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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. 1 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 3 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 4 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. 5 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% 6 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 7 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%) 8 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 9 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 10 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). 11 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. 12 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 13 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) 16 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. 17 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%) 18 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. 19 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. 21 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. 24 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. 41 MJP 2008, Vol.17 No.1 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, 198:17:243-247. 5. Vazquez-Barquero JL, Garcia J, Simon JA, Iglesias C, Montejo J, Herran A, Dunn G. Mental Health in Primary Care: An Epidemiological Study of 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 Psychiatric Disorders in a Primary Care Practice. Archives of General Psychiatry, 1988:45:1100-1106. 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. Acta 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 journal of 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 42 MJP 2008, Vol.17 No.1 17. Abdul Hamid AR, Mohamed Hatta SA. Validation Study of the Malay language Translation of General Health Qustionnaire-30 (GHQ-30). Malaysian Journal of Psychiatry, 1996:2:4:118-122. 18. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, 4th edition. Washington 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, 46 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 47 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. 60 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. 61 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 62 MJP 2008, Vol.17 No.1 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 63 MJP 2008, Vol.17 No.1 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 . 65 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). 66 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). 67 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) 68 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. 69 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/ 71 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). 73 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 74 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. 75 MJP 2008, Vol.17 No.1 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. 76 MJP 2008, Vol.17 No.1 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 77 MJP 2008, Vol.17 No.1 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 79 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 80 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 81 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 82 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 83 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. 84 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 86 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 87 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 88 MJP 2008, Vol.17 No.1 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 89 MJP 2008, Vol.17 No.1 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. 90 MJP 2008, Vol.17 No.1 REFERENCES 1. Premack, D. G. & Woodruff, G. (1978). Does the chimpanzee have a theory of mind? Behavioral and Brain Sciences 1, 515-526. 2. Fonagy, P. (2001). Attachment Theory and Psychoanalysis. Other Press, New York. 3. Gabbard, G. (2005). Mind Brain and Personality Disorders. Am J Psychiatry 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). Theory of Mind – evolution, ontogeny, 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. 9. Cashdan, E. (1989). Hunters and Gatherers: Economic Behavior in Bands. Economic Anthropology, 21 – 48, edited by Plattner, S., Stanford University Press, Stanford, CA. 10. Cosmides, L., Tooby, J. (1989). Evolutionary Psychology and the generation of culture. Part II. Case Study: a computational theory of social exchange. Ethol.Sociobiol.10, 51-97. 11. Falck-Ytter,T., Gredebäck, G. & von Hofsten, C. (2006). Infants predict other people’s action goals. Nature Neuroscience 9, 878 – 879. 12. Piaget, J., & Inhelder, B. (1948/1967). The Child's Conception of Space. New York: W.W. Norton. 13. Baron-Cohen,S. (2001). Theory of mind in normal development and autism. Prisme 34, 174-183. 14. Axelrod,R., Hamilton, W.D. (1981). The Evolution of Cooperation. Science 211, 1390-1396. 15. Nowak, M., Sigmund, K. (1993). A strategy of win-stay, lose-shift that outperforms tit-for-tat in the Prisoner’s Dilemma Game. Nature 364, 56-58. 16. Sugiyama, L., Tooby, J., Cosmides , L. (2002). Cross-cultural evidence of cognitive adaptations of social exchange among the Shiwiar of Ecuadorian Amazonia. PNAS 99, 11537-11542. 17. DiPellegrino, G., Fadiga, L., Fogassi, G., Gallese, V., Rizzolatti, G. (1992) Understanding motor events: A neurophysiological study. Experimental Brain Research 91, 176 -281. 18. Umlita, M.A., Kohler, E., Gallese, V.,Fogassi, L., Fadiga, L., Keysers, C., 91 MJP 2008, Vol.17 No.1 Rizzolatti, G. (2001). I Know What You Are Doing: a Neurophysiological Study. Neuron 31, 155-165. 19. Fogassi,L., Ferrari, P.F., Gesierich, B.,Rozzi, S., Chersi, F., Rizzolatti, G. (2005). Parietal Lobe: from action organization to intention understanding. Science 308, 662-667. 20. Iacoboni, M., Molnar-Szakacs, I., Gallese, V., Buccino, G., Mazziotta, J.C. (2005). Grasping the intentions of others with one's own mirror neuron system. PLoS Biology 3, 529-535. 21. Stone, V.E., Cosmides, L., Tooby, J., Kroll, N., Knight, R.T. (2002). Selective impairment of reasoning about social exchange in a patient with bilateral limbic system damage. PNAS 99, 1153111536. 22. Adolphs, R., Tranel, D., Damasio, A. (1998). The human amygdala in social judgement. Nature 393, 470-474. 23. Damasio, A. (1994). Descartes’ Error:Emotion Reason and the Human Brain. Avon, New York. 24. Brothers, L. (1990). The Social Brain:A project for integrating primate behaviour and neurophysiology in the a new domain. Concepts in Neuroscience 1, 27-51. 25. Dunbar, R.I.M. (1998). The social brain hypothesis. Evolutionary Anthropology 6, 178-190 26. Frith, C.D. (1992). The Cognitive Neuropsychology of Schizophrenia. Lawrence Erlbaum Associates, Hove, UK. 27. Baron-Cohen, S., Leslie, A.M., Frith, U. (1985). “Does the autistic child have a ‘Theory of Mind’ ?” Cognition 21, 3746. 28. Leslie, A. M. (1991). Theory of mind impairment in autism. In A. Whiten, Ed., Natural theories of mind: Evolution, development, and simulation of everyday mindreading. Cambridge, MA: Basil Blackwell. 29. Hobson, R.P. (1995). Autism and the development of mind. Hillsdale, N.J.: Lawrence Erlbaum Associates Ltd. 30. Hardy-Bayle, M.C. (1994). Organisation de l’action, phenomenes de conscience et representation mentale de l’action chez des schizophrenes. Actualites Psychiatriques 20, 393-400. 31. Abu-Akel, A. (1999). Impaired Theory of Mind in Schizophrenia. Pragmatics and Cognition 7, 247-282. 32. Crow, T.J. (1993). Sexual Selection, Machiavellian intelligence, and the origins of psychosis. Lancet 342, 594598. 33. Narr, K.L., Thompson, P.M., Sharma,T., Moussai, J., Zoumalan, C., Rayman, J., Toga, A. (2001). Three– dimensional mapping of gyral shape cortical surface asymmetries in schizophrenia. Gender Effects. American Journal of Psychiatry 158, 244-255. 34. Langdon, R., Coltheart, M. (1999). Mentalising, schizotypy, and schizophrenia. Cognition 71, 43-71. 35. Kerr, N., Dunbar, R. I. M., Bental, R. 92 MJP 2008, Vol.17 No.1 P. (2003). Theory of Mind in Bipolar Affective Disorders, Journal of Affective Disorders 73, 253-259 36. Inoue Y, Tonooka Y, Yamada K, Kanba S. (2004). Deficiency of theory of mind in patients with remitted mood disorder, Journal of Affective Disorders 82, 403-409 43. Fonagy, P., Target, M., Gergely, G., Allen, J. G., Bateman, A. W. (2003).The Developmental Roots of Borderline Personality Disorder in Early Attachment Relationships: A Theory and Some Evidence. Psychoanalytic Inquiry 23, 412-459. 37. Inoue, Y., Yamada, K., Kanba, S. (2006). Deficit in theory of mind is a risk for relapse of major depression, Journal of Affective Disorders 95, 125127 44. Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoun, G., Target, M., Gerber, A. (1996). The relationship of attachment status, psychiatric classification, and response to psychiatry. J. Consult Clin.Psychol. 64, 22-31. 38. Malhi, G. (2007). Modern Management of Bipolar Disorder 5, Highlights from the 7th International Conference on Bipolar Disorder, June 7-9 2007, Pittsburgh USA. * Department of Psychological Medicine, Royal Hobart Hospital 39. Blair, R.J.R., Sellars, C., Strickland, I.,Clark, F., Williams, A., Smith, M., Jones, L. (1996). Theory of Mind in the psychopath. J. Forens. Psychiatr. 7, 15-25. ** University of Tasmania, Hobart, Tasmania 40. Richell, R. A., Mitchell, D. V. G., Newman, C., Leonard, A.,Baron-Cohen, S., Blair, R. J. R.(2003). Theory of mind and psychopathy: can psychopathic individuals read the ‘language of the eyes’? Neuropsychologia 41, 523-526. Giap Kian ANG Royal Hobart Hospital, Tasmania, Australia Correspondence: 41. Dolan, M., Fullam, R. (2004). Theory of mind and mentalizing ability in antisocial personality disorders with and without psychopathy. Psychological Medicine 34,1093-1102. 42. Fonagy, P., Target, M. (1997). Attachment and reflective function: their role in self organisation. Dev. Psychopathol. 9, 679-700. 93 MJP 2008, Vol.17 No.1 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 94 MJP 2008, Vol.17 No.1 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 95 MJP 2008, Vol.17 No.1 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, 96 MJP 2008, Vol.17 No.1 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. 97 MJP 2008, Vol.17 No.1 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. 98 MJP 2008, Vol.17 No.1 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] 99 MJP 2008, Vol.17 No.1 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 100 MJP 2008, Vol.17 No.1 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. 101 MJP 2008, Vol.17 No.1 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 102 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] 103