight, obesity and
high waist circumference in relation to
demographic profile, Binge eating and
lifestyle factors in patients with
schizophrenia.
METHODOLOGY
This study was conducted at Psychiatric
Outpatient Clinic, Hospital Universiti
Kebangsaan Malaysia (HUKM). It was a
cross sectional study, and was conducted
from 1st April 2006 until 15th July 2006.
Sample size calculation is based on the
formula used to estimate a population
proportion with specific absolute
precision which is N=[z/d]2 p(1-p) this
resulted in 96.
The patients were selected using
systematic sampling in which every fifth
patients who had a diagnosis of
schizophrenia were selected. A total of
278 patients were approached and their
diagnoses were reviewed by researchers
(postgraduate psychiatric trainee and
consultant psychiatrist) using Structured
Clinical Interview for DSM-IV Axis I
Disorder (SCID) (17). Inter-rater
reliability, for the diagnosis of
schizophrenia was good (Kappa value
1.00). The assessment of Binge Eating
Disorder was done using the Eating
Disorder, Module H of SCID. The
subjects were given Patient Information
Sheet and explained about the study. The
participation was on voluntary basis.
Those who signed an informed consent
aged 18 to 60 years old and fulfilled the
selection criteria were enrolled in this
study. The lifestyle factors were assessed
using a validated questionnaire; Health
14
MJP 2008, Vol.17 No.1
Promoting Lifestyle Profile II (HPLP II)
(11). Discussion with dietitian was done
earlier to ensure dietary subscale of the
questionnaire conform to Malaysian
context. The pretest of HPLP had been
done during a pilot study which involved
30 subjects include supporting medical
staffs, staff nurses, medical students and
10 patients with schizophrenia in
HUKM. The internal consistency
reliability was satisfactory.
ii. Primary education
iii. Secondary education
iv. Tertiary
4. Total household income:
i. High income
> RM 3500
ii. Middle income > RM 1500-3500
iii. Low income
< RM 1500
(Malaysian Department of Statistics)
(5,18).
Study criteria
Definitions of variables
The anthropometric measurements
1. BMI and waist circumferences were
measured. The weight was classified as:
i.
Normal weight: BMI 18.5 - 22.9
2
kg/m .
ii. Overweight : BMI 23 -27.4 kg/m2.
iii. Obese
: BMI > 27.5 kg/m2.
(according to Malaysian Practice
Guideline in Management of Obesity)
(5,18).
2. Waist circumference (WC) is a
measurement midway between the
inferior margin of the last rib and the
crest of ilium in a horizontal plane and if
these landmarks were difficult to
palpate,
measurement
of
waist
circumference was noted at the level of
umbilicus. It is measured to the nearest
0.1 cm.
In this study: The waist circumference
was interpreted as
i. High: WC for female: WC > 80 cm
and for male : WC > 90 cm
ii. Normal: WC For female : WC < 80
cm and for male : WC < 90 cm
3. Level of Education:
i. Nil
1. Inclusion criteria include:
i. subjects age 18 to 60 years
ii. sufficient command and
understanding of the Malay or English
and well literate
iii.the diagnosis of schizophrenia based
on DSM-IV .
2. Exclusion criteria include:
i. substance dependence
ii. medical illness such as Cushing’s
disease, polycystic ovarian syndrome
(PCOS), hypothyroidism, patient with
severe edema
iii. BMI < 18.5 kg/m2
Instruments
i. Structured Clinical Interview for
DSM-IV Axis I Disorders (SCID)
including Eating Disorder, module-H
to establish the diagnosis of Binge
Eating Disorder.
ii. Health Promoting Lifestyle Profile-II
(HPLP-II).
Statistical Analysis
The data was analyzed using Statistical
Package for Social Studies (SPSS)
Version 11.5 which was licensed to
HUKM. The relationship between the
studies parameters were analyzed using
15
MJP 2008, Vol.17 No.1
appropriate statistical tests. Chi-Square
test was used to compare the difference
between groups of categorical data. The
T-test (for normally distributed data) and
Mann Whitney U test (for not normally
distributed data) were used in order to
look at the difference between two
groups. Either Pearson Correlation or
Spearman Correlation was used to
examine the correlation between two
continuous variables which were
normally and not normally distributed
respectively. Analysis of Variance
(ANOVA) was used to examine the
difference between three difference
groups of variables with normally
distributed continuous data.
RESULTS
Table 1: Sociodemographic characteristic of the patients
Characteristic
Male
Female
Total
Sample
n=97(%)
44 (45.4)
53 (54.6)
Ethnic
Group
Malay
Chinese
Indian
Others
55 (56.7)
28 (28.9)
14 (14.4)
0 (0.0)
Age
(years old)
<30
30 to 39
40 to 49
>50
43 (44.3)
30 (30.9)
21 (21.6)
3 (3.1)
Marital
Status
Single
Married
Divorce
Widow
67 (69.1)
20 (20.6)
6 (6.2)
4 (4.1)
Level of
Education
None
Primary
Secondary
Tertiary
0 (0.0)
0 (0.0)
58 (59.8)
39 (40.2)
Occupational
Status
Employed
52
(53.6%)
45
(46.4%)
49 (50.5)
Gender
Unemployed
Monthly
Total House
Income
(RM)
low income
(<1500)
middle income
(1500-3500)
high income
Median
±IQR
32.0±15.5
RM1500±1500
30 (30.9)
18 (18.6)
(>3500)
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MJP 2008, Vol.17 No.1
Background Sociodemographic
Two hundred seventy eight subjects; one
hundred thirty five (48.6%) male and
one hundred forty three (51.4%) female
patients with schizophrenia who came
for follow up to Outpatient Psychiatry
Clinic, HUKM were approached for this
study between a period of three and a
half months from 1st April until 15th
July 2006. one hundred twenty four
(44.6%) were Malays, one hundred
twenty one (43.5%) Chinese, thirty two
(11.5%) Indians and one (0.4 %) was
from other race. Ninety seven patients
met the selection criteria and agreed to
participate in the study. Table 1 shows
the overall sociodemographic data of
patients
Smoking Habit
Only 27 patients smoked cigarettes. Of
total 27 patients who smoked, 20(74.1%)
were either overweight or obese and
7(25.9%) had normal weight. No
significant different found between those
who smoked and those who did not
smoke in relation to BMI (x2=0.00,
p=0.98). Similarly, no significant
different found between those who
smoked and those who did not smoke in
relation to WC (x2=0.15, p=0.90).
Diet and Nutrition
Table 2 showed the frequency of diet
intake in relation to difference
proportion of food among patients.
There was no difference between total
score of diet among patients who had
normal weight and those who were
either overweight or obese BMI (t=1.30,
p=0.20). There was also no difference
between total score of diet among
patients who had normal WC and those
with high WC (t=0.91, p=0.36).
Physical activity and exercise
There was no difference between total
score of exercise among patients who
had normal weight and those who were
overweight and obese (t=0.80, p=0.43).
There was also no difference between
total score of exercise among patients
who had normal WC and those with high
WC (t=0.02, p=0.98). Table 3 describes
the frequency of exercise and related
activity among patients.
Psychological Factors
There were no differences between total
score of all four domains of
psychological lifestyle i.e. stress
management,
health responsibility,
spiritual growth and interpersonal
relationship among patients who had
normal weight and those who were
overweight and obese. Similarly no
significant findings were found between
these four domains of psychological
lifestyle and waist circumferences of
patients.
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MJP 2008, Vol.17 No.1
Table 2: Frequency of diet intake in relation to difference proportion of food
Frequency of diet intake
Limit use of sugars and food
containing sugar(sweet)
Eat 6-11 servings of bread, cereal, rice
and pasta each day
Eat 2-4 servings of fruit each day
Eat 3-5 servings of vegetables each
day
Eat 2-3 servings of milk, yogurt or
cheese each day
Eat only 2-3 servings from meat,
poultry, fish, dried beans, eggs and
nuts group each day.
Never
12 (12.4%)
Sometimes
42 (43.3%)
Often
31 (12%)
Routinely
12 (12.4%)
29 (29.9%)
34 (35.1%)
22 (22.7%)
12 (12.4%)
20 (20.6%)
12 (12.4%)
50 (51.5%)
50 (51.5%)
20 (20.6%)
29 (29.9%)
7 (7.2%)
6 (6.2%)
34 (35.1%)
46 (47.4%)
14 (14.4%)
3 (3.1%)
13 (13.4%)
36 (37.1%)
38 (39.2)
10 (10.3%)
Table 3: Frequency of exercise and physical activity among patients
Follow a planned exercise program
Exercise vigorously for 20 or more minute at least
three times a week ( such as walking bicycling,
aerobic dancing, using a stair climber)
Take part in light to moderate physical activity (
such as sustained walking 30-40 minutes 5 or
more times a week)
Take part in leisure-time (recreational) physical
activities (such as swimming, dancing, bicycling).
Do stretching exercises at least 3 times per week
Get exercise during daily activities ( such as
walking during lunch, using stairs instead of
elevators, parking car away from destination and
walking)
Check my pulse rate when exercising
Frequency of exercise and physical activity
Never
Sometimes
Often
Routinely
38
41 (42.3%)
12
6 (6.2%)
(39.2%)
(12.4%)
22
40 (41.2%)
27
8 (8.2%)
(22.7%)
(27.8%)
35
(36.1%)
32 (33.0%)
19
(19.6%)
11
(11.3%)
39
(40.2%)
35
(36.1%)
29
(29.9%)
39 (40.2%)
15
(15.5%)
21
(21.6%)
31
(32.0%)
4 (4.1%)
59
(60.8%)
28 (28.9%)
10
(10.3%)
0 (0.0%)
40 (41.2%)
31 (32.0%)
1 (1%)
6 (6.2%)
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MJP 2008, Vol.17 No.1
Table 4: Distribution of mean / median score of stress management, health
responsibility, spiritual growth and interpersonal relationship in relation to BMI
and WC.
Psychological lifestyle
Normal weight
Overweight & Obese
Med ±IQR
Med ±IQR
Stress management
20.0± 4.5
19.0± 5.0
Health responsibilities
17.0± 7.5
Spiritual growth
Interpersonal
Relationship
P value
Normal WC
High WC
P value
Med ±IQR
Med ±IQR
Z=-0.87
p=0.38
20.0± 4.0
19± 5.3
Z= -0.77
p= 0.44
16.0± 6.0
Z=-0.27
p=0.79
17.0±6.0
16.0±6
Z= -0.14
p= 0.89
25.0± 6.5
23.0± 6.0
Z=1.53
P=0.13
24.0±6.0
23.0±7.0
Z= -1.50
p= 0.38
Mean ± SD
Mean ±SD
22.9 ± 4.8
22.4 ±4.4
t = 0.49
P = 0.62
Mean ± SD
Mean ± SD
22.4 ± 4.5
22.6 ± 4.5
t = -0.29
p= 0.77
DISCUSSION
The results showed among patients with
schizophrenia
who
were
either
overweight or obesity, 52.8% were
females and among those with high
waist circumference, 54.5% of them
were also female. There was no
difference found between patterns of
food consumption by patient with
schizophrenia
who
were
either
overweight or obese compared to those
who had normal weight. However, in
terms of gender, female patients with
schizophrenia had better overall nutrition
intake compared to male. Further detail
analysis on each composition of food,
showed only a very minimal percentage
of patients with schizophrenia routinely
took proper diet. For example, only 7%
and 6% of patients with schizophrenia
had routinely taken two to four servings
of fruit and vegetables each day
respectively.
The percentages were
lesser compare to percentages of patient
with schizophrenia in Scotland (7) i.e.
33% male and 43% female patient with
schizophrenia take fresh fruit once a day
and 10% male patient and 27% female
patients cooked green food five times a
week or more and more higher
percentage of patients took raw
vegetables or salad..
In terms of limiting the use of sugar and
food containing sugar, 12% of patients
in this study routinely limit their sugar
intake. A study reviewed diet and other
lifestyle factors in patients with
schizophrenia and noted that sugar
consumption was high among patient
with schizophrenia and that most of this
was due to excessive sugar consumption
by patients with treatment-resistant
disease taking Clozapine (19). Overall
view on the data collected regarding diet
intake of patients with schizophrenia
shows majority of patients have poor
nutritional
intake
and
warrant
collaboration
with
dietitian
and
nutritionist not only for proper studies
but more important to liaise with them in
the management of weight problems
among patients with schizophrenia.
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MJP 2008, Vol.17 No.1
Generally, we found most of them
regardless of their weight status had poor
physical activities. Almost all of the
patients with schizophrenia in this study
who were employed had sedentary
activities. Twenty to forty percents of
them never did any exercise and only
about six percent routinely exercise.
Brown et al. (1999) also found similar
finding; thirty six percent of patient with
schizophrenia in his study never did any
exercise (9). It is therefore create a major
challenge for mental health clinician to
promote weight reduction program in
attempt to overcome problem of obesity.
The psychological lifestyle was not
found to be significantly difference with
both anthropometric measurements.
There are several limitations noted in
this study. Due to a short duration of
time and high rate of refusal among
patients to participate in the study, small
sample was collected and this increased
the type II error. It is suggested that to
increase the sample size and hence to
increase the power of the study, it has to
be conducted on patients regardless
whether they attended Outpatient
Psychiatric Clinic HUKM, which do not
reflect the true samples of patients with
schizophrenia. Therefore, the result
could only be interpreted as the hospital
based population that may have different
demographic data, lifestyle and other
characteristic
in
comparison
to
community based population.
In term of sampling bias, the
schizophrenic subjects in this study had
optimum cognitive function and wellliterate, therefore those with poor
cognitive function and not able to
understand and answer the questions
may be left behind. These patients may
have more risk factors for obesity.
The major drawback in the questionnaire
is regarding the understanding of
conversion of actual food intake to
quantity of ‘serving’ of each food
composition. This exposed to poor
content validity. The issue of “How do
we measure the actual food intake” is
not a simple issue. Johnson (2002) who
examined the use of food records, food
frequency questionnaires (FFQs), and
24-hour recalls concluded that each
method has strengths and weaknesses
(20). During our pilot study, pretest of
the questionnaire had to be done and the
internal consistency of the questionnaire
had been calculated and found to be
good. In the future, we recommend that
a validation study should be conducted
by dietitians so that a comparison of this
subscale to the standard measurement
can be done with a correct precision.
We did not examine the effect of
medications in relation to BMI and WC,
prescribed by managing psychiatrists.
Recent review suggests that 40% to 80%
of
patients
taking
antipsychotic
medication experience weight gain that
exceed ideal body weight by 20% or
greater.
It is difficult to investigate the effects of
medication since the non-adherence rate
is high ranging from 20% to 89% with
average rate of approximately 41.0% for
oral medication and 2 5% for depot
antipsychotic (21).
This study should be replicated using a
proper design in a bigger scale, in
collaboration with other experts such as
dietitians,
nutritionists
and
physiotherapists.
20
MJP 2008, Vol.17 No.1
CONCLUSION
5.
This study demonstrated that binge
eating and lifestyle factors in
schizophrenia do not contribute to
overweight or obesity. This observation
suggests that other factors including
medications may be the primary cause of
obesity in this group of patients.
Ismail MN, Chess SS, Nawawi
H, Yusoff K, Lim TO, James WP.
Obesity in Malaysia .Obesity
Reviews, 2002;:3:3:203-8.
6.
Chan S & Yu IW. 2004. Quality
of
Life
of
Clients
with
Schizophrenia. Journal of Advance
Nursing, 45:1:72–83.
7.
McCreadie R, Macdonald E,
Blacklock C, Tilak-Singh D, Wiles
D, Halliday J, John PJ. Dietary
intake of schizophrenic patients in
Nithsdale, Scotland Case-control
study. British Medical Journal,
1998:317:784-785.
8.
Gothelf D, Falk B, Singer P,
Kairi M, Phillip M, Zigel L, Porazl,
Frishman S, Constantini N, Zalsman
G, Weizman A, Apter A. Weight
Gain Associated With Increased
Food Intake and Low Habitual
Activity Levels in Male Adolescent
Schizophrenic Inpatients Treated
With Olanzapine. American Journal
of Psychiatry, 2002:159:6:10551057.
9.
Brown S, Birtwistle S, Birtwistle
J, Roe L. The Unhealthy Lifestyle of
People
with
Schizophrenia.
Psychological
Medicine,
1999:
29:697–701.
10.
Peet M. Diet, diabetes and
schizophrenia:
review
and
hypothesis.
Schizophrenia
and
Diabetes: An Expert Consensus
Meeting.The British Journal of
Psychiatry, 2003:184(suppl 47):102105.
ACKNOWLEDGMENT
The authors would like to thank all the
patients who had participated in this
study as well as to all doctors who had
help in managing the patients.
REFERENCES
1.
Allison DB, Mentore JL, Heo M.
Antipsychotic-induced weight gain:
A comprehensive research synthesis.
American Journal of Psychiatry,
1999:156:11:1686–1696.
2.
Coodin S. Body mass index in
persons
with
schizophrenia.
Canadian Journal of Psychiatry,
2001:46:549–55.
3.
4.
Daumit
GL,
Clark
JM,
Steinwachs DM, Graham C, Lehman
A, Ford DE. Prevalence and
Correlates of obesity in a
Community Sample of individuals
with Severe and Persistent Mental
Illness, 2003:191:2:799-805.
Green A, Patel JK, Goisman RM,
Allison, DB, Blackburn G. Weight
gain from novel antipsychotic drugs:
need for action. General Hospital
Psychiatry, 2000:22:224-235.
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MJP 2008, Vol.17 No.1
11.
Walker SN, Hill-Polorecky DM.
Psychometric evaluation of the
Health-Promoting Lifestyle Profile
II.
Unpublished
manuscript.
University of Nebraska Medical
Center. 1996.
12.
Thakore JH. Metabolic syndrome
and schizophrenia. The British
Journal of Psychiatry, 2005:186:455456.
13.
Deckelman MC, Dixon LB,
Conley RR, Comorbid Bulimia
Nervosa
and
Schizophrenia.
International
Journal
of
Obesity.1999: 25: 399-404.
14.
Holmberg S, Kane C. Health and
self-care practices of persons with
schizophrenia.
Psychiatric
services,1999:50:6:827-829.
15.
Charles B.
Binge Eating
Disorder. Curr Opin Psychiatry,
2004:171:43-48.
16.
Dingemans AE, Bruna MJ, Van
Furth EF. Binge Eating Disorder: A
review. International Journal of
Obesity, 2002:26:299–30711.
17.
18.
American
Psychiatric
Association:
Diagnostic
and
Statistical Manual of Mental
Disorder (DSM-IV), Washington
DC, APA. 2000.
Lim TO, Ding LM, Zaki M,
Suleiman AB, Maimunah AH,
Rugayah, B, Rozita H. Distribution
of body weight, height and body
mass index in National Sample of
Malaysian
Adults
Malaysian
Medical Journal, 2000:55:108-128.
19.
Henderson DC, Cagliero E, Gray
C, Nasrallah R, Hayden DL,
Schoefeld DA, Goff DC. Clozapine,
Diabetes Mellitus, Weight Gain and
Lipid Abnormality: A Five Year
Naturalistic Study. American Journal
of Psychiatry, 2000:157:6:975-981.
20.
Johnson RK. Dietary Intake:
How do we measure what people are
really eating? Obesity Research,
2002:10:63-68.
21.
Lieberman JA, Stroup TS,
McEvoy JP, Swartz MS, Rosenheck
RA at al. Effectiveness of
Antipsychotic Drugs in Patients with
Chronic Schizophrenia. The New
England Journal of Medicine,
2005:353:12:1209-1223.
*
Department of Psychiatry, Universiti
Kebangsaan Malaysia
** Unit of Psychiatry, Universiti
Teknologi Malaysia
Correspondence:
Dr Osman Che Bakar,
Associate Professor and Senior Lecturer,
Department of Psychiatry,
Faculty of Medicine,
UKM
E-mail:[email protected]
22
MJP 2008, Vol.17 No.1
ORIGINAL PAPER
VALIDATION OF THE MALAY VERSION OF CHILDREN
DEPRESSION INVENTORY (CDI) AMONG CHILDREN AND
ADOLESCENTS ATTENDING OUTPATIENT CLINICS IN KOTA
BHARU, KELANTAN.
MY Rosliwati* MMed; H Rohayah** MMed; BYM Jamil** MMed,
M.Sc; S Zaharah*** McomMed
ABSTRACT
The aim of this study is to validate the Malay version of CDI among
children and adolescents attending outpatient clinics at Universiti
Sains Malaysia Hospital (USM), Kota Bharu, Kelantan. Sixty children
and adolescents attending outpatient clinics were interviewed using
the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) and completed the Malay version of CDI.
Reliability and validity of the Malay version of CDI were analyzed.
Validation study showed that the Malay version of CDI had a
satisfactory reliability (Cronbach’s alpha 0.83). At the cut-off score of
18, the Malay version CDI had 90% sensitivity and 98% specificity in
detecting depression. In conclusion, the Malay version of CDI has a
satisfactory validity and reliability.
Keywords:
Children
Depression
Inventory,
depression
INTRODUCTION
The validation of instrument such as CDI
across different cultural groups is crucial to
provide evidence of the scale sensibility to
cultural diversity and to help identify
symptomatic difference between groups (1).
CDI differentiates depressive disorder from
anxiety and disruptive behaviour disorder
(2). CDI also differentiates children and
adolescents with major depression or
dysthymia from those with other psychiatric
disorders or from the normal ones (3).
It is, in fact, a self-report, symptomoriented scale which requires at least a first
grade reading level and was designed for
school-aged children and adolescents. It
has 27 items, each of which consists of
three choices. The child is instructed to
select one sentence for each item that best
describes him or her for the past two
weeks. It measures depressive symptoms in
children and adolescents, aged 7 to 17
years. The CDI profile contains the
following five factors plus a total score
normed according to age and sex: (i)
negative
23
MJP 2008, Vol.17 No.1
mood, (ii) interpersonal problems, (iii)
ineffectiveness, (iv) anhedonia and (v)
negative symptoms. pppppppppppppp
Written informed consent was obtained
from parents or guardians after detailed
explanations given on the study.
Previous study used CDI to detect and
evaluate symptoms of major depressive
disorder or dysthymic disorder in
children or adolescents, and to
distinguish between children with those
disorders and children with other
psychiatric conditions (4,5,6). CDI can
be administered repeatedly in order to
measure changes in depression over time
and to evaluate the result of treatment
for depressive disorders. It is regarded as
adequate for assessing the severity of
depressive symptoms. Shemesh et al.
found that at cut-off score of 11, the
inventory correctly identified 80% of
cases, with specificity of 70% (7).
However, in another study, Charman
(1994) found that there was a great
variability in the cut-off score ranged
from
12
to
25
(8).
Sixty children and adolescents aged 7-17
attending outpatient clinics were
randomized using systematic random
sampling. The exclusion criteria include
children with mental retardation and
children with organic brain syndrome.
Lack of validation measures in the
Malay version for local population
especially in children and adolescents is
the main concern for clinicians.
The aim of this study is to validate the
Malay version of Children Depression
Inventory (CDI) among children and
adolescents attending outpatient clinics
at Universiti Sains Malaysia Hospital
(HUSM), Kota Bharu, Kelantan.
METHODS
This study was approved by the
Research & Ethical Committee, School
of Medical Sciences, Universiti Sains
Malaysia.
CDI was translated to the Malay
language and back translated into
English by two school teachers who are
proficient in both languages. Both
scales, the original and the backtranslated versions were compared to
determine the accuracy of the
translation. Assistance from the Centre
for Language and Translation, USM was
sought to finalize the draft. CDI was first
tested on 20 children at the HUSM
Paediatric outpatient clinics.
All
subjects were asked to fill in the selfadministered Malay version of CDI
before clinical interview. The researcher
was blind to CDI scores at time of
interview.
All subjects were then interviewed
individually by a researcher (the first
author) who was trained in psychiatric
interview and examination. A diagnosis
was made based on the criteria of Major
depressive episode in DSM-IV and Mini
International Neuropsychiatric Interview
(MINI) for Major Depressive Episode
(2004)
(MINI
kid).
Internal consistency of CDI was
determined using corrected item-total
correlation and Cronbach’s alpha
coefficient. Correlation between CDI
scores and MINI kid was used to
indicate concurrent validity.
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MJP 2008, Vol.17 No.1
MINI kid
It is designed as a brief structured
interview for the Axis I psychiatric
disorder in Diagnostic and Statistical
Manual of Mental Disorders, Fourth
Edition (DSM-IV) and International
Classification of Diseases Tenth Edition
(ICD-10). Its validity and reliability
studies have been done comparing MINI
to SCID-P for DSM-III-R and the CIDI
(a structured interview developed by
WHO for lay interviewers for ICD-10).
It has a high validity and reliability,
takes about 12 minutes to be
administered and has nine questions
which answered yes or no. The total
answer of YES for more than 5 was
considered as Major depressive episode.
Table 1
Demographic
characteristic of depressed vs. nondepressed respondents (using clinical
diagnosis)
Demographic
characteristics
All
Sex
Depression status
Depressed
Nondepressed
n
%
n
%
11 18.3 49 81.7
Male
Female
7
4
11.7
6.7
25
24
41.7
40.0
7-12
years
13-17
years
6
10.0
28
46.7
5
8.3
21
35.0
Age
group
Statistical analysis
Data entry and analyses were carried out
using SPSS software version 12.0.
Validity Analysis of CDI
a) CDI
RESULTS
Characteristic of the respondents
The age of the subjects ranged from 7 to
17 years, (mean: 12.2 years, SD 2.34).
11 (18.3%) respondents were diagnosed
to have depression (Table 1).
Reliability Analysis of CDI
Internal consistency of CDI was
determined using corrected item-total
correlation and Cronbach’s alpha
coefficient. (Table 2)
scores
versus
diagnoses
clinical
Total score of CDI was compared with
the clinical diagnoses and the mean
score of CDI was highest in depressive
group and lowest in non-depressive
group. The mean scores were 25.1 and
10.3 in depressive group and nondepressive group respectively. CDI
scores do significantly differ across
clinical diagnoses (χ2=21.45, p<0.05).
b) Concurrent validity with MINI
kid.
The correlation between scores on CDI
and MINI kid was satisfactory, with
Kappa agreement= 0.88, p<0.05.
25
MJP 2008, Vol.17 No.1
Question
Corrected
item-total
correlation
1
0.44
2
0.19
3
0.35
4
0.07
5
0.65
6
0.17
7
0.68
8
0.41
9
0.49
10
0.55
11
0.48
12
0.36
13
0.26
14
0.53
15
0.47
16
0.35
17
0.46
18
0.26
19
0.02
20
0.49
21
0.50
22
0.48
23
0.38
24
0.28
25
0.29
26
0.30
27
0.14
Cronbach’s alpha
Alpha if
item
deleted
0.83
0.83
0.83
0.84
0.81
0.83
0.82
0.83
0.82
0.82
0.82
0.83
0.83
0.82
0.82
0.83
0.82
0.83
0.85
0.82
0.82
0.82
0.83
0.83
0.83
0.83
0.83
0.83
Figure
1:
Receiver
Operating
Characteristic
curve
(ROC) for CDI
ROC Curve
1.0
0.8
Sensitivity
Table 2: Internal consistency for CDI
0.6
0.4
0.2
0.0
0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
Diagonal segments are produced by ties.
At the cut-off score of 18, CDI detects
depression at the
.sensitivity of 90%
.specificity of 98%
c) The optimum cut-off score for CDI
The optimum cut-off score for
depression was 18 according to
coordinates of the ROC curves.
.positive predictive value of 100%
. negative predictive value of 96%
26
MJP 2008, Vol.17 No.1
Table 3: Sensitivity and specificity at
different cut-off points
Positive if
greater or
equal to
0
2.0
3.5
4.5
5.5
6.5
7.5
8.5
9.5
10.5
11.5
12.5
13.5
14.5
15.5
16.5
17.5
19.0
20.5
22.5
25.5
28.5
33.0
36.5
38.0
Sensitivity
(%)
Specificity
(%)
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
90.0
90.0
90.0
90.0
90.0
90.0
90.0
80.0
70.0
60.0
50.0
40.0
30.0
10.0
0.0
0.0
2.0
4.0
8.0
14.0
22.0
32.0
34.0
46.0
52.0
58.0
62.0
70.0
78.0
84.0
92.0
98.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
DISCUSSION
The Malay version of Children
Depression Inventory (CDI) is a selfadministered instrument validated for the
Malaysian population.
Several studies have assessed its
internal consistency, structural factor
reliability,
test-retest
(stability),
administration methods and cut-off
scores. For instance, Kovacs (1992) had
proposed the Cronbach’s alpha range
between 0.71-0.87 (3). He suggested an
adequate cut-off score, based on raw
total scores needs to be established to
minimize false negatives (i.e. clinically
diagnosed children and adolescents with
a depressive disorder who are not
classified as such by means of the CDI)
and false positives (i.e. children and
adolescents who are falsely classified as
depressed by means of the CDI).
Furthermore,
Kovacs
(1992)
recommended a cut-off score of 13 as to
minimize false negatives and for clinical
sample; a higher cut-off score of 19
minimizes false positives and used in
non-clinical sample.
Most studies use multi-stage
strategy in non- clinical samples with a
cut-off score of 19, which seem to be
specific enough in identifying samples
of potentially depressed children and
adolescents following the suggestions by
Kovacs (6).
In this study, at the optimum
score of 18, the CDI had a sensitivity of
90% and a specificity of 98%. Rivera et
al (2005) used depression section of the
Spanish version of Diagnostic Interview
Schedule for Children (adapted to a
Spanish version) and Beck Depression
Inventory as the gold standard. He
reported the cut-off score of 20 with a
sensitivity of 69%, specificity of 43%,
positive predictive value of 64% and
negative predictive of 49%. It is clear
that sensitivity and specificity scores
differ from one population to another
and one cannot assumes based on metric
equivalents (9). On the other hand,
Timbremont & Braet (2004) suggested
cut-off scores of 13 and 19. They had
shown a satisfactory receiver-operating
characteristic (ROC) for screening
purposes using KID-SCID (Dutch
27
MJP 2008, Vol.17 No.1
version) as a gold standard for clinical
diagnosis (2).
Finally, this study illustrates the fact that
the Malay version of Children
Depression Inventory could be used as a
valid and reliable screening tool for
depression in the Malaysian population.
The cut-off score of 18 in this sample
has shown good sensitivity and
specificity.
ACKNOWLEDGEMENT
This study was conducted under shortterm grant from Universiti Sains
Malaysia.
REFERENCES
1. Abdul-Khalec AM, Solimon HH. A
cross
cultural
evaluation
of
depression in children in Egypt,
Kuwait and the United State.
Psychological Reports, 1999:85:973980.
2. Timbremont B, Braet C. Assessing
depression in youth: Relation
between the Children’s Depression
Inventory and a structured interview.
Journal of Clinical Child and
Adolescent
Psychology,
2004:33:1:149-157.
3. Kovacs M. Children Depression
Inventory. New York: Multi-Health
Systems, 1992.
4. Fristad MA, Weller EB, Weller RA et
al. Self-report versus biological
markers in assessment of childhood
depression. Journal of Affective
Disorder, 1988:15:3:339-345.
5. Hodges-Kay U, Ypisilanti US.
Depression and anxiety in children:
A
comparison
of
self-report
questionnaires to clinical interview.
Psychological assessment, 1990:2:4:
376-381.
6. Bahls
SC.
Epidemiology
of
depressive symptoms in adolescents
of a public school in Curitiba, Brazil.
Revision
Brazil
Psychiatry,
2002:24:2:204-212.
7. Shemesh E
et al. Children’s
Depression Inventory validated in
medically ill children. Journal of the
American Academy of Child
&Adolescent
Psychiatry,
2005:44:12: 1249-1257
8. Charman T. The stability of
depressed
mood
in
young
adolescents: a school based survey.
Journal of Affective Disorder,
1994:30:109-16.
9. Rivera CL, Bernal G, Rosello J. The
Children
Depression
Inventory
(CDI) and the Beck Depression
Inventory (BDI): Their validity as
screening measures for major
depression in a group of Puerto
Rican adolescents. International
Journal of Clinical and Health
Psychology, 2005:5:485-498.
* Dept of Psychiatry, Hospital
Sentosa, Kuching, Sarawak
** Dept of Psychiatry,
*** Women’s Health Development Unit,
School of Medical Sciences, Universiti
Sains Malaysia.
28
MJP 2008, Vol.17 No.1
Correspondence:
Dr Rohayah Hussein,
Dept of Psychiatry,
USM.
E-mail: [email protected]
29
MJP 2008, Vol.17 No.1
ORIGINAL PAPER
PSYCHIATRIC MORBIDITY AND ATTITUDES TOWARDS
MENTAL ILLNESS AMONG PATIENTS ATTENDING PRIMARY
CARE CLINIC OF HOSPITAL UNIVERSITI KEBANGSAAN
MALAYSIA
Riana AR*, Osman CB**, Ainsah O**
ABSTRACT
The prevalence of psychiatric morbidity among patients attending
primary care clinics is high and their attitudes towards psychiatry are
often negative. The objectives of this study were to assess the
prevalence of psychiatric morbidity and attitudes towards mental
illness in relation to socio-demographic factors among primary care
patients. A cross-sectional study was conducted on 245 patients
attending the primary care clinic of Hospital Universiti Kebangsaan
Malaysia at Bandar Tasik Selatan. A two-stage case identification
process was used to detect psychiatric morbidity. The Malay
translation of General Health Questionnaire–30 (GHQ-30) was used
for screening and the Structured Clinical Interview for DSM-IV
(SCID) was used to generate Axis-1 diagnosis. The Attitudes Towards
Mental Illness Questionnaire was used to assess their attitudes
towards mental illness. 8.2% of patients were found to have
psychiatric morbidity, and they were significantly associated with the
younger age group (p<0.05). Nevertheless, there was no significant
association between psychiatric morbidity and sex, race, marital
status, educational level and social class of patients. The attitudes
towards mental illness were significantly associated with age, race,
marital status, educational level, social class and the presence of
family history of psychiatry illness (p<0.05). There was no significant
association between attitudes towards mental illness and patients' sex.
Primary care doctors need to be equipped with psychiatry knowledge
in order not to miss patients with psychiatry morbidity. Patients with
psychiatric morbidity significantly believed in supernatural causes of
mental illness compared with those without psychiatric morbidity.
Keywords: primary care, psychiatric morbidity, attitude towards
psychiatry
30
MJP 2008, Vol.17 No.1
INTRODUCTION
Like many other countries, primary care
setting has been the first-line provider
for health services in Malaysia. This has
been in line with the introduction of
community psychiatric services and the
move towards decentralization of
psychiatric services.
The study of psychiatric disorders in
primary care largely evolved from the
work of Professor Michael Shepherd
(1,2). Since then, many studies had been
published on the topic. Most studies had
applied the two-phase design or the twostage case identification process in
which, an initial sample was screened
for psychiatry morbidity followed by
and a full Structured Clinical Interview.
Among the screening tools used was
General Health Questionnaire (3,4,5).
The prevalence rate of psychiatric illness
in the primary care was found to be
between 25% to 35% (3,4,5,6).
In Malaysia, to the investigator's best
knowledge, there has not been any large
study done on psychiatric morbidity in
primary care settings. However, a few
authors had published their findings on
psychiatric morbidity in the community.
Amin S.M. et al. (1997) had studied the
heads of household in five villages in a
district of Kota Samarahan in Sarawak
using General Health Questionnaire–30
(GHQ-30) and noted that 24.7% fall into
those groups with probable psychiatric
morbidity (7). Rashid Y.N et al. (2000)
had conducted a psychiatric morbidity
assessment on students from three
different secondary schools and a
university in Kelantan. It was found that
the university students had a higher
GHQ-30 score than the school students
(8).
Varma S.L and Azhar M.Z (1995) had
conducted a study on psychiatric
symptomatology in a primary health
setting in two districts in Kelantan i.e.
Bachok and Tumpat. Patients, who
attended the primary care centres, as
well as a key family member, were
screened using a mental health item
sheet to determine the presence of
psychiatric
symptomatology.
They
reported that 13.2% had depressive
symptoms, 8.2% had hypochondriacal
symptoms, 6.1% had anxiety symptoms
and 5.1% had sleep disturbance (9).
Razali S.M. et al. (1996) had studied the
concept of aetiology of mental illness in
134 Malay patients in Kelantan,
Malaysia. About 53% of the patients
attributed their illnesses to supernatural
agents
whereby
witchcraft
and
possession by evil spirits were regarded
as the common causes (10). This belief
was not significantly associated with
age, gender, level of education or
occupation of the patients. The number
of patients who believed in the
supernatural cause of mental illness was
significantly higher among those who
had consulted ‘bomoh’ (traditional
healer) than among those who had not
consulted them. The patients who
believed in the supernatural cause of
mental illness were also found to show
poor drug compliance (10).
In Singapore, Kua E.H. et al. (1993)
studied the illness behaviour among 100
Chinese psychiatric patients. He reported
that 22% of the patients believed that
they were possessed by spirit (11). A
study on community health workers in
South India using a case vignette
reported that a significant proportion of
them did not recognize chronic
31
MJP 2008, Vol.17 No.1
psychosis as a disease condition,
believing that it was caused by black
magic, evil spirits and poverty, and felt
that doctors could not help (12).
METHODOLOGY
Negative attitudes towards mental illness
will not only influence treatment seeking
behaviour, but also interfere with the
implementation of community-based
care. A popular belief among the public
is that mentally ill people are aggressive.
Therefore, the family or caregivers
would insist for the patient to be
admitted to the ward. Many studies had
reported the association between
sociodemographic factors and attitudes
towards mental illness (13,14,15).
Female, those with high education and
those from high social status were
reported to be more sympathetic and
more tolerant towards the mentally ill. A
group of workers had done a study to
examine the effects of a lecture on
mental health on public attitudes towards
mental illness in Japan. They concluded
that an educational lecture on mental
health and welfare was effective in
reducing stigma attached to mental
illness and disorder (16).
This study was conducted at the primary
care clinic of Hospital Universiti
Kebangsaan Malaysia (HUKM) which is
located in Bandar Tasik Selatan, Cheras,
Kuala Lumpur.
In this study, patients attending the
primary care clinic of Hospital
Universiti Kebangsaan Malaysia in
Bandar Tasik Selatan were screened for
psychiatric morbidity and their attitudes
towards mental illness were assessed.
The relationship between having
psychiatric morbidity and the attitudes
towards mental illness was looked into.
The findings obtained could be used to
assist managers plan the psychiatric
services at primary care levels. The
managers could also identify the target
population and the content of the
awareness program.
Study setting and design
This is a cross-sectional study conducted
from the first week of February 2004 to
the first week of June 2004. The sample
size calculation was based on the
formula;
sample
size
=
n/(1(n/population)) with power of study
equivalent to 80% and the standard error
was 0.05. The calculation was done by
using Epi-Info 6 software. The
calculated samples were 246.
All consecutive patients underwent the
initial screening and all subjects who
fulfilled the inclusion criteria were
selected for this study. The patients were
explained about the study and written
permission was obtained. They were
assured of their anonymity and the
confidentiality of the data. A coding
system was used to identify the subject.
Inclusion criteria include all patients
between 18 to 65 years and those who
have a sufficient command of the Malay
or English language. The exclusion
criteria include those who could not
understand the Malay or English.
Data collection
This study applied a two-stage case
identification process i.e. a screening
instrument followed by a structured
psychiatric interview. In the first stage,
the Malay version of General Health
32
MJP 2008, Vol.17 No.1
Questionnaire (GHQ-30) (17) was used
to screen the selected patients for the
presence of probable psychiatric
morbidity. At the same time, they were
interviewed using a standard form
containing sociodemographic variables
and a questionnaire for assessment of
their attitudes towards mental illness.
All patients with a screening score of
eight or greater (Abdul Hamid A. R. and
Mohamed Hatta S, 1988) (17) or with a
history of psychiatric illness proceeded
to the second stage where they were
interviewed
for
the
psychiatric
diagnosis. The investigator used the
Structured Clinical Interview for DSMIV (SCID) (18) to make the diagnosis.
The investigator was trained to use SCID
by a senior consultant psychiatrist who
was trained to use the diagnostic
instrument. In this study, a psychiatrist
was called in to assess the patient
together in the ratio of one in four. It was
found that the diagnosis made by the
investigator was similar to the diagnosis
made by the psychiatrist.
Attitudes Towards
Questionnaire
Mental Illness
This is a 10-item guided questionnaire
assessing the attitudes towards local
psychiatric practice and mental illness.
There are four questions that are related
to psychiatric practice and another six
are linked to mental illness. The
participants were required to answer all
the questions based on four scales i.e.
never true, seldom true, often true and
always. This questionnaire was devised
by Razali S.M. (1998) (19), a local
psychiatrist who had used the
questionnaire in a local setting. The
permission to use the questionnaire was
obtained from him.
Definition of variables
Psychiatric morbidity
The subject is said to have a psychiatric
morbidity if the GHQ-30 score is eight
or more, or if the subject has a history of
psychiatric illness.
Instruments
Educational level
Sociodemographic Data
1. No education was referred to those
who never had any formal education.
2. A primary school level was referred to
standard one to standard six.
3. A lower secondary level was referred
to those who had education, 9 years or
less that was from form one to form
three.
4. An upper secondary level was referred
to those who had education, 11 years or
less.
5. A higher secondary level was referred
to those who had education, 13 years or
less.
6. A tertiary education level was for
those who obtained a degree or diploma.
Sociodemographic data were assessed
using a brief questionnaire to obtain
information on names, age, sex, marital
status, educational level, employment
status, monthly family incomes, family
history of psychiatric illness and
patient's history of psychiatric illness.
The Malay version of General Health
Questionnaire–30 items (GHQ-30)
Structured Clinical
DSM-IV (SCID)
.
Interview
for
33
MJP 2008, Vol.17 No.1
Monthly family income
Statistical analysis
Monthly family income was referred to a
combination of husband and wife
monthly income. For those who were
still single and studying, monthly family
income was referred to the parents' total
income. For unemployed widows or
divorcee, it was referred to the income of
the children that she was staying with.
Based on the incomes, the patients'
social class can be classified (Abdul
Kadir A. B., 1991) (20).
Analysis of the data was done by using
the computer program, Statistical
Package for Social Studies (SPSS)
Version 11.5). The relationship between
the studied parameters were analysed
using the appropriate statistical test. The
parametric test was used to determine
the significant difference between two
groups for data that is normally
distributed, this include t-test and Chisquare while non-parametric test was
done for data which was not normally
distributed i.e Mann-Whitney U-test and
Kruskal-Wallis test.
Social class
I
II
III
IV
V
RM 2000 and more
RM 1000 - RM 1999
RM 500 – RM 999
RM 200 – RM 499
Less than RM 200
Race
Others were referred to the minority
ethnic group i.e. Kadazan.
Marital status
For statistical analysis, the marital status
was divided into two groups only.
1. Married
2. Non-married were referred to the
subjects who are single, divorced or
widowed.
History of psychiatric illness
The patient was said to have a history of
psychiatric illness when:
1. they have a history of consulting a
medical doctor for a psychiatric disorder
in the past and present.
2. the past history suggestive of
psychiatric disorder (based on clinical
interview) but had never consulted a
psychiatrist.
Ethical consideration
This research project was approved by
the Research Committee, Faculty of
Medicine,
Universiti
Kebangsaan
Malaysia. The purpose of this study was
explained to the subjects and written
permission was obtained from them.
Those who were found to have
psychiatric disorder were referred to the
psychiatric clinic for further evaluation
RESULTS
250 patients who attended the primary
care clinic of HUKM in Bandar Tasik
Selatan, Cheras, Kuala Lumpur were
invited to participate in the study.
However, five patients were unable to
complete the study because of reasons
such as unable to make the time (three
patients) and did not feel comfortable
with the questions (two patients).
Therefore, the response rate was 98%
with total subjects of 245.
34
MJP 2008, Vol.17 No.1
Sociodemographic data
Table 1 shows that 29.8% (n=73) of the
respondents were in the age group of 5059 years old, 22.9% (n=56) in the group
of 40-49 and 18.8% (n=46) in the group
of 30-39 years. The mean age was 44.8
(sd=12.4) years. Majority of the patients
were female (n=156, 63.7%). 69.4%
(n=170) were Malays, 20.8% (n=51)
were Chinese and 9% (n=22) were
Indians. Majority of the patients were
married (n=204, 83.3%).33.9% (n=83)
of respondents had their education until
upper secondary level and 24.5% (n=60)
until tertiary level (Table 2). 61.7%
(n=151) of them were employed and
most were government servants. Half of
the patients (n=132, 53.9%) had monthly
family income of RM2000 and more.
4.5% (n=11) of patients had a history of
psychiatric illness. Majority of the
patients (n=234, 95.5%) did not have
any psychiatric morbidity. The mean
GHQ score was 1.94 (sd=3.46).
Psychiatry diagnosis among patients
with psychiatry morbidity
The 20 patients who were found to have
psychiatric morbidity based on the initial
screening were further interviewed for
psychiatric diagnoses using Structured
Clinical Interview for DSM-IV (SCID).
Majority of the patients had mood
disorder. 10% (n=2) of the patients were
diagnosed to have major depressive
disorder and 15% (n=3) had dysthymia.
5% (n=1) had major depressive disorder
with dysthymia. 35% (n=7) were
diagnosed to have lifetime major
depressive disorder. Only 5% (n=1)
were found to have anxiety disorder i.e.
generalized anxiety disorder. 30% (n=6)
of patients were diagnosed to have
adjustment disorder relating to family,
job or financial problems. 10.3% of
female
patients
had
psychiatric
morbidity as compared to only 4.5% of
male patients. However this finding was
not statistically significant.
The distribution of the race of the
patients with psychiatric morbidity.
For statistical analysis, the Chinese,
Indian and the others groups were
combined as non-Malay and when this
was compared with Malay, they were no
significant difference. 18.3% of the
married patients were found to have
psychiatric morbidity whereby only
7.3% of the non-married group (single,
divorcee, widow) had psychiatric
morbidity. However, statistical test
revealed no significant difference in the
marital status of the patients with
psychiatric morbidity. There was no
significant difference in the level of
education of the patients with psychiatric
morbidity and without psychiatric
morbidity. There was also no significant
difference in the monthly family
incomes of patients with psychiatric
morbidity and without psychiatry
morbidity.
The attitude towards mental illness
Table 3 shows the frequency and
percentage of responses of all the
respondents to each of the questionnaire.
Majority of them did not think that
consulting a psychiatrist is a stigma
(no.1), and they would not bring their
relatives to ‘bomoh’ (traditional healer)
first for their mental illness (no.2), and
majority of them also thought that
chronic schizophrenia cannot be
managed at home (no.3).
35
MJP 2008, Vol.17 No.1
Table 1: Sociodemographic characteristics of the patients
Variables
Characteristics
Number
Percentage (%)
Age
< 20
20-29
39-39
2
36
46
8.0
14.7
18.8
40-49
50-59
60-65
56
73
32
22.9
29.8
13.1
Sex
Male
Female
89
156
36.3
63.7
Race
Malay
Chinese
Indian
Others
170
51
22
2
69.4
20.8
9.0
0.8
Marital status
Single
Married
Divorced
26
204
4
10.6
83.3
1.6
Widow
11
4.5
No education
12
4.9
Primary
Lower Secondary
Higher Secondary
Upper Secondary
Tertiary
39
33
17
85
59
15.9
13.9
6.9
33.9
24.5
Private
Government
42
89
17.1
36.3
Self-employed
Labourer
Student
19
1
5
7.8
0.4
2.0
Housewife
49
20.0
Unemployed
40
16.3
Present
Absent
11
234
4.5
95.5
Educational level
Employment
History of
Psychiatry illness
36
MJP 2008, Vol.17 No.1
Table 2: Distribution of the mean age, sex, race, education level, marital status and
family income among patients with or without psychiatry morbidity
Sociodemographic
Profile
Psychiatric morbidity
N (%)
Present
Absent
Total
Number of
Patients
Mean age
20
39.40±11.20
245 (100)
225
45.20±12.30
t-test
Chi-Square
N(%)
t=2.051p
=0.04*
Sex
Male
Female
4 (4.5)
16 (10.3)
85 (95.5)
140 (89.7)
89 (100)
156 (100)
2.510
p=0.113
13 (7.6)
157 (92.4)
170 (100)
0.197
68 (90.7)
75 (100)
p=0.657
Race
Malay
Non-Malay
Educational
level
No education &
Primary
7 (9.3)
1 (20)
50 (98)
Secondary
11 (8.2)
123 (91.8)
134 (100)
51 (100)
4.757
Tertiary
education
8 (13.3)
52 (86.7)
60 (100)
p=0.093
Marital status
Married
Non-married
17 (18.3)
187 (91.7)
204 (100)
0.047
3 (7.3)
38 (92.7)
41 (100)
p=0.828
8 (7.1)
105 (92.9)
113 (100)
0.329
12 (9.1)
120 (90.9)
13 2(100)
p=0.567
Family income
< RM2000
≥RM2000
*p<0.05
37
MJP 2008, Vol.17 No.1
Table 3: The frequency and percentage of response to the 10-item questionnaire
Response
Questionnaire no.
Never true
Seldom true
Often true
Almost always true
n (%)
n (%)
n (%)
n (%)
1
213 (86.9)
24 (9.8)
6 (2.4)
2 (0.8)
2
200 (81.6)
26 (10.6)
18 (7.3)
1 (0.4)
3
105 (42.9)
105 (42.9)
30 (12.2)
5 (2.0)
4
74 (30.2)
137 (55.9)
30 (12.2)
4 (1.6)
5
69 (28.2)
127 (51.8)
43 (17.6)
6 (2.5)
6
147 (60)
94 (38.4)
3 (1.2)
1 (0.4)
7
136 (55.5)
89 (36.3)
18 (7.3)
2 (0.8)
8
47 (19.2)
115 (46.9)
78 (31.8)
5 (2.0)
9
79 (32.2)
31 (12.7)
127 (51.8)
8 (3.3)
10
24 (9.8)
25 (10.2)
184 (75.1)
12 (4.9)
Relationship between
sociodemographic characteristics and
attitudes towards mental illness
a. Age and attitudes towards mental
illness
The higher percentage of young patients
would bring their relatives to ‘bomoh’
first and they believed that hysteria was
caused by possession of evil spirit as
compared with the middle-aged and
elderly. These findings were found to be
significantly different by the MannWhitney test (p<0.05).
b. Sex and attitudes towards mental
illness
of the items when tested using the
Mann-Whitney test.
b. Race and attitudes towards mental
illness
By using the Mann-Whitney test there
was a significant difference between the
Malays and non-Malays in questionnaire
number 2, 5, 7 and 9 (p<0.05). Higher
percentage of the Malays would bring
their relatives to ‘bomoh’ first for their
mental illness. They believed that
charming or witchcraft can cause mental
illness. They believed that ‘bomoh’ is
more competent than psychiatrists in
treating hysteria, and they would see a
psychologist rather than psychiatrist to
solve their problem.
There was no significant difference
between male and female patients in any
38
MJP 2008, Vol.17 No.1
c. Marital status and
towards mental illness
attitudes
There was a higher percentage of the
non-married respondents did not think
that schizophrenia was aggressive and
dangerous to family members compared
with the married respondents. This was
significantly different with the MannWhitney test (p<0.05).
d. Monthly family incomes and
attitudes towards mental illness
By using the calculation of MannWhitney test the difference between
those earning RM2000 or more and
those earning less than RM2000 in items
2, 3 and 5 was found to be significant
(p<0.05). Higher percentage of those
who earned RM2000 or more would not
bring their relatives to ‘bomoh’ first for
their mental illness than those who
earned less than RM2000 and they also
did not think that hysteria was caused by
possession of evil spirit. They did not
believe that charming or witchcraft
could cause mental illness.
f. Family history of mental illness
and attitudes towards mental
illness
There was a higher percentage of
patients with a family history of mental
illness
thought
that
chronic
schizophrenia only at times cannot be
managed at home, and this was
significantly different by the MannWhitney test (p<0.05).
Relationship between psychiatric
morbidity and attitudes towards
mental illness
By using Mann-Whitney test, the only
significant difference (p<0.05) found in
the patients with and without psychiatric
morbidity was their beliefs that
charming or witchcraft can cause mental
illness. There was a higher percentage of
those with psychiatric morbidity
believed that charming or witchcraft can
cause mental illness comparing to those
without psychiatric morbidity.
DISCUSSION
e. Level of education and attitudes
towards mental illness
Higher percentage of patients with
secondary and tertiary education would
see a psychologist rather than
psychiatrist to solve their problems. This
was significantly different by using the
Kruskal-Wallis test (p<0.05).
This study made an attempt to examine
at the presence of psychiatric morbidity
and the attitudes towards mental illness
at the primary care setting. At the same
time,
the
relationship
between
sociodemographic
factors
and
psychiatric morbidity as well as the
attitudes towards mental illness were
examined. It was conducted in only one
centre i.e. primary care clinic of Hospital
UKM. It is a semi-government clinic
that charges a higher pay for the
consultation
fee,
laboratory
39
MJP 2008, Vol.17 No.1
investigations
and
medications
compared with
government clinics.
Thus, not many people from lower
socioeconomic status attended this clinic
and this might affect our findings related
to sociodemographic variables and the
lower prevalence rate of psychiatry
morbidity. Previous studies have shown
that the prevalence of psychiatric
illnesses is higher in lower social class
(3,6).
Several sampling bias were identified in
this study. Due to the investigator’s
tremendous clinical workload, the
samples were collected only from two
sessions of the clinic i.e. Tuesday
morning and Wednesday morning in a
week.
Only patients who entered one particular
consultation room in the clinic during
the day of the sample collection were
invited to join this study and only those
patients who could either understand
English or Malay were selected for the
diagnostic interview using SCID. Even
then, there is a possibility of
misinterpretation of the questions and
giving incorrect information. But this
was minimized by having an interpreter
whenever possible. Some patients did
not take the questionnaire seriously.
Some rushed to complete the study
because of the time factor. It is
suggested that in the future, home visit
should be done to interview these
subjects who could not provide longer
time during the clinic session.
Being a cross-sectional study, it is not
possible to identify factors that are truly
predictive of psychiatric morbidity and
attitudes towards mental illness because
the study design does not allow
discrimination of “cause and effect”.
In this study, patients were detected to
have “anxiety-depressive disorder”
ranging from major depressive disorder,
generalized anxiety disorder and
adjustment disorder. This demonstrated
the need for the primary care doctors to
be able to identify patients with
psychiatry disorders and to treat them
accordingly. By increasing the number
of doctors in the primary care clinics, it
could reduce the heavy workload and
they could spend more time to elicit
psychiatric symptoms in patients. In
addition, adequate budget should be
allocated for new medications used in
the primary care clinic.
Whilst the previous local studies were
done on health personnel who were
familiar with the technical terms, our
study’s respondents were from the
patients attending the primary care
clinic. Razali S.M. (1998) (19) had
compared the attitudes towards mental
illness between the medical students and
nursing students using a self-devised 10item questionnaire. Ahmad H. et al.
(2004) (21) had used a case vignette
depicting a man with schizophrenia, and
two dependent measures i.e. social
distance scale and dangerousness scale
to look into the attitudes of paramedics
(nurses and medical assistant) towards
the mentally ill.
Study on public attitudes towards mental
illness and the mentally ill done abroad
had used the Community Attitudes
towards Mentally Ill (CAMI) inventory
(15), the ‘Star Vignettes’ (22) and selfconstructed vignettes (23). Link B.G. et
40
MJP 2008, Vol.17 No.1
al (1999) had created a set of vignettes
based on DSM-IV criteria. The vignettes
depicted people with schizophrenia,
major depressive disorder, alcohol
dependence, drug (cocaine) dependence
and a “troubled person” with sub-clinical
problems and worries. They were used
to assess (1) recognition of mental
illnesses, (2) beliefs about the causes of
mental illnesses, (3) beliefs about how
dangerous people with mental illnesses,
and (4) the amount of social distance
desired from people with mental
illnesses. The questionnaire and
vignettes did not use medical or
technical terms, and thus, should be
easily understood by the public.
The authors had decided to use the 10item questionnaire on attitudes towards
mental illness devised by Razali S.M.
(1998) (19) because it was easier and
less time-consuming. Furthermore, it had
been used locally. Though, it contained
some technical terms such as hysteria,
ECT, schizophrenia and psychologist;
those terms can be explained easily to
the public.
The questionnaire is
however, has it’s limitations in assessing
the public attitudes towards mental
illness.
Generally,
it
was
not
comprehensive and the questions were
limited to only two disorders i.e. hysteria
and schizophrenia. There was no specific
question on major depression or anxiety
though they are common disorders.
It
was
noted
that
certain
sociodemographic factors had an effect
on the attitudes towards mental illness.
Thus, any intervention to improve the
public attitudes should be aimed towards
those with these identifiable factors. It
was also noted that there were some
aspects of the mental illness that were
viewed most negatively by them.
Therefore, emphasis should be made on
these particular aspects when dealing
with the public. In this study, majority of
patients,
regardless
of
their
sociodemographic factors, believed that
chronic schizophrenia could not be
managed at home. Therefore, a more
intensive action should be taken to
introduce them to the availability of
community mental health service and to
provide continuous education from time
to time.
This study had also shown that patients
with psychiatric morbidity did not have
better attitudes towards mental illness
compared to patients without psychiatric
morbidity. Any educational or awareness
program should pay more attention to
them, as their attitudes will have an
effect on the outcomes of the illness.
ACKNOWLEDGEMENT
Authors would like to thank all patients
who have agreed to participate in this
study.
REFERENCES
1. Acheson ED. Introduction. Shepherd
M, Wilkinson G, Williams P. (editors).
Mental Illness in Primary Care Setting.
First Edition London: Tavistock
Publications. 1986.
2. Buszewicz M, Mann A. Psychiatry
and Primary Care (Social, Community
And Public Health Psychiatry). Current
Opinion in Psychiatry, 1997:10:2:168172.
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3. Kessler LG, Cleary PD, Burke JD.
Psychiatric Disorders in Primary Care:
Results of Follow-up Study. Archives of
General Psychiatry, 1985:42:583-587.
4. Bellantuono C, Fiorio R, Williams P,
Cortina P. Psychiatric Morbidity in an
Italian Practice. Psychological Medicine,
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5. Vazquez-Barquero JL, Garcia J,
Simon JA, Iglesias C, Montejo J, Herran
A, Dunn G. Mental Health in Primary
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Morbidity and Use of Health Resources.
British Journal of Psychiatry, 1997:170:
529-535.
6. Barrett JE, Barrett JA, Oxman TE,
Gerber PD.
The Prevalence of
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Practice.
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7. Amin SM, Hushaimi B, Syed Hassan
A. Recognizing people with psychiatry
problems in community. Malaysian
Journal of Psychiatry, 1997:5:2:50-54.
8. Rashid YN, Azhar, MZ, Noor Jan.
Psychiatric
Morbidity
Assessment
among Students. Malaysian Journal of
Psychiatry, 2000:8:2: 31-38.
9. Varma SL, Azhar MZ. Psychiatric
Symptomatology in a Primary Health
Setting in Malaysia. Medical Journal of
Malaysia, 1995:50:1:11-16.
treatment. Acta Psychiatrica
Scandinavica. 1996:94: 229-233.
11. Kua EH, Chew PH, Ko SM. Spirit
Possession and Healing Among Chinese
Psychiatric Patients. Acta Psychiatrica
Scandinavica, 1993: 88: 447-450.
12. Joel D, Sathyaseelan M, Jayakaran
R, Vijayakumar C, Muthuratnam S,
Jacob KS.
Exploratory Models of
Psychosis among Community Health
Workers in South India.
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Psychiatrica Scandinavica, 2003:108:
66-69.
13. Taylor SM, Dear MJ. Scaling
Community Attitudes Toward the
Mentally Ill. Schizophrenia Bulletin,
1981:7:2:225-240.
14. Brockington IF, Hall P, Levings J,
Murphy C. The Community’s Tolerance
of the Mentally Ill. British Journal of
Psychiatry, 1993:162: 93-99.
15. Wolff G, Pathare S, Craig T, Leff J.
Community Knowledge of Mental
Illness and Reaction to Mentally Ill
People.
British
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Psychiatry,1997:1682:191-198.
16. Tanaka G, Ogawa T, Inadomi H,
Kikuchi Y, Ohta Y. Effects of an
Educational Program on Public Attitudes
towards Mental Illness. Psychiatry and
Clinical Neurosciences, 1996:57: 595602.
10. Razali SM, Khan UA. Hasanah CI.
Belief in Supernatural Causes of Mental
Illness among Malay patients: impact on
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17. Abdul Hamid AR, Mohamed Hatta
SA. Validation Study of the Malay
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18. American Psychiatric Association.
Diagnostic and Statistical Manual of
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DC: American Psychiatric Association.
19. Razali SM. Attitudes Towards
Psychiatrists, Traditional Healers and
Mental Illness. Malaysian Journal of
Psychiatry, 1998:62:29-35.
*
Department of Psychiatry, Taiping
General Hospital lllllllllllllllllllllllll
**
Department of Psychiatry, Faculty
of Medicine, UKM
Correspondence:
Dr Osman Che Bakar.
Clin Assoc. Professor and Senior
Lecturer,
Faculty of Medicine, UKM,
Bandar Tun Razak, Cheras,
Kuala Lumpur.
Email: [email protected]
20. Abdul Kadir AB. Prevalence of
Psychiatric Illness in Patients with
Breast Cancer. Thesis Master Med
(Psych).
Universiti
Kebangsaan
Malaysia. 2001.
21. Ahmad H, Mas Ayu Rawiyah R.
Attitudes of Paramedics Towards
Mentally Ill Patients. Malaysian Journal
of Psychiatry, 2004:12:1: 25-31.
22. Dohrenwend BP and Chin-Shong E.
Social Status and Attitudes Towards
Psychological Disorder: The Problem of
Tolerance of Deviance. American
Sociological Review, 1967:32: 417-433.
23. Link BG, Phelan, J, Bresnahan M,
Stueve A, Pescosolido BA.
Public
Conceptions of Mental Illness: Labels,
Causes, Dangerousness, and Social
Distance. American Journal of Public
Health, 1999:89:9: 1328-1333.
43
MJP 2008, Vol.17 No.1
ORIGINAL PAPER
Satisfactory And Achievement In Basic Sciences Among Postgraduate
Psychiatry Candidates Attending Universiti Kebangsaan Malaysia’s
Revision Course - A Short Report.
Hatta Sidi*
Abstract
Satisfaction on teaching in basic science is an important element for
academic performance in final postgraduate examination. Basic
sciences is an important subject in bridging understanding in clinical
psychiatry but often poses difficulties among young postgraduate
trainees, especially if they have not been exposed frequently to the
topic areas like integrative neuroanatomy, neurophysiology and
neurochemistry. Simple questionnaire regarding satisfaction on
teaching was asked to 17 postgraduate candidates from Universiti
Kebangsaan Malaysia (UKM) and Universiti Malaya (UM) and their
MCQ paper performance was obtained to validate between
satisfaction on teaching and their academic achievement. This simple
descriptive study was to determine areas of difficulties and teaching
satisfactory levels on basic sciences. Moderately satisfied candidates
scored better on basic sciences topic compared to candidates with low
and high satisfaction ((Mean, SD = 49.7 ± 4.5, 41.6 ± 5.9 and 39.6
± 0) respectively. Recommendation avenues for improvement in the
near future, especially concerning the ongoing revision course that is
organized by the Department of Psychiatry, Universiti Kebangsaan
Malaysia was briefly discussed.
Keys words: satisfaction, postgraduate psychiatry, training
INTRODUCTION
Postgraduate psychiatry is a subspecialty
overlapping medicine, psychology, basic
sciences and sociology. Recently the
course has attracted many young doctors
to choose psychiatry as their future
career. Since Malaysia independence,
postgraduate
training
programs have been started in local
universities, first in Universiti Malaya
(UM) and followed by Universiti
Kebangsaan Malaysia (UKM) in the
1970s and 1980s respectively, to fulfil
specialist needs in our local psychiatric
services. Since then, the Masters
program organized by the two local
universities have trained a substantial
number of specialists to fill vacancies in
the local hospitals and mental institution
posts with latest Universiti Sains
44
MJP 2008, Vol.17 No.1
Malaysia (USM) offering a masters
degree program in psychiatry. A Master
degree in psychiatry is called either
Master of Medicine in Psychiatry
[MMed(Psych.)] as offered by UKM and
USM, or Master of Psychological
Medicine [MPM] as offered by UM
[1,2].
The master degree – as an equivalent to
the MRCPsych, is a recognized
qualification required for a Malaysian
doctor to hold a post as a specialist in a
psychiatric institution. The minimum
years required to complete a master
degree is four years. The program
consists of three parts: Part I, Part II and
Part III. Part I is a one year and at the
end of this period the postgraduate
resident is examined in basic sciences
such as neuroanatomy, neurophysiology,
psychology, statistics and epidemiology,
genetics,
immunology
and
neuropathology. Clinical aspects of
psychopathology and clinical psychiatry
were also included. In the current
conjoint
psychiatry
examinations,
clinical examination in the form of short
cases has been incorporated in Part I.
Part II and part III encompass written
papers, clinical and oral examinations,
and submission of research thesis at the
end of the program.
In postgraduate psychiatry, both theory
and clinical aspects are assessed during
examinations to help the educationist
validate students’ knowledge and
competencies [3]. The format of
examination was designed by the local
academicians, with part of it was
adapted
from
the
MRCPsych
examination style. Minimal changes
were introduced recently, for example, a
section on critical appraisal was
incorporated in the Part II exam paper.
For the Part I theory papers, multiple
choice questions (MCQ) make up the
components for testing the amount and
depth of the candidate’s critical thinking
in theoretical concerns, consisting of
MCQ theory paper I and II. Paper I
MCQ exam usually consists of basic
sciences
such
as
neuroanatomy,
neurophysiology,
neurochemistry,
genetics,
neuropathology
and
immunology. Paper II MCQ usually
consists of areas such as psychology,
sociology,
ethology,
statistics,
epidemiology, psychopathology and
general psychiatry.
Multiple choice questions (MCQ) or
items are a form of assessment where
candidates are asked to select one or
more of the choices from a list [4]. This
type of question is used in education,
market research as well as other areas.
Frederick J. Kelly is credited with
creating multiple choice questions in
1914 at the University of Kansas. Unlike
essays and orals, the well-constructed
MCQ format excludes the subjective
bias of examiners and ensures all
candidates are examined on the same
material [5]. For a candidate who lacks
essential learning skills or fails to apply
active strategies, multiple choice exams
can be extremely difficult [5,6]. Some
candidates have even gone as far as to
label themselves incapable of answering
multiple choice exams effectively. Some
have even taken the step of opting out of
a major area of study to avoid having to
take exams in this format. However in
postgraduate psychiatry, students cannot
escape the MCQ papers and they have to
adjust their style of learning and
studying to equip themselves better for
these often difficult exams [5,6]. Debate
on this issue has been growing out of a
need to have an objective method of
45
MJP 2008, Vol.17 No.1
assessing and ranking candidates in
psychiatry examinations [6,7] especially
in part II examination.
This study aims to assess the satisfactory
levels
and
achievement
among
postgraduate psychiatry candidates on
basic sciences of the part I MCQ paper.
METHODS AND MATERIALS
This was a descriptive cross-sectional
study which was carried out on data
obtained from a group of postgraduate
psychiatry students from Universiti
Kebangsaan Malaysia (UKM) and
Universiti Malaya (UM) who were
attending a revision course organized by
the Department of Psychiatry, UKM on
8th Mac 2006 and 5th April 2006.
Revision Course in Psychiatry is an
annual intensive course organized by the
Department of Psychiatry, UKM to help
postgraduate psychiatry examination
candidates to refresh and consolidate
their knowledge on basic sciences and
clinical psychiatry. It was first initiated
by the first author in the year 2000 and
the basic sciences were usually taught by
psychiatrists and lecturers experienced in
teaching those subject areas for many
years.
The candidates attended this revision
course were psychiatry trainees from
UKM, UKM and USM. Lecturers from
the Department of Psychiatry, UKM
contribute to this program from time to
time, such as by facilitating seminars
and coordinating simple mock clinical
examinations. Candidates from UKM,
UM and USM sitting for part I exam and
who had completed their lectures and
training in basic sciences were invited to
attend this course which was held in
Hospital UKM’s library, meeting rooms
and auditorium. The candidates were
required to pay minimal course fees
covering their meals and some
honorarium for the participating
lecturers.
A set of MCQs (consisting of 45 items,
totaling in 45 x 5 = 200 statements) was
retrieved from a large MCQ mock
examination question bank randomly,
consisting
of
questions
on
neuroanatomy,
neurophysiology,
psychology, statistics and epidemiology,
genetics, immunology, neuropathology,
psychopathology and general psychiatry.
The mock MCQ paper was a modified
version of this. No mock MCQ questions
were allowed to be taken out from the
room before, during and after discussion.
This set of MCQ was reviewed twice by
a group of consultant psychiatrists and
lecturers
from
the
psychiatry
department, between year 2001 and
2004. Out of 17 candidates attended this
MCQ workshop during the above period
and participated in this research, 11
candidates are from UKM, with the
remaining from UM. No candidates from
USM attended due to a distance and
logistic problem. All 17 candidates
attempted all 40 MCQ given to them and
11
questionnaires
on
teaching
satisfactory levels. llllllllllllllllllllllllll
Calculation on how to score the marks in
percentage for MCQ was quoted
elsewhere
[8]).The
satisfactory
questionnaire was basically question
asking : Q. Are you satisfied on the
teaching on basic sciences in the area of
a)neuroanatomy,
b)neurophysiology,
c)neurochemistry,
d)neuropathology,
e)psychology,
f)
aetiology
and
psychiatric genetics, g)stress and
immunology,h)
sychopathology,
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MJP 2008, Vol.17 No.1
i)psychopharmacology, j)statistics and k)
epidemiology? The candidates answered
either satisfied (S), not satisfied (NS)
and not sure (Ns). Each MCQ items (or
question) has 5 statements (A,B,C,D and
E) with marking system of minimum 0
and maximum 5 marks on each item. If
mistake was done, a minus mark was
given with a total of minimum 0 for each
item (eg. if a candidate has 2 correct
answers and 3 incorrect answers on 5
statements, he will get -1 marks but
would appear 0 on that MCQ item). The
total score was calculated based on 17
candidates who make an attempt, eg. the
total scores of 5 x 17 = 85. A few
candidates refused to answer one or two
statement in a given MCQ item and he
ended up with 0 marks on that particular
statement/s, as they would get minus
marks for each wrong answer. The
following result was tabled in Table1.
Table 1. The profile of satisfactory
levels on basic sciences teaching and
scoring marks in various domains of
basic sciences in 17 candidates from
UKM and UM.
Topic / areas
1
Neuroanatomy
Satisfactory
levels of
teaching
(N=17)
(S=satisfied
; NS=not
satisfied;Ns
= not sure)
(S= 0,
NS=17)
MCQ
mean
marks ±
standard
deviation
score
(Percenta
ge of
MCQ
scorings,
%)
42.5 ± 2.9
3
Neurochemistry
2
Neurophysiology
4
38.5 ± 4.9
Neuropathology
Satisfactory
level = 0/17
x 100 = 0%
(S=0,
NS= 17)
28.5 ± 4.9
(33.5%)
5
6
7
Psychology
Aetiology &
psychiatric
genetics
Stress &
immunology
Satisfactory
level = 0/17
x 100 = 0%
(S= 3,
NS=14)
Satisfactory
level = 3/17
x100 =
17.6%
(S=2,
NS=15)
39.6 ±
4.5
(46.6%)
38.5 ± 0.7
(45.3%)
Satisfactory
level = 2/17
x 100 =
11.8%
(S= 0, Ns =
2, NS = 15)
32 ± 3.5
(37.6%)
8
Psychopathology
Satisfactory
level = 0/17
x 100 = 0%
(S= 10,
NS=7)
33.7 ± 9.1
(39.6%)
9
Psychopharmaco
lo-gy
Satisfactory
level =
10/17 x 100
= 59%
(S=2, NS=
15)
44 ± 4.2
(51.8%)
10
47.2 ±
10.3
(55.5%)
(45.3%)
(50%)
Satisfactory
level = 0/17
x 100 = 0%
(S=2,
NS =15)
Satisfactory
level = 2/17
x 100 =
11.8%
(S= 0,
NS=17)
Statistic
Satisfactory
level = 2/17
x 100 =
11.8%
(S=0, NS=
17)
33.7 ± 8.2
(39.6%)
Satisfactory
level = 0/17
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MJP 2008, Vol.17 No.1
x 100 = 0%
11
Epidemiology
(S=0, NS=
17)
39 ± 1.0
(43.5%)
Satisfactory
level = 0/17
x 100 = 0%
Questionnaire on satisfactory level (S=
satisfied, NS = not satisfied, Ns = not
sure) was answered by all candidates and
scored on 1st column. Subsequently 40
MCQ items was asked, with each items
scores minimum 0 and maximum 5
statement questions x 17 = 85 marks,
with scored individual percentage marks
on each items at 2nd column.
Table 2. Summary of satisfactory levels
and MCQ achievement
Satisfactory
levels
Very dissatisfied
(satisfactory levels
= 0%)
Moderately
dissatisfied
(satisfactory levels
= 11.8 – 17.6 %)
Satisfied
(satisfactory levels
= 59 %)
Mean (± SD)
percentage scores
on MCQ
41.6 ± 5.9 %
49.7 ± 4.5 %
39.6 ± 0 %
Looking at the above simple descriptive
data in Table 2, moderately satisfied
candidates on basic sciences topic
generally scores higher (49.7 ± 4.5%)
compared to higher and poorly satisfied
candidates (39.6 ± 0% and 41.6 ±
5.9%) respectively. kkkkkkkkkkkkkkkkk
DISCUSSION
Examination at postgraduate level can be
very anxiety provoking, especially in the
MCQ paper, which tests vast areas of
knowledge ranging from basic sciences
to clinical syndromes in psychiatry.
Candidate’s satisfaction in teaching can
affect their morale and confidence level.
Despite of poor scoring in MCQ, the
MCQ is still an important instrument and
a crucial way of assessing breadth and
depth of candidate’s knowledge and
critical thinking [5,7]. The advantages
of
having
postgraduate
MCQ
examination in basic sciences would be:
(i) efficiency: multiple choice questions
allow a large amount of material to be
tested in a small amount of time,
encompass wide range of areas in both
basic sciences and general psychiatry,
(ii) universality: most subject matter
can easily be broken down into multiple
choice selections, (iii) neutrality: test
does not allow the grader to introduce
personal bias or misinterpretation. The
disadvantages of MCQ examination
would be (i) ambiguity: failing to
interpret information as the test maker
intended can result in an "incorrect"
response, for example to make the
choice appear to be true despite the
answer being false [9] , (ii) no partial
credit: even if a candidate has some
knowledge of a question, they receive no
credit for knowing that information if
they select the wrong answer, for
example the candidate knows something
but not everything of Type-I error in a
difficult statistics question [10], (iii)
deductive reasoning: candidates may be
able to rule out answers (due to
infeasibility), or even test each answer
individually (especially when dealing
with a statistical result), thereby
increasing the chance of providing a
correct answer without actually knowing
the subject matter.
48
MJP 2008, Vol.17 No.1
Based on the above results (table 1 and
figure 1), perception on satisfactory
teaching can be misleading – and may
reflected confidence levels among young
trainee candidates in postgraduate
psychiatry. Satisfaction on teaching
subject may not always be associated
with good results, but at least it can
improve self-esteem and increase
motivation among our candidates. As
candidates have satisfaction in what they
have done, they would continuously
seeking for knowledge which can
improve clinical aspect of competency.
Future research should be geared
towards intensive and continuous
assessment in both objective assessment
such as MCQ and clinical setting like
short cases examination in psychiatry,
and built the candidates confidence by
much more practice, both in theory
papers and in clinical competency.
There a few limitations of this study. It
is too simplistic to say that this study
adequately bring to light the real
problems in basic sciences and their
satisfaction on teaching areas – as
questions in an area of basic sciences
can be very difficult at times –
depending on whether the candidate read
the particular area being tested.
According to the first author’s
experience in coordinating postgraduate
and revision courses, the basic difficulty
in answering MCQ is not usually based
on the subject itself, but rather due to
inadequacy of knowledge, choosing
answer hastily (based on assumption),
guessing or not meticulous in reading the
statement questions properly. There was
no partial credit on MCQ – as the
candidate’s knowledge can be partially
acknowledged in their theory short
essays and long essays paper, or in
clinical exam. The issues of simplistic
question on satisfactory level – the
dichomotous answer (T/F) rather than
continuous spectrum of likert scales
(mild to fully satisfaction/ severely to
mild dissatisfaction) can be too crude
for
assessment
of
candidate’s
satisfactory level. Future research to
look on likert scale’s continuum of
satisfaction can be more precise in
looking at the crucial areas of difficult
subjects. In our sample, only 17
candidates was assessed – and this is
consider a small numbers – but the
pooled of postgraduate students in
psychiatry are limited.
Based on the authors’ experience,
intensive course in basic sciences should
be held more frequently to assess
student’s competency and pick up weak
student for further supervised guidance
under an experienced consultant
psychiatrist in academic settings.
Candidates must be given a room to
ventilate their worries, and constant
morale support to increase their
concentration in their field of study. The
use of multiple choice questions in
educational fields is sometimes very
anxiety provoking as it tests some details
on most subjects of basic sciences, but
the format remains popular due to its
utility [9].
In summary, the MCQ is an important
and crucial way to assess candidate’s
knowledge on various areas of basic
sciences. Refresher courses focusing on
statistics and other relevant topics should
be held more frequently to help
postgraduate students in future. Revision
course in basic sciences is very be
helpful [11] and can be gratifying both
for the students and lecturers involved,
especially when the candidates passed
49
MJP 2008, Vol.17 No.1
their exam and become future specialist
[12].
ACKNOWLEDGEMENT
All respondents were given an
explanation about the study and consent
was obtained from them. They were
assured with regards to their anonymity
and the confidentiality of the data
obtained. The author would like to thank
the organizing committee of the
Revision Course for helping this
research to be published in a journal.
REFERENCES
1.http://www.ummc.edu.my
2.http://www.medic.ukm.my
3. Royal College of Psychiatrists.
General General
Information and
Regulations
for
the
MRCPsych
Examinations 1994. London. Royal
College
of
Psychiatrist.
problems in basic science? An
experience with Mock Multiple Choice
Questions (MCQ) in postgraduate
revision course. Malaysian
Journal
Psychiatry. Sept 2006, vol.15, no2:40–
45.
9. Strauss GD, Yager J & Strauss GE.
Assessing assessment: the content and
quality of the psychiatry in-training
examination. American Journal of
Psychiatry, 139, 1982: 85 - 88.
10. Bisson JI. The psychiatric MCQ: are
“possibles” always true? Psychiatric
Bulletin,15,1991:90-91.
11.Hatta
Sidi.
Assessment
in
Postgraduate psychiatry: How To
Answer MCQ. Malaysian Psychiatric
Bulletin, September & December, 1997,
Vol.3, No.3–4:85.
12. Hatta Sidi. Written Exam Questions
(Postgraduate Psychiatry). Malaysian
Psychiatric Bulletin, July, 1996, Vol.2,
No.3 – 4: 76 - 78.
4.http://en.wikipedia.org/wiki/Multiple_
choice
* Department of Psychiatry, UKM
5. Anderson, J. The Multiple Choice
Question in Medicine. 1976. Tunbridge
Wells:
Pitman
Medical.
6. Anderson, J. The Multiple Choice
Questions. 1979. Medical Teacher,1,37.
7. Malhi GS. The Multiple Choice
Question for the MRCPsych. Part II
Basic Sciences Examination. 2000.
Butterworth
Heineman.
Correspondence:
Associate Professor Dr. Hatta Sidi.
Department of Psychiatry,
Universiti Kebangsaan Malaysia (UKM)
Jalan Yaakob Latif, 56000
Kuala Lumpur.
E-mail: [email protected]
8. Hatta Sidi and Fairuz Nazri AR. Are
our postgraduate candidates having
50
MJP 2008, Vol.17 No.1
ORIGINAL PAPER
Exploratory and confirmatory factor validation and psychometric
properties of the Beck Depression Inventory for Malays (BDI-Malay)
in Malaysia
Firdaus Mukhtar* and Tian PS Oei**
ABSTRACT
The Beck Depression Inventory (BDI) has been shown to have good
psychometric properties in Western and non-Western populations for
the past 40 years. The present study reported on the factor structures
and provided evidence of the psychometric properties of the BDI for
the Malays in Malaysia. A total of 1090 Malays in four samples
(students, general community, general medical patients, and patients
with major depressive disorders) were recruited in this study. They
completed a battery of questionnaires that included symptoms,
cognition and quality of life measures. Two-factors of the BDI-Malay
namely Cognitive/Affective and Somatic/Vegetative were extracted
from Exploratory Factor Analysis (EFA) and were confirmed through
Confirmatory Factor Analysis (CFA). Internal consistency
(Cronbach’s α) ranging from = .71 to .91 and validity of the BDIMalay were satisfactory. The BDI-Malay can be used with confidence
as an instrument to measure levels of depression for Malays in
Malaysia.
Keywords: Beck Depression Inventory, Malaysia, psychometric,
confirmatory factor analysis
INTRODUCTION
Mood disorder is one of the most
prevalent
psychiatric
disorders,
involving approximately 3.6% of the
population 1 . One of the reasons why
depression is under-recognised and
under-treated is because of a lack of
validated instruments to assess this
mental health condition that are
particularly essential as a treatment
outcome measure. Empirical studies
have indicated that the Beck Depression
Inventory (BDI) has been established
worldwide, both in Western and Eastern
populations, to measure the symptoms of
51
MJP 2008, Vol.17 No.1
depression. To date, no study has been
reported on the psychometric and factor
structure of the BDI among Malays in
Malaysia. The BDI 2 ,3 has been one of
the leading instruments for measuring
level of depression in clinical and
research domains for the past 40 years
4,5
.
factors of the BDI among the Chinese
population. 15 In the case of Malaysia,
even though the BDI has been validated
in a study of urological patients 16 , the
majority of these patients were Chinese
and this limited the instrument as a
reliable and valid measure in Malaysia,
in particular for Malays.
Although it was originally developed for
clinically depressed patients, its validity
and reliability has been demonstrated
within non-clinical samples, such as
university undergraduates 6 and the
general community 7 . In a meta-analysis,
previous study revealed high internal
consistencies of the BDI (psychiatric
patients = 0.86; nonpsychiatric sample =
0.81) with an alpha mean of 0.87 4 .
Furthermore, findings from test-retest
reliability analyses also provided support
for the reliability of the BDI;
specifically, studies that used this
procedure
revealed
correlation
coefficients of 0.60 and 0.77 8,9 . Along
with evidence of reliability, a growing
number of studies have reported
indications of discriminant validity 10
and concurrent validity 11 .
Furthermore, their study reported on
internal
consistency,
test-retest
reliability, and specificity and sensitivity
of the BDI but gave no evidence of using
exploratory and confirmatory analysis to
confirm its psychometric properties and
factor structure. It is therefore the
intention of this paper to report on the
psychometric properties and validity of
the BDI with Malays. ppppppppppp
Thus, in light of the previous literature,
the main aims of the present study were
to (a) examine the factor structure of the
BDI for Malays in Malaysia, and (b)
provide evidence of the psychometric
properties of this scale so that the BDI
may be used with confidence in
Malaysia, particularly for Malays.
Method
However, results on the factorial
structure of the BDI are less clear. There
are studies discovered three dimensions
of the BDI (negative attitude,
performance difficulty and somatic
elements) 12 ,13 while one study found
six factors related to the BDI in the nonclinical population 14 . Inconsistencies
were also revealed in a number of other
studies within non-Western samples for
instances found four factors 11 could be
extracted from the BDI (alarm,
irritability, somatic symptoms, and
depression and retardation) and two
Participants
A total of 1090 participants were
recruited for this study. The sample
consisted of 315 students (28.9%), 495
members of the general community
(45.4%), 167 patients from a primary
care unit (15.3%), and 113 patients
diagnosed with major depressive
disorder from a psychiatric clinic
(10.4%); 820 participants were female
(75.2%), and the participant’s ages
ranged from 18 to 63 years, with a mean
52
MJP 2008, Vol.17 No.1
of 26. The educational backgrounds of
the participants included (a) high school
certificate (47.6%),(b)diploma/certificate
level (17.1%) and a university degree
(32.5%); 1% of the total number of
participants had only completed primary
school and 1.8% did not specify their
level of education.
Measures
Demographic data
Background information, including age,
gender, and level of education were
collected along with other data.
Beck
Depression
Inventory-Malay
The BDI-Malay is a translated version of
the original BDI 3 with 21 items that
provide an indication of the level of
depressed mood. Participants respond to
questions in relation to how they have
felt over the past week, with higher
scores
indicating
more
severe
depression. The 21 items of the BDI are
divided into two subscales: a
cognitive/affective subscale formed from
the
first
13
items,
and
a
somatic/performance subscale formed
from the last eight items. The full scale
is
considered
to
have
strong
psychometric properties, with mean
alpha coefficient exceeding 0.90 and
test-retest
reliability
of
0.80 4 .
Automatic
Malay
Thoughts
Questionnaire-
The 17 items of the Automatic Thoughts
Questionnaire-Malay (ATQ-Malay) 17 , is
a translated version of the original ATQ
18
with 30 items that measure the
frequency of negative automatic
thoughts.
Respondents
rate
the
frequency of the 30 negative thoughts on
a 1 to 5 scale. For instance, how
frequently negative automatic thoughts
such as “I’m a loser” have occurred in
the past week; higher scores indicate
increased severity of negative thoughts.
Internal consistency is strong, ranging
between 0.83 and 0.93, there is a
moderately strong relationship (r> 0.60)
between the ATQ and depressive
symptomatology, and the scales were
able to differentiate between depressed
and
non-depressed
samples 17 .
Dysfunctional Attitude
(Oei & Mukhtar, 2008)
Scale-Malay
The 19 items of the Dysfunctional
Attitude Scale-Malay (DAS-Malay) 19 is
a translated version of the original DAS
20
with 40 items that require responses
ranging from “totally agree” to “totally
disagree”, with seven options for each
statement. The scale has acceptable
internal consistency and concurrent
validity and was able to discriminate
between depressed and non-depressed
samples 19 ; lower scores indicate less
dysfunctional attitudes.
Zung Depression Self-Rating ScaleMalay
The Zung Depression Self-Rating ScaleMalay (Zung SDS-Malay) is a translated
version of the original Zung SDS 21 ,
which was designed for assessing
depression in patients whose primary
diagnosis was of a depressive disorder.
The 20 items address each of the four
most commonly found characteristics of
depression: its pervasive effect, its
53
MJP 2008, Vol.17 No.1
physiological
equivalents,
other
disturbances, and psychomotor effects.
Range of total score is from 20 to 80,
within which most people with
depression score between 50 and 69,
while a score of 70 and above indicates
severe
depression 21 .
WHO Quality of Life-BREF
The WHO Quality of Life-BREF
(WHOQOL-BREF) version in Bahasa
Malaysia (WHOQOL-BREF Malay) 22 ,
consisting of 26 items, has been
validated in Malaysia, with indications
of good discriminant validity, construct
validity, internal consistency (0.64 to
0.80) and test-retest reliability (0.49 to
0.88). The scale is a valid and reliable
assessment of quality of life, especially
for those with illness. Four domains that
can be extracted from WHOQOL-BREF
are physical and psychological health,
social, and environment, which assesses
general quality of life.
Beck
Hopelessness
Scale-Malay
The Beck Hopelessness Scale-Malay
(BHS-Malay) is a translated version of
the original BHS 23 with a 20-item scale
for measuring negative attitudes about
the future. The scale’s manual claims
internal consistency ranging from 0.82 to
0.93 and a test-retest reliability of 0.69
23
.
voluntarily in this study to partially
satisfy a research requirement of their
course. All of the data for this study
were
collected
through
group
administrators. Each subject was
provided with a battery of questionnaires
as described above, with an explanation
and accompanying directions for their
use. There were a number of non-Malay
students who participated in this study;
however their data was not included in
the analysis so as to ensure that the
conditions of this study were met.
General community sample. Members of
the general public participated in this
study by completing questionnaires that
had been randomly distributed in public
places by research assistants, and
returning them in envelopes supplied.
Medical patients sample. The Malay
medical patients recruited in this study
were from primary care clinics, an
obesity clinic, Ear, Nose and Throat
(ENT) clinics, and community care
clinics. The medical patients participated
in
this
study
by
completing
questionnaires that had been distributed
by research assistants, and returning
them
in
envelopes
supplied.
Procedure
Subjects in all categories were discarded
from the study if they were current drug
or alcohol abusers, had a history of
organically based cognitive dysfunction,
demonstrated reading difficulties, were
not fluent in Bahasa Malaysia, or were
not ethnic Malays.
ooooooo
Student sample. The subjects in this
study were 315 undergraduate students
from various faculties of two
universities.
Subjects
participated
Patients with major depressive disorders.
Malay patients with depression were
invited via mail, phone or through
referral from psychiatrists who had been
54
MJP 2008, Vol.17 No.1
informed of the study. A letter of
invitation and information regarding the
study was provided and those
participants who were willing to
participate presented at the psychiatric
clinic for the intake procedure
assessment. The first author of this
study, further evaluated the early
diagnosis of major depressive disorder
using a structured clinical interview
from the Diagnosis and Statistical
Manual of Mental Disorder- Fourth
Edition
(DSM-IV)
to
ascertain
participants’ eligibility. ooooooooooooo
Participants were included if they were
diagnosed as suffering from major
depression or dysthymia as defined by
the DSM-IV. Patients were excluded if
their depression was secondary to
another major psychiatric disorder (e.g.,
schizophrenia), if they were currently
abusing drugs or alcohol, had a history
of
organically
based
cognitive
dysfunction,
demonstrated
reading
difficulties, or were not fluent in Bahasa
Malaysia.
Translating
and
back-translating
procedure. In this study, the Malay
version of all instruments (except
WHOQOL-BREF) was translated using
back-translating procedures by four
psychologists with at least a Master’s
level of study and bilingual expertise.
A professional language interpreter was
recruited to proofread the translated
questionnaires to ensure their overall
suitability and to resolve issues of word
ambiguity after translation. The backtranslated versions were similar to the
original versions and to each other.
Minor
differences
in
colloquial
expressions in both languages were
reconciled.
Signed informed consent was obtained
from all participants in the study before
they undertook the assessment. Ethical
approval was sought from the research
ethics committee of the Ministry of
Health of Malaysia and all the hospitals
and institutions that participated in this
study.
Statistical analyses pppppppppppppp
Statistical Program Social Sciences
version 14.0 and AMOS version 6.0
were used to analyse data in this study.
A number of statistical procedures were
used. Descriptive statistics were used for
data screening. In addition, Cronbach’s
alpha coefficients (α) were computed to
evaluate
the
reliability
of the
questionnaire, and correlations were
calculated to examine the concurrent
validity of the BDI, using the total
sample. Discriminant analyses were used
to evaluate the discriminant validity,
specificity and sensitivity of the BDIMalay scores.
oooooooooooooooo
The CFA model fit was evaluated using
multiple fit indices 24 . The indices
selected were the chi-square statistics
(χ25²), the comparative fit index (CFI)
25, the Standardized Root Mean-square
(SRMR) 26 , the goodness of fit index
(GFI), the Root Mean Square Error of
Approximation (RMSEA) 27 , and the
Akaike Information Criteria (AIC) 28 . A
good model fit is indicated by values of
0.90 or higher for the CFI and GFI. For
the SRMR and RMSEA, values of 0.05
or lower indicate a close fit, while values
less than 0.08 indicate an acceptable fit
55
MJP 2008, Vol.17 No.1
27
and the one with the lowest AIC is
preferred in model comparison 24 .
Results for the BDI-Malay pppppppp
Assumption testing pppppppppppppp
Prior to conducting the primary analyses,
the data were examined for accuracy,
missing values, outliers and multivariate
assumptions. The number of missing
values was minimal (<5%) and seemed
to be distributed randomly across the
remaining cases, therefore, mean
substitution was employed where
necessary.
Mahalanobis distance was used to
identify multivariate outliers; with a cutoff of 0.001, no outliers were identified.
The frequency distributions were further
assessed using skewness and kurtosis
statistics. Inspection of skewness and
kurtosis indices indicated that departures
from normality were not severe, so no
variable transformations were deemed
necessary.
Group
A:
Analysis
Exploratory
Factor
It was decided to divide the total sample
(N=1090) into two groups by using the
odd-even split method (Group A
[N=545]; Group B [N=545]). Group A
was used for Exploratory Factor
Analysis (EFA) to establish the factor
structure and Group B was used for
Confirmatory Factor Analysis (CFA) to
confirm the BDI-Malay factor structures
found in Group A. pppppppppp
correlations greater than 0.33 were
found, suggesting favourability of the
data set. Favourable values of the
Kaiser-Meyer-Olkin
value
(0.96)
indicating sampling adequacy and a
significant value (p<.001) of Barlett’s
Test of Sphericity also suggested that
relationships existed between at least
some of the subscales and the data were
suitable for factor analysis. A number of
criteria were used to determine the most
appropriate number of factors to retain:
(a)
minimum eigenvalues of 1,
(b)
(b) minimum factor loadings
of 0.30,
(c)
(c)
minimal
factorial
complexity (multiple loading),
and
(d)
(d) meaningful interpretation
of factors.
The result was that the two factors
explained 43.7% of the total variance.
Their respective Eigenvalues were 7.49
(factor one) and 1.26 (factor two). A
detailed description of item statistics is
presented in Table 1-1.
Upon examination of the correlation
matrices, substantial numbers of
56
MJP 2008, Vol.17 No.1
Table 1-1. Component matrix of Exploratory Factor Analysis for group A and
Cronbach’s alpha
Item
Title
Factor 1
Factor 2
Communalities
7
Self-dislike
0.83
0.66
3
Sense of failure
0.77
0.56
9
Suicidal ideas
0.74
0.49
2
Pessimism
0.72
0.50
8
Self-accusation
0.71
0.44
1
Mood
0.68
0.49
6
Punishment
0.67
0.46
5
Guilt
0.66
0.45
13
Indecisiveness
0.65
0.49
10
Crying
0.63
0.37
4
Self-dissatisfaction
0.60
0.42
12
Social withdrawal
0.48
0.38
19
Weight loss
0.42
0.25
11
Irritability
0.30
0.19
18
Loss of appetite
0.79
0.51
16
Insomnia
0.58
0.48
15
Work difficulty
0.50
0.44
17
Fatigability
0.49
0.42
20
Somatic preoccupation
0.33
0.39
0.38
14
Body image change
0.34
0.37
0.36
7.49
1.26
variance
37.41
6.28
Cronbach’s (α) 0.91
0.89
0.72
Factor
1,
which
was
labelled
cognitive/affective, accounted for 37.41%
of the variance while Factor 2 accounted
for 6.28% of the variance and was
subsequently labelled somatic/vegetative.
Item 21 (loss of libido) was discarded, as it
did not load onto any of the factors. There
are two items that load onto both factors
(item 20 and 14), and to be consistent
Eigenvalues
Percent of
20 items (43.7)
57
MJP 2008, Vol.17 No.1
structure is demonstrated. The model
tested was Beck et al.’s 4 two-factor model,
and reasonable fit indices were also
obtained (χ ² =422.3, df =188, p =0.000;
SRMR = 0.04; CFI = 0.94; GFI = 0.93;
RMSEA = 0.05) (see Table 1-2). The
analyses showed that Beck et al.’s twofactor model with 21 items was an
acceptable fit of the data.
with existed literature and the higher
loading factor, these items are interpreted
best in the somatic/vegetative factor.
Confirmatory factor analysis of the
BDI-Malays
Before the results from EFA are presented,
comparison with one Western’s factor
Table 1-2 Results of the comparison of different factorial models for Beck Depression Inventory-Malay
Model
No of items
χ2
df
χ2/df
SRMR
CFI
GFI
RMSEA
AIC
ratio
1. Beck et al. (1987)
21
422.3*
188
2.25
0.04
.94
.93
0.05
508.26
2. Group A (N=545)
20
383.8*
169
2.27
0.04
.94
.93
0.05
465.79
3. Group B (N=545)
20
395.6*
169
2.34
0.04
.94
.93
0.05
477.64
*p < .001
CFA testing for Group A. A CFA was
conducted on group A to further explore
whether the model achieved good fit
indices with the data set; it was tested
using maximum likelihood estimation
procedures. Table 1-2 shows the GFIs for
all models tested in this study. A CFA was
subsequently used to examine the
construct validity of a two-factor model
extracted from EFA analysis. The null
hypothesis, that the data would perfectly
fit the model, was rejected (χ2545 = 383.8,
p=.000). The analyses showed that the two
factors with 20 items of the BDI-Malay
made an acceptable fit with the data.
Therefore, a range of goodness-of-fitindices was also examined to determine
how accurately the present data fit the
model. Using 20 indicators (items)
representing the two latent variables
(quadrants) in Figure 1-1, all indices
suggested that a moderate fit was obtained
(χ ² =383.8; df =169, p =0.000; SRMR =
0.04; GFI = 0.93; CFI = 0.94; RMSEA =
0.05). The final screening on the model
comparison using AIC demonstrated that
the present model with 20 indicators was
substantially smaller than Beck’s model
indicated the improvement of the model
from EFA and CFA are evident.
CFA testing for Group B. The two-factor
model was further evaluated using an
independent validation sample (N = 545).
Results of CFA for group B are also
displayed in Table 1-2. Using maximum
likelihood estimation procedures, an
excellent fit of the indices was obtained (χ
² =395.6 df =169, p =0.000; SRMR = 0.04;
GFI = 0.93; CFI = 0.94; RMSEA = 0.05),
for latent factors model of the BDI-Malay,
suggesting the stability of its factor
structure. These findings confirmed the
CFA results from group A and suggest that
the factor structure for the BDI-Malay is
valid and stable.
Reliability and validity of the BDIMalay for the total sample (N = 1090)
Internal consistency
Given an adequate overall fit, the
reliability of the two latent factors was
evaluated. Table 1-1 shows the results of
internal consistency of the BDI-Malay.
Using Cronbach’s alpha to estimate the
reliability coefficient, a moderate to high
result was obtained for the overall scale
(0.91)
and
the
subscales
(cognitive/affective
=
0.89;
somatic/vegetative = 0.72).
58
MJP 2008, Vol.17 No.1
Figure 1-1 Standardised Regression Weight for Items in BDI-Malays
.45
bdi 1
.67
bdi 2
.68
bdi 3
.71
bdi 4
COGAFF
bdi 5
.64
bdi 6
.80
bdi 7
.55
bdi 8
bdi 9
.39
.57
.67
bdi10
bdi11
.46
bdi12
.83
e3
.39
e4
e5
.41
e6
.64
e7
.36
.60
.65
e2
.51
.40
.63
.63
e1
.46
bdi13
e8
.42
e9
.30
e10
.15
e11
.32
e12
.45
e13
.21
.21
e19
bdi19
.32
.56
.61
.60
SOMVEG
.59
.31
e14
bdi14
.38
bdi15
bdi16
bdi17
.58
bdi18
bdi20
e15
.36
e16
.35
e17
.10
e18
.33
e20
59
MJP 2008, Vol.17 No.1
Concurrent validity
Concurrent validity was evaluated using
Pearson correlation coefficients. Detailed
descriptions of the scales and their
intercorrelations are shown in Table 1-3.
Evidence of concurrent validity is shown
when a high correlation is obtained
between measures of a similar construct.
The results revealed a significant positive
correlation between BDI-Malay total
scores with Zung (r = 0.80), ATQ
(r=0.65), DAS (r= 0.84), and BHS-Malay
(r= 0.52), while showing a significant
negative relationship with WHOQOLBREF (r=-0.79). Furthermore, the results
also revealed a significant positive
relationship between cognitive/affective
and Zung, SDS-Malay (r=0.81), ATQ (r=
0.64), DAS (r= 0.65), and BHS-Malay (r=
0.54), with a significant negative
relationship with WHOQOL-BREF (r=0.78). Meanwhile, the final subscale of the
BDI-Malay somatic/vegetative showed a
significantly moderate relationship for
both cognition measures (ATQ; r= 0.53,
DAS; r= 0.48), WHOQOL-BREF (r=0.61), Zung SDS-Malay (r= 0.61), and
BHS-Malay (r= 0.36). This illustrates that
the BDI-Malay holds good concurrent
validity.
Table 1-3 Intercorrelations for BDI-Malay total scores and subscales with ATQ-Malay,
DAS-Malay, Zung SDS-Malay, WHOQOL-BREF, and BHS-Malay
Variables
ATQ-
DAS-
Zung
BHS-
WHOQOL-
Malay
Malay
SDS-
Malay
BREF
Malay
Total BDI-Malay
0.65**
0.64**
0.80**
0.52**
-0.79**
Cognitive/Affective
0.64**
0.65**
0.81**
0.54**
-0.78**
Somatic/Vegetative
0.53**
0.48**
0.61**
0.36**
-0.61**
p <. 01**
Discriminant Validity
Subsequently, a direct discriminant
analysis using all BDI-Malay’s 20 items
was performed. The clinical group
demonstrated significantly higher mean
scores on the BDI-Malay than subjects in
the three non-clinical groups (see Table 14).
The clinical group was represented by
patients with depression, and the nonclinical group was represented by students,
general community and general medical
patients. Classification sub-analysis used a
linear combination of all 20 items. In
terms of sensitivity, the analysis indicated
that the BDI-Malay total scores were able
to detect 91.2% of patients with depression
(Table 1-5). Meanwhile, the specificity
analysis found that only 2.7% of the nonclinical subjects were detected as having
symptoms of depression. Additionally,
97.3% of all subjects in the non-clinical
group (N = 977) and 8.8% of the subjects
in the clinical group (N = 113) did not
have symptoms of depression. The overall
percentage of correctly classified cases
was 96.7%. This result suggests clearly
that the BDI-Malay items are able to
discriminate between clinical and nonclinical subjects.
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MJP 2008, Vol.17 No.1
Table 1-4 Mean and standard deviation of BDI-Malay total
and subscales scores for clinical (depressed patients) and
non-clinical groups (students, general community & medical
patients)
Variables
Group
N
Mean (SD)
Total
1. Non-clinical (students,
977
12.4 (7.48)
BDIgeneral community &
Malay
medical patients)
2. Clinical (depressed
113
36.6 (5.48)***
patients)
Cognitive 1. Non-clinical (students,
/
general community &
977
7.95 (5.44)
Affective
medical patients)
2. Clinical (depressed
113
27.0 (4.47)***
patients)
Somatic/
1. Non-clinical (students,
977
4.40 (2.78)
Vegetativ general community &
e
medical patients)
2. Clinical (depressed
113
9.53 (3.01)***
patients)
p <.001***
Table 1-5 Discriminant analyses of the total BDIMalay,
cognitive/affective, and somatic/vegetative
Group
Total score of
BDI-Malay
Non-clinical
Clinical
Cognitive/aff
ective
Non-clinical
Clinical
Somatic/Vege
tative
Non-clinical
Clinical
Non-clinical
Clinical
Total
951 (97.3%)
10 (8.8%)
26 (2.7%)
103 (91.2%)
977 (100%)
113 (100%)
951 (97.3%)
8 (7.1%)
26 (2.7%)
105 (92.9%)
977 (100%)
113 (100%)
961 (98.4%)
71 (62.8%)
16 (1.6%)
42 (37.2%)
977 (100%)
113 (100%)
Table 1-5 also shows the results in terms
of the cognitive/affective factor. The
analysis indicated that this factor was able
to detect 92.9% of the clinical subjects and
2.7% of the non-clinical subjects who were
reported as having cognitive/affective
symptoms of depression. The overall
percentage of correctly classified cases
was 96.9%.
Further, Table 1-5 shows the results in
terms of the somatic/vegetative factor. The
analysis indicated that this factor was able
to detect only 37.2% of the clinical
subjects and 1.6% of the non-clinical
subjects who were reported as having
somatic/vegetative
symptoms
of
depression. The overall percentage of
correctly classified cases was 92.0%.
Discussion
The purpose of the present research was to
assess the psychometric properties,
reliability, and validity of the BDI among
Malays in Malaysia. The EFA in this study
revealed two correlated factors, one
reflecting cognitive/affective, and the other
somatic/vegetative behaviour. This result
was clearly consistent with those reported
by most researchers, who presumably
accept the notion that the BDI represents a
strong general factor of a depressive
syndrome that can be subdivided into two
highly correlated factors depicting the
cognitive and somatic symptoms of
depression. Specifically, all items loading
on factor one were consistent with Beck’s
model, except that item 21 (loss of libido)
did not load into any of the factors in the
exploratory analysis. Meanwhile, item 19
(weight loss) in this study was loaded into
the cognitive/affective factor whereas Beck
et al. reported that the item was loaded into
the somatic/performance factor in their
study. This two-factor solution also
supported several previous studies on
either clinical 15 or non-clinical samples.
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MJP 2008, Vol.17 No.1
The two factors shared almost 43.7% of the
variance with the 20-item subscale, which
appears to be sufficient, although it is not
unique. It should be noted that item 21 was
discarded due to cultural and religious
perspectives, as was also supported by other
non-Western studies. Being Muslim and still
holding the strong Malay cultural values of
these participants may have presented
certain barriers, since issues of sexuality will
not be revealed, in contrast to Western
populations. This finding was also
supported, by non-Western studies, that the
item on loss of libido showed a poor
relationship to measurement of depression
(11)
Intuitively, work inhibition and fatigue
would be expected to load together, given
the types of problems seen most often in all
these subjects’ situations. The BDI-Malay
proved to have sufficient internal
4
consistency (i.e., reliability). Beck et al.
reported a similar range of internal
consistency coefficients for both clinical and
non-clinical samples. Interestingly, the
coefficient alpha value (α= 0.91) in the
present study is higher than in a previous
16
study of urological patients in Malaysia .
The subscale of the BDI also yielded
satisfactory reliability coefficients. The
results of the present study further verified
he concurrent validity of the BDI . Our
findings also showed that BDI-Malay scores
have good sensitivity and specificity in
discriminating between clinical and nonclinical
samples.
This is one of the first studies to validate the
BDI-Malay for use within a large and
culturally different population and in which
three subscales were subjected to factor
analysis. This study provides clear evidence
that the BDI-Malay is sufficiently reliable
and a valid measure of depression
symptoms. The major strengths of the
present study included a large sample size
(N = 1090 for both groups A and B), the use
of EFA and CFA methodology and the
direct application of a theoretically derived
measure to a clinical setting and a specific
sample. Furthermore, cross-validation of
different samples for CFA strengthens the
robustness of this study.
In conclusion, the findings show that the
BDI-Malay has sound psychometric
properties and is a reliable instrument for
measuring levels of depression among
Malays in Malaysia. Therefore, it can be
used with confidence in the future.
REFERENCES
1.Malaysian
Psychiatric
Association.
Consensus statement on management of
depression. Retrieved 9th August 2004,from
http://www.psychiatrymalaysia.org/html
2004
2.Beck AT, Rush AJ, Shaw B. F, Emery G.
Cognitive therapy of depression. New York:
Guilford 1979
3.Beck AT, Ward CH, Mendelson M, Mock
J, Erbaugh J. An Inventory for Measuring
Depression. Arch Gen Psych 1961; 4, 53-63.
4.Beck AT, Steer RA, Garbin MG.
Psychometric properties of the Beck
Depression Inventory: Twenty-five years of
evaluation. Clin Psych Rev 1988; 8, 77-100.
5. Bedi RP, Maraun MD, Chrisjohn RD. A
multisample item response theory analysis
of the BDI-1A. Can Jou Beh Sc 2001; 33,
176-187.
6. Abdel-Khalek AM. Internal consistency
of an Arabic adaptation of the Beck
Depression Inventory in four Arab countries.
Psych Rep 1998; 82, 264-266.
7.Richaud de Minzi MC, Sacchi C.
Adaptations of Beck Depression Inventory
to a sample of Argentine general population
sample.
Revista
Iberoamericana
de
Diagnostico y Evaluacion Psicologica 2001;
12, 11-17.8.
Carro IL, Bernal I L, Vea
HB. Depression in Cuba: Validation of Beck
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Depression Inventory and the Dysfunctional
Attitudes Scale with Cuban population.
Avances
en
Psicologia
Clinica
Latinoamericana 1998; 16, 111-120.
psychometric properties of Automatic
Thoughts Questionnaire for Malays in
Malaysia, Hong Kong Jou of Psych (in
press).
9. Zimmerman M, Coryell W, Corenthal C,
Wilson S. A self-report scale to diagnose
major depressive disorder. Arch Gen Psych
1986; 43, 1076-1081.
18.Hollon SD, Kendall PC. Cognitive selfstatements in depression: development of an
Automatic
Thoughts
Questionnaire.
Cognitive Therapy and Research 1980; 4,
383-395.
10.Vazquez C, Sanz J. Reliability and
validity of the Spanish version of the Beck
Depression Inventory in patients with
psychological disorders. Clinical y Salud
1999; 10, 59-81.
11. Zheng Y, Lin K. Comparison of the
Chinese Depression Inventory and the
Chinese version of the Beck Depression
Inventory. Acta Psych Scand 1991; 84, 531536.
12.Clark DC, Cavanough SV, Gibbons RD.
The core symptoms of depression in medical
and psychiatric patients. Jou Nerv Ment Dis
1983; 171, 705-713.
13. Tanaka
JS, Huba G J. Confirmatory
hierarchical factor analyses of psychological
distress measures. J Pers Soc Psychol 1984;
46, 621, 635.
14.Ibanez I, Penate W, Gonzalez M. Factor
structure of the Beck Depression Inventory.
Psicologia Conductal Revista Internacional
de Psicologia Clinical de las Salud 1997; 5,
71-91.
15.Shek DTL. Reliability and factorial
structure of the Chinese version of the Beck
Depression Inventory. Jour Clin Psych 1990;
46, 35-43.
16.Quek KF, Low WY, Razack AH, Loh
CS. Beck Depression Inventory (BDI): A
reliability and validity test in the Malaysian
urological population. Med J Malaysia 2001;
56, 285-292.
19.Oei TPS, Mukhtar F. Exploratory and
confirmatory
factor
analyses
and
psychometric properties of Dysfunctional
Attitude Scale for Malays in Malaysia,
Paper presented at 10th Johor Mental Health
Convention; 2008.
20.Weissman AN, Beck AT. Development
and validation of the Dysfunctional Attitude
Scale: A preliminary investigation. Paper
presented at the Paper presented at the
meeting of the Association for the
Advancement of Behavior Therapy,
Chicago; 1978
21.Zung WWK. A self-rating depression
scale. Arch Gen Psych 1965; 12, 63-70.
22.Hasanah CI, Naing L, Rahman, ARA.
World Health Organization Quality of Life
Assessment: Brief Version in Bahasa
Malaysia. Med J Malaysia 2003; 58, 79-88.
23.Beck AT, Steer RA. Beck Hopelessness
Scale. San Antiano: TX: Psychological
Corp.1988
24.Kline
RB.. Principles and practice
of structural equation modeling. New York:
The Guildford Press.1998
25.Bentler PM. Comparative fit indices in
structural models. Psych Bull 1990; 107,
238-246.
26.Hu, LT, Bentler PM. Evaluating model
fit. In R. H. Hoyle (Ed.), Structural Equation
Modeling. Thousand Oaks, CA: Sage. 1995
17.Oei TPS, Mukhtar F. Exploratory and
confirmatory
factor
analyses
and
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27.
Browne MW, Cudeck R. Alternative
ways of assessing model fit. Soc Methods and
Res 1993; 21, 230 258.
28.
Akaike, H. Factor analysis and AIC.
Pyschometrika 1987; 52, 317-322.
*School of Health Sciences, Universiti Sains
Malaysia, Kelantan, Malaysia.
**School of Psychology, University
Queensland, Brisbane, Australia
of
Correspondence:
Dr Firdaus Mukhtar, School of Health Sciences,
Universiti Sains Malaysia, 16150 Kubang Kerian,
Kelantan,Malaysia. Tel: +60 9 766 3968; Fax:
+60 9 764 7884; E-mail: [email protected]
64
MJP 2008, Vol.17 No.1
ORIGINAL PAPER
FACTORS AFFECTING READMISSION IN A TEACHING
HOSPITAL IN MALAYSIA
Amer Siddiq AN,* Ng CG,* Aida SA,* Zuraida NZ,* Abdul Kadir R,**
ABSTRACT
Objective: The aim of this study was to study the rate of readmission
and look into factors that may contribute to this. Methods: This is a
retrospective descriptive study of all psychiatric patients who were
discharged from University Malaya Medical Center (UMMC). Case
notes of those discharged during the study period was retrieved and
analyzed. Those fulfilling the inclusion criteria were recruited and
subjected to a questionnaire. Results: A total 107 patients were
identified and only 95 participated. The readmission rate was 16.8%.
Severity of illness was identified as the main risk factor for
readmission in this study. Conclusion: Our readmission rate was
similar to some developed nations and indicated good quality of care
in UMMC. There appears to be other factors that may influence rate
for readmission other than quality of in-patient care and outpatient
community care.
Key words: readmission, mental illness, quality of care, Malaysia
INTRODUCTION
Readmission is a common problem
encountered in psychiatric care today.
Since
the
initiation
of
deinstitutionalization, the locus of care
has shifted from the mental institutions
to the community 1 . This resulted in an
increase in readmissions into hospitals or
institution
on
discharge.
This
phenomenon is due to many reasons
among
them
are
poor
patient
compliance, aggression, inability to cope
in the community due to poor social
skills and also disease severity among
others 2,3 . Frequent readmission has also
been coined the “revolving door
phenomenon” 4 . In many countries the
rate of readmissions has been used as a
performance indicator 5 and for this
reason it has gathered much attention.
Globally the 6 monthly readmission rate
has been said to be between 15 - 38% 6 .
However there have been many
problems with the estimated prevalence
in part due to differences in the
methodology used to calculate the rate
and the study design. In some countries
including Malaysia, readmission rate is
calculated as the number of readmitting
patients over total number of admissions
for the given period 7,8 . However lately
the trend has shifted to number of
readmitting patients over the number of
discharge for a given period 9 . The latter
appeared to be a better way to truly
reflect the readmission rate. In Malaysia,
a period of 6 months has been practiced
in keeping with our National Indicator of
Psychiatry (NIP) 10 .
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MJP 2008, Vol.17 No.1
As the readmission rate is used as a
performance indicator, there have been
many studies looking into the reasons for
readmission. At present, only a history
of previous admission has been found to
be an independent risk factor 11 . Other
associating factors have also included
non-compliance to medication, poor
social support and substance abuse to
name a few 2,9 . A study done in
Singapore has identified male gender,
history of self-harm and short duration
of illness as risk factors for the revolving
door phenomenon 12 . However a study
done in a local mental institution noted
that default in treatment, disease severity
and presence of substance abuse as the
main cause of readmission 8 . This clearly
highlights the differences in factors for
readmission even among neighboring
countries with similar settings. The aim
of this study is to study the rate of
readmission and look into factors that
may contribute to this. As of late, there
is very little if any published data
regarding this in Malaysia. In addition,
there has been no published data on
readmission rate with the newer and
more acceptable form of calculation to
date.
Methods
Sampling
The sampling frame of this study is the
Psychiatric Wards at University Malaya
Medical Center (UMMC), located on the
border of Kuala Lumpur and Petaling
Jaya cities. Its catchment area is the
population of Petaling Jaya which at the
last count stands at 450,000.
They are mainly of Chinese descent,
urbanized and are in the middle income
bracket 12,13,14 .
Study Design ppppppppppppppppppppp
This is a retrospective descriptive study
of all psychiatric patients who were
discharged from UMMC between the
periods of 1st to 31st January 2006.
The patients were identified from the
discharge book of both the male and
female wards. Case notes of these
patients obtained from the medical
record office was then traced and
reviewed. Inclusion and exclusion
criteria were implemented on all cases.
All patients who were readmitted within
six months from being discharged during
the study period were included. Those
who were readmitted for clinical drug
trial, for maintenance electroconvulsive
therapy (ECT) and forensic case were
excluded. All cases that met the
inclusion criteria were studied using a
questionnaire which was designed and
used
in
a
previous
study 8 .
The
variables
included
were
sociodemographic data, risk factors for
readmission, usage of electroconvulsive
therapy and usage of atypical
antipsychotic medications. All patients
were also assessed on their risk factors
for
readmission
which
included
assessment of presence of life events,
default treatment, use of substance and
disease severity. Ethical approval was
obtained earlier from the UMMC ethical
committee, (Ethical reference number
584.6).
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MJP 2008, Vol.17 No.1
Analysis
Data collected was analyzed using the
Statistical Program for Social Sciences
(SPSS) version 13. Where appropriate,
chi square test was used for categorical
data to look at significant differences.
In addition Fisher’s exact test was also
used when necessary. Log regression
analysis was also carried out to look at
the
correlation
between
the
independent and dependent variables.
Table 1. Socio-demographic data of the
subjects
Total N=95
Readmission
N=16
Age
37.8S.D+14.3
36.8
S.D+14.8
Gender
Male
40 (42.1%)
5 (31.3%)
Female
55 (57.9%)
11 (68.8%)
Marital Status
Single
Married
Divorced
Widowed
54 (56.8%)
35 (36.8%)
3 (3.2%)
3 (3.2%)
11 (68.8%)
4 (25%)
0 (0%)
1 (6.3%)
Race
Malay
Chinese
Indians
Others
14 (14.7%)
47 (49.5%)
23 (24.2%)
11 (11.6%)
4 (25%)
10 (62.5%)
2 (12.5%)
0 (0%)
Results
A total of one hundred and seven case
notes were obtained from the discharge
book. Of these, twelve were excluded
(5 for maintenance ECT, 5 for clinical
drug trial, 1 forensic case) and one
missing data (case note was in
microfilm and could not be opened).
Ninety-five cases were included and
later analyzed. A total of sixteen
patients were readmitted within a sixmonth period. This resulted in a
readmission rate of 16.8%.
Table 1 showed that the mean age of
the patients was 37.8 years old with a
range of 23.5 to 52.1 years. Majority of
patients who were admitted were also
found to be females (57.9%), mostly
unmarried (56.8%) and were of
Chinese descent (49.5%).
Findings also showed the readmission
rate of females (68.8%) was two times
more than the male patients (31.3%).
Unmarried (68.8%) and of Chinese
descent (62.5%) were also found to be
more likely to be readmitted.
Table 2 Numbers and time to readmission
Admission
(Total)
Readmitted
Yes
No
Timefrom
discharge
to
readmission
No. of
patients
95
Mean No.
of days (+S.D)
10.6 (7.2)
16
79
10.4 (5.8)
10.7 (7.4)
16
54.4 (49.9)
Mean duration of stay for all patients
was 10.6 days (1-38 days, S.D+7.2).
There was no difference in the duration
of stay whether they were readmitted
or otherwise. For those who were
readmitted, the mean time to
readmission from discharge was 54.4
days (range 5- 161 days, S.D+49.9)
(Table 2).
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MJP 2008, Vol.17 No.1
Table 3. Clinical Characteristics of the subjects
Diagnosis
Psychosis
Non-psychosis
Medical Use
Atypical
Conventional/Combination
Use of ECT
Yes
No
Use of Depot Medication
Yes
No
Readmission
Yes (N=16)
No (N=79)
Odd Ratio
(OR)
95% CI
6 (17.1%)
10 (16.7%)
29 (82.9%)
50 (83.3%)
1.03
0.34-3.14
11 (17.5%)
5 (15.6%)
52 (82.5%)
27 (84.4%)
1.14
0.36-3.63
5 (25%)
11 (14.7%)
15 (75.0%)
64 (85.3%)
1.94
0.59-6.42
2 (11.8%)
14 (17.9%)
15 (88.2%)
64 (82.1%)
0.61
0.13-2.97
Analysis also showed that in general,
the clinical pattern of subjects who
were readmitted was not different from
the total sample (Table 3). Patients
who were diagnosed as non-psychotic
(OR 1.03; 95% CI 0.34-3.14) or given
atypical treatment (OR 1.14; 95% CI
0.36-3.63) had an equal chance being
readmitted. However, those who were
not given ECT had two times more
chances of being readmitted (OR 1.94;
95% CI 0.59-6.42), while those who
did not use depot medication is also
less likely to be readmitted (OR 0.61;
95% CI 0.13 - 2.97) . None of the
differences however was statistically
significant.
Table 4
Log regression analysis for risk factors for readmission
Risk factors
Exp (B)
95% Confidence Interval for Exp (B)
Sig.
Default treatment
4.26
Lower
0.77
Upper
23.68
0.097
Substance use
Poor support
Disease severity
0.58
0.63
14.39
0.06
0.06
1.86
5.64
7.19
111.49
0.641
0.713
0.011*
Life events
0.51
0.13
2.07
0.347
When the readmission group was
reanalyzed for the risk factors
contributing to readmission, it was
noted that only disease severity was
statistically significant (OR 14.39,
95% CI 1.86 - 111.49, p=0.011). Other
risk factors measured including default
treatment, use of substance, poor
support and presence of life events
were not statistically significant in this
study. (Table 4)
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MJP 2008, Vol.17 No.1
DISCUSSION
Readmission rate is a contentious issue
as it has been widely used as a measure
of quality of health care in most
hospitals and institution. Traditionally,
the rate has been calculated as number of
readmission divided by the total number
of admissions. This method is also used
here in Malaysia. However there has
been a debate on this as stated by Moon
and Patton 7 whereby they argued that
this method of calculating rate does not
meet the criteria of including those who
are exposed to the risk of the event
occurring. They felt that these
individuals were those who were
admitted and subsequently discharged.
Therefore in measuring their rate of
readmission they had used the number of
readmission as the numerator and the
total discharged as the denominator. The
term used was readmission index.
Readmission Index has been used in
calculating the readmission rate in
subsequent publications 2,9 . The above
method was also used in this study and
found the rate to be 16.8%. This finding
is comparable with many other
readmission rates in more developed
nations. This finding was crucial as it
indicates that the level of care provided
in our center is on par with more wealthy
countries. An earlier study donein a
mental institution in Malaysia by the
authors had rates doubled this and both
data will be useful for further planning
of services.
This study revealed socio-demographic
data that was different from the general
Malaysian
profile
which
is
predominantly Malays. Interestingly our
findings showed more females and
Chinese being readmitted. This is in
keeping with another study done here
which showed more female admissions
23
to UMMC. Other studies done in
UMMC usually show a higher sample
for the Chinese ethnic group in keeping
with the population of its catchment area
and also their involvement in trade
resulting them to cluster in the cities 16 . It
was postulated that this phenomenon is
due to more awareness among the urban
female population who are generally
working, are more educated and more
aware of mental illness.
In a previous study, schizophrenia was
found to be the most commonly
diagnosed mental illness among those
readmitted into a local mental
institution 8 . This present study indicated
more admissions and readmission among
those with non psychotic disorders
namely mood disorders. This can be due
to UMMC being a tertiary referral center
resulting in more accurate and stringent
diagnosis being given leading to this
change in diagnostic demographics. As
those with mood disorders tend to be of
higher functioning pre-morbidly, our
catchment area may also influence this
result. Our study also had more female
samples, we are aware that mood
disorders predominate in the female
population which may also give rise to
this result.
In this study, it was noted that the
majority of patients readmitted were on
an atypical medication on discharge
from the hospital. This could explain
why depot use and ECT was low.
Atypical antipsychotic use has been
documented to increase compliance due
to increase efficacy, less side effects and
increased quality of life, 17,18 which is
helpful for the patients . In Malaysia,
however, the market is still controlled by
19
when
the typical antipsychotic
indicated.
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MJP 2008, Vol.17 No.1
The observed positive findings in this
study perhaps are explained by the fact
that UMMC being a teaching hospital is
semi public in its funding. In addition,
being situated in an urban setting with a
middle income population thus, is able
to afford these newer more expensive
medication resulting in more patients
being put on this type of medication. It is
also noted that patients who had ECT
during index admission tended to have a
higher probability of being readmitted.
This could be due to ECT being used
only for more severe cases and hence an
increase in readmissions 20 . Another
explanation is that ECT may mask the
effectiveness of oral treatment and social
factors.
hospital providing psychiatric care this
may not be feasible. Our center has an
annual admission of 1265 patients per
year and 40 acute beds only for both
male and female. The department has a
policy of 14 days acute admission where
by day 15 cases still not resolved will be
reviewed in the morning rounds 23 .
Hence a mean stay of 11 days as shown
in our study is hardly enough if
following earlier mentioned studies. A
study done in the United Kingdom
showed that longer duration of stay may
be worse off compared to a short stay
and also indicated as we did that it may
be the severity of the illness itself that
led patients to be readmitted frequently
and not length of stay 24 .
The only independent risk factor for
readmission found in this study was
disease
severity
at
the
index
11
admission . This study did not find
increase risk in those who defaulted
treatment, use substance, had poor social
support and those who had multiple life
events. This is interesting as many
studies done elsewhere highlighted some
of
these
as
risk
factor
for
4,21
readmission . Other risk factors also
mentioned included aggression and
diagnosis as reasons for readmission 9 .
The low readmission rate observed in
this study perhaps indicate better inpatient care in UMMC with better
provision of medication and also better
social work up prior to discharge care in
resolving life event issues.
In conclusion
Readmission rate of 16.8% is similar to
some developed nations and indicated
good quality of care in UMMC. There
appears to be other factors that may
influence rate for readmission other than
quality of inpatient care and outpatient
community care. More studies are
needed in this field as it will help in the
provision of care in our mental health
patients and also those caring for them.
Acknowledgment
We are grateful for the assistance of
the staffs from Psychiatric wards,
for
their
cooperation.
UMMC
Several studies concluded that in order
to prevent frequent readmission a longer
stay was needed 22 . The reason being that
patient could be more adequately treated
and community care prepared prior to
discharge. Although ideal, with the
current pressure on psychiatric beds in
70
MJP 2008, Vol.17 No.1
REFERENCE
1. Davies S, Presilla B, Strathdee G,
Thornicroft G. Community beds:
the future for mental health care?
Soc
Psychiatry
Psychiatry
Epidemiol. 1994 Nov;29(6):2413
2. Craig TJ, Fennig S, TanenbergKarant M, Bromet EJ. Rapid
versus delayed readmission in
first-admission psychosis: quality
indicators for managed care?
Ann Clin Psychiatry. 2000
Dec;12(4):233-8.
3.Lyons JS et al. Predicting
Readmission to the Psychiatric
Hospital in a Managed Care
environment: Implications for
Quality Indicators. The American
Journal of Psychiatry. 1997
March; 154(3): 337-340
Community Ment Health J. 1997
Feb;33(1):13-24.
7. Moon LE, Patton RE. First
Admissions and Readmission to
New York State mental Hospitals
– A Statistical Evaluation.
Psychiatric Quarterly. 1965
Jul;39:476-86.
8. Ng CG, Amer Siddiq AN, Aida
SA, Jambunathan ST. Reasons
for Early Readmission in a
Mental Institution in Malaysia.
Oral presentation 13th Malaysian
Congress
of
Psychological
Medicine
9. Bernardo AC, Forchuk C.
Factors
associated
with
readmission to a psychiatric
facility. Psychiatr Serv. 2001
Aug; 52(8):1100-2.
4. Haywood TW, Kravitz HM,
Grossman LS, Cavanaugh JL Jr,
Davis JM, Lewis DA. Predicting
the "revolving door"phenomenon
among
patients
with
schizophrenic, schizoaffective,
and affective disorders. Am J
Psychiatry. 1995 Jun;152(6):
856-61.
10. Malaysia
National Indicator
in Psychiatry (NIP-2)
5. Hughes MR, Johnson NJ,
Nemeth LS. Classifying reasons
for hospital readmissions. Top
Health Inf Manage. 2000
Feb;20(3):65-74.
12. Mahendran R, Chong SA, Chan
YH.
Brief
Communication:
Factor
Affecting
Rehospitalization in Psychiatric
Patients in Singapore. Int Jour of
Social Psychiatry 2005 51(2):
101 -105
6. Owen C, Rutherford V, Jones M,
Tennant C, Smallman A.
Psychiatric
rehospitalization
following hospital discharge.
11. Klinkenberg D, Calsyn RJ:
Predictors of receipt of aftercare
and recidivism among persons
with severe mental illness: a
review. Psychiatric Services
1996 47:487-496,
13. http://www.mbpj.gov.my/
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MJP 2008, Vol.17 No.1
14. http://www.pjnet.com.my/petalin
g-jaya.htm
15. https://www.cia.gov/library/publi
cations/theworldfactbook/print/my.html
16. Amer Siddiq AN, Gill JS, Koh
OH. Phenomenological Ethnic
Differences in first Episode
Schizophrenia
Spectrum
Disorder
Patients.
Oral
presentation in The 5th Kuala
Lumpur
Mental
Health
Conference 2006
17. Conley RR, Love RC, Kelly DL,
Bartko JJ Rehospitalization rates
of
18. Hasanah Che Ismail, Razali M
Salleh. Objective and Subjective
Improvements on Changing from
Conventional
to
Novel
Antipsychotic.
19. IMS data 2006
20. Use of electroconvulsive therapy
(ECT) in New Zealand: A review
of efficacy, safety, and regulatory
controls.http://www.moh.govt.nz
/moh.n sf/pagesmh/3930?Open
21. Talbott JA. Stopping the
revolving door--a study of
readmissions to a state hospital.
Psychiatr Q. 1974;48(2):159-68
23. Aida SA, Ng CG, Jemilah, Amer
Siddiq
AN.
Patterns
of
Admission in a Teaching
Hospital
in
Malaysia
(Unpublished 2007) patients
recently discharged on a regimen
of risperidone or clozapine. Am J
Psychiatry. 1999 Jun;156(6):8638
Malaysian Journal of
Psychiatry 2000 March 8(1): 2228
24. Hodgson
RE,
Lewis
M,
Boardman AP. Prediction of
readmission to acute psychiatric
units. Soc Psychiatry Psychiatr
Epidemiol. 2001 Jun;36(6):3049.
*Department
of
Psychological
Medicine,
Faculty
of
Medicine,
University of Malaya, Kuala Lumpur
** Faculty of Dentistry, University of
Malaya, Kuala Lumpur
Correspondence:
Dr Ng CG Department of Psychological
Medicine,
Faculty
of
Medicine,
University of Malaya, 50603 Kuala
Lumpur
22. Caan W,Crowe M (1994) Using
readmission rates as indicators of
out-come
in
comparing
psychiatric services. J Ment
Health 3: 521–524
72
MJP 2008, Vol.17 No.1
REVIEW PAPER
ASSERTIVE COMMUNITY TREATMENT (ACT) FOR ATIENTS
WITH SEVERE MENTAL ILLNESS: EXPERIENCE IN
MALAYSIA.
Z Ruzanna*, M Marhani*
ABSTRACT
Psychiatric community-based services are being developed in
Malaysia currently to ensure more comprehensive mental health care
to especially patients with severe mental illness. Assertive Community
Treatment (ACT) as one of the earliest component of communitybased services has been observed to be useful and able to provide
favourable outcomes in this group of patients. Though the paradigm
shift has gradually occurred among mental health practitioners and
policy makers, challenges are mainly in the implementation process.
This article will present the discussion and academic view on various
aspects of ACT including the rationale, elements, clinical and
psychosocial impacts on patients as well as the current challenges in
the Malaysian context.
Key words: Psychiatric community-based services, Assertive
community treatment (ACT), severe mental illness (SMI)
INTRODUCTION
There have been fundamental changes in
the treatment model of severe mental
illness especially in the world developed
countries since the second half of the
20th century (1-3). The fundamental
changes in the treatment of mental
illness have been contributed by the
increasing discovery of effective
psychotropic drugs and the recognition
that ‘confinement could be damaging’
(1, 4). Today, apart from being
established in many developed countries,
the reform in mental health care has also
been disseminated in many developing
countries (1,3,5-7).
Malaysian mental health services are
currently getting into the mainstream of
this reform. Beginning in 1960s, the care
for mentally ill has been decentralized
and integrated into the general health
system. Subsequently, the development
of community-based services have been
developed
to
ensure
more
comprehensive mental health care could
be delivered effectively (8, 9). The
earliest component of community-based
services that has been introduced in
Malaysia
recently
is
assertive
community
treatment
(ACT).
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MJP 2008, Vol.17 No.1
treatments. In practice, there have been a
number of modifications and adaptations
of this model based on different
population
and
settings
(13).
The advantages of ACT
ACT has been researched extensively in
patients with schizophrenia for more
than 20 years and is now being widely
used for other groups of patients (12).
The recent meta-analysis establish that
ACT is superior in giving more
favourable outcomes as compared to
‘standard care’ (14). Many other studies
have consistently found that ACT has
positive impact on several outcome
domains such as: reduced hospitalization
rate; improvement of symptoms; greater
percieved life-satisfaction and health
status among consumers (14-18).
However, the effects of ACT on other
outcome domains such as vocational and
social functioning are less consistent due
to difficulty in the measurements (12).
ACT in Malaysia
At present, ACT has been initiated in the
three mental institutions and a number of
general hospitals in Malaysia. Since this
relatively new service has taken place in
the health setting, it is timely to review
the available experiences. Generally, in
all these hospitals, ACT has been
initiated as small pilot projects since mid
1990. Over the years, many community
psychiatric units have been set up in
general hospital settings and responsible
to deliver ACT to patients who suffer
from severe mental illness. Patients who
are identified as having ‘severe mental
illness’ usually suffer from psychotic
disorders such as chronic schizophrenia,
bipolar mood disorders and patients with
comorbidities. Majority of these patients
have been identified as ‘requiring ACT’
as the care providers perceived that this
group of patients need more than just
medication and hospitalization to deal
with the their unmet needs. In fact, many
of these patients require repeated
admissions to inpatient services due to
unsolved
psychosocial
problems.
Depend on the availability of resources,
the multidiciplinary team of ACT
usually needs to include consultant
psychiatrist,
psychiatric
registrar,
psychiatric nurse, occupational therapist
and social worker. Every patient needs
to be referred using a standadized form
to the unit and the intake meeting would
discuss the suitability of the particular
patient to be managed with ACT. The
clinical, social and occupational
assessment will be conducted by
designated case manager and the
individual treatment strategies will be
discussed in the multidiciplinary meeting
which is conducted at least once a week.
Consultant psychiatrist is responsible in
chairing the clinical discussion and any
urgent consultation can be arranged
accordingly. The service operated during
office hours and the activities include
home
visits,
psychoeducation,
rehabilitation activities, and liasion with
other
related
agencies.
Despite the lack of local scientific
evidence of its effectiveness, the
subjective perception of care providers
towards ACT in many of these centers is
favorable. ACT is generally perceived as
useful at least to the most complicated
and chronic patients with schizophrenia.
Challenges of the ACT development in
Malaysia
Up to date, Malaysia only has handful
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MJP 2008, Vol.17 No.1
number of mental health professionals
who has been especially trained in
conducting ACT. In addition, some of
mental health professionals in Malaysia
are still alien to the reformed ideas of
mental health care resulting in the
resistance among them to change their
work scope. Fortunately, this factor does
not seem to limit the development of
ACT services as many psychiatrists
especially the younger generation are
motivated in joining the mainstream.
They have taken the leadership roles in
initiating the services especially when
they are given trust and opportunity to
develop services at new hospital setting.
It is possible that this motivation comes
from their positive experience during the
postgraduate training where community
psychiatry has become one of the
compulsary
training.
Some of the other general challenges by
the current mental health services in
Malaysia also contribute to the difficulty
in further development of ACT. This
include inadequate number of acute beds
in all general hospitals, lack of trained
staff, and unavailability of community
support services that are needed in ACT.
Therefore, the services cannot provide
the best care to the population whereby
many of mentally ill people still need to
be transferred to mental institution for
continuity of care and rehabilitation
programs.
Though the paradigm shift has gradually
occurred
among
mental
health
professionals, problems are appearing to
be mainly in the implementation process.
This include determining whether ACT
is the most effective program and need
to be given priority specially when it
involves budget allocation. Overall,
mental health care issues are still being
given a low priority resulting in
inadequate resources. The mental health
budget is still considerably low with
only 1.5% of total health budget (9, 19).
The acute psychiatric beds are only 2.7
per 10,000 populations and there is also
a shortage of mental health professionals
(9, 19). For example psychiatrist ratio
per 100,000 populations is only 0.3 and
the ratio of mental health nurses to
100,000 populations is only 0.5 (19).
Among these nurses, only about 19% of
them were psychiatrically trained (8).
This percentage could be higher now but
the fact is, not all nurses working in
psychiatric settings in Malaysia are
formally
trained
in
psychiatry.
The current trend of mobilizing the
hospital staff to work at the ACT
services cannot be done without
jeopardizing the quality of inpatient care
in the hospitals. Lacking in human
resources and absent of intersectoral
collaboration have contributed to
incomprehensiveness of the ACT. This
has given a significant impact to the
consumers in long term especially when
rehabilitation programs take place after
the symptoms control phase. Many of
the needs of severely mentally ill in the
ACT for instance are still cannot be met
especially
the
accommodation,
employment and rehabilitation aspects.
Apart from that, there are possible
problems in the training continuity of
primary care staff as there has been
inadequate supervision. The state or
district psychiatrists are burdened up
with administrative and other clinical
responsibilities making it hard for them
to maintain the training and supervision
of staff. The specialized services are still
centralized in cities and urban areas
causing them to be not easily accessible.
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The separation between administration
of community services in primary
healthcare and hospital services also at
times resulting in poor coordination
between primary care and specialist
services in general hospital. Further
more, stigma and discrimination towards
people with mental illness are still a
concerning problem in Malaysian
context. They often give negative
impacts
on
overall
help-seeking
behaviors of the consumers even when
the services are made available to them.
Since its implementation there have been
many challenges noted subjectively to be
related to the consumer’s acceptance and
satisfaction with the services. As many
of these challenges can become barriers
to further progress of ACT, they need
therefore be identified, understood and
modified if not fully solved. Apart from
that, the understanding and acceptance
of consumers towards the new model of
care is important concern to the mental
health providers. Firstly because the
information is useful as an outcome
measure and can encourage further
improvement of the service quality.
Secondly the sevices need to be
appropriately responsive and tailored to
the expectation and needs of the
consumers in order to promote their
involvement and partnership in the
overall mental health care program.
CONCLUSION
ACT can be considered as one of the
most important elements of mental
health care reform in Malaysia.
Obviously it needs to be developed
further to achieve what is considered as
comprehensive model of care involving
both community and hospital-based
services. Within the limitation of
funding and staffs, it is crucial to
strengthen the capacity of available
resources in order to serve the
population at the most optimum level. In
doing so, it is also essential to ensure
that the delivery planning is being based
on the ethical and evidence-based
principles.
Often while making this reform, there
are an overwhelming problems and
difficulties, this does not mean the
system should surrender to those
challenges. In regard to this, a well
coordinated and powerful mental health
work force could further contribute in
making changes in Malaysian mental
health system. The future development
therefore needs to be continued from
where it is now and at this point, it is
also crucial in ensuring these services
are making progress into the right future
direction.
As it clear that the ACT is observed to
be useful in further enhancing the
management of patients with severe
mental illness, it is timely to conduct an
evaluative research to find out whether
ACT helps to achieve the treatment
goals in a defined period of time.
REFERENCES
1. Rose N. Historical changes in mental
health practice. In: Thonicroft G,
Tansela M, (editors). Textbook of
community psychiatry. Oxford: Oxford
University Press, 2001:13-28.
2. Thornicroft G, Szmukler G. What is
community psychiatry? In: Thornicroft
G, Tansela M. (editors). Textbook of
community psychiatry. Oxford: Oxford
University Press, 2001:1-12.
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3. World Health Organization. World
Health Report 2001.Mental health: new
understanding new hope. Geneva: World
Health Organization:2001.
4. Tansela M, Thornicroft G. The
principle of underlying community care.
In: Thonicroft G, Szmukler G. (editors).
Textbook of Community Psychiatry.
Oxford: Oxford University Press,
2001:155-165.
5. Crabtree S, Chong G. Standing at the
crossroad: mental health in Malaysia
since independence. In: Haque A, editor.
Mental health in Malaysia. Kuala
Lumpur: University of Malaya press,
2001:21-34.
6. Mechanic D. The scientific
foundations of community psychiatry.
In: Thonicroft G, Tansela M, (editors).
Textbook of community psychiatry.
Oxford: Oxford University Press,
2001:41-52.
7. Tan E, Lipton G. Mental health
service in Western Pacific Region.
Manila: World Health Organization,
2001.
8. Abu Bakar SR. Community mental
health service delivery in Malaysia.
Third Kuala Lumpur Mental Health
Conference.11-13 July. Kuala Lumpur,
2002.
9. Aziz A. Mental health Framework in
Malaysia. Third Kuala Lumpur Mental
Health Conference.11-13 July. Kuala
Lumpur, 2002.
10. Mueser KT, Bond GR. Psychosocial
treatment approaches for schizophrenia.
Current
Opinion
in
Psychiatry,
2000:13:27-35.
11. Stein L, Test M. Alternative to
mental hospital treatment: 1. Conceptual
model, treatment program and clinical
evaluation. Archives of General
Psychiatry, 1980:37:392-7.
12. Scott JE, Lehman AF. Case
management and assertive community
treatment. In: Thonicroft G, Szmukler G.
(editors). Textbook of Community
Psychiatry. Oxford University Press,
2001:252-263.
13. Dixon LB, et al. Modifying the
PACT model to serve homeless persons
with severe mental illness. Psychiatric
Services, 1995:46:684-688.
14. Marshall M, Gray A, Lockwood A.
Case management for people with severe
mental illness, in. In: Adams C,
Anderson J, Mari JDJ. (editors). The
Cochrane database of systematic
reviews. London. BMJ Publishing
Group, 1996.
15. Baronet A, Gerber G. Psychiatric
Rehabilitation: efficacy of four models.
Clinical
Psychology
Review,
1998:18:189-228.
16. Bond GR, McGrew JH, Fekete DM.
Assertive outreach for frequent users of
psychiatric hospitals: a meta-analysis.
Journal of Mental Health Administration
1995:22:4-16.
17. Latimer E. Economic impacts if
assertive community treatment: a review
of literature. Canadian Journal of
Psychiatry, 1999:44:443-454.
18. Calsyn RJ, Morse GA, Klinkenberg
WD et al. The impact of assertive
community treatment on the social
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relationships of people who are
homeless and mentally ill. Community
Mental Health Journal, 1998:34:579593.
19. World Health Organization. World
Health Report 2000. Geneva: World
Health Organization, 2000.
* Department of Psychiatry, UKM
Correspondence:
Dr Ruzanna ZamZam,
Department of Psychiatry,
Faculty of Medicine,
Jalan Yaakob Latiff,
56000 Cheras,
Kuala Lumpur.
E-mail: [email protected]
78
MJP 2008, Vol.17 No.1
REVIEW PAPER
A REVIEW OF ECT PRACTICES: NEUROBEHAVIOURAL
Prem Kumar C*
ABSTRACT
The use of Electro-Convulsive Therapy (ECT) has again risen,
and so have the restrictions laid in the path for its use. This
communication serves to discuss the thoughts and practices of
ECT in our setting and that in the West, which we all know
vary from center to center and individual to individual. A
reminder guide, incorporating those ideas along with a simple
risk-benefit assessment checklist, is suggested to induce an
approved perspective that will enable the drawing-up of a
standard, sanctioned guideline on the applications of ECT in
our region. This proposal will then be hoped to be of
substantial
medico-legal
benefit
in
the
future.
Keywords: Re-stimulation, dosing, unilateral ECT, bilateral
ECT, frequency, multiple monitored ECT
INTRODUCTION
There will always be negative reviews
about
Electro-Convulsive
Therapy
(ECT), be it tales of experiences from
patients or family members, and even
anecdotes by physicians from other
specialties. The press highlights the
negative effects of this form of treatment
in terms of benefit and cost to the
patient, mainly voiced by the outraged
public and critics. This could be
attributed to the fact that the potential
benefits of ECT by evidence-based
information has never been impressively
put forward and considering that a
newspaper is probably the foremost form
of media communication, it is no wonder
then that the public has become wary of
it’s use. However, psychiatrists very
well know the benefits of ECT from
clinical experience but pressure from the
public may force us to come up with
some accredited guidelines on its use,
tapered for our region. The reputation of
the Joint Commission International
(JCI), an accreditation body that sets
standards on medical care worldwide, is
on the up-rise and most private hospitals
in our part of the world have made the
decision to conform to their stringent,
but
noteworthy,
accreditation
requirements. This, surely, must come as
bad news for a number of private
psychiatrists who have been relying on
their clinical acumen and experience on
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MJP 2008, Vol.17 No.1
the use of ECT, and who have achieved
considerable success whilst using this
mode of treatment for their patients.
Thus, a proposed risk-benefit assessment
checklist and a reminder guide are put
forward for that purpose.
DISCUSSION
In spite of the development of guidelines
for the use of ECT by the Royal College
of Psychiatrists in 1995, the National
Health Service (NHS) in the UK
commissioned the National Institute for
Clinical Excellence (NICE) to look at
the available evidence on ECT and to
provide guidance that would help the
NHS decide when ECT should be used
in England and Wales. A total of more
than 200 randomized controlled trials
(RCTs) and a number of observational
studies were reviewed and considered.
The then on-going deficiencies in the
current practices of ECT were
highlighted and consideration was given,
as well, to a majority of RCTs thought to
be inapplicable to modern practice
because of advances in pharmacological
management and ECT administration
techniques. Finally, in April 2003, NICE
did come up with safe but somewhat
stringent guidelines, which were poorly
received by many psychiatrists there.
Concerns of the psychiatrists ranged
from the new restrictions put forward on
their previously ‘free-hand’ on the use of
ECT, to the fact that there were no
psychiatrists present in the NICE
appraisal committee. Expert perspectives
were obtained from only 2 qualified
psychiatrists and an ECT Accreditation
Service (ECTAS) had been formed to
further raise their standards by ensuring
that not only are the health professionals
there following the NICE guidance, but
also that they are properly trained and
their modes of ECT practices have been
peer-reviewed (1).
In a summarized form, NICE had
recommended that ECT should only be
used for the treatment of:
Severe depressive illnesses
Prolonged or severe episodes of
mania, and,
Catatonia.
ECT should be used to gain fast and
short-term improvement of severe
symptoms after all other treatment
options have failed, or when the
situation is thought to be life threatening.
The treatment should be stopped as soon
as the person has responded, if there are
any adverse events, or if they withdraw
their consent. It should also not be used
as a long-term treatment to prevent
recurrence of a depressive illness, and
that it should not be used in the general
management of schizophrenia (Table 1).
Table 1: Circumstances and ECT
When Not to Give ECT
Moderate depression
Schizophrenia
Maintenance therapy
Immediately upon recovery
Development of adverse events
If patient withdraws consent
When ECT is Not Contraindicated
Any trimester of pregnancy
Patients with cardiac pacemakers
Epilepsy
Orthopaedic conditions
Old age
A repeat course of ECT is only provided
if all other treatment options have been
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MJP 2008, Vol.17 No.1
considered or in those who have been
known to previously respond well to it.
Finally, the individual’s cognitive
function is tested and monitored on an
on-going basis after every ECT (usually
employing the Mini-Mental State
Examination [MMSE], a cognitive
assessment tool that is able to detect the
degree of confusion post-ECT) and at
the very minimum, at the end of each
course of treatment (2). A summary of
the treatment algorithms frequently
employed is that there are often 6-8 steps
before ECT is given. Some protocols
even recommend about 2-4 years before
this treatment is indicated. Thus arises
the question, “Why save the best for
last?” when we know that the triad of
good response to ECT is the presence of:
Endogenous affective symptoms
Acute / florid Type 1 symptoms,
and,
Change in psychomotor activity
(3).
Prior to the new guidelines implemented
by NICE, the indications for ECT and
methods by which it was used in the UK
varied considerably from centre to centre
and from individual to individual, as is
the case here in Malaysia. We have
variations on its use and practice
especially where the frequency of
administration in a week and the total
number of ECTs given are concerned.
There are differences on the indications
for its use and there is confusion
surrounding the use of maintenance
ECT, although it has been known to be
efficacious and well tolerated, as well as
reducing hospital use for a population of
chronically depressed patients refractory
to medication (4). The use and practice
of ECT also differs between the
government and private settings here.
Notwithstanding some similarities in the
practice of ECT between clinicians in
the UK and here in Malaysia, there are
significant differences in the approaches
undertaken, especially in the post-NICE
era.
Table 2: Risk-benefit assessments
Document risks and benefits carefully
Document patient’s choice
Document against NICE guidance (if it
is considered perverse)
-Previous good response in moderate
depression
-Seek 2nd opinions for maintenance
ECT
Informed consent when treatment is
‘not-NICE’
A risk-benefit assessment (Table 2) of
the individual should be made and
documented. Someone who is mentally
capable of making a decision about their
treatment should decide, after discussion
with their doctor, whether or not they
want to give their consent to have ECT.
If discussion and informed consent are
not possible at the time treatment is
needed, any advance directive from the
patient should be fully taken into
account and someone who speaks on
behalf of the person who is ill, or their
carer(s), should be consulted. A special
committee consisting of psychiatrists
appealed for ECT to be administered in
moderate
depression
and
for
maintenance ECT to be sanctioned, on
the grounds that the NICE guidance was
perverse. This was lost to NICE as ECT
was considered ‘toxic’. Therefore,
documentation of risk-benefit would
have to be done carefully if one were to
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MJP 2008, Vol.17 No.1
go against the NICE guidance, even if a
patient with moderate depression had
previously responded well to ECT. The
patient would also have to be informed
that their treatment would be ‘not NICE’
and their consent recorded. As for
maintenance or continuation ECT,
second opinions were recommended if
treatment was going against the NICE
guidelines. Evidence that ECT is more
effective than repeated trans-cranial
magnetic stimulation (TMS) reinforced
Nice’s stand on the lack of value of
maintenance ECT. Therefore, it is only
considered when a patient is resistant to
all anti-depressants and combination
treatments and he or she may benefit
from indefinite maintenance ECT e.g.
every 7, 10 or 14 days for a few years. In
a study by Datto et al (2001), giving
ECT at a rate of 1 per 2.92 weeks and
with telephone contact the day after ECT
found
no
progressive
cognitive
impairment or an increase in the ST (5).
Fox (2001) also discovered that relapses
could be reversed by 3-4 closely spaced
ECTs and the MMSE after 6 weeks was
still
unimpaired
(6).
Table 3: Issues in ECT administration
1. If there is a missed seizure or
increasing doses are required, consider
poor electrode placement (this problem
does not exist with the newer ECT
machines which indicate if there is
satisfactory electrode placement).
However, with older machines, the
suggestion is to re-stimulate after 20secs
2. If abortive or brief seizures occur
(<15secs), consider an excess of general
anaesthetic (GA) agents, then restimulate after 40-90secs
3. If prolonged seizures occur (>3mins,
but some centers advocate >60-90secs
on EEG monitoring), pharmacological
termination of seizures is advocated
4. Adequacy of seizure determines the
dosing to be given – consider that postictal suppression index is less
pronounced with unilateral ECT and an
increased amplifier gain
5. Preferably use machines employing
EEG monitoring with options of
adjusting pulse width and frequency,
train duration, current and charge
6. If seizure adequacy is not satisfactory
after the 1st stimulus during the 1st
treatment, ECT can be repeated 2 more
times with increasing charge until the
ST is determined
7. If the ST is not determined, the same
can be repeated for the 2nd ECT but
only 1 re-stimulation is allowed for the
3rd ECT
8. Once the ST is determined, add 75mC
of charge for efficacy and maintain the
Dose, unless the seizure length decreases
by 20%
Where dosing is concerned, if increasing
doses are required, poor electrode
placement has to be ruled out first (Table
3). The majority of psychiatrists in the
UK go by adequacy of a seizure to
determine the dosing of ECT to be
given. No longer are data like the postictal suppression index considered
accurate, as it is likely to be less
pronounced with unilateral than with
bilateral ECT. This index may also be
diminished when the EEG amplifier gain
is too high. As a lot of British centres
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MJP 2008, Vol.17 No.1
use the newer ECT machines with EEG
monitoring and the options of adjusting
pulse width, pulse frequency, train
duration, current and charge, monitoring
the adequacy of a seizure is possible.
Ictal EEG monitoring has been
recommended for routine use as it
actually records and reflects the action of
the brain generating the seizure, and
especially because it is able to appreciate
the seizure activity that is typically 1020 seconds longer than motor activity
(considering that motor responses may
not always be observable). Furthermore,
prolonged seizures may be detectable
only by EEG. While the patient is still
under the cover of anaesthesia and if the
seizure adequacy is not satisfactory after
the first stimulus, it can be repeated 2
times more during the same treatment
with increasing charge until the seizure
threshold (ST) is determined (in the US,
restimulation can be done 3 more times
during the first ECT treatment). If the ST
has still not been achieved, the same
process can be repeated when ECT is
given the second time and by the third
time, the charge can be increased for restimulation only once more, although it
is unlikely that the ST would not be
known by then. Once the ST is
determined, they add 75mC (millicoulombs) of charge for efficacy and
maintain that dose unless the seizure
length reduces by 20% or more.
Unilateral ECT is considered the firstline treatment in most UK centers, even
though it is known to be less efficacious
than bilateral electrode placement. This
inefficacy is characterized by lesser midseizure ictal amplitude in the 2-5 Hertz
(Hz) frequency band than those
amplitudes induced by bilateral ECT (7).
The electrode placement would usually
be on the right side (fronto-temporal and
occipito-temporal), even in left-handed
subjects, to avoid the administration of
ECT on the dominant hemisphere. Male
dominance is mostly on the left side and
in females, 50%. This practice of
unilateral ECT has evolved from the
controversies surrounding the adverse
effects of ECT on cognitive function. If
there is progressive rise in time to reorientation after every ECT, the risk of
running into cognitive impairment is
more likely. (Sobin, 1995)(Sackeim,
2000) Thus, the recommendation is to
decrease the stimulus dosing. Decreasing
the pulse width has been found to be
associated with less memory loss and
this practice is frequently adhered to
over there. However, McCall et al
(2000) found that the efficacy of
unilateral ECT increases with doses
higher than the ST, and perhaps up to 12
fold (8). On the other hand, Sackeim et
al (2000) found that high-dose unilateral
ECT only provided a 70% response as
compared to bilateral ECT, which
conferred an 80% response (9). He also
later discovered that even a low-dose
bilateral ECT secured a 70% response as
compared to unilateral ECT, which only
gave a 28% response. (Sackeim, 19911993) Although the best outcomes are
obtained with doses 50-100 times greater
than the ST, it must be remembered that
side-effects also increase with doses
higher than the ST but they are
considerably less with unilateral as
compared to bilateral ECT.
ECT is generally given twice weekly in
the UK as it was found that there is no
great increase in its effectiveness when
given thrice weekly. However, once
weekly administration was found to
produce a slower recovery. The majority
of us tend to follow the US method of
thrice weekly administration of ECT
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MJP 2008, Vol.17 No.1
although of late, the Americans seem to
be moving towards administering
Multiple Monitored ECT (mmECT) in
an attempt to decrease the total duration
of the treatment course by inducing
multiple seizures (usually 2-10) during a
single treatment. Most ECT seizures are
self-limited and last less than 2 minutes.
The problem arises when prolonged or
spontaneous seizures occur (Table 3).
This could lead to the risk of going into
status epilepticus and they should be
terminated pharmacologically after 3
minutes of sustained seizure activity
with further general anaesthesia (GA) or
benzodiazepines (BDZs) as even if
oxygenation is adequate, the brain could
use up its glucose supplies beyond
dangerous levels. And when considering
confusion and memory complaints, it
would be prudent to remember that “in
many patients, the recovery from
retrograde amnesia will be incomplete
and there is evidence that ECT can result
in persistent or permanent memory loss”
(Sackeim, 2000). This is more likely in
the elderly and there is a strong
association between post-ictal confusion
and the development of memory side
effects.
Confusion
and
memory
complaints could be limited by reducing
treatment from twice to once per week,
changing from bilateral to unilateral
ECT
and
administering
neuropsychological assessments pre- and
regular post-ECT (especially when
administering
maintenance
ECT).
Taking in account the above concerns,
ECT treatment is stopped the moment
the patient improves but what constitutes
satisfactory clinical response still
remains arbitrary and varies from
individual to individual. Therefore,
teachings dictating that once a patient
shows significant improvement after
ECT and then the ‘process’ of
administering 3 more ECTs to provide
optimization of treatment will no longer
hold good in any court of law, given the
focus on evidence-based medicine these
days.
Going further into the side-effects of
ECT, a large number of British
psychiatrists stop all medications when a
course of ECT is given but the standard
practice in most of Asia is basically
limited to stopping only lithium therapy
as post-ECT hypomania can occur if it is
given concurrently. On the other hand,
differing thoughts about this practice
have been published (10). Also, if postictal agitation occurs, it could be treated
with bolus BDZs or GA and if there are
post-ECT headaches, they could be
relieved
by
painkillers.
Lastly,
neuroleptics are widely omitted in the
West, as they are pro-convulsive in
small doses but increase the seizure
threshold
in
high
doses.
However, most of us do not practice this,
as there is an unwritten ‘rule’ in that
many believe that ECT weakens the
blood-brain barrier to facilitate the entry
of neuroleptics. Thus, as with
recommendations from NICE, further
research needs to be done to assess the
cost-effectiveness,
mechanisms
of
action, long-term efficacy and safety of
ECT. It would be wise on our parts to
learn from the medico-legal restrictions
our peers in the West are facing and look
ahead in our practices of ECT before the
same restrictions are imposed on us,
meaning the drawing up of our own
regionally-sanctioned guidelines on it’s
use. The following reminder guide and
proposed
risk-benefit
assessment
checklist (Tables 1-3) may serve to bring
about this much-needed adherence.
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MJP 2008, Vol.17 No.1
REFERENCES
1. Guidance on the Use of
Electroconvulsive
Therapy:
Technology Appraisal 59. (online) Apr 2003. Available from:
http://www.nice.org.uk/nicemedi
a/pdf/59ectfullguidance/pdf
(accessed
Dec
4,
2007)
2. Beyer,
Weiner,
Glenn.
Electroconvulsive Therapy – a
Programmed
Text.
Second
Edition.
Washington
DC:
American Psychiatric Press,
1998.
3. Beale MD, Kellner CH. ECT in
Treatment Algorithms: No Need
to Save Best for Last. Journal of
ECT,
Mar
2000;16(1):1-2.
4. Russel JC, Rasmussen KG,
O’Connor MK, et al. Long-term
Maintenance
ECT:
a
retrospective Review of Efficacy
and Cognitive Outcome. Journal
of ECT, Mar 2003;19(1):4-9.
5. Datto CJ, Levy S, Miller DS, et
al. Impact of Maintenance ECT
on Concentration and Memory.
Journal of ECT, Sep 2001; 17(3):
170-174.
6. Fox HA. Extended Continuation
and Maintenance ECT for Longlasting Episodes of Major
Depression. Journal of ECT, Mar
2001;17(1):60-64.
1998;15(5).
8. McCall, Reboussin DM, Weiner
RD, et al. Titrated Moderately
Suprathreshold versus Fixed
High-dose
Right
Unilateral
Electroconvulsive
Therapy:
Acute
Anti-depressant
and
Cognitive Effects. Archives of
General
Psychiatry,
May
2000;57(5):438-444.
9. Sackeim, Prudic J, Devanand
DP, et al. A Prospective,
Randomized, Double- blind
Comparison of Bilateral and
Unilateral
Electroconvulsive
Therapy at Different Stimulus
Intensities. Archives of General
Psychiatry, May 2000;57(5):425434.
10. Stewart
JT.
Lithium
and
Maintenance ECT. Journal of
ECT, Sep 2000;16(3): 300-301.
* NeuroBehavioural Medicine, Penang
Adventist Hospital, Malaysia
Correspondence:
Dr. Prem Kumar Chandrasekaran,
Consultant Neuropsychiatrist,
Penang Adventist Hospital, 465 Burmah
Road, 10350 PENANG.
E-mail: [email protected]
7. Fink, Abrams. EEG Monitoring
in ECT: a Guide to Treatment
Efficacy. Psychiatric Times, May
85
MJP 2008, Vol.17 No.1
REVIEW PAPER
THEORY OF MIND FOR THE PSYCHIATRISTS
Ang GK*, Pridmore S**
ABSTRACT
The “theory of mind”, frequently abbreviated as ToM, is a concept
borne out of the study of primates and their social organisation.
Scholars in philosophy, anthropology,psychology, psychiatry and
neuroscience are interested in ToM from different perspectives. Here,
we describe the origins of ToM in primates and humans, the
neurobiology of ToM, and the possibility that ToM deficits are
important in certain psychiatric disorders. The idea of ToM had been
around since the 1970s, and still being debated by scholars. It is,
however, still a relatively new idea not widely familiar by many
practicing psychiatry in clinical settings. We think ToM is a new way
of approaching clinical psychiatry. We expect further work in ToM
will have an impact on better understanding and the management of
mental illness.
Key words: theory of mind, mental illness, primate society, human
evolution
INTRODUCTION
“Theory of mind” (ToM), first coined by
Premack and Woodruff (1), was
referring to an individual’s “ability to
understand that, one’s mental state can
be the reason for their behaviour”. ToM
has been later defined as the ability to
“recognise that other people can have a
‘mind’ different to oneself” (2), or to
infer what is happening (thoughts,
assumptions, plans, ambitions) in
someone else’s mind (3). In short, ToM
is used to explain and predict the
reactions of other people. ToM is crucial
in any successful social interaction,
allowing accurate perception and
interpretation of social signals e.g.
motivation, emotion, attention, memory
and decision making (4). Recently, it has
been proposed that deficits of ToM
explain certain psychiatric phenomena
(5).
How did ToM arise?
In the 1960s and 70s, primatologists
noted that, monkeys and chimpanzees
have cognitive abilities beyond simple
feeding and foraging needs (6, 7), and
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MJP 2008, Vol.17 No.1
are group-living for reasons of better
protection and economical resource
management (8). To be successful in
group living, all members must identify
those who will potentially cooperate
with them. Each member must first
understand and be aware that other
members can act differently according to
what they each want. This will enable
one party to predict another party’s
behaviour. Premack and Woodruff thus
ask the important question “Do
chimpanzees have a theory of mind?” in
1978. Since then, research in ToM and
its potential applications has been
conducted by expert groups in the fields
of
philosophy,
anthropology,
psychology,
psychiatry
and
neuroscience.
Do humans have ToM?
Presence of ToM in chimpanzees
indicates that ToM may have existed
long before the first homosapiens (9),
and the persistence of ToM throughout
primate evolution may mean it is a trait
positively selected for. ToM may
therefore be advantageous, even
essential to the development of human
society (10). The age that a child
acquires ToM had been the subject of
debate (11). Piaget (12) wrote that very
young children “[do] not understand that
others’ views and thoughts can differ
from his or her own”. Most authors seem
to agree that ToM develops in children
between 3 and 4 years of age (2). BaronCohen (13), who worked with children
with autism spectrum disorders, believes
that a normal 4 years old should be able
to understand that, different people can
have different thoughts about the same
situation, and keeping track of how
another person might think in a given
situation. Children with autism often
have difficulty with these processes, and
report only what they themselves, know.
This ability becomes more sophisticated
as the child matures. By 6 years old, the
normal child understands that different
people can have different thoughts about
another person’s thoughts. By 8 years of
age, a normal child can consider even
more complex mental states, allowing
them to, for example, detect a bluff.
How is ToM studied?
The
maturing
ToM
has
been
indispensable to our participation in
more complex situations/societies/group
settings as we continue to grow and
develop, ensuring maximum returns and
mutual benefit to its members (9). A
widely studied ToM aspect is detecting
potential violations to the rules of a
contract/of a society, or “cheatdetection”. 2 studies below serve to
illustrate this. The “Prisoner’s Dilemma”
psychological experiment, devised by
Axelrod and Hamilton (14), later
repeated with a larger sample by Nowak
and Sigmund (15), asked 2 study
participants to be ‘prisoners accused of
wrong-doing’. They were essentially
allowed to cooperate or look after their
individual interests by accusing the
other. It was found that the response
from one party in a pair usually matched
or reciprocated by the other person of
the pair.
Sugiyama et al (16) believed ToM to be
universal, and hypothesized that the
ability to detect cheaters, transcend
cultural and language development.
They studied the isolated, non-literate
hunter–horticultural Shiwiar tribe of
Ecuadorian Amazonia. The Shiwiar
subjects’ were proficient at identifying
non-reciprocators, demonstrating the
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MJP 2008, Vol.17 No.1
presence of ToM in this society. The
Shiwiar also performed just as well, on
tests of ToM, as matched Harvard
university students. The investigators
concluded that cultural factors did not
affect ToM.
trustworthiness of others (22). These
patients have often been vulnerable to
scams, bad business deals and
exploitative relationships (23).
So, is ToM relevant to Psychiatric
Disorders?
Is there a biological basis for ToM?
There may be evidence for ToM at the
microscopic and macroscopic levels. On
the microscopic level, enormous
excitement followed the discovery of
“mirror neurons” (MNs) (17), first in the
pre-motor cortex and parietal regions of
macaque monkey brains, and later
identified in similar geographical areas
of human brains. These unique cells
activate when an individual performs an
action or when he observes the same
action performed. (To the present, only
small movements of the lips or fingers
have been studied.) Observing an action
with part of the movement obscured
from view (18), and hearing the sound of
an un-observed action may activate
mirror neurons (17,19). This has been
taken to mean, and argued that the
animal is able to predict the action,
allowing the experimental animal is to
determine the goal of the animal it was
observing (19). MNs are thus believed to
provide the neural basis for ToM (20).
On the macroscopic level, neuroimaging
studies have been identifying brain
regions that may be involved in ToM
(20). The frontal, temporal, and parietal
cortices, and cerebellum are among the
most important regions (20). Stone et al
(21) compared the performance of
people with extensive brain damaged
and normal controls. Their results are
consistent
with
that
of
other
investigators, in which subjects with
damage to orbitofrontal cortex or
amygdala or both are poor at judging
Individuals with better ToM skills will
exhibit better social skills and
outperform those with less good ToM
skills (24, 25). When ToM malfunctions,
the individual may incorrectly interpret
the signals he/she perceives (about
him/herself or others) and arrive at
wrong conclusions. This malfunction is
believed to be the basis of a variety of
neuropsychiatric disorders (26, 13), most
notably, autism spectrum disorders. It
may have a role in understanding
schizophrenia and personality disorder.
Studies also suggest ToM deficits occur
in normal aging, bipolar disorder, frontal
lobe injury and dementia.
Do Autism spectrum disorders have
ToM?
Autism is characterised by qualitative
impairments in their communication
(verbal/non verbal language), behaviour
(interacting with others, frequently
found
isolative),
have
limited
imagination, a restricted range of
interests and stereotyped repetitive
behaviours/mannerisms.
“Does
the
autistic child have a ‘Theory of Mind’?”
asked Baron-Cohen et al (27), and
suggested that autistic children have
difficulties with tasks requiring them to
understand another person’s beliefs. This
lack of ToM abilities is now considered
to be a key feature of autism. Several
relationships between autism and ToM
deficits have been proposed. Leslie (28)
and Hobson (29) hypothesized that
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autistic individuals are born without a set
of ToM skills. They thus have an
inability to mentally represent thoughts,
beliefs, and desires, regardless of
whether the circumstances involved
were real. This may explain why autistic
individuals perform poorly in theory of
mind tasks, unable to engage in “pretend
play” and have trouble comprehending
and reacting to other’s feelings. Other
scholars suggested that autism involves a
specific
developmental
delay
in
acquiring these skills. These children do
not acquire ToM skills, at the same age
as their normal counterparts. These early
setbacks alter proper development of
ToM, and failure to form a full theory of
mind (13). However at least some ToM
skills are eventually acquired (albeit
some years later than normal
individuals).
Does Schizophrenia have ToM?
The prominent features of schizophrenia
are positive and negative symptoms.
Positive symptoms consist of delusions,
hallucinations, and formal thought
disorder. The Negative symptoms are
characterized by disorganisation and
social withdrawal. Again, there are many
opinions regarding the relationship
between ToM and schizophrenia
symptoms. Frith (26) proposed that
defective ToM abilities in schizophrenia
led to failure in monitor mental states
and behaviour of themselves and others.
Disorders of “willed action”, “self
monitoring” and “monitoring others”
result in the negative symptoms,
disorganisation,
delusions
of
passivity/being controlled, and “voice
commenting” auditory hallucination.
Failure to recognize one’s own thoughts
can be interpreted by patients as
“voices”, while disorders in monitoring
others’ thoughts and intentions, result in
delusions
of persecution and reference (26).
Hardy-Bayle (30) holds a different view
about ToM in schizophrenia. He believes
that ToM deficits causes impaired
executive
planning,
resulting
in
disorganisation
of
thought
and
communication in schizophrenia. AbuAkel (31) believes an overactive ToM
results in “reading too much into” the
intention of others, leading to the
phenomenon of delusions. Preliminary
neuroimaging studies of schizophrenia
patients (32, 33) appear to support the
above hypotheses with evidence of
abnormally functioning cerebral regions
thought to be involved in ToM. Ongoing
research will further elicit the
mechanism of the ToM impairment in
schizophrenia. It will also investigate
whether the resolution of symptoms of
schizophrenia will show normalisation
of ToM (34).
Do Mood Disorders have ToM?
It is reasonable to assume that disorders
of ToM are present in mood disorders.
This is because these conditions also
display delusions, hallucinations and
formal thought disorder like in
schizophrenia. There are differing views
as to whether ToM dysfunction is
continually present regardless of whether
during the active or remitting phases of
mood disorders. Kerr et al (35) found
deficits of ToM in symptomatic bipolar
patients, but apparently not while bipolar
patients are in remission. Inoue et al (36)
seemed to arrive at a different view from
Kerr et al (35). Studying depressed
unipolar and depressed bipolar patients
currently in remission, they found ToM
deficits persist on during remission
phase of depression. A follow up study
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by Inoue et al (37) also suggested an
increased risk of relapse to depression
among those noted to have significant
ToM deficits while in remission. Like
schizophrenia, there is preliminary
functional neuroimaging evidence (38)
of abnormally functioning cerebral
regions, suggestive of lowered activation
of cerebral regions, among bipolar
patients, thought to be responsible for
ToM. Ongoing research will hopefully
clarify the mechanism and / or
significance of these early findings,
which are nonetheless exciting.
Do psychopathic personalities have
ToM?
Psychopathic personalities
characteristically possess superficial
charm, unreliability, ‘cold-heartedness’
and emotional unresponsiveness. It is
frequently associated to antisocial and
dissocial
personality
disorder
respectively. For sometime, it has been
assumed that psychopathic individuals
lack ToM ability. Several researchers
have instead found that, compared to
controls
and
under
controlled
experimental conditions, psychopathic
individuals are able to appreciate the
mental states of others (39, 40). Dolan et
al (41) concluded that the deficit is a
lack of concern about the impact of
violence on potential victims. This
combination of ‘lack of concern for
others’ and normal ToM is thought to
contribute to the maintenance of a
criminal lifestyle ToM is thought to have
evolved to identify individuals who
cheat/not cooperate, thus improving the
survival rate of those who possess/have
better ToM ability. It is logical that these
“cheats”/psychopathic
individuals
increase their chances of survival by
taking advantage of those with lower/no
ToM ability. They remain unconcerned
by the consequences their actions have
on those affected.
.
Do Borderline Personality disorders
have ToM?
ToM develops as a child matures
psychologically.
Normal
ToM
development requires a securely attached
caregiver, helping the child to consider a
range of possible perspectives (42) and
allowing him/her to think about his/her
own and others' minds (43). Fonagy et al
(44) demonstrated the impairment of
ToM when they studied a group of
patients with severe personality disorder.
Using a scale measuring ToM ability,
they found that a high proportion of
abused patients with low ToM ability,
fulfill the diagnosis of borderline
personality disorder. They concluded
that patients with high ToM ability are
able to understand the events
surrounding
the
traumatic
episode/period, enabling them to resolve
the trauma. Those with lower ToM
ability will be unable to resolve the
trauma and exhibit signs and symptoms
of borderline personality disorder.
Conclusion
We have described theory of mind
(ToM), a new field of study. ToM may
be a new approach to understanding
psychiatric disorders, and is gaining
prominence. We expect this new way of
thinking about psychiatry will bring
about some changes to our approach to
management. The full implications of
this approach will not be apparent until
ToM is further examined and gains
wider acceptance in mainstream clinical
psychiatry.
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and Psychoanalysis. Other Press, New
York.
3. Gabbard, G. (2005). Mind Brain and
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162, 648-655.
4. Adolphs, R. (2001) The Neurobiology
of Social Cognition, Curr. Opin.
Neurobiol. 11, 231-239.
5. Brune, M. & Brune-Cohrs, U. (2006).
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brain mechanisms and psychopathology.
Neuroscience
and
Biobehavioral
Reviews 30, 437–455.
6. Jolly, A. (1966). Lemur social
behaviour and primate intelligence.
Science 153, 501-506.
7. Humphrey, N. K. (1976). The social
function of intellect. Growing Points
in Ethology, 303-317, edited by Bateson,
P.P.G & Hinde, R.A., Cambridge
University Press, Cambridge.
8. Alexander, R. D. (1987). The Biology
of Moral Systems. Aldine de Gruyter,
New York.
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P. (2003). Theory of Mind in Bipolar
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CASE REPORT
VOYEURISM WITH SEXUAL FANTASY ON FEMALE BODY
PARTS: A SUBTYPE OF OBSESSIVE-COMPULSIVE ISORDER?
- A CASE REPORT
Hatta Sidi*, Marhani Midin*
ABSTRACT
The compulsive behaviour of observing an unsuspecting person
undressing or being naked in voyeurism may be related to ObsessiveCompulsive spectrum disorder. The aim of this paper is to report a
case that reiterates a unique psychopathology of a Malaysian male
voyeur with an obsession on female body parts. This 35 year-old
voyeur man who attended psychiatric outpatient clinic in an academic
medical centre presented to a psychiatrist for taking photos of his
sisters’ naked bodies and collected nails and hairs from their body,
coded them with intend for masturbation. His voyeuristic thoughts
and urges which came repeatedly and intrusively, involving attempts
to resist them and was associated with an inner tension for the urges
to be fulfilled. He responded both to Paroxetine and behaviour
therapy. The possibility that voyeurism, a paraphilia can manifest
itself as a subtype of OCD is discussed.
Keywords: Malaysian
disorder, body parts
voyeur,
obsession-compulsive
spectrum
BACKGROUND
Voyeurism refers to recurrent, intense,
sexually arousing fantasies, sexual urges,
or behaviors involving the act of
observing an unsuspecting person who is
naked, in the process of disrobing, or
engaging in sexual activity over a period
of at least 6 months, which significantly
cause distress to the person or
impairment in the person’s social,
occupational, or other important areas of
functioning (1). The word voyeurism
derives from a French verb voir (to see)
with the -eur suffix that translates as -er
in English (2). The stereotypical voyeur
is male, although many women also
enjoy being voyeurs (2,3). In some
institutions, such as in gyms and schools,
camera phones are banned because of
the privacy issues they raise in areas like
changerooms. In Muslim country like
Saudi Arabia, the sale of camera phones
nationwide for a period was banned
temporarily but reallowed their sale for
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fear of voyueristic behaviour among
handphone users (2).
Voyeuristic practices may take a number
of forms and may not directly interact
with the object of their voyeurism. The
objects often unaware that they are being
observed. The
observing acts are
conducted from a distance by either
peeping through an opening or using
aids such as binoculars, mirrors and
cameras (4). This stimulus sometimes
becomes part of masturbation fantasies
during or after the observation. These
sexual fantasies, urges and behavior
patterns in voyeurism which are legally
and socially unacceptable are at the same
time unique because when they are fused
or encoded to a particular sexual erotic
ritualistic behaviour, or object, as a
contigency requirement for maximum
sexual
gratification
resembling
obsessive-compulsive behaviour (5,6).
In Malaysia, the topic of voyeurism like
any other areas of paraphilia is rarely
discussed (7). Voyeurs will only come to
the attention of psychiatrists when they
become involved with law. When they
do, consultation is expected from
psychiatrists and therefore it is important
for psychiatrists to be well equipped
with knowledge about the nature of the
condition. The objective of this paper is
to unfold the nature of voyeurism
through a case report.
CASE REPORT
Mr. HL is a 35 year-old Malay
gentleman, a general manager in one of
the successful companies in the city of
Shah Alam, Selangor. He first came for
psychiatric assessment at the out-patient
clinic of an academic medical centre in
February 2007. This reluctant man
agreed to undergo psychiatric treatment
as a condition put forward by his exwife, failing which, she would proceed
with her intention of taking legal action
against him for secretly taking photos of
her sisters’ naked bodies.
His voyeuristic behaviour came to his
wife’s attention one month before the
first psychiatric consultation when his
wife’s younger sister accidentally
opened his secret file in his personal
laptop and found pictures of her own
naked body. HL had denied being
responsible for the pictures initially
when confronted by both ladies. It was
only when the matter was brought into
the attention of the police and after a
warning of an impending prosecution in
the court of law that would risk him
losing his top managerial post and
suffering the subsequent embarrassment
that he finally admitted to his act. His
voyeuristic behaviour is punishable
under the Malaysian court of law (8).
HL’s voyeuristic history started since he
was in his early adolescence. He liked to
peep other women especially his
neighbours when they were naked while
taking bath. He described feeling flushed
and aroused by his voyeuristic behavior.
However, he denied peeping on his
mother or his sisters. He started to
become interested in seeing his sister-inlaws’ being naked since he started to
stay with his in-laws 5 years back. He
had installed a hidden digital camera on
top of the house common bathroom to
capture all his sister-in-laws’ naked
bodies while they undressed and took
their shower. He had secretly recorded
their bathing acts many times which he
would upload them to his personal
laptop for later use. Each time when he
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heard the sound of any of his sister-inlaw taking shower, he would become
sexually aroused and developed a strong
urge to watch them. He would also
experience mounting anxiety as he tried
to control his urge. He would usually
end up watching pictures or videos of
them being naked which he had captured
earlier and use them to masturbate while
fantasizing of having sex with them.
This would notably give him a sense of
relief of his urge and his “inner tension”
but would later be coupled with feelings
of frustration over his inability to control
his behaviour.
HL experienced satisfactory sexual
intercourse with his wife, however, at
the same time, while having sex with
her, he would fantasize having sex with
his wife’s sister(s). He found this to be
sexually stimulating, but at the same
time felt guilty of having these thoughts
and not being able to resist or stop them.
He also had the obsession of collecting
his sister-in-laws’ hairs and finger nails.
He would go to the bathroom after the
ladies finished their baths to unplug the
digital camera for serial uploading of
pictures or videos and to search for their
pubic hair, scalp hair, clipped finger
nails or whatever he could find for his
personal collection. He collected a series
of these items in a manner like collecting
stamps. He would code each item with
the initials of the item’s owner and date
it. An example of these is KL-ph-05-082006: KL is one of the sister-in-law’s
initials, ph is a short form for pubic hair
and 05-08-2006 is the date when the
pubic hair was collected.
His voyeuristic thoughts and urges
which came repeatedly and intrusively,
involving attempts to resist them and
was associated with an inner tension for
the urges to be fulfilled. The thoughts
and urges which inevitably compelled
him to carry out certain act may also
resemble a compulsive act, which served
him with sexually pleasure and
satisfaction that was followed by a deep
sense of shame and guilt. He did not
have other obsessions or compulsions
involving
other
themes
like
contamination, dirt, doubt, safety,
blasphemy etc. He never experienced
any symptom suggestive of psychosis.
HL had normal and uneventful
developmental history. He completed his
tertiary education and obtained his
degree from a local university. After
completing his study, he secured a job in
a managerial line and had remained in
the same job since. He has been
functioning well at work and has
received several promotions accordingly.
He had never been involved in any
extra-marital affairs or having past
history of criminal or other paraphiliacs
behaviour like exhibitionism. HL had
been married 7 years ago and he was
blessed with one daughter, aged 5. Upon
his admittance to his voyeuristic
behaviour, he and his wife agreed for a
divorce as his wife and her family were
unable to accept his “shameful
behaviour” besides it was “unsafe”
according to them for him to father his
only daughter.
Mental state examination revealed a
young Malay good looking gentleman
with fair complexion, confident looking
and neatly attired. He was cooperative
and spontaneous in relating his
problems. He was euthymic and his
cognitive function was intact. He had
partial insight of his sexual deviation and
was motivated for psychiatric treatment,
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as he feared that he might do it again in
future. He was prescribed with an
antidepressant, Paroxetine 20mg daily to
control his obsessional thoughts and
impulses on voyeurism. This had
controlled the thoughts and impulses
moderately and HL remained in therapy
for 6 months as required by his ex-wife.
Aversion therapy was taught to him by
inflicting pain to his hand every times
when he has his voyeuristic ideas. He
denied any voyeuristic ideas since on
combined
pharmacotherapy
and
behavioural modification.
DISCUSSION
As literature review in the area of
voyeurism in general is very limited (9),
it is hoped that this case report would
add some value to the body of
knowledge in this area, especially
coming from Asian countries like
Malaysia. In term of forensic psychiatry,
under the Malaysian law, criminal
offence for peeping is punishable with
imprisonment term which may extend to
five years or more (8). This case report
also examined voyeurism as part of
Obsessive-Compulsive
spectrum
disorder. This case study reiterates the
unique psychopathology of a young
successful
male
manager
with
voyeuristic fantasy and act, as part of his
acts are bizarre like collecting woman’s
body part. HL used a digital camera,
which is uncommon in Malaysian setting
as a way to peep (7) in gaining access
into the most private activities where
victims were covertly videotaped.
Research found that women are the usual
victims of video voyeurs and their act
are captured as they change their clothes,
perform natural functions or engage in
sexual activities (9) as depicted in the
above case report. Despite of knowing
the
legal,
marital
and
social
consequences of his act, he was unable
to control his voyeuristic impulse and act
as his sexual arousal was at its the peak
and he was not able to resist it
completely which clinically sound more
like obsessive and compulsive in nature.
HL had a relatively stable life despite his
voyeuristic behaviour, unlike other
typical voyeurs. Långström N, 2006 (3),
found in 191 samples of respondents
who enjoyed sexual arousal by spying on
others, also had characteristically less
stable life with more psychological
problems, lower satisfaction with life,
greater alcohol and drug abuse, more
sexual partners, higher frequency of
masturbation, higher frequency of
pornography use, and greater likelihood
of having had a same-sex sexual partner.
Unlike seen in other typical voyeurs, HL
also did not report either exhibitionistic
or other atypical sexual behaviour
(sadomasochistic
or
cross-dressing
behaviour). He neither had any medical
or neurological problems.
It is also interesting to note that the
ritualistic compulsive behaviors seen in
sexual paraphilia like in this case may be
related to OCD. The sexual fantasies
experienced by HL presented repeatedly
in the form of “attacks” in between
which he was free from them, and they
occur in a very ritualistic fashion during
sexual arousal. These thoughts were
sexually exciting, but were followed by
a deep sense of shame and guilt. His
obsession was also reflected from his
compulsion to collect a series of his
sister-in-laws’ body parts and his extra
effort to code them. These coding
appeared to others as odd but had certain
meaning for HL.
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He was successfully treated with
Paroxetine, and showed a decrease in
intensity and frequency of these thoughts
as well as an improvement in impulse
control. Based primarily upon case
reports as well as studies indicating the
effectiveness of Selective serotonin
reuptake inhibitors in the treatment of
sexual parapilias, it has been speculated
that sexual paraphilias lie within
Obsessive-Compulsive
spectrum
disorder (10). The clinical response
observed in patients with sexual
paraphilia to selective Serotonin
reuptake inhibitors (SSRI) has added to
the hypothesis that sexual paraphilia
could be a component of the OCD
spectrum (10).
There is a possibility that HL had
minimized his sexual misconduct – as
having sexual fantasy with other women
than his own wife, and what more
enjoying the sight of naked body of
other women has an infidelity element in
it and is strongly condemned if not
prohibited in the Malay culture (7).
Intervention like Cognitive behavior
therapy (CBT) based on sexual learning
theory using cognitive restructuring
methods and behavioral techniques
primarily directed at reducing patients’
sexual arousal cues. Other psychological
treatment options include analytic
psychotherapy or group therapy, but
other forms of therapy such as aversion
and avoidance conditioning are being
attempted with increasing success (9).
Due to social stigma, paraphiliacs will
try to hold back their voyeuristic
fantasies and as they do so, craving
reaches to an unbearable level that leads
to loss of impulse control, which
probably a manifestation of serotonin
neurotransmitter dynamic (6). This
probably explains why HL had
responded to Selective serotonin
reuptake inhibitor (SSRI).
REFERENCES
1. American Psychiatric Association
Guidelines.
Diagnostic
and
statistical manual of mental
disorders, 4th ed. (DSM-IV).
Washington, DC:1994.
2. http://en.wikipedia.org/wiki/Voyeu
rism (Accessed on 1st November
2007)
3. Långström
N,
Seto
MC.
Exhibitionistic and voyeuristic
behaviour in a Swedish national
Arch Sex
population survey.
Behav, 2006:35:4:427-35. E-pub
11 Aug 2006.
4. Simon RI. Video voyeurs and the
covert videotaping of unsuspecting
victims: psychological and legal
J
Forensic
consequences.
Sci,1997:42:5:884-9.
5. McElroy SL, Philips KA, Keck PE
Jr. Obsessive-compulsive spectrum
disorders. J Clin Psychiatr (suppl),
1994:55:42.
6. Balyk ED. Paraphilias as a subtype
of
obsessive-compulsive
behaviour:
A
hypothetical
biosocial model. J Orthomol Med,
1997:12:1:29-42.
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7. Sidi H, Hatta SM, Ramli H.
Seksualiti Manusia: Keharmonian
Jalinan Antara Jantina. Dewan
Bahasa dan Pustaka. Edisi-ke 2,
Kuala Lumpur, 2006.
8. Chapter
XXII:
Criminal
intimidation, insult and annoyance.
Section 509 Penal Code. Laws of
Malaysia. Compiled by Legal
Research Board. Published by
International Law Book Series,
1990. Kuala Lumpur, 181.
9. Smith RS. Voyeurism: A review of
literature. Arch Sex Behav,
1976:5:6:585-608.
10. Abouesh
A,
Clayton
Compulsive
Voyeurism
A.
and
Exhibitionism:
A
Clinical
Response to Paroxetine. Arch Sex
Behav, 1999:28:1:23-30.
* Department of Psychiatry, UKM
Correspondence:
Clinical Associate Professor Dr. Hatta Sidi.
Department of Psychiatry,
Universiti Kebangsaan Malaysia (UKM)
Jalan Yaakob Latif, 56000
Kuala Lumpur.
E-mail: [email protected]
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CASE REPORT
BRIDGING A MALAY MYSTICAL BELIEF AND PSYCHIATRY:
A CASE OF FETUS ‘STOLEN’ BY ORANG BUNIAN IN ADVANCED
PREGNANCY
Ruzanna Z*, Marhani M*
ABSTRACT
The phenomenon of 'lost fetus' to orang bunian is quite commonly
heard of in our culture. It may present in psychiatric settings and may
potentially create confusion and difficulties in diagnostic and
management aspects. A case of feigned full-term pregnancy followed
by a pregnancy loss is described. This review emphasizes the need to
recognize this phenomenon of ‘lost advanced pregnancy’ in context of
the Malay belief. Possible etiological factors, diagnostic indicators of
factitious disorder and management strategies are discussed. The
possibility of cultural beliefs being used as psychological defenses is
also discussed.
Keywords: lost pregnancy, orang bunian, Malay mystical belief,
factitious disorder
CASE REPORT
S.U is a 43 year-old clerk referred for a
psychiatric assessment by her employer
for allegedly taking maternity leave
without being able to produce evidence
of delivery. She was seen four months
after the so-called delivery. She
described an experience of full term
pregnancy and claimed to have
maternity check-up at a particular
maternity center. She claimed an
ultrasound done at 30 weeks showed a
female fetus. Interestingly her husband
never witnessed her check-up sessions,
even though he verified the signs and
symptoms of pregnancy in her such as
morning sickness, increased appetite,
weight
gain,
amenorrhoea,
and
increasing abdominal distension.
S.U later experienced a spiritual event
few days before her supposed due date.
She was first, visited by an unknown
lady preparing her for delivery and later
had a dream of a man telling her that she
had lost her baby. Her husband sent her
for an ultrasound following her concern
about the lost baby. The ultrasound film
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traditional healers also shared the belief.
She then took maternity leave for two
months until her employer started an
investigation on her for being absent
from work without any evidence of
delivery.
She denied any past psychiatric or
medical history. She was brought up in a
family environment, which adopts strong
beliefs of orang bunian. She completed
secondary school, secured a job as a
telephone operator and was able to
maintain the job and get promoted. She
was quite a shy person. She perceived
herself as an unattractive person and had
an arranged marriage at the age of 37.
She received pressure from her husband
and relatives to have children and in
response she was hoping to conceive as
soon as possible.
Her mental status was stable with no
features suggestive of grief or depression.
She has no explicit thought abnormality
or perceptual disturbance. She was
overtly concerned and angry with the
investigations about the ‘pregnancy’ and
the ‘lost fetus’. She did not show
expected grief reactions towards the
supposedly lost precious baby. The
physical examination revealed no
evidence of recent pregnancy except for
obese abdomen. No clinical evidence
was found to suggest any underlying
gynecological problem.
Discussion
Establishing a diagnosis has been of
central importance in the management in
this lady. The feigned ‘pregnancy' could
be considered as a form of ‘somatization'
called
pseudocyesis.
Somatization
occurs when a person is trying to
communicate
the
underlying
psychological distress with somatic
symptoms (1). Pseudocyesis in particular
is described in DSM-IV as ‘ Somatoform
Disorder Not Otherwise Specified' when
there is a false belief of being pregnant
without the objective signs of pregnancy
(2). This condition can occur in the
absence of conception; the menstrual
periods nevertheless ceased, the
abdomen becomes enlarged and the
woman may report sensation of fetal
movements (2, 3). However, this
condition is less likely in this patient as
investigations reveal no evidence of
medical contact related to her
‘pregnancy', which is typical in this
diagnosis. Pseudocyesis rarely reaches
advanced stage of pregnancy or delivery.
The possibility of psychosis was also
considered in trying to explain whether
she is experiencing delusion of
pregnancy. In such case, she should have
reacted to it by seeing the doctors and
argue with them when told otherwise.
She did not have to create evidences to
convince others that she was really
pregnant. That she was going out of her
way to convince others was because she
herself was fully aware that she was not
pregnant. This has excluded delusion.
Furthermore, the belief that her
pregnancy loss is caused by a spirit is
shared by her husband and relatives. It is
still a belief among some Malays that the
developing child is vulnerable to evil
spirits including orang bunian (3). It is
recognized more as cultural belief rather
than delusion. There is also clearly no
other form of psychosis noted as
evidenced by the absence of thought
disorder, perceptual disturbances or
disorganized behavior. She has been
noted to be mentally healthy prior to this
event.
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There are evidenced in this case that
indicates the presence of factitious
disorder. First, the discrepancy between
her claims and investigative findings
which suggest that the pregnancy was
feigned. For example, the details of her
pregnancy were inconsistent and showed
that the pregnancy was deliberately and
intentionally created to convince others
that she was pregnant. In this process,
she made few basic mistakes which were
in accord with her educational level and
personal experiences. Secondly, there
were many reasons for the need to feign
the pregnancy in this lady. In her
condition, pregnancy serves as a way to
gain attention and sympathy from her
husband and relatives. This could be in
consequence of a threatened loss of both
woman's role and her marriage. A
common cultural phenomenon was being
used to explain the mysterious events.
She was sure that the phenomenon of
‘losing her baby' through this mysterious
way would be well accepted by her
husband and relatives knowing it was
within their cultural belief system.
Thirdly, factitious disorder is also
considered after the exclusion of medical
or other major psychiatric conditions.
However, there were few atypical
presentations of factitious disorder in
this lady. First, the symptoms that she
intentionally produced were not illnesses
and she herself did not regard those
symptoms as an illness. Secondly, she
did not want to be cared for in a hospital
and was not eager to undergo further
medical investigations. She was not
suffering
from
any
underlying
personality disorders, had no history of
child abuse and no desire to deceive or
to test authority figures and no wish to
assume the role of a patient which were
typically described in this condition. (2,
4).
There is also a possibility of malingering.
However, she clearly did not have
anything external incentives to gain (5).
There was no evidence to show that she
was trying to escape from work duty or
facing any criminal prosecution. The
maternity leave that she took was more
to convincing others that she was really
pregnant. She knew that the faked
pregnancy would not entitle her for any
financial
compensation
through
insurance claims, lawsuits, or workers'
compensation. Her feigned pregnancy
was also not meant to reach doctor's
attention or prescription. Furthermore,
she did not have any antisocial attitudes
and behaviors (antisocial personality)
which were typical in malingering (2, 4).
Some patients have only one or two
episodes of factitious disorders while
others develop a chronic form that may
be lifelong. Even though successful
treatment of the chronic form appears to
be rare, psychotherapeutic intervention
and medication such as antidepressant or
antipsychotic have been useful in certain
cases (6,7). In this lady, the focus of
long-term psychotherapy is to assist her
in handling all the fears with more
adaptive coping. The use of medications
is not indicated as there are no clear cut
depressive or psychotic features. Further
gynecological
assessment
would
certainly improve her insight toward the
chances of her getting conceived. The
medical report that was sent to her
employer explaining her underlying
psychological problems has enabled her
to return to work. The phenomenon of
orang bunian stealing or abducting
human baby remains as one of the many
interesting psycho-cultural issues in the
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MJP 2008, Vol.17 No.1
Malaysian context that needs further
understanding.
Su's clinical picture illustrates a conflict
of intellectual conception between
science and superstition among the
Malays regarding this phenomenon.
Even though this phenomenon is
commonly reported in tabloid magazines
and newspapers in the Asian regions,
there has been not much discussion
regarding this cultural phenomenon. One
of the reasons could be the common
claim about the so-called pregnancy
being validated by medical professionals
has never been challenged. This
phenomenon probably occurs more
commonly among housewives, which
does
not
involve
occupational
consequences as it happens in this case.
By understanding Su's cultural belief,
the development of Su's symptoms can
be explained. It also helps to develop
emphatic therapeutic relationship with
Su and minimize negative countertransference.
3. Kamil M. Ariff, Khoo S.
Beng .Cultural health beliefs in a
rural family practice: A Malaysian
perspective. Australian Journal of
Rural Health, 2006:14:1:2–8.
4. Gelder M, et al. Oxford Textbook of
Psychiatry. Third ed. Oxford: Oxford
University Press; 1995.
5. Turner M. Malingering. British
Journal of Psychiatry,
1997;17:11:409-11.
6. Folks DG. Munchusen's Syndrome
and Other Factitious Disorders.
Neurol Clin, 1995:13:2:267-81.
7. Edi-Osagie ECO, Hopkins RE, EdiOsagie NE. Munchusen's Syndrome
in Obstetric and Gynaecology: A
Review. Obstetrical and
Gynaecological Survey,
1999:15:11:218-22.
_________________________________
REFERENCES
1. Heinrich TW. Medically Unexplained
Symptoms and the Concept of
Somatization. Wisconsin Medical
Journal, 2004:103:5::83-7.
2. American Psychiatric Association.
Diagnostic and Statistical Manual of
Mental Disorders. Fourth Edition.
Washington,
DC:
American
Psychiatric Association; 1994.
* Department of Psychiatry, UKM
Correspondence:
Dr. Ruzanna ZamZam
Department of Psychiatry
Faculty of Medicine
Jalan Yaakob Latiff
56000 Cheras
Kuala Lumpur
E-mail: [email protected]
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