MJP December 2008 Vol.17 No.2
Dec 2008 Vol. 17 No. 2
CONTENTS
Editorial Prevalence Of Obesity, Lipid and Glucose Amphetamine Type Stimulant (ATS) Abnormalities in Outpatients Prescribed Induced Psychosis: A Rising Problems in Clozapine in University Malaya Medical Malaysia. Center, Kuala Lumpur. 3-6 37-46 Ahmad Hatim S Sharmilla T Ahmad Hatim S Original Paper Jambunathan ST
Validation of the Bahasa Malaysia Impact of Psychiatry Training on Attitudes Version of the Coping Inventory for of Undergraduate Medical Students. Stressful Situation. 47-54 Chandrasekaran R
7-16 Srikumar P. S Ramli M Joshua E Mohd Ariff F Rasamy G Khalid Y Rosnani S Cross-Cultural Adaptation and Validation Social Anxiety Problem among Medical of the Bahasa Malaysia Version of the Students in Universiti Malaya Medical Eating Disorder Examination Center (UMMC) – A Cross-sectional Questionnaire (Ede-Q). Study. 55-63 Ramli M
17-22 Jamaiyah H Salina M Noor Azimah M Ng CG Khairani O Gill JS Adam B Chin JM Chin CJ Yap WF The Prevalence of Depressive Symptoms and Potential Risk Factors That May Student Learning Disability Experiences, Cause Depression among Adult Women Training and Services Needs of in Selangor. Secondary School Teachers. 64-72 23-36 Sherina MS Teoh HJ Rampal L Cheong SK Azhar MZ Woo PJ
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Review Paper Book Review:
Heroin Addiction: The Past and Future Antiepileptic Drugs to Treat Psychiatric 73-78 Disorders Noor Zurani MHR 88-90 Hussain H Edited by Susan L. McElroy Rusdi AR Muhammad Muhsin AZ Paul E. Keck, Jr. and Robert M. Post Is There a Need for a Hospital Based Smoking Cessation Programme in Education Paper Malaysia? 79-82 Are Our Postgraduate Candidates Having Noor Zurani MHR Knowledge Problems in Basic Sciences? Mohammad Hussain H – An Experience with Mock Multiple Choice Questions (MCQ). Case Report 91-97 Hatta Sidi Post Stroke Laughter – A Case Report. Fairuz Nazri AR 83-87 Amarpreet Kaur Nor Zuraida Z Ng CG Aida SA
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EDITORIAL
AMPHETAMINE TYPE STIMULANT (ATS) INDUCED PSYCHOSIS: A RISING PROBLEMS IN MALAYSIA
Ahmad Hatim S
Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur
The past decade has seen a marked increase in the popularity of ATS use, particularly methamphetamine, within East Asia, and the Pacific region (1) In Malaysia, the National Anti Drug Agency has identified 8,870 addicts (from January till August 2008) out of which 1,126 was ATS dependence. During the same period, the police have arrested 46,388 people under the Dangerous Drug Act 1952. They also has seize 283kg of syabu, 545kg of ecstacy powder, 66194 tablets of esctacy pills and 222,376 tablets of yaba pills from Jan till August this year.(2)
The occurrence of psychosis arising from the use of ATS was first reported in the late 1930’s. With growing ATS use, particularly methamphetamine, ATS-induced psychosis has become a major impact on public health.
Symptoms of ATS-induced psychosis Methamphetamine use produces a variety of effects, ranging from irritability, to physical aggression, hyperawareness, hypervigilance, and psychomotor agitation. Repeated or high-dose use of the stimulant can cause drug-induced psychosis resembling paranoid schizophrenia, characterized by hallucinations, delusions and thought disorders.
When used in long term, methamphetamine may lead to development of psychiatric symptoms due to dopamine depletion in the striatum. The most common lifetime psychotic symptoms among methamphetamine psychotic patients – as reported in a cross-country study (3) involving Australia, Japan, the Philippines and Thailand – are persecutory delusion, auditory hallucinations, strange or unusual beliefs and thought reading. Those patients were also reported to suffer from impaired speech, psychomotor retardation, depression and anxiety.
An ATS psychosis can be distinguished from primary psychotic disorders by time. In ATS-induced psychosis symptoms usually resolve after the drug is discontinued. If symptoms do not resolve within 2 weeks after cessation of stimulant use, a primary psychiatric disorder should be suspected.(4)
When compared with other stimulants, such as cocaine, psychosis is induced more commonly by ATS, possibly due to the longer duration of action produced by amphetamines. For example, while smoking cocaine produces a “high” that lasts for 20- 30 minutes, smoking methamphetamine produces a “high” that lasts 8-24 hours.(5)
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Other symptoms of ATS-induced psychosis reported include affective blunting,(6) violent behavior, and self-mutilation and self-injurious behavior.(7)
Duration of ATS-induced psychotic state Duration of amphetamine and methamphetamine-induced psychoses varies considerably. ATS-induced psychoses can be transient or persistent based on the duration of psychoses. In general, there are two types of methamphetamine psychosis.(8, 9)
• Transient type The majority of ATS-induced psychosis is a shorter psychotic state that begins to improve along with changes in the acute central action of the stimulant. The psychotic symptoms of transient type ATS psychoses last only hours, and usually abate within a week of withdrawal from the drug. However, prolonged symptom episodes have been observed in some individuals.
• Persistent type With this type of ATS psychoses, individuals experience psychotic symptoms for a considerably longer period of time. The psychotic state may last for more than 3 months and up to or beyond 6 months after cessation of drug use.
Prevalence of ATS-induced psychosis ATS users are a high-risk population for psychosis.(10) Heavier methamphetamines users have been indicated to be at higher risk of psychosis compared with the general population.(9, 11) Methamphetamine users who already have a pre-existing proneness to psychosis are at particularly high risk of experiencing symptoms of psychosis.
Besides at risk of developing an ATS-induced psychosis, ATS users are also more prone to developing schizophrenia and other psychotic disorders.(10) Similarly, in people who are suffering from schizophrenia, methamphetamine use can precipitate and exacerbate psychotic symptoms.(12)
The high level of methamphetamine use has been associated with an increased prevalence in functional psychosis. This was demonstrated in two separate studies involving prison inmates who use stimulant drugs(11) and psychiatric patients (13) with a concurrent diagnosis of amphetamine abuse, respectively. Within these contexts, the prevalence of psychosis among individuals with amphetamine use disorder was up to 28%.
A more recent Australian study (14) further showed an alarmingly high prevalence of psychosis among methamphetamine users when compared with the general population, even among those who had no known history of schizophrenia or other psychotic disorders. Among participants screened, 13% were positive for psychosis compared with 1.2% in the general population (11 times greater in prevalence), and 23% had experienced a clinically significant symptom of suspiciousness, unusual thought content or hallucinations in the past year.
In addition, dependent methamphetamine users were noted to be three times more likely to have experienced psychotic symptoms than their non-dependent counterparts, even
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after adjusting for history of schizophrenia and other psychotic disorders. (14) This clearly shows that dependent methamphetamine users are a particularly high-risk group for psychosis. Therefore, there is a strong need to have more local data and research on this important and rising public health problem.
References
1. Farrell M, Marsden J, Ali R, Ling W. Methamphetamine: drug use and psychoses becomes a major public health issue in the Asia Pacific region. Addiction. 2002 Jul;97(7):771-2.
2. Laporan Dadah Jan - Ogos 2008, Agensi Anti Dadah Kebangsaan. Available at http://www.adk.gov.my/download/laporan/laporanogos.pdf.
3. Srisurapanont M, Ali R, Marsden J, Sunga A, Wada K, Monteiro M. Psychotic symptoms in methamphetamine psychotic in-patients. Int J Neuropsychopharmacol. 2003 Dec; 6(4):347-52.
4. Larson M. Amphetamine related psychiatric disorders. eMedicine, Jan 29 2008. Avaiable at: http://www.emedicine.com/med/topic3114.htm.
5. National Institute on Drug Abuse. Methamphetamine: abuse and addiction (NIH Publication No. 98 - 4210). Washington DC; April 1998.
6. Bell DS. Comparison Of Amphetamine Psychosis And Schizophrenia. Br J Psychiatry. 1965 Aug;111:701-7.
7. Kratofil PH, Baberg HT, Dimsdale JE. Self-mutilation and severe self-injurious behavior associated with amphetamine psychosis. Gen Hosp Psychiatry. 1996 Mar;18(2):117-20.
8. Iwanami A, Sugiyama A, Kuroki N, Toda S, Kato N, Nakatani Y, et al. Patients with methamphetamine psychosis admitted to a psychiatric hospital in Japan. A preliminary report. Acta Psychiatr Scand. 1994 Jun;89(6):428-32.
9. Hall W, Hando J, Darke S, Ross J. Psychological morbidity and route of administration among amphetamine users in Sydney, Australia. Addiction. 1996 Jan;91(1):81-7.
10. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990 Nov 21;264(19):2511-8.
11. Farrell M, Boys A, Bebbington P, Brugha T, Coid J, Jenkins R, et al. Psychosis and drug dependence: results from a national survey of prisoners. Br J Psychiatry. 2002 Nov;181:393-8.
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12. Curran C, Byrappa N, McBride A. Stimulant psychosis: systematic review. Br J Psychiatry. 2004 Sep;185:196-204.
13. Dalmau A, Bergman B, Brismar B. Psychotic disorders among inpatients with abuse of cannabis, amphetamine and opiates. Do dopaminergic stimulants facilitate psychiatric illness? Eur Psychiatry. 1999 Nov;14(7):366-71.
14. McKetin R, McLaren J, Lubman DI, Hides L. The prevalence of psychotic symptoms among methamphetamine users. Addiction. 2006 Oct;101(10):1473-8.
Associate Professor Dr Ahmad Hatim Sulaiman. [email protected] Editorial Board Member
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ORIGINAL PAPER
VALIDATION OF THE BAHASA MALAYSIA VERSION OF THE COPING INVENTORY FOR STRESSFUL SITUATION
Ramli M1 , Mohd Ariff F2 , Khalid Y2 , Rosnani S3 1 Kulliyah of Medicine, International Islamic University Malaysia, Bandar Indera Mahkota, 25200 Kuantan Pahang, Malaysia 2 Faculty of Medicine, University Technology MARA, 40450 Shah Alam, Selangor Malaysia 3 Hospital Universiti Kebangsaan Malaysia, Cheras Kuala Lumpur, Malaysia
ABSTRACT
Introduction: There is an appealing need to have a validated Bahasa Malaysia (BM) questionnaire that is able to gauge stress coping styles among Malaysian population. A culturally accepted questionnaire will generate further research in the aspect of stress coping patterns in the Malaysia population. Objective: To translate the Coping Inventory for Stressful Situations (CISS) questionnaire into BM and to determine the construct validity, reliability and other psychometric properties of the translated BM version of the English CISS 48-item. Method: Two parallel forward and backward translations were done in BM in accordance to guideline and its validation was determined by using confirmatory factor analysis among 200 Malaysian subjects. Results: The BM CISS had very good Cronbach’s alpha values, 0.91, 0.89 and 0.85 respectively for Task-, Emotional- and Avoidance-oriented. The overall Cronbach’s alpha was 0.91. It also had good factor loading for most of its items where 44 items out of 48 had Confirmatory Factor Analysis values of more than 4.0. Conclusions: BM CISS had been adequately and correctly translated into Bahasa Malaysia with high psychometric properties. Minimal readjustment may be required in a few of its items to obtain excellent results.
Keywords: Stress, coping styles, reliability, validity, Bahasa Malaysia.
Introduction
Coping strategy refers to the acts or mechanisms are determined by the types thoughts that people adopt to overcome of personality of individuals other or the internal and external demands posed apart from environmental factors. The by a stressful encounter. The coping effectiveness depends on the approach
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the individual takes. Coping can be The CISS is a self-rated questionnaire divided into two dimensions: problem- and has multidimensionality in exploring focused coping, which addresses the coping styles [12]. The CISS 48-item stressful situation, and emotion-focused has a great precision in predicting coping, which deals with the feelings various types of coping mechanism. It and reactions to the stressful event [1]. has two versions; adult and adolescent. Problem-focused coping refers to task For both versions, they are able to orientation i.e. Strategies used to solve a classify coping styles into task-oriented problem, reconceptualise it or minimize (16 items), emotional-oriented (16 its effects. Emotion-focused coping items) and avoidance-oriented (16 strategies refer to person orientation items). For avoidance, it can be further which basically includes emotional subdivided into 2 subscales; distraction responses, self-preoccupation and (8 items) and social diversion (5 items) fantasizing reactions [2]. In [9]. In this study the authors will focus uncontrollable situation, emotional-focus on the effort of translating the CISS 48- coping style is effective in reducing item into Bahasa Malaysia (BM) and stress. Problem-focused coping has been eventually to validate this version. found to decrease emotional distress and is negatively related to depression, Objectives whereas emotion-focused coping increases emotional distress and is The main objective of this study is to positively related to depression. In the produce an acceptable CISS Bahasa long term, problem-focus or task- Malaysia version through a sound oriented coping style is most practical translation process. The second main way reducing stress [3]. objective is to determine the validity of this version by looking at its Recent tremendous increase in confirmatory factor analysis among awareness and number of studies Malaysian population. focused on the aspect of coping style related to personalities and other Materials and Methods: stressful situations triggered the initiative to translate and validate a Study Design questionnaire that can be used to Malaysian population. Various This is a multi-center cross sectional questionnaires are designed to measure study. This study had been reviewed and coping styles such as adolescent coping fully approved by the internal review scale [4], coping responses inventory board of University of Technology [5], coping operations preference MARA. Special permissions from the enquiry [6], ways of coping original author of CISS (James D.A. questionnaire [7], coping skills inventory Paker) and the authorized company [8] and coping inventory for stressful (multi-health systems inc) were also situations [9]. Apart from that we also acquired before commencement of this have coping questionnaire related to study. Informed consents of the certain condition; depression coping participants were obtained after the questionnaire [10] and pain coping nature of the procedure was fully questionnaire [11]. explained.
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Translation Process of CISS Malaysian population from different backgrounds. Reliability in this study Based on us census bureau guideline of was determined by its internal translation, 2 forward and 2 back consistency by looking at Cronbach’s translations were done in parallel by alpha values and confirmatory factor medical and language experts. Two analysis was used to ensure the validity language experts would ensure the of this BM-CISS by having acceptable translated version would be factor loadings (>0.4). grammatically and terminologically correct. The medical experts were to Selection of Respondents secure the meanings and contents of original CISS would be preserved. Study population of this study was the The two forward and back translations Malaysian general population with age then had been reconciled and sentence- range between 19 to 60 years. The age by-sentence revision was done with the range was in tandem with a help of two language experts from the recommendation in CISS manual book academy of language studies University for adult [9]. The subjects were selected of Technology MARA (UITM). Good from 3 government clinics in Klang translations were reflected by production Valley; Poliklinik Seksyen 7 Shah Alam, of 2 English backtranslations which Poliklinik Tanglin and City Hall Clinic almost similar to original English Kuala Lumpur. Permission was also version. At the end of this process we obtained from relevant authorities. produced a harmonized version of BM Patients who came to these clinics were CISS before we proceed for pre-test. from different backgrounds and ethnicity. After participants were briefed Harmonized BM version was tested to a about this study they were given small group of medical students before demographic and consent forms. the authors embarked on real major Heterogeneous participants were taken validation study. Pre-test was done on 6 care of in the aspects of age, gender, race respondents with good background for and socio-economic class. both languages, English and Bahasa Malaysia. Simple random sampling was done by taking every third patient registered at The objective of pre-test was to identify the clinic counter a total of 200 subjects any flaws in the harmonized version with various age groups, ethnicity and which might affect the comprehension of socio-economic backgrounds were the subjects during the actual field study. selected in this study. Composition of At the end of pre-test, we produced ethnic groups was tried to reflect the finalized BM version of CISS which actual Malaysian population. Based on then was used for real validation Malaysian statistic department, process. Malaysian population consists of Malays (54.1%), Chinese (25%), Indians (7.5%) Validation Study and from other races (13.2%) [13].
The finalized BM version was tested for Questionnaires its reliability and validity among 1) Demographic questionnaire -
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age, gender, ethnicity, level of education fluency test was administered and and types of occupation. integrated at the end of the questionnaire form in order to have a reliable 2) Finalized BM version of CISS. assessment about their language CISS is a self-rated questionnaire and it competency, it involved building up a shall take at the most 15 minutes to short sentence based on 3 words. This complete. test required good grammar and wide knowledge of BM vocabulary and Steps Taken to Ensure the Accuracy grammar in order to create a good of Responses sentence. The subjects were considered passed this test if they were able to During the course of BM CISS construct a good BM sentence based on questionnaire administration, the 3 words given. subjects were left without any interference especially from facilitators Results of the project. If subjects raise any queries about the terminology, they Demographic analysis of the subjects should be explained as minimal as showed that there was fairly equal possible to maintain the objective of this diversity in the aspects of age, gender, study and it should be recorded. educational and occupational status. The mean age of these subjects was with Inclusion and Exclusion Criteria gender composition of 51% males and 49% females. Although the CISS is not 1) Inclusion criteria:jjjjjjjjjjjjjjjjj recommended be used among people with only primary education, in this a) The age of the subjects was sample of population there was 7% of between 19 to 60 year.s…………. them came from this group and majority of them (63.3%) obtained secondary b) They must be proficient in school as their highest level of Bahasa Malaysia. education. Chinese (11%) was obviously underrepresented in this study as 2) Exclusion criteria: compared to actual Malaysian population (25%) [13]. a) Subjects with learning disabilities and cognitive impairments. Reliabilities of the CISS Bahasa Malaysia Version. b) Subjects who were unable or refuse to give informed consent. The reliabilities (internal consistencies) of BM CISS were determined by looking c) Subjects who were illiterate and at Cronbach’s alpha values. The overall not proficient in BM and failed a short Cronbach’s alpha value for all items was BM fluency test. very good .91 (ci 95%). Furthermore, the BM version had very good Cronbach’s BM Language Fluency Test. alpha values for all its 3 scales, .91, .89 and .85 respectively for task-, emotional- In this study a simple BM language and avoidance-oriented. Task-oriented
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had among the best value with mean From all 48 items in CISS, four items score .67 and standard deviation .11. had factor loadings less than .40. Among all items, item 28 (“wish that I could Validity Test change what had happened or how I felt”) and 35 (“talk to someone whose The construct validity was evaluated by advice I value”) had the poorest factor using confirmatory factor analysis loading (.22 and .24 respectively). (CFA). Table-1 shows factor loadings for CFA of each BM CISS item by using These items didn’t cross culturally varimax rotation. This table proves that sensitive to gauge emotional- and BM CISS managed to delineate its items avoidance-oriented but rather had high into 3 main entities (task-oriented, factor loading for task-oriented; .51 and emotional-oriented and avoidance- .60 respectively for item 28 and 35. oriented). Factor loadings of 0.4 or more were considered good. Among all 3 Correlations (Spearman’s) between scales in CISS, task-oriented generally scales gathered from this study were had the best value of CFA of all of its between .20 to .35. Internal correlation items. The lowest CFA value in this between distraction and social diversion scale was item 1 “schedule time” (.41). subscales in avoidance domain was .44.
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CISS-48 Task Emotional Avoidance 1. Schedule time. Mengurus masa lebih baik .41 2. Focus the problem… Memberi tumpuan kepada masalah... .53 6. Do what I think is best…. Membuat perkara yang saya fikirkan terbaik. .53 10. Outline priorities. Tentukan perkara diberi keutamaan. .62 15. ..solved similar problems. ..menyelesaikan… masalah serupa. .57 21 …course of action. Tentukan..penyelesaian dan laksanakannya. .65 24. ..to understand the situation. Berusaha untuk memahami situasi tersebut. .67 26. ..corrective action immediately … tindakan pembetulan segera .64 27. Think.. and learn from my mistakes. Fikir...dan belajar daripada kesilapan. .71 36. Analyze the problem. Meneliti masalah... .77 39. Adjust my priorities. Menyesuaikan …keutamaan saya. .65 41. Get control of the situation. …Cuba kawal keadaan. .69 42. …an extra effort to get things done. ….usaha.. menyelesaikan masalah .79 43. …several different solutions... Dapatkan .. penyelesaian masalah .81 46. ….to prove can do it. ..membuktikan boleh mengatasi.. .74 47. Try to be organized….. menjadi seorang yang sistematik…... .71 5. Blame self putting things off.. Menyalahkan diri sendiri.... .62 7. Preoccupied with aches and pains. Melayan rasa sakit dan sengal .55 8. Blame self ..into situation. Menyalahkan diri terlibat dengan masalah .67 13. Feel anxious... Resah tidak mampu menangani masalah .76 14. Become very tense. Rasa sangat tertekan .78 16. Tell .. not happening to me. Berkata kepada diri sendiri.. .43 17. Blame for too emotional... Menyalahkan diri..mengikut perasaan .72 19. Become very upset. ...sangat marah dan tertekan .77 22. Blame myself.. not knowing to do. Menyalahkan diri kerana tidak tahu… .77 25. "Freeze" don't know to do. Buntu dan tidak tahu apa yang perlu dibuat .57 28. ..change what happened or feeling mengubah keadaan atau perasaan.. .51 .22** 30. Worry about what I am going to do. Risau tentang apa yang perlu dibuat .70 33. …it will never happen... Berkata pada diri masalah tidak berulang .41 .33* 34. Focus on general inadequacies. Tumpu perhatian kepada kekurangan diri .52 38. Get angry. Menjadi marah. .61 45. Take it out on other people. Menyalahkan orang lain. .52 3. Think about the good times... Mengingati masa gembira…. .52 .39* 4. Try to be with other people. …bersama orang lain. .33 9. Window shop. Menengok-nengok barang di pusat membeli-belah. .67 11. ..go to sleep. Cuba tidur. .43 12. Treat with favorite food or snack. Makan makanan kegemaran. .71 18. Go for a snack or meal. Keluar makan. .72 20. Buy something. Beli sesuatu untuk diri sendiri. .79 23. Go to a party. Pergi berparti atau ke majlis keramaian. .56 29. Visit a friend. Menziarahi rakan. .36 31. Spend a special people. ..bersama orang tersayang atau teman istimewa .41 32. Go for a walk. Keluar berjalan-jalan. .67 35. Talk to someone. Berbincang dengan seseorang… .60 .24** 37. Phone a friend. Menelefon kawan. .52 40. See a movie. Menonton wayang gambar (movie). .47 44. Take time off ... Hindarkan diri sementara waktu.. .55 48. Watch a TV. Menonton television. .58 Mean .67 .60 .53 Std. Deviation .11 .17 .16 Variance .01 .03 .03
Table 1: Factor loadings based on confirmatory factor analysis for each item of BM CISS. *Poor value
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Discussion randomization. The similar finding was also found in other studies in the past Malaysia is a well known multi-racial [14]. country. Its population is composed of 3 major ethnic groups. According to Internal consistency of new BM version Malaysian Statistic Department (2005) of the CISS found in this study was quite 54.1% were Malays, 25% were Chinese comparable to the original English and 7.5% were Indians. Although much version. Original author recorded that emphasis paid on the aspect of internal consistencies for Task scale was randomization in the selection of the between .87 to .92. Emotional scale .82 subjects, this study had a limitation in its to .90 and Avoidance .85 to .76 [9]. study population. Study population in These figures are quite similar to figures this project didn’t reflect the actual obtained in this study (.91, .89 and .85 Malaysian population. Chinese was respectively for Task-, Emotional- and underpresented as only 11% of this Avoidance-oriented). We could also see ethnic contributed to a total population a downward pattern of Cronbach’s alpha as compared to 25% actual percentage from Task-, Emotional- and Avoidance- [13]. The lack of Chinese percentage oriented. The overall Cronbach’s alpha was replaced by Malays where Malay in of all items in this study was .91. this study was over presented (78%). Generally most of items in the BM Indians were roughly corresponded to version of CISS 48-item were having actual percentage. Other aspect paid to good confirmatory factor analysis values ensure equal distribution of ethnic in the except 2 items (28, 35) which may need study population was the selection of to reexamine. The CFA of these items participated clinics. The attendees of 3 were not very bad but can be further selected clinics were good mixture of all improved either by altering the structure ethnicities and represented the of the sentence or replacement. These Malaysian population. There were a few items were not culturally bound to any explanations to this discrepancy. specific ethnic groups. Possible Randomization in the subjects selection explanation as to why it had poor CFA is managed to draw fairly good sample Emotional- and Avoidance-oriented are population according to ethnicity, mainly incline towards maladaptive however non-cooperation and refused to coping style, whereas Task-oriented is give consent had hindered the effort. We adaptive [15]. Further analyzing of the found there was quite substantial number items; item 28 “Wish that I could change of Chinese selected during what had happened or how I felt” or randomization refused to give “Berharap agar saya dapat mengubah cooperation to participate in this study. keadaan atau perasaan saya” and item 35 “Talk to someone whose advice I There were about 20 Chinese subjects or value” “Berbincang dengan seseorang if we translate into percentage, it was yang pandangannya saya hargai” about 10% refused to give their although these items were measuring consents. The number of Chinese who emotional and avoidance but they are turned down their participations was adaptive in nature. Comparing with the replaced with other races during English version, there are a few
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similarities found in this study. First, in subscales was .44 which indicates that general Task-oriented had better CFA there is a moderate correlation. values as compared to other scales. Secondly among all items in Task- The present study provides a preliminary oriented, item 1 was the poorest item in milestone for further establishment of this scale. Thirdly, item 35 was not this BM version. Future study need to stable both in the English version (from look at the correlation and comparison the manual) as well as the BM version in with other coping questionnaire such as this study. It generated the lowest value Coping Operations Preference Enquiry when administered among (COPE) which has been translated and undergraduate and general adults, and it used by various institutions [18,19]. The shifted to task-oriented among authors concluded that this version is psychiatric patients. Finally looking of adaptable to the Malaysian population pattern analysis of CFA by using but further study is needed and a few Varimax rotation, the result of this study may need replacement of 2 poorest CFA was more incline towards 3-factor which are item 28 and item 35. solution as found in a few studies [9, 16, 17]. Acknowledgement
Authors identified a few items in We would like to express our gratitude Avoidance scale such as “Go for a and thanks to all subjects who had party” or “See a movie” were expected participated in this study for their kind to have low because it rather culturally consent. bound. Not many Malaysian would go for a party or theater to watch movie in References their daily activity as part of stress compensation mechanism. This item “go 1. Latack JC, Kinicki AJ, Prussia for party” had been extended and GE. An integrative process model of broadened the scope in its translation coping with job loss. Academy of where the authors added to “religious Management Review, 1995; 20:311-342. gathering” (majlis keramaian) which was culturally significant. Due to this 2. Mitchell RE, Cronkite RC, Moos reason, both items yielded good CFA RH. Stress, coping, and depression values. among married couples. Journal of Abnormal Psychology, 1983; 92:119– Correlations (intercorelation) between 133. scales gathered from this study were between .20 to .35 as displayed in figure 3. Endler NS. Stress, anviety and 1. These figures correspond with figures coping: The Multidimentional recorded in the CISS manual book .0 to Interaction Model. Canadian 0.4. The low correlation between 3 Psychology, 1997; 38:136-153. scales implies that the 3 scales stand as different entities. There was moderate 4. Frydenberg E, Lewis R. A correlation between 2 subscales in replication study of the structure of the Avoidance. The correlation between Adolescent Coping Scale: Multiple Distraction and Social Diversion forms and applications of a self-report
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8. Jerabek I. Coping Skills 16. Furukawa T, Suzuki-Moor A, Inventory. Plumeus Inc. 1996. Saito Y, Hamanaka T. Reliability and http://www.psychtests.com/tests/career/c validity of the Japanese version of the oping_skills.html Coping Inventory for Stressful Situations (CISS): A contribution to the cross- 9. Endler NS, Parker JDA. Coping cultural studies of coping. Seishin Inventory for Stressful Situations Shinkeigaku Zasshi, 1993; 95:602-620. (CISS): Manual (2nd ed.). Toronto, Canada: Multi-Health Systems. 1990. 17. Cosway R, Endler NS, Sadler AJ, Deary IJ. The Coping Inventory for 10. Kleinke CL, Staneski RA, Mason Stressful Situations: Factorial structure JK. Depression Coping Questionnaire and association with personality traits Journal of Clinical Psychology, and psychological health. Journal of 1982;44:516 – 526. Applied Biobehavioral Research, 2000; 5:121-143. 11. Reid GJ, Chambers CT, McGrath PJ, Finley GA. Coping with pain and 18. Zaidah A, Khairani O, Normah surgery: Children's and parents' CD. Coping styles of Mother with perspectives. International Journal of disable Children at rural community Behavioral Medicine. 1997; 4:339-363. rehabilitation centre in Muar, Malaysia. Medical Journal of Malaysia, 2004; 12. Endler NS, Parker JDA. The 59:384-390. multidimensional assessment of coping:
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19. Yusoff, N, Low WY, Yip CH. Coping strategies of couples with Breast Cancer. Conference on Behavioural Medicine, Pulau Pinang, 2008.
Corresponding Author: Dr. Ramli Musa, Kulliyyah of Medicine, International Islamic University Malaysia, Bandar Indera Mahkota, 25200 Kuantan, Pahang Malaysia.
Email: [email protected] Tel No: (+609) 5716400 @ (+6012) 2484076 Fax No: (+609) 5716770
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ORIGINAL PAPER
SOCIAL ANXIETY PROBLEM AMONG MEDICAL STUDENTS IN UNIVERSITI MALAYA MEDICAL CENTER (UMMC) – A CROSS-SECTIONAL STUDY
Salina M*, Ng CG*, Gill JS*, Chin JM*, Chin CJ*, Yap WF*, Sumaiyah MN* *Department of Psychological Medicine, University Malaya Medical Centre.
ABSTRACT
Objective: To study the prevalence of social anxiety problem and potential risk factors that may be associated with social anxiety among medical students. Methods: Social Phobia Inventory (SPIN) and a questionnaire assessing gender, religion, number of siblings, type of school and partner status were given to 167 final year medical students. Results: There were 101 respondents of which 56% of the medical students scored > 19 in the Social Phobia Inventory (SPIN) suggesting that they were having social anxiety problem. None of the variables analysed were significantly associated with social anxiety. Conclusion: More than half of the medical students have significant social anxiety symptoms. No specific variables were found to be significantly associated with those at risk of developing social anxiety disorder.
Keywords: social anxiety, Social phobia, medical students
Introduction females (2,3). Studies in other western nations (eg, Australia, Canada, Sweden) Studies conducted in the USA and note similar prevalence rates as in the Europe support the view that social USA, as do those in culturally anxiety disorder (social phobia) ranks westernised nations such as Israel (4). among the most prevalent of the anxiety Even countries with strikingly different disorders in the general population (1). cultures for example; Iran (5) note The National Co-morbidity Survey evidence of social anxiety disorder in provides prevalence estimates of 12- their population. month and lifetime DSM-IV social anxiety disorder as 7.1% and 12.1%, Social anxiety disorder has an early age respectively, with higher prevalence in of onset. It usually starts in childhood or
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early adolescence (6), where 50% begins Social Phobia Inventory (SPIN) is a 17 by the age of 11 years old and by the age item self administered questionnaire of 20 years old in about 80% of with good sensitivity (73%) and individuals (7). It has significant impact specificity (84%) for social anxiety on the individual’s functioning such as disorder where a SPIN score of > 19 reduced workplace productivity, distinguished subjects with and without increased financial costs, and reduced social phobia, and good efficiency with health-related quality of life (8) with diagnostic accuracy of 79% (12). negative impact on career progression Furthermore it has positive predictive (1). value (PPV) of 81% and negative predictive value (NPV) of 77% (12). Social anxiety disorder can have negative impact on any profession The results were analysed using of the including the medical profession. There Statistical Package for the Social are several studies being done in the Sciences (SPSS) version 13.0. West and other Eastern countries regarding social anxiety disorder in Results medical students (9), and it appeared that female students (10) and those without Out of the 167 medical students, 101 of partners (11) had a higher risk of having them filled the questionnaire. Table 1 social anxiety disorder. shows the characteristics of the medical students involved in this study. This study is conducted to look at the There were more female respondents as probability of having social anxiety compared to the male respondents, 74 disorder in medical students and the students and 27 students respectively. associated factors in developing social There were 101 respondents; among anxiety disorder. them 2 did not answer the type of school question and 4 did not answer the Method question on religion.
This is a cross sectional study involving Overall, 56% of the medical students University Malaya final year medical scored 19 or above in the Social Phobia students. A self-administered Inventory indicating that they have a questionnaire was given to the students higher probability of possessing a who were willing to participate in the diagnosis social anxiety disorder. The study. The medical students were students whose SPIN score were more approached after class in the clinical than 19 were offered further assessment auditorium and the 167 medical students to confirm the diagnosis by going to the present were given the Social Phobia psychiatric clinic and if need be Inventory (SPIN). Additional variables treatment. After analyses, none of the such as gender, religion, number of variables (gender, type of school, partner sibling, having partner or not and type of status, religion and number of siblings) school were included to assess whether when tested against their score of >19 these can be associated with developing were significant. The results are social anxiety disorder. summarized in Table 1.
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Table 1 – Characteristics of the medical students predicting social anxiety problem
Characteristic n(%) SPIN score Χ 2 Odds ratio (95% CI) P value > 19 (%) Sex Male 27 26 0.12 1.05 (0.43-2.55) 0.91* Female 73 74 Partner status With 34 30 1.10 0.68 (0.29-1.55) 0.35* Without 66 70 Type of school Mixed school 93 93 0.86 0.66 (0.12-3.80) 0.64* Not mixed school 6 7 Religion Muslim 46 50 0.22 0.65 (0.29-1.45) 0.29* Non Muslim 54 50 Number of sibling Only child 19 16 0.78 1.57 (0.58-4.27) 0.38* Has siblings 81 84 * P > 0.05 SPIN = Social Phobia Inventory CI = Confident Interval N (Number of medical students) = 101
Discussion However, in the US Epidemiologic Catchment Area (ECA) study, the rates In this study, 56% of the medical of social phobia were highest among students screened scored above 19 in the women, persons who were younger (age, Social Phobia Inventory (SPIN) 18 to 29 years), less educated, single, suggesting that more than half of the and of lower socioeconomic class (10). medical students probably have a This was further supported by other diagnosis of social anxiety problem. A studies that found the prevalence is twice similar study that was done previously, as high among women as men (11). using Liebowitz Social Anxiety Scale (LSAS) found 4% of the students was One Canadian study found that diagnosed with social anxiety disorder religiousness was significantly with 85% showed some symptoms of associated to lower lifetime social avoiding behavior and 56% experienced phobia (13), however this was not somatic symptoms of social anxiety (9). replicated in this study. Social anxiety symptoms in medical students may This study also found that gender, influence their undergraduate clinical number of siblings, type of school, training, decrease their academic religion or partner status was not performance, affect their choice of future significantly associated with the social specialties, and may lead to other anxiety symptoms the students had. psychiatric co-morbidities such as
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depression and substance abuse However, more prospective studies are especially alcohol abuse. Undergraduate required to look into this possibility. medical training involves clinical and coursework. Any students with social As one of the effects of social anxiety is anxiety symptoms may find clinical the breakdown in social interactions, training difficult and this may lead to students with social anxiety disorder additional stress and anxiety. This may may choose specialties which are less further decrease academic performance. stressful and has little involvement with There is also evidence to suggest that people. The careers of students with stress during undergraduate training may social phobia might be significantly result in psychological or emotional influenced by behaviors and decisions impairment during professional life and based on avoidance of stressful therefore affect the quality of patient situations. However, a study looking into care (14). whether social anxiety disorder influences future career choices of Patients with social anxiety disorder medical students reported that there was have a higher tendency to become no significant association among high dependent on alcohol (15). Alcohol stress, social phobia, and choice of least serves as a form of self medication stressful specialties in them. Certain where the individuals can manage their students, who indicated that stress was symptoms (16) through its anxiolytic unfavorable, chose high-stress properties (17). One study using self- specialties (22). report questionnaire methods were interested in examining the relationship This study did not find any significant of social anxiety to alcohol problems in variables that could be associated with 116 undergraduates. The results social anxiety symptoms found in the demonstrated that that those classified as medical students. Given the high problem drinkers reported greater social prevalence of social anxiety symptoms, anxiety and shyness, compared to those more studies ought to be conducted to characterized as non-problem drinkers, identify other factors that could play a confirming the significant positive role in the development of the disorder. relationship between social anxiety and This in turn would allow us to carry out problem drinking. (18). a longitudinal study looking at the outcomes and possible interventions. Social anxiety disorder frequently co- occurs with major depression and like This study has several limitations. It has other anxiety disorders it is a powerful no control group to allow for a more risk factor for the subsequent onset of accurate comparison. Furthermore, an major depression (19,20). It was found analysis of the individual social anxiety that social anxiety disorder precedes symptoms – fear, avoidance and major depression by at least 1 year in physiological response with another approximately 75% of patients with a instrument to assess quality of life would lifetime diagnosis, which raises the be of greater value. Other factors could question of whether social anxiety have been looked at for example disorder is predictive of developing personality type, socioeconomic subsequent psychiatric disorders (21).
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background and possible stressors giving Adolescence Psychiatric Clinics of rise to social anxiety in medical students. North America, 14, pp 797–818.
7) Stein, M. B., Stein, D. J (2008). References Social anxiety disorder. Lancet, 371, pp 1115-1125. 1) Wittchen, H-U, Fehm, L (2003). Epidemiology and natural course of 8) Stein MB, Roy-Byrne PP, Craske social fears and social phobia. Acta MG, Michelle G, Bystritsky, A, Psychiatrica Scandinavica, 108 (Suppl. Sullivan, G, Pyne, JM, Katon, W, 417), pp 4–18. Sherbourne, CD (2005). Functional impact and health utility of anxiety 2) Ruscio, AM, Brown, TA, Chiu, disorders in primary care outpatients. WT, Sareen J, Stein MB, Kessler RC Medical Care, 43, pp 1164–70. (2008). Social fears and social phobia in the 9) Raboch, J (1996). Prevalence of USA: results from the National social phobia among medical students. Comorbidity Survey Replication. European Psychiatry, 11 (suppl 4): pp Psychological Medicine, 35, pp15–28. 374.
3) Kessler RC, Chiu WT, Demler 10) Schneier FR, Johnson J, Hornig O, Walters EE (2005). Prevalence, CD, Liebowitz MR, Weissman MM severity, and co-morbidity of 12-month (1992). Social phobia. Comorbidity and DSM-IV disorders in the National Co- morbidity in an epidemiologic sample. morbidity Survey Replication. Archives Archives of General Psychiatry, 49(4), of General Psychiatry, 62, pp 617–27. pp 282-288.
4) Iancu I, Levin J, Hermesh H, 11) Kessler RC (2003). The Dannon P, Poreh A, Ben-Yehuda Y, impairments caused by social phobia in Kaplan Z, Marom S, Kotler M (2006). the general population: implications for Social phobia symptoms: prevalence, intervention. Acta Psychiatrica sociodemographic correlates, and Scandinavica, 108 (Suppl. 417), pp 19– overlap with specific phobia symptoms. 27. Comprehensive Psychiatry, 47, pp 399– 405. 12) Connor KM, Davidson JR, Churchill LE, Sherwood A, Foa EB, 5) Mohammadi MR, Ghanizadeh A, Weisler RH (2000). Psychometric Mohammadi M, Mesgarpour B. properties of the Social Phobia Inventory Prevalence of social phobia and its co- (SPIN): a new self- rating scale. British morbidity with psychiatric disorders in Journal of Psychiatry, 176, pp 379–386. Iran (2006). Depression and Anxiety, 23, pp 405–11. 13) Bowen R, Jones G, Koru-Sengul 6) Chavira DA, Stein MB (2005). T, Baetz M (2006). How spiritual values Childhood social anxiety disorder: from and worship attendance relate to understanding to treatment. Child & psychiatric disorders in the Canadian
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population. Canadian Journal of college students, Addictive Behaviors, Psychiatry, 51 (10), pp 654-661. 25, pp 295–299.
14) Rosal MC, Ockene IS, Ockene 19) Rush AJ, Zimmerman M, JK, Barrett SV, Ma Y, Hebert JR (1997). Wisniewski SR, Fava M, Hollon SD, A longitudinal study of students' Warden D, Biggs MM, Shores-Wilson depression at one medical school. K, Shelton RC, Luther JF, Thomas B, Academic Medicine, 72, pp 542–6. Trivedi MH (2005). Comorbid psychiatric disorders in depressed 15) Zimmermann P, Wittchen H-U, outpatients: demographic and clinical Hofler M, Pfister H, Kesslar RC, Lieb R features. Journal of Affective Disorders, (2003). Primary anxiety disorders and 87, pp 43–55. the development of subsequent alcohol use disorders: a 4 year community study 20) Beesdo K, Bittner A, Pine DS, of adolescents and young adults. Stein MB, Höfler H, Lieb R, Wittchen Psychological Medicine, 33, pp1211– H-U (2007). Incidence of social anxiety 1222. disorder and the consistent risk for secondary depression in the first three 16) Brady KT, Lydiard RB (1993). decades of life. Archives of General The association of alcoholism and Psychiatry, 64: pp 903–12. anxiety. Psychiatric Quarterly, 64, pp 135–149. 21) Lecrubier Y (1998). Co- morbidity in social anxiety disorder. 17) Morris EP, Stewart SH, Ham LS impact on disease burden and (2005). The relationship between social management. Journal of Clinical anxiety disorder and alcohol use Psychiatry, 59 (Suppl. 17, pp 33–38. disorders: a critical review. Clinical Psychology Review, 25 (6), pp 734-760. 22) Onady AA. Rodenhauser P. Markert RJ (1988). Effects of stress and 18) Lewis B, O'Neill K (2000). social phobia on medical students' Alcohol expectancies and social deficits specialty choices. Journal of Medical relating.. to.. problem.. drinking.. among Education, 63(3), pp 162-70.
Correspondence: Dr Salina Mohamed, Department of Psychological Medicine, Faculty of Medicine University of Malaya, Kuala Lumpur
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ORIGINAL PAPER
STUDENT LEARNING DISABILITY EXPERIENCES, TRAINING AND SERVICES NEEDS OF SECONDARY SCHOOL TEACHERS
Teoh HJ*, Cheong SK*, Woo PJ*
*Department of Psychology, School of Health and Natural Sciences, Sunway University College, Petaling Jaya, Selangor, Malaysia
ABSTRACT
107 secondary school teachers were surveyed to find out about their observations of children with learning disorders at schools. The respondents reported that the most commonly observed disorders involved difficulty paying attention, difficulty learning a second language, being fidgety and having difficulty sitting still, and having poor comprehension. They also indicated that whilst some children made fun of their classmates with learning disorder, others tried to assist their classmates. The most common reaction of parents was to send the child for lots of tuition, and to be very frustrated with the child. In addition, some parents neglected their children’s learning disorder, and many did not seem to realise how serious the problem was. When it came to the needs of teachers, the most common need that the teachers reported was to have the parents cooperate with them and to have support from the education authorities. The paper discusses the implications of these findings and proposes suggestions for dealing with the training needs of teachers working in the area of learning disorders.
Keywords: Leaning disorder, schools, prevalence, inter-personal relations
Introduction suggestions on what needs to be focused on to enhance services. This research Learning disabilities is viewed with paper studies the observations of growing concern amongst educators. teachers of children with learning Much has been said about different kinds disorders. of learning disabilities and this has lead to attempts to create a suitable education Defining Learning Disorders environment for these children. However, despite these initiatives, there Before moving on, it is appropriate to is still a lack of published research on review definitions of learning disabilities the state of these services, along from various perspectives. Kirk’s
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earliest definition on learning disability Prevalence of Learning Disorders in states that a learning disability is “a Schools in Malaysia, Across Countries retardation, disorder or delayed development in one or more areas of The prevalence of learning disabilities speech, language, reading, writing, among school children differs from arithmetic or school subjects due to country to country. This is largely possible cerebral dysfunction with or dependent on the definition used to without emotional and behavioural classify learning disabled children in disturbances”. However, this learning each of the country. There are nearly 3 disability is not due to “mental million school-age students in the United retardation, sensory deprivation, or States identified with specific learning cultural and instructional factors” (1). disabilities who are currently receiving special education services (4). This In 2000, a redefinition of the term accounts for approximately 5.5% of learning disability was proposed by the students in the school years (ages 6 to U.S Department of Education Office of 17) needing special education due to Special Education Programs. Thus learning disabilities. However, this Bradley redefined the concept of percentage reported may be slightly learning disabilities, as specific learning underestimated as it only consists of disability (SLD). The “central concept students identified by public schools to specific learning disability is disorders without taking into account private of learning and cognition which are schools (2). intrinsic to individual, specific disorders that affect only a narrow range of In a study by Komoula on 240 Greek academic and performance outcomes students between 7 to 11 years old from and not due primarily to other conditions urban and rural schools, it was found such as mental retardation or that prevalence of developmental behavioural disturbances” (2). dyscalculia among students were higher in rural schools than urban schools (5). Where the Malaysian Ministry of Therefore, specific learning disabilities Education is concerned, special needs are prevalent in other countries, and may children are only categorised into three be especially more prevalent amongst categories, those who are visually rural school students. handicapped, or partially or fully deaf, or suffering from the disability to learn (3). Where Asian countries are concerned, the National Statistics Office of Thailand In this present study, learning disability in 1991 reported a prevalence rate of is defined in terms of behaviour 10% for intellectual disability, 13.2 % characteristics that are observed and for hearing impairment, 5.4 % for speech considered by the teacher as forms of impairment and 1.9% of visual learning problems such as being unable impairment (6). In Malaysia the to read, poor comprehension, hearing Department of Special Education in problems and/or difficulty paying 2002 reported 14, 535 children with attention. learning disabilities in 700 schools nationwide (3). The statistics here includes children with visual
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impairment, hearing impairment and awareness of the parent for dealing with learning disabilities in special schools or the situation. Most parents may integrated schools. encounter feeling of disappointment as they may have difficulty imagining their Treatment of Children With Learning child’s future career, at least until they Disorders by Classmates begin to develop an understanding of their new situation and to build new School children with learning disabilities expectation for the child (9). often lack of social support at school or at home. Pavri and Monda-Amaya Realising that a child has a learning studied 30 students with learning disability may affect the parents disabilities between 3rd to 5th grade and relationship with the child and the entire 60 general and special education family. Babb expresses that family teachers and reported that the students relationships are often very different and experienced less social support from complex when one child has a learning parents, classmates and friends (7). disability (10). Russell also indicated However, they experienced a higher that many parents require emotional amount of support in certain areas such support to help them adjust to the new as companionship, self worth and self situation and intellectual support to help esteem, and instrumental assistance, them learn new ways of handling their from their teachers. child (9).
Other findings also yield similar reports Families of children with learning on support perceived by children with disabilities may respond in various ways. learning disabilities. In a study by Falik reported that the family either Martinez on 120 middle school students contains the information, or takes action with different degree of learning to deal with the problem (11). Thus, the disabilities, it was found that students family either mobilises into effective with multiple learning disabilities action, flexibly adapting or freezes in suffered from lower parent, classmate varying degrees of rigid, ineffective and friend support as compared to peers reactions. with a single learning disability or peers without learning disabilities (8). This is Focusing on parental attitudes, of concern given that support from Humphries and Bauman conducted parents, classmates and friends is an research to identify the relationship important element in children between learning disabilities in children development. and maternal child-rearing attitudes (12). By comparing 42 children with How Parents React to a Child With disabilities and 42 normal achievers, Learning Disorders they found that mothers of learning disabled children were more Individuals respond to similar situation authoritarian and controlling in child differently, thus knowing that one has a rearing. At the same time, however, child with a learning disability may mothers of learning disabled children invoke feelings and reaction which may were less hostile and rejecting towards very based on the preparedness and their children. Thus knowing that
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parenting attitudes on differ based in the Special education in Thailand has a child’s abilities is important for history which dates back to 1951 when predicting how parents would reacts the government first introduced a towards their child with learning specialised programme for deaf children. disability. By 1999 the Thai government had advocated that all children be given Services that are Available similar rights to education, including those with disabilities, in an inclusion Most parents of children with disabilities situation following the implementation express concern over services available of The Rehabilitation of Disabled to support their children and family. Persons Act of Thailand in 1991. Leading from this, many countries have However, Carter reported that these examined various strategies to provide phases had been implemented in a rapid for the need of these children and their pace thus leading to many logistical families. difficulties such as experiencing a lack of qualified educators and provisions for In the US, early intervention services for appropriate services for the programmes infants and toddles and their families (6). were authorised by the Individuals with Disabilities Education Act (IDEA). Special education in Malaysia is Three groups of children from birth to 3 governed by two departments, which are years old were eligible for early the Special Needs Department within intervention services – children with Ministry of Education, and the Social developmental delay, children with an Welfare Department, Ministry of identified physical or mental condition National Unity and Social Development that carries a high probability of (14). The Malaysian government has set developmental delay and children who up specialised schools for children with are medically or environmentally at risk visual and hearing impairment. Where for developmental delay if early other forms of disabilities are concerned, intervention is not provided (13). children are being placed into either special schools or integrated schools When the child is ready to go to school, with special needs classes. In later inclusion or exclusion education is years, the child may be enrolled in a prepared depending on the severity of technical or vocational schools to be the child’s condition. However, IDEA further trained in a specific skill aimed at emphasises educating children with independent living. disabilities in less restrictive environment thus advocating more Services for children with learning inclusion where possible. disabilities are an area that still requires much attention. As there is very limited Inclusion education ranges from full research conducted to evaluate the time, complete membership of the child experiences of services for these with disabilities in the general education children in developing countries, this classroom to part-time participation for research was designed to obtain non-academic subjects and activities information from the perspective of (13). teachers.
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The research questions of this study are: 7.5%), private (47, 43.9%), and (i)What is the observed prevalence of international schools (3, 2.8%). Subjects learning disorder in schools? (ii) How reported that they had all encountered are children with learning disorders students with learning disorders, and that treated by their classmates? (iii) How do the number of students that they had parents react towards their child with dealt with at any one time in a class learning disorder? (iv)What types of ranged from 1 to 46 students (mean = facilities are available for children with 12, SD = 12), learning disorders? (v) What are the perceived needs of teachers when it Measurement comes to assisting children with learning disorders? The questionnaire was developed by the staff of the Department of Psychology, Methodology Sunway University College.
To answer the research question, a single School Learning Disability survey was used to obtain the Questionnaire information from the subjects. The questionnaires were administered to The School Learning Disability participants who were attending a day Questionnaire is a self-report scale workshop on children’s issues in designed to measure the respondents schools. observations on learning problems amongst school children. There are a Subjects total of 65 questions which were grouped into six categories which are The sample consisted of a total of 107 demographics, prevalence of learning subjects. Their ages ranged from 21 to disability, treatment by classmates, peer 59 years, with a mean age of 39 years. reactions and actions, facilities, and There sample consisted of more female teacher’s needs. All questions generally (95, 88.8%), as compared with male (12, require the respondent to report on what 11.2%) teachers. The races consisted of they have observed and experienced Malays (42, 39.3%), Chinese (40, with regards the issue of learning 37.4%), Indian (22, 20.6%) and disorder at their respective schools. All Caucasians (3, 2.8%). Most of the the questions offered several answers subjects had undergraduate degrees (87, ranging from two responses (i.e., “Yes”, 81.3%), and the remaining possessed “No”) to three responses (i.e., “Never”, either Diploma (13, 12.1%) or 6th Form “Occasionally”, “Very Often”). No qualifications (7, 6.5%). The number of validity data are available on the years of teaching experience ranged questionnaire. from 1 to 36 years, with mean of 13 years of experience. Most of the sample Results consisted of teachers (76, 71%), with the remainder being administrators (7, 6.5%) To answer the questions posed by the and counselors (24, 22.4%). They were research hypotheses, a series of from government national type (49, statistical analyses was conducted. The 45.8%), government Chinese type (8, main analyses consisted of a series of
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frequency counts and percentages that behaviours related to the issue of compared the data sets of the prevalence learning disorders at schools.
Table 1. Learning Disorders Observed in Schools ______Learning Disabilities Responses Occasionally (%) Very Often (%) ______Unable to read 74(69.2) 18(16.8) Poor comprehension 55(51.4) 46(43.0) Difficulty pronouncing words 67(62.6) 26(24.3) Difficulty expressing him/herself 71(66.4) 22(20.6) Difficulty learning a second language 42(39.3) 53(49.5) Hearing problems 51(47.7) 8(7.5) Difficulty paying attention 40(37.4) 63(58.9) Fidgety and difficulty sitting still 50(46.7) 50(46.7) Impulsive and wants to do things quickly 61(57.0) 28(26.2) Constantly seeking attention 63(58.9) 36(33.6) Unable to socialize or interact with other children 84(78.5) 7(6.5) Clumsy and constantly getting into accidents 70(65.4) 3(2.8) Unreadable handwriting 74(69.2) 16(15.0) Constantly breaking pencils when writing 40(37.4) 2(1.9) Cannot seem to write words on a line, and constantly write 56(52.3) 11(10.3) off the margin. Does not respond to what the teacher says. 72(67.3) 20(18.7) ______
seen disorders involved difficulty paying The subjects were asked about their attention (58.9%), difficulty learning a observations of a variety of learning second language (49.5%), being fidgety disorders within their schools (see Table and having difficulty sitting still (46.7%), 1). They reported that the most commonly and having poor comprehension (43%).
Table 2. Observed Negative Treatment of Learning Disorder Students by Classmates ______Classmate Behaviours Sometimes (%) Always (%)
______Ignored by classmates 82(76.6) 12(11.2) Classmates make fun of the disability 71(66.4) 21(19.6) Classmates call the child names like “stupid” 59(55.1) 15(14.0) Classmates find fault with the child with the disability 67(62.6) 17(15.9) ______
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When the teachers were asked about the treatment seemed to do with being made existence of negative treatment by students fun off (19.6%) (see Table 2). The least towards other students with learning common form of negative treatment disorders, the most common negative appeared to be being ignored (11.2%).
Table 3. Observed Positive Treatment of Learning Disorder Students by Classmates ______Classmate Behaviours Sometimes (%) Always (%)
______Classmates try to help them understand by teaching 81(75.7) 15(14.0) Classmates try to be friends 81(75.7) 6(5.6) Classmates provide comfort when they are upset 77(72.0) 14(13.1) Classmates protect them from bullies 75(70.1) 18(16.8) ______
(see Table 3). The most reported positive There was also evidence of positive behaviours were protection from bullies behaviours of classmates towards their (16.8%), and trying to help their other classmates with learning disorder classmates understand by teaching (14%).
Table 4. Reactions of Parents Towards Their Children with Learning Disorders ______Reaction of Parents Some parents All parents (%) (%) ______Scold the child in front of the teacher. 67(62.6) 3(2.8) Beat the child when the exam marks are bad. 54(50.5) 2(1.9) Call the child “stupid” or a humiliating name. 55(51.4) 1(9) Frustration. 75(70.1) 23(21.5) Seek the class teacher’s help to teach the child. 79(73.8) 20(18.7) Try to understand the child. 77(72.0) 17(15.9) Sympathetic and try to tutor the child. 75(70.1) 12(11.2) Sit with the child in class. 23(21.5) 0 Give the child lots of tonic, herbs or medicines to improve their 67(62.6) 2(1.9) educational potential Send the child for lots of tuition. 73(68.2) 25(23.4) The child has to change school. 58(54.2) 3(2.8) The child is constantly trying different forms of treatment. 62(57.9) 1(9) The parent is not at all bothered about the child. 70(65.4) 0 The parent does not seem to realize that the problem is serious. 77(72.0) 7(6.5) Parent tries to a classmate to help their child. 73(68.2) 0 ______
The subjects were also about parents’ frustrated with the child (21.5%). Some reactions to their children with learning parents did neglect their children’s disorders (see Table 4). The most learning disorder (65.4%), and many did common reaction was to send the child for not seem to realize how serious the lots of tuition (23.4%), and to be very problem was (72%).……………………..
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Table 5. Facilities Currently Available in Schools ______Current Facilities in Schools All (%) Government Chinese Private International (%) (%) (%) (%) ______Teacher or Counselor who is trained in 48(44.9) 21 (42.9%) 1 (12.5%) 25 1 (33.3%) special needs and learning disability. (53.2%) Special needs class within the school. 31(29.0) 11 (22.4%) 2 (25%) 18 0 (0%) (38.3%) Special needs class at a school nearby. 35(32.7) 18 (36.7%) 2 (25%) 15 0 (0%) (31.9%) Special one-to-one tutoring in school. 32(29.9) 11 (22.4%) 2 (25%) 17 2 (66.7%) (36.2%) Private after-school group tutoring at a 28(26.2) 13 (26.5%) 1 (12.5%) 13 1 (33.3%) nearby special needs centre. (27.7%) Private one-to-one tutoring. 38(35.5) 14 (28.6%) 2 (25%) 21 1 (33.3%) (44.7%) Books and manuals that teachers can 51(47.7) 22 (44.9%) 2 (25%) 26 1 (33.3%) refer to within the school. (55.3%) Regular talks and workshops, 64(59.8) 22 (44.9%) 4 (50%) 35 2 (66.7%) organized by the school or education (76.6%) ministry, that the teacher can attend. ______
The prevalence of facilities within each could refer to. Finally, all schools group of type of school (i.e., Government reported that there was a large number of National, Government Chinese, Private, talks and workshops organized to educate International) was observed (see Table 5). them on special needs issues (44.9% to It was noted that there was generally a 76.6%). larger number of Government National (42.9%) and Private schools (53.2%) with When it came to the needs of teachers, the teachers or counselors trained in special most common need that the teachers needs or learning disability. When it came reported was to have the parents cooperate to special needs classes, Private schools with them (72%) (see Table 6). Amongst (38.3%) seemed to report the largest the other more important needs that number of classes available. International teachers had were support from the (36.2%) and Private (66.7%) schools both education authorities (66.4%), learning reported a much greater availability of exercises and techniques for assisting the one-to-one tutoring in their respective child (63.6%), receiving understanding schools. In terms of resources, the and support from the school authorities Government National type (47.7%), (63.6%), and having more cooperation Government Chinese type (44.9%) and between the school authorities and Private (55.3%) schools reported a larger professionals 62.6%).……………………. number of manuals and books that they
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Table 6. Teacher’s Needs with Regards Dealing with Learning Disorders ______Needs of Teachers Sometimes (%) Regularly (%) ______Education about the specific learning problem 43(40.2) 52(48.6) Exercises and techniques for assisting the child 32(29.9) 68(63.6) Books and manuals explaining the disability 39(36.4) 56(52.3) More special needs classes within schools 38(35.5) 54(50.5) More teachers with special needs qualifications 34(31.8) 57(53.3) More cooperation between school authorities and 29(27.1) 67(62.6) professionals (i.e., psychologists, paediatricians, speech therapists, occupational therapists, special needs tutors) Understanding and support from the school authorities 29(27.1) 68(63.6) Support from the education authorities 25(23.4) 71(66.4) Cooperation from parents 22(20.6) 77(72.0) ______
The present study was undertaken to other countries. In the United States, it is investigate the following on learning estimated that the overall lifetime disability within the psychiatric prevalence of learning disability for community in Malaysia: children age 18 years and below in year 2003 was 9.7% (15). In Nepal, the • What is the observed prevalence of estimated national prevalence of learning learning disorder in schools? disability in year 2001 was 1.63% while in • How are children with learning Sri Lanka (16), it was reported that 10.6% disorders treated by their of school aged children are disabled (17). classmates? In Korea, 2.71% of children aged between • How do parents react towards their 6 -11 years old were disabled in year 2001 child with learning disorder? (18). There is generally a wide • What types of facilities are discrepancy in terms of prevalence of available for children with learning learning disability amongst children in disorders? each country. This variation could be due • What are the needs of teachers to the diversity of the procedural criteria when it comes to assisting children and definition of learning disability used with learning disorders? by various researchers and educational agencies.
It was found that the most commonly seen When the teachers were asked about the learning problems in this study involved existence of negative treatment by students difficulty paying attention (58.9%), towards students with learning disorders, difficulty learning a second language the most common negative treatment (49.5%), being fidgety and having seemed to do with being made fun off difficulty sitting still (46.7%), and having (19.6%). The least common form of poor comprehension (43%). This is a negative treatment appeared to be being much higher figure, when compared with ignored (11.2%). The results are similar to a study conducted by Juvonon and Bear on
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third grade elementary school children Chinese, Private, International). It was (19). They found that 17% of 46 students noted that there was generally a larger with learning disability were rejected by number of Government National (42.9%) their peers, and 15% were neglected by and Private schools (53.2%) with teachers their peers. Only 7% of children with or counselors trained in special needs or learning disability were nominated as learning disability. When it came to popular; indicating that their peers liked special needs classes, Private schools playing with them. In the present study, (38.3%) seemed to report the largest there was also evidence of positive number of classes available. International behaviours of classmates towards their (66.7%) and Private (36.2%) schools both other classmates with learning disorder. reported a much greater availability of The most reported positive behaviours one-to-one tutoring in their respective were protection from bullies (16.8%), and schools. In terms of resources, the trying to help their classmates understand Government National type (44.9%), by teaching (14%). Government Chinese type (25%) and Private (55.3%) schools reported a larger It is frequently reported that children with number of manuals and books that they learning disabilities have difficulties in could refer to. Finally, all schools social adjustment. This has been supported reported that there were a large number of by a growing body of research that shows talks and workshops organized to educate that children with learning disabilities them on special needs issues (44.9% to exhibit significant behaviour problems or 76.6%). Despite having talks and social skills deficits (20), and are often workshops as well as special needs teacher poorly accepted by peers who do not have and counselors in these schools, teachers learning disabilities (21, 22, 23). However, still report a lack of support in assisting there are studies suggesting that having children with learning disability. The most one or two good friends in class may serve common need that the teachers reported as a buffer to negative effects such as was to have the parents cooperate with loneliness and depressions in these them (72%). Amongst the other more children (24, 25, 26). important needs that teachers had were support from the education authorities In terms of parents’ reactions to their (66.4%), learning exercises and techniques children with learning disorders, the most for assisting the child (63.6%), receiving common reaction was to send the child for understanding and support from the school lots of tuition (23.4%), and to be very authorities (63.6%), and having more frustrated with the child (21.5%). Some cooperation between the school authorities parents neglected their children’s learning and professionals (62.6%). disorder (65.4%), and many did not seem to realize how serious the problem was In most schools, children with cognitive (72%). These statistics indicate that there learning disability are usually grouped in is a need to educate parents of learning the same classroom due to lack of special disabilities and its consequences and ways needs teachers and classroom resources. to assist their children with learning These children have very different problems. learning disabilities ranging from reading difficulty (dyslexia), dyscalculia, autism, The prevalence of facilities within various mental retardation, attention deficit, types of school was observed (i.e., emotional problems, borderline Government National, Government intellectual capacity, lack of motivation
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and conduct disorders to name a few. This have the adequate skills and knowledge in is a problematic phenomenon as the teaching children with learning disability. problems, intervention and teaching methods for each of these disabilities are The results of this study are subject to very different. Moreover, children in each several limitations. Given that this was a disability (i.e. autism) are individually small sample of general education different in terms of their severity as well teachers, the results should be interpreted as manifestation of symptoms and require with caution. Additionally, although these individualized intervention programs. This teachers were encouraged to provide then leads to another problem of the detailed retrospectives information on amount of time the special need teacher is children with learning problems in their required to spend with each children. Most schools, time, fatigue, and memory factors of the time, special needs teachers are may have limited the accuracy of the data. given additional responsibilities in school As this was a preliminary study to find out such as student counselors or about information regarding learning extracurricular activities coordinator disability amongst children in Malaysia, because they are perceive to have more detail follow up studies on parents and time due to the small number of students children perspectives on learning disability in their classes. The lack of resources, time should be gathered. In addition, more and support by educational authorities specific information on the knowledge and would have cause frustration amongst needs of teachers dealing with learning teachers involved with learning disability disability children needs to be children. investigated. Effectiveness of current intervention practices should also be Teachers are often expected by parents investigated. and educational authorities to be able to help children with learning problems. Conclusions However, in a study by Lambert, it was found that teachers typically were unable The present study indicates that there a lot to identify students’ problem behaviours that needs to be done in the area of operationally, had a lack of knowledge of services for children with special needs in intervention strategies and relied primarily Malaysia. on global solutions, regardless of the nature of the presenting problem (27). In There are many models that may be another follow up study by Wilson, adopted within the school systems. These Gutkin, Hagen and Oats on twenty general include team teaching, use of teacher education teachers in the United States, consultants/school psychologists, building they found that most teachers in their based on teacher support teams, study demonstrated only a vague multidisciplinary team meetings, regular knowledge of classroom interventions scheduled screening examinations for (28). Prior research indicates that teacher general health status, visual and hearing knowledge of interventions are positively acuity, intellectual potential, speech and related to their use of classroom language functioning, academic intervention (29). In addition, knowledge achievement and skills level and social apparently influences teachers' sense of and adaptive functioning. Formal referral competence and willingness to work with procedures and guidelines for eligibility mildly handicapped children (30). Hence, and placement of special needs could untrained teachers may not necessarily
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be shared with teachers and parents. 6. Carter SL. The development of Planning, material development, research special education in Thailand. support, teacher training, classroom International Journal of Special Education organization, parental and community 2006; 21(2): 32-36. support are also much needed. 7. Pavri S, Monda-Amaya L. Social Finally, teachers need considerable Support in Inclusive Schools: Student and support such as information on the nature Teacher Perspectives. The Council for of children’s problems, the types of Exceptional Children 2001; 67: 391-411. classroom intervention strategies available, training to develop 8. Martinez RS. Social Support in individualized programs, and support from Inclusive Middle Schools: Perceptions of educational authorities in terms of time, Youth with Learning Disabilities. physical resources and human resources. Psychology In the Schools 2006; 43: 197- 209.
References 9. Russell F. The expectations of parents of disabled children. British 1. Kirk as cited in Kalave KA, Journal of Special Education 2003; 30(3): Forness SR. What Definitions of Learning 144-149. Disability Say and Don’t Say. Journal of Learning Disabilities 2000; 33: 241. 10. Babb C. Living with shattered dreams: A parent’s perspective of living 2. Bradley et al. as cited in Hallahan with learning disability. Learning DP, Llloyd JW, Kauffman JM, Weiss MP, Disability Practice 2007; 10(5): 14-18. Martinez EA. Learning Disabilities: Foundations, Characteristics, and Effective 11. Falik LH. Family patterns of Teaching. Pearson, Boston MA, 2005; 18. reaction to a child with a learning disability: a mediational perspective. 3. Akta Pendidikan 1996 as cited in Journal of Learning Disabilities 1995; Manisah M, Ramlee M, Zalizan MJ. An 28(6): 335-341. empirical study on teachers’ perception towards inclusive education in Malaysia. 12. Humphries TW, Bauman E. International Journal of Special Education Maternal child rearing attitudes associated 2006; 21(3): 36-44. with learning disabilities. Journal of Learning Disabilities 1980; 13(8): 54-57. 4. The Advocacy Institute, Students with Learning Disabilities: A National 13. Hunt N, Marshall K. Exceptional Review, 2000. children and youth. (4th ed.). United States of America: Houghton Mifflin, 2006. 5. Koumoula A, Tsironi V, Stamouli V, Bardani I, Siapati S, Graham A. et al. 14. Kementerian Pelajaran Malaysia. An Epidemiological Study of Number Pengenalan kepada pendidikan khas. 2007, Processing and Mental Calculation in August. Retrieved from http://www. Greek Schoolchildren. Journal of Learning moe.gov.my 2007, October 23. Disabilities 2004; 377-388.
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15. Altarac M, Saroha E. Lifetime perceptions, and social skills of learning Prevalance of Learning Disability Among disabled students prior to identification. US Children. Pediatrics 2007; 119: 77 – Journal of Educational Psychology 1990; 83. 82: 101-106.
16. NPC/UNICEF/New Era. A 24. Berndt TJ. The nature and Situation Analysis of Disability in Nepal. significance of children's friendships. National Planning Commission, UNICEF Annals of Child Development 1988; 5: and New Era. 2001. 155-186.
17. APEID. Sri Lanka country paper. 25. Berndt TJ. Friendships in In Proceedings of the Fourth APEID childhood and adolescence. In Damon W Regional Seminar on Special Education. ed. Child Development Today and Asia and Pacific Programme on Tomorrow. San Francisco: Jossey-Bass: Educational Innovation for Development, 1989 : 332-348. Yokosuka, Japan 1994. 26. Buhrmester D, Furman W. The 18. Kim HJ. Educational supports for changing functions of friends in children with multiple disability in Korea. childhood: A neo-Sullivanian perspective. Journal of Special Education in the Asia In: Derlega VJ, Winstead BA eds. Pacific 2005; 14- 20. Friendship and Social Interaction. New York: Springer-Verlag, 1986: 41-62. 19. Junovan J, Bear G. Social adjustment of children with and without 27. Lambert NM. Children’s Problem learning disabilities in integrated and Classroom Interventions from the classrooms. Journal of Educational Perspective of Classroom Teachers. Psychology 1992; 84 (3): 322-330. Professional Psychology 1976; 7: 507-517.
20. Bender WK, Smith JK. Classroom 28. Wilson CP, Gutkin TB, Hagen behavior in children and adolescents with KM, Oats RG. General Education learning disabilities: A meta-analysis. Teachers’ Knowledge and Self-Reported Journal of Learning Disabilities 1990; 23: Use of Classroom Interventions for 298-305. Working with Difficult-to-teach students: Implication for Consultation, Prereferral 21. Bursuck WD. A comparison of Intervention and Inclusive Services. students with learning disabilities to low School Psychology Quarterly 1998; 13 (1): achieving and higher achieving students 45-62. on three dimensions of social competence. Journal of Learning Disabilities 1989; 22: 29. Hall CW, Wahrman E. Theoretical 188-194. orientations and perceived acceptability of Intervention strategies applied to acting- 22. Stone WL, LaGreca AM. The out behavior. Journal of School social status of children with learning Psychology 1988; 26: 195-198. disabilities: A reexamination. Journal of Learning Disabilities; 1990: 23: 32-37. 30. Hannah ME, Pliner S. Teacher attitudes toward handicapped children: A 23. Vaughn S, Hogan A, Kouzekanani review and synthesis. School Psychology K, Shapiro S. Peer acceptance, self- Review 1983;12 : 12-25.
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Correspondence address: Dr Teoh HJ, No.5, Jalan Universiti, Bandar Sunway, 46150 Petaling Jaya,Selangor Darul Ehsan, Malaysia.
Email:[email protected] Tel: 603-74918622 Fax:603-56358633
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ORIGINAL PAPER
PREVALENCE OF OBESITY, LIPID AND GLUCOSE ABNORMALITIES IN OUTPATIENTS PRESCRIBED CLOZAPINE IN UNIVERSITY MALAYA MEDICAL CENTER, KUALA LUMPUR
Sharmilla T*, Ahmad Hatim S*, Jambunathan ST*
*Department of Psychological Medicine, University Malaya Medical Center , Kuala Lumpur
ABSTRACT
Objective: The objectives of this study were to asses body mass index, fasting blood sugar , serum cholesterol levels and prevalence of Diabetes Mellitus among outpatients attending the Clozapine clinic at University Malaya Medical Center. Method: 36 patients had their height and weight taken at the start of the study. Their BMI (body mass index) was calculated. Fasting blood sugar, (FBS) and Fasting Serum Lipid (FSL) were performed. Result: The mean body mass index was 24.63. The prevalence of obesity was 13.89%. The prevalence of overweight was 27.8 % and the prevalence of underweight was 5.55%. The prevalence of Diabetes Mellitus was 2.78 %. Serum triglyceride levels appear to be elevated in those receiving Clozapine. Conclusion: It appears that Clozapine may predispose one to obesity. From our study we cannot conclude if Clozapine causes Diabetes Mellitus. However treatment with Clozapine may be associated with elevated levels of serum triglycerides.
Keywords: Schizophrenia, Clozapine , Metabolic Syndrome
Introduction the attitude of the treating psychiatrists (3). It has also been noted that patient’s Schizophrenia has frequently been called with Schizophrenia do not lead healthy a disease that decreases longevity (1). lifestyles as compared to the normal People with mental illness die 10-15 population (4). The Schizophrenics tend years earlier than the general population to have a diet higher in fat and lower in (2). Although individuals with fibre as compared to the general Schizophrenia have increased mortality population (5). Numerous articles have rates from cardiovascular and respiratory been published about the association of disorders many of these physical Schizophrenia and physical illness. problems are not noticed by their Research has shown that the risk of psychiatrists. This may in part be due to death from a large group of
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cardiovascular diseases is higher in but only 5% among 239 sedentary office Schizophrenia than in the general workers (11). population (6). In 1899 Sir Henry Maudsley wrote in the Pathology Of The Schizophrenia is often associated with Mind, “ Diabetes is a disease that shows Type 2 diabetes mellitus and not Type 1 itself in families in which insanity diabetes mellitus (12). A family history prevail”(7). Also the relative risk is of Type 2 Diabetes Mellitus is found in considerably greater in younger patients as many as 18-19% of Schizophrenics than in the older patients and those in the further predisposing them to the chronic stages of the disease (6). As we development of this illness (12). know risk factors for the development of In addition to this, it has come to light cardiovascular diseases are obesity, that many neuroleptic drugs induce diabetes mellitus, hypercholesterolemia, hyperglycemia (13 ,14) . Among these, hypertension and cigarette smoking patients those who received atypical among many others. It has been shown neuroleptics were 9% more likely to that weight gain increases the risk of have diabetes than patients who received coronary heart disease (8). Weight gain typical neuroleptics (15). also increases the risk of Type 2 Diabetes Mellitus and blood cholesterol Further complicating this picture is the levels and this in turn leads to an fact that weight gain has been increased risk of coronary heart disease documented by almost all neuroleptics, (9). both typical and atypical. (16) Both conventional and atypical antipsychotics An increase of 10% weight in men aged are associated with weight gain (17). 35-44 is accompanied by a 38 % risk in Long-term administration of typical and the incidence of CHD and a 20% atypical antipsychotic drugs induces increase correspond with an 86% excessive weight gain which afflicts up increase (9). This reflects the association to 50% of patients, impairs health and between weight gain, higher blood interferes with treatment compliance cholesterol and glucose concentrations (18). Among newer antipsychotics mean (9). Studies also show that impaired increases in weight after 10 weeks were glucose tolerance, Diabetes Mellitus and as follows; Clozapine 4.45 kg; insulin resistance may be more common Olanzapine 4.15kg; Sertindole 2.92 kg; among patients with psychiatric disorder Risperidone 2.10 kg and Ziprasidone such as Schizophrenia than in the 0.04 kg. The associated weight gain may general population (10). In one study by affect patient’s health and also impede Muhkerjee et al ,the prevalence of compliance (19). This is not helped by diabetes was examined in 95 the fact that many Schizophrenics suffer Schizophrenic patients in Italy aged from obesity themselves (20). between 45 to 74 years. The prevalence of diabetes was found to be 15.8%. Clozapine is currently regarded as the These rates are higher than that reported ‘gold standard’ in adults in terms of in population surveys in Italy (10). A antipsychotic efficacy with regards to study conducted in Japan by Tabata et al the management of treatment resistant among 248 Schizophrenic patients noted Schizophrenia (21). Clozapine has been that the prevalence diabetes was 8.8% known to produce a response in 30% of
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treatment resistant Schizophrenics in a 6 Diabetes Mellitus but several studies week trial and up to 60% in 6 months have also linked it to the development of (22). A study done by Kane and hyperlipidaemia in some patients with colleagues found Clozapine superior to Schizophrenia (26). A study conducted doses of Chlorpromazine twice as large by Ghaeli et al showed that subjects in patients with chronic Schizophrenia taking Clozapine had higher serum who had been unresponsive to treatment triglyceride levels than subjects taking with up to 60 mg of Haloperidol a day typical antipsychotics. This was a before the start of the comparison trial difference that could not be accounted (23). However the drug implicated in for by concurrent illnesses or producing the greatest weight gain is medications, antipsychotic dosages ,or Clozapine (19).It has been shown that patient characteristics (27). Medical after a 10 week treatment on a standard records of 222 men treated with dose Clozapine produced a mean weight Clozapine were reviewed by Gaulin et gain of about 4.45 kg(17). Leadbetter et al, Clozapine treated men had al in 1992 reported that weight gain significantly higher serum triglyceride occurred in 67% of patients treated with levels at follow up than those treated Clozapine during a 16 week period (20). with Haloperidol (28). A study done on 26 patients in Ireland who were receiving Clozapine showed Objective that 6 patients met the criteria for obesity and 12 met the criteria for overweight. The primary objective of the study is to Over half of the patients had lipid asses prevalence of diabetes mellitus, abnormalities (24). body mass index and serum cholesterol levels in the patients attending the The fact that Clozapine appears to cause Clozapine clinic at the University Diabetes Mellitus is suggested by a Malaya Medical Center. number of reports. The temporal relationship to the start of Clozapine Method treatment, the relatively young age of the affected patients and the immediate This is a descriptive cross sectional reversibility on withdrawal of the drug in study of patients attending the Clozapine some patients has also been noted (25). clinic at the University Malaya Medical In a study by Koller et al most new- Center. The University Malaya Medical onset diabetes were documented within Center is a Government Hospital serving the first 6 months of therapy (25). 27 % the population of Selangor and Kuala were diagnosed in the first month of Lumpur as well as referral cases from all Clozapine initiation and 57% within the over the country. The Clozapine Clinic first three months. was set up in 1998 for those patients who are on our psychiatric follow up and In a study done by Henderson et al it who had been prescribed Clozapine. All was noted that 30 out of 82 patients together 68 patients attend this clinic. (36.6%) developed diabetes in a 5- year For the first 18 weeks of treatment Full study (22). Not only has Clozapine been blood count is done weekly, after that it implicated as the drug with the greatest is done monthly. The full blood count is potential to produce weight gain and done routinely to look out for such side
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effects such as leucopenia induced by 1.68-4.53 were considered to indicate Clozapine. normal levels of high- density lipoprotein and low -density lipoprotein The probability of the other side effects respectively. such as hyperglycemia, obesity and hypertriglyceridemia occurring has so Fasting blood glucose levels were far not been looked into. Only those classified as follows: 3.9 mmol/L- patients who were reliable informants as 6.1mmol/L=normal, 6-7 mmol/L to their fasting status or who were =impaired fasting glucose (IFG) and accompanied by reliable informants >7mmol/L=hyperglycemia (30). In our were used. Patients who were on study we require one reading of impaired Clozapine for 6 months or more were fasting glucose of more than 7 mmol/L used in the study. Written informed in accordance to the criteria set by the consent was taken before the interview American Diabetic Association to and blood taking. diagnose a patient to be suffering from Diabetes Mellitus. This recommendation A total of 36 patients were eligible to is made in the interest of standardization take part in this study. A two- page and also to facilitate field- work, questionnaire was used to record particularly where the Oral Glucose information about the patient. In this Tolerance Test (OGTT) may be difficult questionnaire such information as age, to perform and where the cost and gender, race, height, weight , body mass demands on participants' time may be index, duration of diagnosis of the too much. This method will lead to illness in years, reason to start slightly lower estimates of prevalence Clozapine, duration of treatment of than would be obtained from the Clozapine in months, past and family combined use of the Fasting Blood history of Diabetes Mellitus were Glucose and Oral Glucose Tolerance recorded. Old notes were also looked Test. into to verify the information. All this was done by the investigator herself. Results
The height and weight were taken in Important demographic characteristics of order to calculate their body mass index the participants are summarized in Table (BMI) using the formula weight in kg/ 1. 36 patients participated in this study height in metres. Patients were classified with almost equal gender distribution. as overweight if their BMI was 25-30 The mean age was 36.1 years (SD=9.9). and obese if the BMI was >30 (29). The mean age of the male patients was 33.00 years (SD= 8.23) and the mean Fasting venous blood samples were age of the female patients was 39.65 taken from each patient for the (SD=10.61) years. Most of the patients estimation of lipid and glucose levels. 28(77.77%) were single. The mean Hypertriglyceridemia was defined as a duration of illness was 14.64 years fasting triglyceride level of >1.82 (SD=8.48). Most of the patients have mmol/L. The normal level of serum been ill for between 11-20 years. tryglycerides was between 0.45-1.82 mmol/L. A serum level of 0.80-1.8 and
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Table 1. Demographic Characteristics Of overweight and 5 (13.89%) were obese. Patients 2 (5.56%) were underweight. Of the five patients who were obese the average Patient (%) duration in months they were on N=36 Clozapine was 45.4(3.78 years) Of the two patients who were underweight one Sex of the patients was on Clozapine for 25 Male 19 (52.8%) months (2.08 years) and the other for 12 Female 17 (47.2%) months. The mean BMI was 24.63 ( SD= 4.44). Age 16-25 4 (11.1%) Table 2 :- Distribution of patients based on 26-35 14 (38.9%) duration of Clozapine as well as the BMI. 36-45 9 (25%) 46-55 9 (25%) Patient (%) >55 0 (0%) N=36
Marital Status Duration On Clozapine Single 28 (77.8%) 0-24 months 12 (33.3%) Married 8 (22.2%) 25-48 months 6 (16.7%) 49-72 months 11 (30.6%) Race 73-96 months 7 (19.4%) Malay 1 (2.8%) Chinese 29 (80.6%) BMI Indian 5 (13.9%) BMI Less than 18.5 2 (5.6%) Eurasian 1 (2.8%) BMI 18.5-<25 19 (52.8%) BMI 25-30 10 (27.8%) Duration Of Illness BMI <30 5 (13.9%’) 1-10 years 12 (33.3%) 11-20 years 14 (38.9%) 21-30years 8 (22.2%) Fasting Blood Sugar and Fasting 31-40 years 2 (5.6%) Serum Lipid
The mean (+/- SD) fasting blood sugar Duration Of Clozapine and BMI was 5.37 (SD=0.68 ) mmol/L. Out of the 36 patients 5(13.89%) had impaired Table 2 shows the distribution of fasting glucose (IFG). However on patients based on duration on Clozapine subsequent assessment of those 5 as well as the distribution of BMI. The patients, two of the readings were mean (+/-SD) duration of being on normal, two continued to have IFG and Clozapine was 44.25 months one patient had hyperglycemia with a (SD=26.57). 13 (36%) had family value of 7.1 mmol/L and was therefore history of Diabetes Mellitus. Half of the diagnosed to have Diabetes Mellitus. patients have been on Clozapine for less The mean (+/-SD) value for Hba1c was than 2 years. Most of the patients 5.10 (SD=0.4). There was no correlation (52.78%) are in the normal range. Out of between the duration of being on the 36 patients 10(27.77%) were Clozapine and the fasting blood sugar.
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The mean (+/-SD) values for HDL, There were no patients who had serum LDL, and triglycerides were 1.28 LDL levels less than normal. There were (SD=0.33), 3.25 (SD= 0.86) and 2.22 32 (88.89%) patients who had serum (SD=1.63) respectively. 14(38.89%) LDL levels in the normal range i.e. patients had hypertriglyceridemia. between 1.68- 4.53. There were 4 (11.11%) patients who had serum LDL The number of patients in whom there levels more than normal. was presence of family history of Diabetes Mellitus was 13 (36.11%). The Discussion number of patients who had no family history of Diabetes Mellitus was 23 The main purpose of our study was to (63.89%). assess the adverse effects of Clozapine on our patients so that steps may be The number of patients who had fasting taken in future to counteract it. blood sugar less than 3.9 mmol/L is 1(2.78%) . The number of patients who Even though our findings are based on a had their blood sugar in the normal limited sample size a significant number range was 30(83.33%) The number of of them were classified as obese or patients who had fasting blood sugar overweight. From this study we see that more than 6.1% at the first testing was the mean BMI is 24.63. This is at the 5(13.89%) On subsequent testing 2 upper range of normal value for BMI of patients continued to have impaired the general population. The mean BMI fasting blood sugar but did not exceed of the general population is only 22.48 the level of 7 mmol/L and one had (29). Also the prevalence of obesity is hyperglycemia 7.1 mmol/L. Therefore 13.89%, which is much higher than the by our criteria which are similar to that general population of only 4.4% (29). recommended by the American Diabetic The prevalence of overweight is 27.8% Association, only 1 patient was compared to the national value of 16.6%. diagnosed to have Diabetes Mellitus. The percentage of underweight is much less 5.5% as compared to the general There were no patients who had serum population of 25.2% (29). Similar triglyceride levels less than 0.45%. findings have been noted in various There were 22 (61.11%) patients who other studies. had their serum triglycerides in the normal range i.e. between 0.45-1.82% In a study by Homel P et al the (31) There were 14 (38.89%) of patients who body mass index (BMI; kg/m2) and the had their serum triglycerides more than prevalence of overweight and obesity normal i.e. 38.89%. among Schizophrenic versus non- Schizophrenic individuals among The number of patients who had serum nationally representative samples of the HDL levels less than normal was 1 US adult population were evaluated. (2.75%). The number of patients who had serum HDL levels in the normal This study was carried out between the range was 31 (86.11%) The number of 1987 to 1996, a period during which the patients who had serum HDL levels use of novel/atypical agents increased. more than normal was 4(11.11%.) Results showed that mean BMI (body
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mass index) for individuals with (29). This may be due to the fact that the Schizophrenia is significantly higher mean age of our patients is only 36.1 than individuals who are not years with an age range of 29 –54 years. schizophrenic. Another study done by Studies have shown that the risk of Hummer M et al showed that weight developing Diabetes Mellitus increases gain induced by Clozapine is much more with age. In addition we used the criteria than that induced by Haloperidol (32). In of one reading of IFG (Impaired Fasting the study done by Hummer M et al on 81 Glucose) to diagnose Diabetes Mellitus patients it was also noted that 35.7 % of when IGT (Impaired Glucose Tolerance) the patients treated gained weight. If will diagnose a greater percentage of patients gained weight this side effect people from suffering from Diabetes was noted within the first 12 weeks of Mellitus. This also may have contributed therapy (32). Also weight gain was not to a lower prevalence value for Diabetes influenced by gender, and the weight Mellitus. Since we have no baseline gain may continue till the 46 month from BMI (body mass index) values we the start of therapy with Clozapine (22). cannot ascertain if the Diabetes Mellitus occurred with or with out weight gain. The values of increased BMI among Schizophrenics may be accounted for by The prevalence of hypertriglyceridemia the medication the patient is on or it may is 38.89 %. However no figures are also be due to the illness itself. Either available for comparison with the way measures have to be taken to general Malaysian population. Also we safeguard against excessive weight gain did not take into account if patients were among patients. Studies also show that on lipid lowering agents when weight gain is more among those who conducting our study. This finding may were underweight initially. Due to the be attributable to either the illness, cross-sectional nature of the study it is medication or may be due to the weight- not known to what extent Clozapine is gain induced by the medication. The fact responsible for these findings. Although that Clozapine causes an elevation in Clozapine is known to be frequently serum triglyceride levels has been associated with substantial weight gain it replicated in many studies (22, 33). is important to highlight that obesity is a Although these findings are preliminary common concomitant of Schizophrenia. annual monitoring of fasting blood sugar Whether the cause of obesity is due to and serum lipid concentrations may be the illness or the drug, psychiatrists need prudent in those patients receiving to address the issue of obesity amongst Clozapine. their patients who are prescribed Clozapine. Unfortunately, some of the From the above results it is evident that cognitive and motivational deficits Clozapine may contribute to the associated with Schizophrenia may limit occurrence of cardiovascular disease. these patients from benefiting from weight loss programmes. While these are important findings with potential clinical significance, these The prevalence of Diabetes Mellitus in results must be viewed with caution due our study is 2.78% which is the less than to certain limitations of our study. that of the national population of 8.3%
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Some of the limitations of the study are 6. Baldwin J .A. Schizophrenia And listed below. As this is a cross sectional Physical Disease. Psychol Med. 1979; 9 study the temporal relationship between : 611-618. the initiation of Clozapine treatment and the onset of the side effects cannot be 7. Mukherjee M, Schnur D and studied. Prospective, case controlled ReddyR. Family History Of Type Two studies may be better. The prevalence of Diabetes In Schizophrenic Patients. The Diabetes and hypertrigyceridemia may Lancet. 1989; 495. have been affected by the treating clinician’s knowledge of the side effects 8. Silverstone T, Smith G and of the medication and of having avoided Goodall E. Prevalence Of Obesity In prescribing Clozapine to those patients Patients Receiving Depot who already had Diabetes Mellitus and Antipsychotics. Br J Psychiatry. 1988 hypertriglyceridemia. This may have ;153: 214-217. contributed to the low prevalence of Diabetes Mellitus in our study. 9. The Health Consequences Of Overweight And Obesity. J Of The Reference Royal College Of Physicians Of London. 1983; 17 (1); 6-17. 1. Allebeck P. Schizophrenia: A Life Shortening Disease. Schizophr Bull. 10. Mukherjee S, Decia P, Bocola 1989; 15(1):81-90. V, Saraceni F and Scapicchio P.L . Diabetes mellitus In Schizophrenic 2. Marder SR, Essock SM, Miller Patients. Compr Psychiatry. 1996; 37(1): AL, et al. Physical Health Monitoring Of 68-73. Patients With Schizophrenia. Am J Psychiatry. 2004; 161:1334-1349. 11. Tabata H, Kikuoka M, Kikuoka H, Bessho H ,Hirayama J, HanabusaT et 3. Lambert TJ, Velakoulis D, al. Characteristics Of Diabetes Mellitus Pantelis C. Medical Comorbidity In In Schizophrenic Patients. J Med Assoc Schizophrenia . Med J Aust .2003; 178 Thai. 1987; 70(2): 90-93. (9 Suppl): 67-70. 12. Finney G. Juvenile Onset 4. Davidson S , Judd F ,Hocking B, Diabetes and Schizophrenia? The Thompson S ,Hyland B. Cardiovascular Lancet; 1989. Risk Factors For People With Mental Illness. Aust N Z J Psychiatry . 2001; 13. Hagg S, Joelsson L , Mjorndal T, 35(2):196-202. Spigset O, Oja G and Dahlqvist R. Prevalence of Diabetes And Impaired 5. Brown S, Birtwistle J, Roe Glucose Tolerance In Patients Treated L,Thompson C. The Unhealthy Lifestyle With Clozapine Compared With Patients Of People With Schizophrenia. Psychol Treated With Conventional Depot Med 1999; 29(3): 697-701. Antipsychotics. J Clin Psychiatry. 1998; 59 (6): 294-299.
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14. Haupt DW , Newcomer JW. 21. Baldessarini R.J and Hyperglycemia And Antipsychotic Frankenburg F. Drug Therapy. A Medications. J Clin Psychiatry. 2001; 62 Review Article. N Eng J Med. 1991; 324 Suppl 27:15-26. (11) : 746-754.
15. Michael S, Douglas L, Renato D, 22. Henderson D ,Cagliero E, Gray Miklos F and Rosenheck R. The C, Nasrallah R, HaydenD, Schoenfeld D Association Of Diabetes Mellitus With and Goff D. Clozapine, Diabetes Use Of Atypical Neuroleptics In The Mellitus, Weight Gain, and Lipid Treatment Of Schizophrenia. The Am J Abnormalities: A five –year Naturalistic Psychiatry 2002; 159(4): 561-566. Study. Am J Psychiatry. 2000; 157: 975- 981. 16. Bustillo J, Buchanan R, Irish D and Brier A .Differential Effect Of 23. Kane J, Honingfeld G, Singer J, Clozapine On Weight: A Controlled Meltzer H. Clozapine For The Treatment Study. The Am J Psychiatry. 1996 ; 153: Resistant Schizophrenic: A Double 817-819. Blind Comparison With Chlorpromazine. Arch Gen Psychiatry. 17. Allison D, Mentore J , Heo M, 1988; 45:789-796. Chandler L ,Cappelieri J, Infante M and Weiden P. Antipsychotic Induced 24. Peter L, Brown S, Hailey A. Weight Gain: A Comprehensive Prevalence Of Obesity, Lipid and Research Synthesis. Am J Psychiatry Glucose Abnormalities In Outpatients 1999; 156:1686-1696. Prescribed Clozapine. Irish Med J. 2002; 95 (4 ): 1-4. 18. Baptista T . Body weight gain induced by antipsychotic drugs: 25. Koller E, Schneider B, Bennet K, mechanisms and management. Acta Dubitsky B. Clozapine Associated Psychiatr Scand. 1999; 100(1): 3-16. Diabetes. American J Medicine. 2001; 111 (9):716-723. 19. Hong, Chen- Jee ab, Ching Hua c, Younger W-d , Chang, Su Chenc, 26. Brian C, Lund; Paul J. Perry; Wang, Shu- Ying a; Tsai, Shih-Jen ab. John M Brooks; Stephen Ardnt. Genetic Variant Of The Histamine- 1 Clozapine Use In Patients With Receptor And Body Weight Change Schizophrenia And The Risk Of During Clozapine Treatment. Psychiatr Diabetes Mellitus , Hyperlipidaemia Genetics 2002: 12 (3): 169-171. And Hypertension : A Claims Based Approach. Arch Gen Psychiatry. 2001; 20. Leadbetter R, Shutty M, 58(12): 1172-1176. Pavalonis D ,Vieweg V, Higgins P and Downs M. Clozapine Induced Weight 27. Ghaeli P, Dufresne R L. Serum Gain: Prevalence And Clinical Triglyceride Levels In Patients Treated Relevance. Am J Psychiatry 1992; With Clozapine. Am J Health –Syst 149:68-72. Pharm. 1996; 53: 2079-2081.
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28. Gaulin B D, Markowitz J S , 31. Homel P, Casey D, Allison DB Caley C F ,Nesbit LA and Drufesne RL. .Changes In Body Mass Index For Clozapine- Associated Elevation In Individuals With And Without Serum Triglycerides. Am J Psychiatry. Schizophrenia, 1987-1996. Schizophr 1999; 156(8): 1270- 1272. Res. 2002; 1;55(3):277-284.
29. Report Of The Second National 32. Hummer M, Kemmler G, Kurz Health And Morbidity Survey M, Kurzthaler I, Oberbauer H, Conference. Nov 1997. Published By Fleischhacker WW. Weight Gain Ministry Of Health Malaysia: Nutritional Induced By Clozapine. Eur Status Of Adults. Neuropsychopharmacol. 1995; 5(4):437- 440. 30. Report Of The Expert Committee On The Diagnosis And Classification Of 33. Meyer JM,. MD. Novel Diabetes Mellitus (American Diabetes Antipsychotics and Severe Association: Clinical Practice Hyperlipidemia. Journal Of Clin Recommendations 2003: Committee Psychopharmacology. 2001; 21(4): 369- Report) Vol. 26 supp.1January 2003. 374.
Address for Correspondence: Dr. Sharmilla Thanasan, Department Of Psychological Medicine, Pusat Perubatan University Malaya, Lembah Pantai. 59100 Kuala Lumpur.
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ORIGINAL PAPER
IMPACT OF PSYCHIATRY TRAINING ON ATTITUDES OF UNDERGRADUATE MEDICAL STUDENTS
Chandrasekaran. R. *., Srikumar P. S*., Joshua E*., Rasamy G*.
*School of Medicine, AIMST University
ABSTRACT
Objective: This study assesses the impact of prescribed undergraduate psychiatry training program on medical students’ attitudes to psychiatry. It is hypothesized that training may cause positive attitude changes towards the discipline and status perceptions of the profession of psychiatry. Methods: A 23 item questionnaire was administered to 89 medical students before and after prescribed training in psychiatry as per the medical curriculum. Results: Participation in psychiatry training enhanced students’ belief that it is a rapidly expanding frontier of medicine and that psychiatry can be viewed as precise and scientific. Psychiatric referrals were seen as useful to medical and surgical patients. However there was less agreement that psychiatric treatment is helpful to most people. Support for choice of psychiatry as a career was less as students were more negatively influenced by family. Poor income prospects and perceived low status among other medical disciplines were also endorsed following the completion of training. Conclusion: There is a pressing need to revise the psychiatric training for medical students. A total attitude change is difficult to achieve and hence, the curriculum has to identify focal areas for emphasis. A multidisciplinary, bio-psychosocial model through liaison with other disciplines like medicine and surgery is a definite option. Psychiatrists have to be role models to alter the image of psychiatry among other medical professionals.
Key words: Attitudes, Medical students, Psychiatry, Training program
Introduction that contribute to this negative attitude include lack of scientific rigor in the Failure to attract sufficient residents to discipline, non efficacy of treatment, low specialize in the field of psychiatry is a social status among other disciplines and growing concern in many countries (1). poor financial returns (2). In addition the This trend is partly attributed to the misconceptions about psychiatry may negative attitudes of medical students also arise from negative social stigma that towards psychiatry. Some of the factors
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prevails towards the profession in six week structured psychiatry training general, psychiatrists and patients (3). program for medical undergraduates. Out of a total of 181 hours, 120 hours are There is some evidence to support that devoted to clinical practice rotation and psychiatric education in medical school 15 hours for lecture classes. The may change the opinions of students in a remaining 46 hours are used for favorable direction, though one is not symposia, problem-based learning, certain whether the changes remain tutorial classes and directed self-learning permanent (4). Though the impact of activity. clerkship, in general, has been found to be positive, a recent study failed to bring The subjects who participated in this out any significant change in the attitudes study were medical undergraduates at of students following the clerkship (3). It AIMST University who received training is also realized that the quality of medical in psychiatry from July 2007 to Nov education is a crucial factor in motivating 2007. The only selection criterion applied students to choose psychiatry as a career was that they should have attended both (5). Training that focuses on knowledge theoretical and clinical training classes in acquisition, usefulness of psychiatric psychiatry during the term. interventions, direct contact with patients and liaison activity with other medical In this study, a modified version of departments is likely to yield better Balon’s questionnaire (10) was used. The results (6). questionnaire explores six main areas: i) overall merits, ii) efficacy, iii) role If positive attitudes are built it is expected definition of functioning of psychiatrists, that more students would opt for iv) possible abuse and social criticism, v) specialization in psychiatry (7). But this career and personal reward and vi) has not been confirmed (8). This shows specific medical school factors. Twenty that positive opinions need not lead to an three questions falling under main areas action. It is also possible that the (i) to (v) were chosen for administration. improvement may be temporary and the Area (vi) was felt inappropriate to desire to specialize in psychiatry may administer as it is concerned with the wane following exposure to other medical outcomes after the training, and students disciplines. In spite of various constraints, would not be in a position to respond at the social image and general opinion the start of the program making it towards psychiatry is improving (9). The inconsistent with the before-after design objective of this study is to assess the of this study. A written explanation of the impact of psychiatry training program on purpose of the study preceded the main the attitude towards psychiatry of questionnaire. Students completed the undergraduate medical students. It is same questionnaire before and after hypothesized that exposure to the subject completion of their training. Students may cause positive changes in attitudes of were assured of anonymity of responses students. and failure to participate in the study did not involve academic and /or social risks. Methods In view of these conditions, returning a questionnaire was considered to be The AIMST University, Malaysia offers a indicative of informed consent.
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Compliance was reasonably good and questionnaire after the completion of only a small number of questionnaires training. These two were considered had missing data. Statistical analysis was dropouts. Participants included 43 male performed using SPSS Version 13. The and 46 female respondents. data was converted to relative percentages excluding the missing As shown in Table 1, positive opinions answers. Wilcoxon test for proportions regarding the overall merits of psychiatry was used for comparison. got further strengthened following the training. They more strongly supported Results the view that psychiatry is a rapidly expanding frontier of medicine and The index group consisted of 116 psychiatric research has made good students of which 91 participated in the strides in advancing care of major mental initial assessment and 89 returned the disorders.
Table 1: Overall merits of psychiatry Before training After training
No Question SA MA MD SD SA MA MD SD Z sig 1 Psychiatry has made good strides in advancing care of the major mental 25. 8 58.3 13.9 2.0 46.9 42.5 6.7 3.8 3.8 0.0001 disorders 2 Psychiatry is a rapidly expanding frontier of medicine 11.3 50.7 30.0 8.0 31.0 46.6 17.4 5.0 3.71 0.0001
3 Psychiatry is unscientific and 7.9 36.0 38.3 17..8 2.6 24.5 41.1 31.8 3.45 0.0005 imprecise SA –Strongly agree, MA –Moderately agree, MD –Moderately disagree, SD- Strongly disagree
The students’ opinion concerning However there was a negative shift in the efficacy also changed. Table 2 indicates belief that psychiatric treatment in that the students agreed that psychiatric general is helpful to most people who consultation may be more helpful for receive it. medical and surgical patients.
Table 2: Efficacy Before training After training
No Question SA MA MD SD SA MA MD SD Z sig If someone in my family was very 4 emotionally upset and the situation did not seem to be improving ,I would 74.2 19.9 5.3 0.6 69.4 25.4 3.4 1.7 -1.2 ns recommend a psychiatry consultation
5 Psychiatry consultation for medical and surgical patients is often helpful 37.3 45.3 14.7 2.7 57.3 26.5 4.2 1.9 2.6 0.001
6 Psychiatry treatment is helpful to most 27.4 60.0 11.3 1.3 11.3 58.4 28.3 1.9 -1.9 0.05 people who receive it. SA –Strongly agree, MA –Moderately agree, MD –Moderately disagree, SD- Strongly disagree
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There were not very significant changes After the training a greater proportion of in the attitude of students regarding the students regarded psychiatrists as clear role definition and functioning of a and logical thinkers. (Table 3) psychiatrist.
Table 3: Role definition and functioning of psychiatrist
Before training After training
7 Psychiatry is not a genuine and valid 2.6 7.9 23.2 66.3 2.9 6.5 24 66.4 0.46 ns branch of medicine 8 Most psychiatrists are clear and logical 7.3 55.6 27.8 9.3 26.8 55.8 15.6 2.3 3.21 0.001 thinkers 9 With few exceptions, clinical 30.5 43.7 15.2 10.6 28.0 40.6 18.2 13.2 -0.9 ns psychologist and social workers are just as qualified as psychiatrist to diagnose and treat emotionally disturbed persons 10 Among mental health professionals 38.4 24.7 26 11.3 39.8 22.6 29.0 8.6 0.51 ns psychiatrist have the most authority and influence 11 Psychiatrist are too frequently 6.8 26.1 37.4 29.7 5.5 22.2 39.7 32.6 0.40 ns apologetic while teaching psychiatry
12 Psychiatry is too biologically minded 38.4 24.7 26 11.3 39.8 22.6 29.0 8.6 -0.4 ns and not attentive enough to patients personal life and psychological problems 13 Psychiatry is to analytical, theoretical, 7.7 25.2 54.5 12.6 5.8 24.5 49.5 20.1 -0.5 ns and psychodynamic and not attentive enough to patients physiology
SA –Strongly agree, MA –Moderately agree, MD –Moderately disagree, SD- Strongly disagree
After completion of training students most other doctors. No change in attitude were less inclined to believe that was noticed regarding abuse of power. psychiatrists make as much money as (Table 4)
Table 4: Possible abuse and social criticism Before Training After Training No Questions SA MA MD SD SA MA MD SD Z sig 14 Psychiatrists frequently abuse their legal power to hospitalize patients 6.4 14.3 35.0 44.3 5.2 15.5 32.1 47.2 -0.3 ns against their will 15 On average ,psychiatrists make as 11.1 51.3 28.2 9.4 9.3 39.4 36.6 14.7 -2.3 .05 much money as most other doctors SA –Strongly agree, MA –Moderately agree, MD –Moderately disagree, SD- Strongly disagree
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At the end of clerkship, the students the status of psychiatry as compared to reported a more favorable attitude other medical disciplines. Students at the concerning the prestige enjoyed by the end of training also felt that the family discipline among the general public. The exerted a significant negative influence in fear of being branded as odd or neurotic the choice of psychiatry as a specialty. for the interest in psychiatry became (Table 5) significantly less after the training. But training did not seem to have improved
Table 5: Career and personal reward Before training After training
No Question SA MA MD SD SA MA MD SD Z sig 16 Psychiatry has low prestige among 24.5 39.8 22.4 13.3 10.3 10.1 39.6 39.6 -3.3 .001 the general public
17 Psychiatry has high status among 3.6 16.1 53.2 28.1 4.4 18.0 39.6 37.9 0.51 ns other medical disciplines 18 Many people who could not obtain a 2.9 19.7 39.4 38.0 3.8 26.3 37.4 32.6 0.43 ns residency position in other specialties eventually enter psychiatry
19 Psychiatry is a discipline filled with 3.6 15.1 53.2 28.1 4.4 18 39.6 37.9 0.23 ns international medical graduates whose skills are of low quality
20 My family discouraged me from 5.7 9.2 17.7 67.4 10.3 15 25.3 49.4 2.27 0.05 entering psychiatry 21 Friends and fellow students 6.3 14.1 14.1 65.5 6.3 26.7 30.5 30.4 0.36 ns discourage me from entering psychiatry 22 If a student expresses interest in psychiatry, he or she risks being 6.5 35.0 33.5 24.9 6.2 17.8 28.0 48.0 -3.3 .001 associated with a group of other would be psychiatrists who are often seen as odd, peculiar or neurotic
23 I feel uncomfortable with mentally ill 5.5 27.4 36 31.1 4.8 25.4 38.2 31.6 0.52 ns patients SA –Strongly agree, MA –Moderately agree, MD –Moderately disagree, SD- Strongly disagree
Discussion appreciation that the discipline does not lack scientific basis and it has far more to The results show that some of the offer in terms of research. The training attitudes have changed in a favorable appears to have strengthened the views in direction. Psychiatry has long been a positive direction. These findings are carrying an image that it is imprecise and supported in other studies indicating unscientific. This study shows that opinions on psychiatry have improved. training in psychiatry leads to (3, 11)
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The opinion of students regarding social prestige of the discipline. Students efficacy of treatment appear uncertain. were inclined to view that psychiatry While conceding that psychiatry referrals enjoyed a respectable image among the for medical and surgical patients are often general public. It has been amply helpful, they were not certain about the demonstrated in other studies that a efficacy of treatment in general. The perceived low social prestige can be training program organized for the altered by educational experience. (12) students could have considerably influenced the opinion on this aspect. The Despite improvement in its general students have no liaison experience with standing, many believed that psychiatry other medical specialties and minimal does not enjoy a high status among other exposure to non psychotic conditions disciplines and this trend persisted during such as panic disorder, depression and the training. This brings into focus the obsessive compulsive disorder. While role of practical integration of psychiatry treating chronic psychotic illnesses unlike with other disciplines in the form of other medical illnesses, the therapeutic liaison work. If an essential role of a gains are slow and barely visible and this psychiatrist is built into an may very well explain the nihilism interdisciplinary team approach to expressed by the students. medical and surgical cases, it is bound to enhance the image of psychiatry among A significant proportion of students have other disciplines. changed their opinion and regarded psychiatrists as clear and logical thinkers. There is a significant change in the way The undergraduate psychiatry education the students perceived the family’s over the years has undergone several reaction for considering psychiatry for changes and evidence based medicine has further specialization. The level of brought in clinical algorithms adding discouragement expressed by the family more clarity to teaching the subject. The was perceived to be greater following the mysticism surrounding the subject over completion of training. The reason is not the years has been replaced by very clear although it can be presumed empiricism. that it is due to the stigma attached to psychiatry as a profession. Peer pressure, A significant change concerning income on the contrary, seemed to have lessened prospects was observed before and after following the training proving that training. Following training they were exposure to scientific training can induce less likely to think that psychiatrists make more balanced views. Expressions such as much money as most other specialist as odd, peculiar and neurotic were less doctors. The training in psychiatry is used in reference to psychiatrists. sandwiched between ophthalmology and orthopedics in this medical school. This study has some limitations. The data Choice of surgical specialities has been has been obtained from one batch of significantly correlated with better students from a single medical school. income prospects. This reality might have This limits the generalization of the influenced the opinion of the students findings. regarding income prospects. There is a significant positive change about the
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A little less than 25% of the students did 3. Fischel T, Mana H, Krivoy A, not participate in the study. Among the Lewis M, Weizman A. Does a clerkship strengths of the study, barring two in psychiatry contribute to changing students, all others participated in the medical students’ attitudes to psychiatry? evaluation before and after the training. Acad Psychiatry 2008; 32:147-150 This adds support to the findings of the study. The training program is highly 4. Wilkinson DG,Greer S, Tone BK structured with minimal chances for Medical students’ attitudes to psychiatry. deviation. Psy Medicine1983 ; 13:185-192
Conclusions 5. Nielsen AC. Choosing psychiatry: The importance of psychiatric education The students of today will be (non) in medical school .Am J Psychiatry psychiatrists tomorrow and they will be 1980;137:4 in a position to influence the attitudes of their own students. In this context 6. Alexander DA,Eagles JM. education in psychiatry needs to undergo Changes in attitudes towards psychiatry revision. The focus should be on a bio- among medical students: correlation of psychosocial model and this is to be attitude shift with academic performance. accomplished through liaison activity Medical Education 2003:37:447 with other disciplines. The psychiatrist may be required to be an effective role 7. McParland M, Noble LM, model to alter the image of psychiatry Livingstone G, McManus C. The effect among other medical professionals. of a psychiatric attachment on students’ attitudes to and intention to pursue Acknowledgements psychiatry as a career. Med Edu 2003;37:447-454 The authors thank Batch 5&6 medical students of AIMST University for their 8. Sivakumar K, Wilkinson G, participation in the study. Tonne BK, Greer S. Attitudes to psychiatry in doctors at the end of their first post-graduate year: two year follow- References up of a cohort of medical students. Psy Medicine 1986; 16:457-460 1. Sierles FS,Taylor MA. Decline of U.S medical student career choice of 9. Pailhez G, Bulbena A, Coll J Ross psychiatry and what to do about it. Am J S, Balon R. Attitudes and views on Psychiatry1995;152:1416-1426 Psychiatry: A comparison between Spanish and U.S. medical students. 2. Bulbena A,Pailhez G,Coll J,Balon Academic Psychiatry 2005;29: 82-91 R. Changes in the attitude towards psychiatry among Spanish medical 10. Balon R, Franchini GR, Freeman students during training in psychiatry. PS, Hasenfeld IN, Keshavan MS et al. Eur J Psychiatry 2005; 19:79-87 Medical students attitudes and views of psychiatry: 15 years later.Academic psychiatry1999; 23: 30-36
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11. Garryfallos G, Adamopoulu A, 22: 92-97, Feifel D, Moutier CY, Lavrentiadis G, Giouzepas J, Parashos A Swerdlow NR. Attitudes toward et al.. Medical students’ attitudes towards psychiatry as a prospective career among students entering medical school. Am J 12. Psychiatry in Greece: An eight- Psychiatry 1999:156:1397-1402. year comparison. Acad Psychiatry 1998;
Corresponding author: Dr. Chandrasekaran Ramamurthy , MD Professor , School of Medicine, AIMST UNIVERSITY, Jalan Bedong, Semeling , Kedah 08100
Phone no: 0164138739 Email: [email protected]
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ORIGINAL PAPER
CROSS-CULTURAL ADAPTATION AND VALIDATION OF THE BAHASA MALAYSIA VERSION OF THE EATING DISORDER EXAMINATION QUESTIONNAIRE (EDE-Q)
Ramli M*, Jamaiyah H**, Noor Azimah M***, Khairani O***, Adam B**
*Kulliyyah of Medicine, International Islamic University Malaysia **Clinical Research Centre, Ministry of Health Malaysia ***Faculty of Medicine, UKM Medical Centre
ABSTRACT
Introduction: As eating disorders such as anorexia nervosa and others are generally becoming more prevalent, it is essential to have a culturally accepted and locally validated questionnaire that is able to detect abnormal eating habits. Objective: To translate the Eating Disorders Examination Questionnaire (EDE-Q) into Bahasa Malaysia (BM) and to determine the construct validity, reliability and other psychometric properties of the BM version. Method: Two parallel forward and backward translations were done in BM in accordance to guideline. Its validation was determined by using confirmatory factor analysis among 298 secondary school children. Results: The BM EDE- Q had very good internal consistency with global Cronbach’s alpha value of 0.879. For construct validity, majority of the items managed to produce values of more than 0.4 for confirmatory factor analysis with four unforced distinct factors detected. Conclusions: Analyses of reliability and validity of this BM version of EDE-Q yielded satisfactory results. The BM version produced in this study had good psychometric properties and it is applicable to the Malaysian population. Findings indicated that cultural factors in eating habits certainly influences the effort to adapt the questionnaire within a Malaysian setting.
Keywords: Eating disorders, reliability, validity, Bahasa Malaysia.
Introduction population and these conditions are rarer in Asia than it is in the west1. The The prevalence of eating disorders such presence of these disorders is more as anorexia and bulimia nervosa is low; significant in certain groups of that is between 1-2% of the worldwide community such as in athletes, young
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females and those in the higher time consuming, it is not practical and socioeconomic society 2, 3. quite costly to administer to a big group of people. Alternatively, as the EDE-Q is In Malaysia, there is insufficient data on a self-administered questionnaire, it the prevalence of eating disorders requires little training, is relatively especially among adolescents and inexpensive and is less time consuming. children. Even studies related to eating It can be administered in a group format habits are scarce due to unavailability of 11. screening or measuring tools. Thus it is crucial that a well-validated and As the self-administered EDE-Q is more culturally-accepted questionnaire for the feasible for epidemiological study, it was Malaysian population is developed. chosen to be validated in this study. This Constructing a locally adapted 36-item instrument generates four questionnaire would establish a path for subscale scores (i.e. Dietary Restraint, future studies on eating habits and Eating Concern, Shape Concern and indirectly inculcate better mental health Weight Concern) as well as a global services for children and adolescents in score which is the mean of the four general. subscales. Each subscale item is rated on a seven point system (0–6), with higher The characteristics of a good tool are scores indicating greater frequency or convenient yet comprehensive in which severity. it should be able to measure various aspects related to eating habits such as Objective anorexic and bulimic behaviours and body disfigurement. There are several The main objective of this study is to questionnaires designed to analyse conduct a cross-cultural adaptation of abnormal eating habits such as the the EDE-Q and to assess the reliability Eating Attitudes Test (EAT–26) 4, the and validity of the Bahasa Malaysia Eating Disorder Inventory (EDI-2) 5, the version in Malaysian population. Three Factors Eating Questionnaire (TFEQ) 6, the SCOFF questionnaire, the Methods Eating Disorder Examination (EDE) interview7 and the Eating Disorder Study Design: Examination Questionnaire (EDE-Q) 8. This study was funded by the Ministry Studies had shown that there is a good of Health Malaysia (MOH) under the level of agreement between the MOH grant. It was a multi-centred, interview version of Eating Disorder cross-sectional study, involving four Examination (EDE) and Eating Disorder secondary schools (i.e. SMK Taman Examination Questionnaire (EDE-Q) Maluri, SMK Puteri Titiwangsa, SMK except in behavioural binge eating 9,10. Seri Titiwangsa, SMK Setapak Indah). The EDE-Q is a self-report version of a Within each school, the participants 36-item questionnaire derived from and were selected by stratified quota scored in the same way as the interview sampling to represent the Malaysian schedule6 As the EDE interview population with ratio of race, gender and schedule requires training and can be academic performance as main
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considerations. The study population was conducted on eight bilingual first- consisted of adolescents, aged 12 to 17 year medical students based on a focused years old that fulfilled the inclusion group discussion. Phase 3 was an expert criteria. Consent was obtained from panel review. Pre-final BM EDE-Q 2 parents and participants. The study was reviewed by an expert panel to commenced in June 2006 and ended in further improve the BM version of the December 2007. EDE-Q and to evaluate the clarity, understandability, naturalness and The full protocol was approved by the adequacy of wording. Phase 4 was the Ethics Committee of Clinical Research reliability and validation process. For Centre Kuala Lumpur Hospital. All validation of the final BM version of parents and subjects that participated in EDE-Q, construct validity was done. the study were asked to provide The reliability of the instrument was informed consent. The schools were examined using internal consistency selected based on the student distribution looking at the Cronbach’s alpha values. which should reflect the actual The participants’ recruitment was Malaysian population. Vernacular integrated with the validation effort of schools or schools with one predominant the Family Environment Scale (FES) ethnic group were excluded. questionnaire.
Study Process Results
The study was divided into four phases. A total of 298 students from four schools Phase 1 was the translation process were selected in this study and we where two forward and two backward managed to attain reasonably translations of the original EDE-Q heterogeneous subjects to fit the socio- English version were carried out. One demographic profiles. Majority of the arm consisted of two independent respondents were Malays (63.4%), bilingual medical experts while the other followed by Chinese (28.2%) and arm comprised of two blinded Indians (6.7%), which corresponded to bilinguistic experts. This process was the Malaysian population (i.e., Malays – carefully done in order to ensure that 54.1%; Chinese – 25%, Indians – 7.5% there would be no alteration in the and from other races – 13.2%; as based meaning, removal or addition in the on the 2005 census of the Department of sentences of the original English EDE- Statistics, Malaysia)12. Statistically Q. The BM version at this phase was significant differences were noted for the labelled as Pre-final BM EDE-Q. Phase global score of the EDE-Questionnaire 2 was intended to check for equivalence with regards to gender, ethnicity and between the original English EDE-Q and religion but not for the other variables pre-final BM EDE-Q. The product at the (Table 1). end of this process underwent pre-test using a probe technique. This pre-test
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Table 1: Socio-demographic data No. (%) Mean score SD score p-value EDE-Q score (Range) 10.0 (0, 46.5) 8.2 Age 12-13 21(7.0) 14-15 173(58.0) 16-17 104(34.9) Race Malays 189 (63.4) 10.7 8.1 < 0.001 Chinese 84(28.2) 7.9 8.4 Indians & others 25 (8.4) 13.7 7.1 Gender Male 141 (47.3) 7.9 7.4 < 0.001 Female 157 (52.7) 11.9 8.5 Religion 10.8 Islam 195 (65.4) 8.1 < 0.001 8.9 Christian 11 (3.7) 12.4 13.5 Hinduism 17 (5.7) 7.3 7.5 Buddhism 73 (24.5) 7.7
Others 2 (0.7) Academic achievement Excellent 36 (12.1) 19.2 9.4 0.373 Average 225 (75.5) 10.1 9.5 Poor 37 (12.4) 12.8 10.2 Parents’ Marital status Married/living together 267 (89.6) 9.9 8.3 0.253 Divorced/separated 24 (8.1) 11.4 8.6 No answer 7 (2.3) Parents’ Income < RM 1000 75 (25.2) 11.5 9.1 0.700 RM 1001-5000 117 (39.3) 11.4 8.1 > RM 5000 30 (10.1) 11.0 7.4 Don’t know 76 (25.5) Mother’s Educational level Primary school 20 (6.7) 13.0 8.5 0.226 Secondary school 120 (40.3) 10.7 9.3 Tertiary education 54 (18.0) 9.8 7.5 Don’t know 104 (34.9) Mother’s Job Status Self employed 33 (11.1) 10.1 8.5 0.641 Private staff 42 (14.1) 9.2 9.0 Government staff 60 (20.1) 10.5 7.9 Student 163 (54.8) 10.2 8.2 Father’s Educational level Primary school 19 (6.4) 10.9 7.3 0.871 Secondary school 95 (31.9) 11.1 9.5 Tertiary education 71 (23.8) 9.8 7.5 Don’t know 113 (37.9) Father’s Job Status Self employed 93 (31.2) 8.9 6.6 Private staff 97 (32.6) 10.0 9.3 Government staff 86 (28.9) 11.0 8.5 Student 22 (7.4) 12.4 9.2
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Reliability Eating Concern (0.655) and Restrain (0.635). The Bahasa Malaysia version was found to have a high internal consistency with Validity test global Cronbach’s alpha of 0.879. The participants were highly consistent in The construct validity was evaluated by their responses throughout the using confirmatory factor analysis questionnaire. The version was further (CFA). The Keiser value of 0.890 with evaluated based on its original four sub- cumulative variances of 59.9% was scales. A greater consistency was found yielded. in Shape Concern domain (0.874), followed with Weight Concern (0.775),
Tables 2: Factor loadings of every item by using Varimax rotation (Eigenvalues over 1) based on principle component of confirmatory factor analysis. No Item Factor Factor Factor Factor 1 2 3 4 Restrai Shape Eating Weight n concern concern concern 1 Restraint overeat 0.596 2 Avoidance of eating 0.640 3 Food avoidance 0.594 4 Dietary rules 0.611 5 Empty stomach 0.406 6 Flat stomach 0.367 8 Preoccupation with shape or weight 0.421 10 Fear of weight gain 0.301 11 Feeling of fatness 0.533 23 Importance of shape 0.565 26 Dissatisfaction with shape 0.819 27 Discomfort seeing body 0.805 28 Avoidance of exposure 0.741 7 Thinking about food, eating, calories 0.763 9 Fear of losing control, overeating 0.233* 0.669 19 Eating in secret 0.715 20 Guilt about eating, affecting shape 0.437 21 Social eating 0.522 0.213* 12 Desire to lose weight 0.692 22 Importance of weight 0.596 0.175* 24 Reaction to prescribed weighing 0.709 0.082** 25 Dissatisfaction with weight 0.818 0.271* *factor loading < 0.3
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Table 2 shows that confirmatory factor with extreme care according to a strict analysis of all items managed to draw guideline. Responses from participants four unforced factors. Table 2 shows that during pre-test and validation phase all items except items 9, 21, 22, 24 and were favourable as the terms and 25 had CFA values of more than 0.3 for sentences used were clear. Nevertheless their original subscales. The confirmatory factor analysis yielded confirmatory factor analysis with modest favourable results as only five eigenvalues over 1 and unforced factor items had CFA values below than 0.3 for managed to draw 4 domains. their original subscales. Items 22, 24, 25 were clearly measuring weight but the Discussion result showed these items to have had better factor loading for Shape and In general this study achieved its general Restrain subscales. Minor discrepancies objective of testing the cross-cultural in comparison to the results garnered by adaptation of the BM version of the the original author 11 may be attributed EDE-Questionnaire to the Malaysian to various reasons. teenage population. The constitution of participants represented the Malaysian Firstly, the original English EDE-Q itself population with respect to gender and is still in expansion stage. Of late, more racial distribution based on the 2005 studies were done to explore the census of the Department of Statistics, psychometric behaviours of EDE-Q. Malaysia12. A balance between the Based on the EDE-Q brief preliminary subjects in this study and the actual report, item 8 belonged to two subscales Malaysian population was achieved as (i.e. Shape Concern and Weight schools’ student distribution and Concern). Item 10 (fear weight gain) subjects’ selection were taken into clearly involves issue pertaining to consideration. Schools with multiracial weight but it belongs to Shape Concern students and quota sampling on subjects subscale. Therefore results of this study were based on ethnic groups. However would add more value to the behavioural we advocate the effort of future aspect of all items particularly related to validation efforts of this BM version the Asian context. among the general adult group. Secondly, the variation of certain items The BM version of EDE-Q produced at belonging to different subscales as the end of this project had very good compared to the original version was reliability in which the global internal most likely due to the differences in the consistency for the BM EDE-Q was high socio-cultural nature of the Malaysian with all the subscales showing and Caucasian populations. In particular, consistently good results. The people’s view and concept about Cronbach’s alpha ranged from 0.63 to patterns of eating habits may be different 0.87 which were comparable to other from one culture to another. This is studies which had values between 0.70 evidenced by the different prevalence in and 0.93 based on various types of eating disorders among various community. 9, 13, 14 populations 15, 16. In different health care systems, the definition and the The translation process was conducted importance given to health and diseases
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vary and this is linked to the cultural with the Caucasian population, an setting. Inter-country comparisons equivalent questionnaire would perhaps should use standard measures in be more appropriate than an identical assessing health status equivalently questionnaire. rather than identically over cultural differences 13. Acknowledgement
Thirdly, the subjects in this study were We extend our heartfelt gratitude to the Malaysian adolescents and this group Clinical Research Centre, Ministry of may respond differently to the BM Health Malaysia for grant conferment translated version of the EDE- and for providing dedicated research Questionnaire than adults. assistants; Ms. Norwani, Ms Gunavathy Selvaraj, Ms. Husna and Ms. Azdayanti Nevertheless the original EDE-Q is who had given their endless kind suitable and has been tested on a young cooperation. adolescent population17. Other favourable feature that we found in this References study is that the construct validity reproduced and confirmed that there are 1. Markey CN, Markey PM. four factors or subscales in this Relations between body image and questionnaire. This is in line with results dieting behaviours: An examination of from other studies where consistent gender differences. Sex Roles. 2005; findings of four factors were found 17,18. 53(7/8):519-530.
Further research may help us to entrench 2. Bulik CM, Reba LBA, Siega-Riz our understanding of the psychometric AM, Kjennerud RT. Anorexia nervosa: values of this version particularly with Definition, epidemiology, and cycle of different groups of subjects. Studies on risk. International Journal of Eating the consistency and level of agreement Disorders. 2005; 37(1):2-9. between self-rated questionnaire and clinical interview have high 3. Dotti JC. Eating Disorders, psychometric value in making it more Fertility, and Pregnancy: Relationships colloquial to the general Malaysian and Complications. Journal of Perinatal population. & Neonatal Nursing. 2001; 15(2):36-48.
Conclusion 4. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating Attitudes The translation and validation efforts Test: Psychometric features and clinical produced quite acceptable outcomes. correlates. Psychological Medicine. The different socio-cultural background 1982; 12:871-878. of the studied population could explain the non-identical subscales of the BM 5. Garner DM, Olmsted MP, Polivy version in comparison with the original J. Development and validation of a EDE-Questionnaire. As a result of the multidimensional Eating Disorder distinct multi-racial as well as the Inventory for anorexia nervosa and different socio-culture in comparison bulimia. International Journal of Eating
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Disorders. 1983; 2:15–34. 13. Mond JM, Ha P J, Rodgers B, Owen C, Beumont PJV. Validity of the 6. Yeomans MR, Tovey HM, eating disorder examination Tinley EM, Haynes CJ. Effects of questionnaire (EDE-Q) in screening for manipulated palatability on appetite eating disorders in community samples. depend on restraint and disinhibition Behaviour Research and Therapy. 2004; scores from the Three-Factor Eating 42(5):551-567. Questionnaire International Journal of Obesity. 2004; 28(1):144-151. 14. Rizvi SL, Peterson CB, Crow SJ, Agras WS. Test-retest reliability of the 7. Fairburn CG. Cooper Z. The Eating Disorder Examination. Eating Disorder Examination (12th ed.). International Journal of Eating In C.G.Fairburn & G.T. Wilson (eds.), Disorders. 2000; 28:311–316. Binge eating: Nature, assessment and treatment 1993; 317-360. New York: 15. Rosen DS. Eating disorders in Guilford Press. children and young adolescents: Etiology, classification, clinical features, 8. Kristine H. Luce, Janis H. and treatment. Adolescent Medicine. Crowther. The reliability of the eating 2003; 14:49–59. disorder examination - Self-report questionnaire version (EDE-Q) 16. Engström I, Kroon M, Arvidsson International Journal of Eating CG, Segnestam K, Snellman K. Eating Disorders. 1999; 25(3):349–351. disorders in adolescent girls with insulin-dependent diabetes mellitus: A 9. Luce KH, Crowther JH. The population-based case-control study. reliability of the eating disorder Acta Paediatrica. 1999; 88:175–180. examination – self report questionnaire version (EDE-Q). International Journal 17. Carter JC, Stewart DA, Fairburn of Eating Disorder, 1999; 25:349-351. CG. Eating disorder examination questionnaire: norms for young 10. Black CMD, Wilson GT. adolescent girls. Behaviour Research Assessment of eating disorders: and Therapy. 2001; 39:625-632. Interview vs. questionnaire. International Journal of Eating Disorders, 1996; 18. Mond JM, Hay PJ, Rodgers B, 20:43–50. Owen C, Crosby R, Mitchell JE. Use of extreme weight control behaviors with 11. Fairburn CG, Beglin SJ. The and without binge eating in a community assessment of eating disorders: Interview sample of women: Implications for the or self-report questionnaire? classification of bulimic eating International Journal of Eating disorders. International Journal of Eating Disorders. 1994; 20:43-50. Disorders. 2006; 39:294–302.
12. Department of Statistics, State/District Data Bank, Malaysia; 2005.
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Corresponding Author: Dr. Ramli Musa, Department of Psychiatry, Kulliyyah of Medicine, International Islamic University Malaysia, Bandar Indera Mahkota, 25200 Kuantan, Pahang Malaysia.
Email: [email protected] Tel No: (+609)5716400 @ (+6012) 2484076 Fax No: (+609) 5716770
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ORIGINAL PAPER
THE PREVALENCE OF DEPRESSIVE SYMPTOMS AND POTENTIAL RISK FACTORS THAT MAY CAUSE DEPRESSION AMONG ADULT WOMEN IN SELANGOR
Sherina MS*, Rampal L*,. Azhar MZ**
*Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia, ** Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia
ABSTRACT
Introduction: Women are exposed to stress such as working full time while still being responsible for the family and house. Objective: The objective of this study was to determine the prevalence of depressive symptoms among adult women in Selangor, and to determine the potential risk factors associated with depression. Method: A community based cross sectional study was conducted in all districts of Selangor state, Malaysia in July 2004. Multi stage stratified proportionate to size sampling method was used to collect data. The Patient Health Questionnaire (PHQ-9) was used to determine the presence or absence of depressive symptoms among the respondents. All respondents aged 20 to 59 years old in the selected households were interviewed. Results: Out of 1032 women, 972 agreed to participate in this study, giving a response rate of 94.2%. The mean age of the respondents was 37.91 ± 10.91. Majority were Malays (54.9%), married (83.8%) and had secondary education (54.5%). The results showed that the prevalence of depressive symptoms was 8.3% in Selangor. Race, religion, education level, history of having a miscarriage within the last 6 months and history of difficulty in getting pregnant were significantly associated with depressive symptoms (p<0.05). Women with history of a miscarriage within the last 6 months and absence of formal education were potential risk factors for depressive symptoms (OR, CI = 2.576 (1.165-5.696), p<0.01 and OR, CI = 5.766 (1.949-17.053), p < 0.01). Conclusion: Depressive symptoms among adult women in Selangor was 8.3% and was associated with race, religion, education, history of miscarriage and difficulty in getting pregnant. The main potential risk factors were having a miscarriage within the last 6 months and absence of formal education.
Keywords: Depressive symptoms, Prevalence and Risk Factors, Selangor Women…………………………………………………………..
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Introduction stresses from work, family responsibilities and poverty. 6 The life expectancies of women in both developed and developing countries are Studies in Malaysia have shown that the increasing with improved health services prevalence of mental health problems, and living conditions. The life which consists mainly of depression are expectancy of Malaysian women was higher in women than in men. 7 75.2 years in 2001 compared to 65.6 However, not many studies have been years in 1970. 1,2 done on mental health status of women despite women nowadays being very Today, women are exposed to large much exposed to stress. This study amounts of stress. 3 The stress of taking hopefully can provide information on the care of young children, having an mental health status of women in unstable marriage, or working full time Malaysia, as well as make while still being responsible for the recommendations for the improvement house and family. 3 Women are usually of mental health. the primary caretakers for both young and old, often under financial strain or The objective of this study was to outright poverty. Many women focus so determine the prevalence of depressive much on caring for others that they do symptoms among adult women in not attend to themselves. Their own Selangor, as well as to identify the well-being takes a distant second to the potential risk factors that may cause needs of others. All these affect the depression. mental health status of women making them vulnerable to develop mental Method health problems, namely depression. 4 This community based cross sectional Poor mental health status is a major study was conducted in Selangor in July health problem that occurs more 2004, for a duration of 4 weeks. All commonly in women. 5 Over the course districts were included. Multi stage of a lifetime, depression, which is a stratified proportionate to size sampling common mental health disorder occurs method was used to select households in in approximately 20% of women each district. All women aged 20-59 compared to 10% of men. This statistic years old in the selected households is the same regardless of country or race were included in this study and were or economics. 5 Married women have contacted via home visit. This age group higher rates of depression than was chosen so that only adult women unmarried women, with rates peaking were included in this study, and not during the childbearing years. children, adolescents and elderly. Non- Depression occurs most frequently in Malaysian citizens were excluded from women 25-44 years of age. Reasons why this study. women are at increased risk for poor mental health status are biological A standardized pre-tested structured factors such as hormonal changes and questionnaire was used by trained genetics, physiological factors such as personnel to collect data from the body weight, and social factors such as respondents via face-to-face interview.
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The questionnaire consisted of 4 parts testing was done in another location not which consisted of questions on socio included in the study. Data was analyzed demography (age, ethnicity, religion, using the computer program “Statistical education level, occupation and monthly Package for the Social Sciences” (SPSS) income), marriage profile, obstetrics and version 11.5. Descriptive statistics were gynaecology history, and the Patient used for all the variables studied. Health Questionnaire (PHQ-9) which Pearson Chi-square, Odds ratio (OR) and was used to determine the presence or 95% Confidence Interval (CI) were used absence of depressive symptoms. to test the association and risk between each factor and depressive symptoms. The Patient Health Questionnaire (PHQ- Further analysis using multivariate 9) was developed by Drs. Robert L logistic regression was also done to Spitzer, Janet BW Williams, Kurt study the predictor outcome of the Kroenke and colleagues. It was potential risk factors. developed from the Primary Care Evaluation of Mental Disorders Patient Results Health Questionnaire (PRIME-MD PHQ). It is a self-report questionnaire Out of 1032 women, 972 agreed to and consists of 9 questions that identify participate in this study, giving a depressive symptoms. The PHQ response rate of 94.2%. Age of the Depression Severity Index score is used respondents ranged from 20-59 years to calculate for the presence of old. The mean age was 37.91±10.91 and depressive symptoms. 8 median was 38.00 (95% CI=37.22- 38.60). The profile of the respondents is The questionnaire was translated and shown in Tables 1A and 1B. validated in Bahasa Malaysia. Pre-
Table 1A: Profile of the respondents (Socio-demography) (n=972) Profile of the respondents n % Age 20-29 years 277 28.5 30-39 years 244 25.1 40-49 years 278 28.6 50-59 years 173 17.8 Race Malay 534 54.9 Chinese 194 20.0 Indian 227 23.4 Others 17 1.7 Religion Islam 547 56.3 Buddha 165 17.0 Christian 44 4.5 Hindu 212 21.8 Others 4 0.4 Education level No formal education 58 6.0 Primary education 219 22.5 Secondary education 530 54.5 Tertiary education 165 17.0
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Have you ever been married Yes 815 83.8 No 157 16.2 How old were you when first married Not married 157 16.2 ≤ 20 years 254 26.1 21-25 years 369 38.0 26-30 years 144 14.8 31-35 years 39 4.0 ≥ 36 years 9 0.9
Table 1B: Profile of the respondents (Obstetrics and Gynecology history) (n=972)
Profile of the respondents n % Best describes of your menstrual periods - Periods are unchanged 645 66.4 - No periods because pregnant 67 6.9 or recently gave birth - Periods have become irregular 117 12.0 or changed in frequency - No periods for at least a year 142 14.6 - Having periods because taking 1 0.1 hormone replacement therapy
Have a serious problem with your mood during the week before your periods start Yes 240 24.7 No 732 75.3
(IF Yes : Do these problems go away after end of the periods?)(n=240) Yes 210 87.5 No 30 12.5
Given birth within the last 6 months Yes 51 5.2 No 921 94.8
Had a miscarriage within the last 6 months Yes 22 2.3 No 950 97.7
Having difficulty getting pregnant (For those who are married)(n=815) Yes 51 6.3 No 764 93.7
Out of 972 respondents, 81 had among adult women aged 20 to 59 years depressive symptoms based on the PHQ- old ..in.. this ..study. 9 scores, giving a prevalence of 8.3%
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Table ..2 shows. the association of with education level (p=0.036), race depressive symptoms and socio (p=0.004) and religion (p= 0.001) of the demographic factors. Depressive respondents. symptoms were significantly associated
Table 2: Association between depressive symptoms and socio-demography among the respondents (n=972) Profile of the Depressive No depressive p value OR 95% CI respondents symptoms symptoms n(%) n(%)
Age 20-49 years 65(8.1) 734 (91.9) 0.631 0.88 0.52-1.48 50-59 years 16(9.2) 157(90.8)
Education level Formal education 72(7.9) 843(92.1) 0.036* 0.50 0.26-0.94 No formal education 9(15.8) 48(84.2)
Occupation Yes 35(9.0) 354(91.0) 0.541 1.14 0.75-1.75 No 46(7.9) 537(92.1)
Monthly salary < RM 500 49(7.4) 611(92.6) 0.136 0.70 0.47-1.12 ≥ RM 500 32(10.3) 280(89.7)
Race Malay 42(7.9) 492(92.1) 0.004* Chinese 7(3.6) 187(96.4) Indian 30(13.2) 197(86.8) Others 2(11.8) 15(88.2)
Religion Islam 43(7.9) 504(92.1) 0.001* Buddha 5(3.0) 160(97.0) Christian 2(4.5) 42(95.5) Hindu 31(14.6) 181(85.4) Others 0(0.0) 4(100.0)
* p<0.05=significant
Respondents who had no formal analysis found that the difference was education had significantly higher significant between Malay vs Chinese prevalence of depressive symptoms (p=0.043), Malay vs Indian (p=0.021) compared to respondents who had and Chinese Vs Indian (p=0.001). The formal education (p=0.036). The prevalence of depressive symptoms were prevalence of depressive symptoms were also highest among the Hindus (14.6%) highest among the Indians (13.2%) followed by Muslims (7.9%), Christians followed by other races (11.8%), Malays (4.5%) and Buddhist (3.0%). Further (7.9%) and Chinese (3.6%). Further analysis found that the difference was
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significant between Muslim vs Buddha Further… analysis… using ..multivariate (p=0.030), Muslim vs Hindu (p=0.005) logistic regression to study the and Buddha vs Hindu (p<0.001). association between depressive symptoms and selected associated Depressive symptoms were significantly factors found that history of having a associated with history of having a miscarriage within the last 6 months and miscarriage within the last 6 months (p = absence of formal education were 0.001) and difficulty in getting pregnant potential risk factors for depressive (p = 0.049). Other findings such as symptoms among the respondents (Table menstrual history and problems with 3). mood (before and after menstrual periods) were not significant (p > 0.05).
Table 3: Association between selected associated factors and depressive symptoms among respondents (multivariate logistic regression analysis) (n=972) Variables Regression Coefficient (β) OR (95% CI) p-value
Constant Value -24.426 0.999
Educational level 0.946 2.576 (1.165-5.696) *0.019 Formal education** No formal education
History of miscarriage within last 6 months 1.752 5.766 (1.949-17.053) *0.002 Yes** No
Difficulty in getting pregnant 0.603 1.828 (0.764-4.371) 0.175 Yes** No
Significant at p-value < 0.05*, Reference Category**, OR = Odds Ratio, CI = Confidence Interval
Depressive symptoms in this study were Discussion significantly associated with education level (p=0.036). The odd of having This study found that the prevalence of depressive symptoms was two times depressive symptoms among adult higher for women with no formal women aged 20 to 59 years old was education compared to women who had 8.3%. This finding is slightly lower formal education. Absence of formal compared to the study by Ialongo N et al education was also found to be a who found that the prevalence of potential risk factor for depressive depression was about 11.4% among symptoms among women in this study. African-American adult women from This finding is supported by a study years 1999-2000. 9 done by Berenson et al (2003) who
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found that women were at increased risk times higher for women who had of moderate to severe symptoms of suffered a miscarriage within the last 6 depression if they had not graduated months compared to women who did not high school. 10 Educational status suffer from any miscarriage. This was determines the socio-economic level of a also found to be a potential risk factor person and is significantly linked with for depressive symptoms among women occupational and financial status. Other in this study. Although there was also a studies in Malaysia have confirmed that significant association between low socio-economic status which is depressive symptoms and difficulty of associated with no or low educational getting pregnant, further analysis did not levels, unemployment, low income and find that infertility was a potential risk financial problems are significantly factor for depressive symptoms in this associated with poor mental health status study. Studies have found that in and depression. 11,12 women’s childbearing life, problems such as infertility and miscarriage are This study also found that depressive fairly common. Both are stressful and symptoms was significantly associated can make some women more vulnerable with race (p = 0.004) and religion (p = to depression.5 Swanson (2000) found 0.001), where the prevalence was that the women most at risk for highest among the Indians (13.2%) depressive symptoms after miscarriage compared to other races, and Hindus include women who do not conceive or (14.6%) compared to other religions. A give birth by 1 year after the loss. 13 study by Radziszewska et al (1996) Brier (1999) has described the risk of among 3993 students in Los Angeles intense and long-lasting distress County and San Diego County found following miscarriage as higher if the that ethnicity was significantly woman strongly desired the pregnancy, associated with depressive symptoms, waited a long time to conceive, or has no with Asians having the highest living children. 14 prevalence of depressive symptoms, followed by Whites, Hispanics and In conclusion, the findings of this study African-Americans. The findings of this show that the prevalence of depressive study highlighted the variation in the symptoms among adult women aged 20 prevalence of mental disorders as a to 59 years old in Selangor was 8.3%. function of ethnicity and socioeconomic Factors found to be significantly status. The data suggested that lower associated with depressive symptoms levels of socioeconomic status increase were race, religion, education level, the risk for mental disorder. However, history of having a miscarriage within the link between SES and prevalence of the last 6 months and difficulty in mental disorder varies by the type of getting pregnant. Potential risk factors disorder and by ethnicity. 9 for depressive symptoms in these women were history of having a There was a significant association miscarriage within the last 6 months and between depressive symptoms and the absence of formal education. history of having a miscarriage within the last 6 months in this study. The odds The lower prevalence of depressive of having depressive symptoms was 5 symptoms in this study could be due to
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the higher socio-economic status and References education level of the respondents in Selangor. Other studies in different 1. Department of Statistics. Year states in Malaysia need to be done to Book of Statistics Malaysia 1999. Kuala obtain the overall prevalence of Lumpur, 1999. depressive symptoms among women in Malaysia. This result can then be 2. Department of Statistics. Vital compared to studies done in other Statistics Time Series Peninsular countries. The characteristics of the Malaysia 1911-1985, Kuala Lumpur, groups with statistically higher 1991. prevalence of depressive symptoms also need to be further studied to assess their 3. Alexander JL. Quest for Timely contribution to the burden of illness Detection and Treatment of Women amongst these women. The main With Depression. Journal of Managed limitation of this study was that the Care Pharmacy 2007;13(9):S3-S10. questionnaire used (PHQ-9) had not been validated in the Malaysian setting. 4. Subhash CB, Shashi KB. At present there are very limited Depression in Women: Diagnostic and questionnaires on depression which have Treatment Considerations. American been specifically validated in the Academy of Family Physicians, 1999. Malaysian community. However, as a follow-up to this study, there is another 5. Department of Mental Health and study currently being conducted on the Substance Dependence, World Health validation of depression questionnaires Organization. Depression in Women in government primary care clinics in (Part 2). Women’s Mental Health: An Malaysia, and this includes the PHQ-9. Evidence Based Review, World Health Organization, Geneva, 2000. As women are exposed to large amounts of stress due to the multiple roles they 6. National Mental Health have to play as wife, mother daughter, Association. Clinical Depression and employee or employer and so forth, Women. Alexandria, VA: National factors associated with depressive Mental Health Association,2000. symptoms among these women should http://www.nmha.org/ccd/support/factsh be identified. It is important that eet.women.cfm depressive symptoms and its associated factors be identified early as depression 7. Report of the Second National can have severe effects on the sufferer’s Health and Morbidity Survey quality of life if left untreated for Conference, Kuala Lumpur,1997. extended periods. 8. Spitzer RL, Kroenke K, Williams Acknowledgement JB. Validation and utility of self-report version of PRIME-MD: the PHQ This study was conducted using the primary care study. JAMA Fundamental Research Grant from The 1999;282:1737-1744. Research Management Centre of Universiti Putra Malaysia.
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9. Ialongo N, McCreary BK, 12. Wan Mohd Rushidi WM, Pearson JL, Koenig AL, Schmidt NB, Shakinah S, Mohd Jamil Y. Postpartum Poduska J, Kellam SG. Major depressive Depression: A Survey of the Incidence disorder in population of urban, African- and Associated Risk Factors among American young adults: prevalence, Malay Women in Beris Kubor Besar, correlates, comorbidity and unmet Bachok, Kelantan. Malaysian Journal Of mental health service need. J Affect Medical Sciences 2002; 9(1): 41-48. Disorders 2004;79:127-136. 13. Radziszewska B, Richardson JL, 10. Berenson AB, Breitkopf CR, Wu Clyde W, Flay BR. Parenting Style and ZH. Reproductive Correlates of Adolescent Depressive Symptoms, Depressive Symptoms Among Low- Smoking, and Academic Achievement: Income Minority Women. Obstet & Ethnic, Gender, and SES Differences. J Gynecol 2003; 102:1310-1317. Behav Med 1996;19(3):289-305.
11. Institute of Public Health (IPH). 14. Freda MC, Devine KS. The The.. .Second... National… Health... and Lived Experience of Miscarriage After Morbidity Survey 2006 (NHMS II), Vol Infertility. MCM, Am J MCN 16. Kuala Lumpur: Ministry of Health 2003;28(1):16-23. Malaysia, 1999.
Corresponding Address: Sherina Mohd Sidik, Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia.
Email: [email protected]
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REVIEW PAPER
HEROIN ADDICTION: THE PAST AND FUTURE
Noor Zurani MHR*, Hussain H**, Rusdi AR**, Muhammad Muhsin AZ**
*Department of Primary Care Medicine, Faculty of Medicine, University Of Malaya, Kuala Lumpur. **Department of Psychological Medicine, Faculty of Medicine, University Of Malaya, Kuala Lumpur.
ABSTRACT
Substance misuse, in particular heroin addiction contributes to health and social problems. Although effective medical treatment was available, earlier efforts confined the treatment of heroin addicts to in-house rehabilitation which required them to be estranged from the community and their families for 2 years. The in-house rehabilitative programme, implemented for at least three decades has produced low abstinence rates. On the other hand, being ‘away’ meant that many heroin addicts faced employment problems and family relationship difficulties upon completing the in-house rehabilitation. However, recently, the concerted efforts by various government and non- government organisations, and the acknowledgement that heroin addiction is a medical illness has resulted in a revamp to approaching treatment of heroin addiction. At present, methadone substitution programmes have been offered as part of treatment programme for heroin addicts in Malaysia. This new programme has been shown to be effective in treating heroin addiction and would need support and cooperation from all groups involved.
Keywords: heroin, addiction, methadone, substitution, narcotic
Introduction consumption patterns changed where heroin became the abused substance of Substance abuse has been prevalent in choice and Malays were the main ethnic Malaysia for more than a century. In the group involved in heroin abuse early 20th century, the main drug of compared to other ethnic groups (1, 2). abuse was opium which was mainly consumed by Chinese immigrants who By the later part of the 20th century, the were introduced by the British prevalence of heroin abused increased colonialist to work in Malaya. In the substantially and this made the later part of the 20th century, Malaysian government consider heroin
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addiction as a threat to national security. only recently invited to review the policy Early government response included: the of treatment for heroin addiction in formation of the national anti-drug task Malaysia (iii) the stigma of the illness force to control trafficking and to and rehabilitation treatment which rehabilitate heroin addicts, and resulted in heroin users hesitant of legislation where mandatory death seeking early treatment. Heroin users sentence was implemented for those who were reported to fear rejection by the smuggled more than 15 grams of heroin community and of losing their freedom (3). It is mandatory for heroin addicts once they entered a rehabilitation found to be drug positive to undergo programme (6-8). compulsory rehabilitation for two years (4). Thus, as a consequence of ineffective treatment approach, there has been a Up to 28 government drug rehabilitation continually increasing number of centres, costing approximately RM 50 infectious diseases among heroin users million were established, where each and an escalating incidence of HIV center accommodated up to 500 inmates and/or AIDS in Malaysia (8). The at any one time (5). The centres, Ministry of Health, Malaysia reported managed on a total abstinence that the cumulative number of HIV philosophy however produced poor infections up to December 2005 was results. Reports showed that as high as 71,000 cases, where more than 10% 85% of heroin addicts relapsed after cases were AIDS positive. Most of the completing their rehabilitation at these HIV infected persons are males (82 %) centres (4, 6). In response to the poor aged 20-40 years (6). results, substitute treatment with methadone was recently introduced as One of the requirements of rehabilitation part of treatment programme for heroin was that a heroin addict needed to be addicts (7).……………………………. placed as in-house resident for two years (3). This resulted in majority of heroin Challenges to treating heroin addicts being forced to resign or losing addiction in Malaysia- the past employment. At the end of 2 years, by the time they leave the centres, they lose Heroin misuse contributes to the opportunity to work (2). This could complicated health and social problems be one reason why many of to our country. Despite three decades of rehabilitation inmates resort to crime managing these problems, outcomes are once discharged from in-house unpromising and poor. Among the rehabilitation centres. Some heroin reported contributory factors are: (i) addicts reported that they perpetrated treatment policy which had been crime in order to support themselves and confined to a single treatment modality- their families. However this is partially the regimental rehabilitation programme, truthful as it was observed that many (ii) despite strong published evidence perpetrated crime to support their that addiction to drugs is a medical addictive heroin habit. This is because condition, earlier approach had totally forced abstinence while in the ignored the medical therapeutic rehabilitation centres do not cure the approach. The medical profession was heroin addiction. Once discharged from
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the centres, and without strict abstinent intervened with appropriate medical enforcement, they relapse to their treatment. previous heroin usage (6-8). The consequence of failed rehabilitation The types of crimes commonly treatment not only affect heroin addicts perpetrated by heroin addicts included but also their family members (4). More snatch theft, selling drugs, fraud and than 50% of heroin adicts who house breaking (9). The involvement of underwent rehabilitation programmes heroin addicts in crime may result in were the breadwinners of their family. imprisonment. For the family, the loss of their sole breadwinner to two year rehabilitation Thus, another problem and another programme caused loss of financial and second stigma is added. In this case, emotional support. This caused family imprisonment further confirms the stress which further disrupted the family community’s view that heroin addicts system. This could be one explanation are criminals and should be alienated, why the children of heroin addicts are at hence resulting in total rejection from more risk of social and mental problems the community and from their families and of becoming heroin addict (2). The resulting alienation may cause themselves. depression and loss of hope. This emotional state will worsen their heroin Both professionals and the public have addiction, making it challenging for the expressed concern about the failure of therapist and clinician to motivate them the in-house rehabilitation treatment for treatment (8). The combined programme in tackling heroin addiction rejection by the community and family in Malaysia (4, 8). It is therefore timely limits the heroin addict to confide in for the government to look at the process their peer heroin addicts. Ultimately, the of how to maximise the cost benefit of heroin addict’s condition will get worse, the rehabilitation programmes. For and this is the time when they may start instance, the duration and the type of sharing needles. This could explain the heroin addict who needs such treatment whole cycle of addictive behaviour and should be reviewed. One of the how it correlates with HIV and AIDS. suggestions is that the duration of stay should be shortened to less than 6 It is very unfortunate that in the past, the months. medical community dealt with these heroin addicts after they had already The advantages of shorter rehabilitation contacted these horrendous include: firstly, this maintains the heroin complications (6, 8). The sharing of addicts within the community without needles by heroin addicts’ also exposes depriving them of their employment their spouses at risk of HIV and AIDS potential or maintaining as breadwinners (6). There were many instances where of the family. The second advantage husbands, who were heroin addicts with would be the cost saving to the AIDS transmited the disease to their government. It was reported that each spouses and children (7). This is another addict cost RM3, 000 per month to disaster, which could have been rehabilitate. Thus reducing in-house prevented if the addiction cycle was rehabilitation to less than six months will
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incur less than a quarter of the total cost The national drug substitution task force spent at present. Nonetheless, the most materialised after the realisation that the expensive cost is still borne by the occurrence of HIV/AIDS among heroin heroin addicts’ family who suffer at addicts was out of control (6, 7). being left to fend for themselves Although the initial suggestion was in mentally and financially. This loss is of 2000, it was only fully implemented in course is unquantifiable in Ringgit and 2005. The objective of this task force Cents (7).……………………………….. was to review and determine the role of drug substitution treatment in order to Medical treatment- the future prevent the spread of HIV among heroin addicts. Its successful implementation Managing heroin addiction can only be was mainly due to the combined efforts taken seriously as a medical issue once of the Ministry of Health, Malaysia, the everyone is convinced that heroin universities and non-governmental addiction is an illness (7). Latest organisations (NGOs) which ensured literature confirms that addiction is a urgent implementation of the programme brain disorder and categorised as a (7). A pilot national methadone mental disorder (1). Thus, effective maintenance treatment study was intervention for heroin addiction is only conducted on 1200 heroin addicts. complete when combined with medical Methadone treatment was offered free input (8). ……………………………../ by selected government and private clinics. While on methadone, the Understanding medical treatment for patients also attended regular heroin addiction is not limited to counselling sessions provided by the whether there is medication that could national anti-drug task force (AADK). cure heroin addiction. For the present, no This was the first arrangement nationally reports could offer promise of a that combined the resources of medication to cure heroin addicts (7). clinicians, NGOs and AADK in treating However, the same argument could be heroin addicts (5, 7). used for conditions such as schizophrenia and diabetic mellitus, as At review, the results showed that there is also no medication that promises methadone maintenance therapy cure for such conditions. Hence, as there improved compliance to treatment is no medicine which can cure addiction programmes (7). Compliance to at present, the next objective is to find treatment was observed to reach as high medication which can minimise the as 80% (5). The advantages of this harm caused by heroin addiction. This treatment were not confined to the situation is similar to diabetic mellitus, retention rate only, but also in ensuring where drugs such as insulin and other patients maintain their occupation and hypoglycemic agents are prescribed to quality of life. Many heroin addicts minimise the harm caused by the reported the ability to both maintain their disease. social and family responsibilities.
A New Era of Managing Heroin The cost of treating heroin addicts using Addiction a medical based approach was also found to be cheaper. For example, it cost
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RM 400 per month to treat a heroin with heroin addiction. The new policy addict with drug substitution therapy. On involving methadone substitution the other hand, it cost approximately RM therapy and counselling have been 3000 per patient per month to manage proven to be effective in treating heroin heroin addicts for in-house addiction and would need support and rehabilitation. Another major cost would cooperation from all parties involve. be incurred if the heroin addicts had contracted hepatitis, HIV or AIDS. Reference
For example, the cost of treating heroin 1. Chawarski, M.C.M., addicts with hepatitis C was M..Schottenfeld, R.S., Heroin approximately RM 15,000 per month. dependence and HIV infection in As most of the heroin addicts could not Malaysia. Drug Alcohol Dependence, afford to pay, there is a possibility that 2006. 82: p. 39-42. the cost would have been transferred to the government and this would have 2. Navaratnam, V.F., L., Natural been a financial burden to the nation. history of heroin addiction and adjunctive use, in Research Report The other advantage of methadone Series. No. 16. 1988, National Drug substitution programme was that it Research Centre, University Science ensured that the heroin addicts were Malaysia: Penang. ready for training and counselling (7). They were offered a choice of 3. National Narcotics Report. Kuala programmes to suit their needs. They Lumpur, M.O.H. Affairs, Editor. 1998, could choose to opt for either National Narcotic Agency. psychological counselling or spiritual based counselling. Some were also 4. Navaratnam, V.F., K.. Kulalmoli, offered employment placement/training. S., An Evaluation Study of the Drug On the other hand, it was also observed Treatment and Rehabilitation that the absence of withdrawal Programme at Drug Treatment Centre, in symptoms or intoxicating effects of Centre for Drug research heroin made the heroin addicts ready for UN/WHO/IFNG Research and Training counselling and able to concentrate on Centre University Science Malaysia. their rehabilitation programme. 1992: Penang.
Conclusion 5. www.adk.gov.my. (cited)
In recent years, the approach to heroin 6. Chawarski, M.C.M., M.. addiction in Malaysia has undergone Schottenfeld, R.S., Behavioral drug and various processes. In-house HIV risk reduction counseling (BDRC) rehabilitation programmes were first with abstinent-contigent take-home introduced; however the reported buprenorphine: A pilot randomised success rates were negligible. At present, clinical trial. Drug and Alcohol the government has introduced new Dependence, 2007. policies involving medical professionals that offer more treatment options to deal
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7. Mazlan, M.S., R.S..Chawarski, University Malaya Press. M.C., New challenges and opportunities in managing substance abuse in 9. Karofi, U.A., Drug Abuse and Malaysia. Drug Alcohol Dependence, Crimical Behaviour in Penang, 2006. 25: p. 473-478. Malaysia. A Multivariate Analysis. Bangladesh e-journal of Sociology, 8. Habil, H., Managing heroin 2005. 2(2): p. 1-26. addicts through medical therapy. 2001:
Correspondence: Associate Professor Dr Noor Zurani Md Haris Robson, Department of Primary Care Medicine, Faculty of Medicine, University Of Malaya, Kuala Lumpur.
Email: [email protected] [email protected]
78 MJP December 2008 Vol.17 No.2
REVIEW PAPER
IS THERE A NEED FOR A HOSPITAL BASED SMOKING CESSATION PROGRAMME IN MALAYSIA?
Noor Zurani MHR*, Mohammad Hussain H**
*Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur. **Department of Psychological Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur.
ABSTRACT
Smoking cessation programmes have been available for almost 2 decades in Malaysia. However the programmes have mainly focussed on outpatient primary care settings. More attention is needed to address and treat smokers presenting to hospitals with acute and chronic medical illness as hospitals provide good settings to implement smoking cessation intervention. For instance, a tobacco related medical illness may boosts a smoker's motivation to stop, especially when the smoker perceives smoking as the cause of his illness and understands the gains achieved by smoking cessation. Besides bringing a smoker in contact with health personnel who may offer assistance to a smoker to help him stop smoking, a hospital stay also provide an opportunity for the health carer to initiate and practice the government policy of no smoking in the hospitals. This article addresses the importance of having a hospital-based smoking cessation programme for the Malaysian hospitals.
Keywords: smoking cessation, smoker, hospital, quit, tobacco
Introduction cessation interventions is of urgent public health importance. Smoking is a major public health concern in Malaysia. The prevalence of Smokers who stop smoking have been cigarette smoking in Malaysia is still one shown to have reduced risk of morbidity of the highest in South East Asia despite and mortality from cardiovascular the on-going public health campaigns to disease even after the onset of clinical encourage smoking cessation [1]. illness. Even those who stop after an Smoking thus presents the single most attack of myocardial infarction were important preventive measure to reduce observed to have a lower reinfarction morbidity and premature mortality in rate and survived longer than those who Malaysia. Thus designing and continued to smoke [2]. implementing successful smoking
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Smoking cessation programmes have Why is a hospital-based smoking been available for more than 2 decades cessation programme needed in in Malaysia. However, these efforts have Malaysia? mainly focused on outpatient settings, usually at primary care practices. Much For a start, Malaysian hospitals are less attention has been paid to in-patient smoke-free zones. These smoke-free settings that deliver more acute medical zones provide a conducive environment care e.g. hospitals, despite the for a smoker to start a cessation attempt opportunities that they present for away from the cues of smoking. In changing behaviour. It is well addition, procedures such as cardiac documented that illness, especially a angioplasty or bronchoscopy provide a tobacco related illness such as good opportunity to uncover a smokers’ myocardial infarction, lung cancer and denial of the contributory risk smoking stroke, increases a smoker's motivation has on cardiovascular and respiratory to stop smoking [3, 4]. This is probably diseases. because illnesses increased a smoker's perceived vulnerability to the health Hospital-based smoking cessation hazards of tobacco use. In addition, a programmes have also been reported to medical problem or illness also brings a have many advantages. Among them smoker in contact with the hospital are: setting and providing an opportunity to encourage smoking cessation [5]. 1. An admission to hospital Promoting smoking cessation during a provides an opportunity for smokers to hospital stay also provides a special obtain help and stop smoking. At this incentive for implementing the no time, smokers are more open to advice at smoking policy in conjunction with the a time of perceived vulnerability. government’s policy which prohibits 2. Smoker’s may also find it easier smoking in hospitals. Being hospitalised to stop smoking in an environment also meant that a smoker is prevented where smoking is restricted and from smoking and have access to prohibited. multiple health personnel who could 3. Hospitalisation provides a provide smoking cessation assistance [3, teachable moment for smokers housed in 4, 6]. a temporary smoke-free environment. 4. Hospital personnel, e.g. nurses The importance of hospital based constitute the largest number of health smoking cessation has been care worker in a hospital and have a vital demonstrated over the past two decades. role in promoting smoking cessation [3, Studies have shown that a hospital stay 4]. can effectively initiate smoking cessation even in the absence of Which hospital-based smoking intervention. This was especially noted cessation programme works? in patients with cardiovascular and pulmonary disease and in patients Among the programmes reported in the having surgery [3-5, 7-9]. literature; (1) by type of illness, those programmes designed to target patients recovering from myocardial infarction
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have produced the best results. These The Malaysian Clinical Practice programs showed patients who were Guidelines on Treating Tobacco post-myocardial infarction had double Dependence 2003 had clearly endorsed the smoking cessation rate compared to the concept of hospital based smoking other smokers. The cessation rates intervention. Thus a hospital based reported were as high as 60-70% at one smoking cessation programme should be year [10, 11]. Even research who had especially attractive to hospital focused on a broader target population administrators because comparatively such as all in-patient hospitalized they are more cost effective than smokers regardless of diagnosis smoking programs for outpatients [12]. produced good results, (2) By type of For example, hospital based smoking intervention, interventions with highest cessation programs have been shown to frequency of contact and longer duration achieve higher cessation rates than of follow up showed the highest outpatient programs and reducing the cessation rates [3, 4], (3) when compared, cost per patient cessation. Furthermore it the addition of counselling as part of is also reported that the cost incurred in post-discharge program were also treating a smoker was justified by reported to increase smoking cessation reductions in the cost of medical care for rates after hospital discharge when patients with chronic medical disease compared with usual care [3-5] and (4) than for ambulatory patients. the inclusion of pharmacological treatments such as nicotine replacement Challenges to implementing a hospital therapy and bupropion increases based smoking cessation programme cessation rates [3, 4]. The reported challenges faced by Elements of effective hospital-based dedicated smoking cessation physicians smoking cessation programmes were how to implement the model intervention programs into existing Among the reported characteristics of an hospital delivery systems. Among the effective hospital-based smoking issues that needed to be addressed were: cessation programmes are: (1) adapting the hospital information and registration system to routinely identify 1) systematic identification of smokers patients' smoking status at admission, (2) at (or shortly after) admission; training, maintaining and retaining 2) a bedside counselling session by a experienced staff to provide the smoking nurse or specially trained counsellor and counselling, both in the hospital and supplemented by written or audiovisual after discharge and (3) the coordination material; of inpatient and post-discharge service. 3) continuous physician advice to stop It is suggested that this problem may be smoking and follow-up contact, usually reduced by integrating a hospital based by telephone, for at least three months smoking intervention as part of the after discharge [3-5]. general disease management for all patients [3-5, 13]. Implications for Malaysian hospitals
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Conclusion 6. Rigotti, N.A., II. Smoking cessation in the hospital setting-a new There is a need to develop a hospital opportunity for managed care. based smoking cessation programme to Introduction. Tob Control, 2000. 9 Suppl tailor to our Malaysian setting. This 1: p. I54-5. review suggests that the combination of hospital-based smoking cessation 7. Glasgow, R.E., et al., Changes in interventions with follow up support smoking associated with hospitalization: after discharge increase the success of quit rates, predictive variables, and smoking cessation. With an estimated 5 intervention implications. Am J Health million smokers in Malaysia, a hospital Promot, 1991. 6(1): p. 24-9. based smoking cessation program has the potential to reach many smokers and 8. Perkins, K.A., Maintaining yield substantial clinical and public smoking abstinence after myocardial health benefits. infarction. J Subst Abuse, 1988. 1(1): p. 91-107. References 9. Rigotti, N.A., et al., Smoking 1. Morrow, M. and S. Barraclough, cessation following admission to a Tobacco control and gender in Southeast coronary care unit. J Gen Intern Med, Asia. Part I: Malaysia and the 1991. 6(4): p. 305-11. Philippines. Health Promotion International, 2003. 18(3): p. 255-64. 10. Taylor, C.B., et al., Smoking cessation after acute myocardial 2. Rea, T.D., et al., Smoking status infarction: effects of a nurse-managed and risk for recurrent coronary events intervention. Ann Intern Med, 1990. after myocardial infarction. Ann Intern 113(2): p. 118-23. Med, 2002. 137(6): p. 494-500. 11. DeBusk, R.F., et al., A case- 3. Munafo, M., et al., Interventions management system for coronary risk for smoking cessation in hospitalised factor modification after acute patients: a systematic review. Thorax, myocardial infarction. Ann Intern Med, 2001. 56(8): p. 656-63. 1994. 120(9): p. 721-9.
4. Rigotti, N.A., et al., Interventions 12. Krumholz, H.M., et al., Cost- for smoking cessation in hospitalised effectiveness of a smoking cessation patients. Cochrane Database Syst Rev, program after myocardial infarction. J 2001(2): p. CD001837. Am Coll Cardiol, 1993. 22(6): p. 1697- 702. 5. MacKenzie, T.D., R.I. Pereira, and P.S. Mehler, Smoking abstinence 13. MacKenzie, T.D., Hospitalised after hospitalization: predictors of smokers: characteristics, treatment, and success. Prev Med, 2004. 39(6): p. 1087- transition to ambulatory care. Tob 92. Control, 2000. 9 Suppl 1: p. I57-8.
Correspondence: Assoc Prof Dr NoorZurani MHR, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur.
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CASE REPORT
POST STROKE LAUGHTER – A CASE REPORT
Amarpreet Kaur* , Nor Zuraida Z*, Ng CG*, Aida SA*
*Department of Psychological Medicine, Faculty of Medicine,…….. University of Malaya……..
ABSTRACT
Pathological laughing or crying (PLC) were recognized after the occurrence of stroke, with a prevalence of 15% to 18%. There is no apparent triggering stimulus, and is often misdiagnosed as a mood disorder as it is a disorder of emotional expression rather than a primary disturbance of feeling. We reported a case of a 32 year old lady, who presented with giddiness and altered consciousness progressing to fever and neck stiffness, who’s CT showed a massive left cerebellar infarct. No risk factors were identified. Psychiatrically, she developed sudden crying spells after one month and a diagnosis of Major Depressive Disorder was made with subsequent commencement of anti-depressants. A week later, she developed continuous inappropriate laughter without the feeling of elation, which was beyond her control. There were no symptoms of mania or psychosis.
Keyword: stroke, Post stroke depression, post stroke laughter
Introduction psychiatric history, and personal and family history of suicidal behavior are The post-stroke patient is at significant important items to bear in mind. Careful risk for various psychiatric syndromes. attention to caregivers' and family The most commonly reported of these in members' behavioral observations is the literature are Post-stroke Depression necessary, especially in patients with (PSD) and Post-stroke Dementia cognitive impairment or other neurologic (PSDem) (1). Integrating assessment for barriers to communication, such as psychiatric symptoms into the care of residual aphasia. post-stroke patients is especially critical in the first 6 months following a stroke, Other Post-stroke Psychiatric Syndromes a period of high risk for psychiatric less frequently seen include pathologic complications. Psychiatric and substance crying, pathologic laughter, apathy, and abuse history, past treatment with isolated fatigue (1). These are coded as psychopharmacologic agents, family mental disorder due to a general medical condition not otherwise specified.
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Pathologic laughter and crying are for cerebral protection. Cerebral sometimes grouped as pathologic resuscitation was commenced and emotions (PE) with sudden paroxysms completed after 48 hours. She was of either laughter or crying, irrespective transferred to University Malaya of the ambient mood state. Post stroke Medical Centre (UMMC) for further PE is a distressing and socially disabling management of her condition. problem. It affects 16 to 29% of all stroke survivors. (2) PE can be In UMMC, physical examination triggered by non-specific stimuli or by a showed evidence of tetraparesis. low-threshold emotive stimulus. Supported ventilation continued. Curiously, the PE do not themselves Unfortunately she developed sepsis induce a mood change other than during secondary to a nosocomial infection. A the affective display, and they are not CTV brain scan was done and a under voluntary control. Some literature conclusion of an extensive cerebellar recommends the use of antidepressants and brainstem infarct with no evidence for PE; lithium and anticonvulsants are of venous sinus thrombosis was made. alternatives. Subsequently, a tracheostomy was done and she was weaned off from supported Antidepressants, particularly selective ventilation the next day. The patient had serotonin reuptake inhibitors (SSRls), dysarthria and difficulty communicating have been increasingly recognized as the with others. While in the ward, screening treatment of choice for pathologic crying for possible factors that could have (PC) (2) . However, little is known about precipitated the infarct, such as etiologies and other treatment options connective tissue disease and a for various clinical manifestations of thrombophilic screen were done, PLC. This case report illustrates a case however results were negative. of post stroke laughter, highlighting the journey that brought her there. The patient was reviewed by the psychiatric team a month later, after the Case primary treating team noted that she had sudden crying spells. Based on the This is a case of a 32 year old Indian history and presentation gathered, a lady with no past medical history, who diagnosis of Major Depressive Disorder presented with a sudden onset of was made and she was started on giddiness, followed by altered Escitalopram 10mg daily. With consciousness for one day. She was subsequent observations, a week later brought immediately to Kajang Hospital, she was then noted to have labile mood, where she developed a fever and neck characterized by crying spells as well as stiffness, conscious level dropping to bouts of laughter. In the meantime, her Glasgow Coma Scale of 7/15. A communication had improved as she was computed tomography (CT) scan of the now able to write on an alphabet board brain done to investigate and elicit to convey information. She was causal factor of illness, showed a discharged from ward after having been massive left cerebellar infarct. She was admitted for two months. treated as having meningitis and given a course of antibiotics. She was intubated
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Subsequent reviews in the psychiatric emotional display in the absence of a clinic showed that her mood had pervasive and sustained depressed or improved. Her antidepressant was elated mood. PLC occurs only stopped. However, her family members paroxysmally and is uncontrollable and noted that the crying spells recurred. involuntarily. Such episodes may even Antidepressant medication was occur in the absence of any congruent commenced again three months later. changes in the mood of the patient.11 Upon review from December 2007 Three primary features were emphasized onwards, the patient had continuous by Poeck: 1) sudden loss of voluntary inappropriate laughter. She was not able emotional control; 2) occurrence in to explain why she was laughing. She response to “non specific”, often denied feeling elated but felt that her inconsequential stimuli; and 3) lack of laughter was beyond her control. There clear association with prevailing mood were no other accompanying symptoms state.20 Several scales are available to to suggest mania or hypomania, nor identify and characterize PLC. One of were there any psychotic symptoms. them is Pathological Laughter and Crying Scale.21 It is commonly used in Discussion clinical research.
Sudden, uncontrollable episodes of PLC is a disorder of emotional emotional display or pathological expression rather than a primary laughing or crying (PLC) were disturbance of feeling. The laughter or recognized after the occurrence of a crying behaviours (e.g. the facial stroke.3,4 The prevalence of this morbid expression, the tears etc) in PLC is condition has been reported to range identical with regular laughter or crying from 15% to 18%.5,6,7 The episodes but no associated feeling of happiness or either do not have an apparent sadness. In the past, it was proposed that motivating stimulus or are triggered by a the impaired emotional regulation stimulus that would not have elicited resulted from disinhibition of a such an emotional response before the presumed brainstem center for laughing onset of their neurological disorder. and crying due to lesions of the Various terms have been used to voluntary motor pathways in the describe this condition. These terms are descending corticobulbar pseudobulbar affect, pathological pathways.9,11However, this explanation laughter and crying, emotional lability, has several limitations like patients do emotionalism, emotional dysregulation, sometimes response contradictory to the forced crying, involuntary crying, emotional valence of the triggering pathological emotionality and emotional stimulus, lack of typical features of incontinence.8 The authors use PLC in pseudobulbar palsy and no clear this report as we believe is a precise evidence of single brainstem center for descriptive term for the condition. laughing and crying.11 Based on current studies, other structures like prefrontal In clinical setting, PLC is often cortices9, cerebellum12 and globus unrecognized. The condition can be pallidus13 are suggested to be associated often be misdiagnosed as a mood with PLC. A thorough understanding of disorder. Patients with PLC exhibit the the pathophysiology of PLC is needed.
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3. Ghika-Schmid F, Bogousslavsky Although there is lack of understanding J (1997) Affective disorders following regarding the exact etiologies of PLC, stroke. Eur Neurol 38:75-81. the condition was found improved markedly with the administration of 4. Dark FL, McGrath JJ, Ron MA antidepressants14 like sertraline15, (1996): Pathological laughing and fluoxetine16, amitriptyline17, crying. Aust NZ J Psychiatry 30:472- nortriptyline18 and citalopram.19 The 479. possible explanation for the beneficial affect of selective serotonin reuptake 5. Huse A, Dennis M, Molyneux A, inhibitor (SSRI) and other Warlow C, Hawton K (1989) antidepressants would be that by altering Emotionalism after stroke. Br Med J the operation of higher order cortical 298:991-994. areas involved in cognitive processing, the drugs would alter the cognitive 6. MacHale SM, O’Rourke SJ, context enough to raise the threshold at Wardl0aw JM, Dennis MS (1998) which stimuli engage the system in PLC, Depression and its relation to lesion reducing, in short, emotional lability.11 location after stroke. J Neurol Neurosurg It is important to note that even though Psychiatry 64:371-374. the antidepressant is helpful in treating PLC, does not necessary imply a causal 7. Morris PLP, Robinson RG, relationship between the agent and the Raphael B (1993) Emotional lability condition. However, understanding how after stroke. Aust NZ Psychiatry 27:601- serotonergic substitution can improve 605. emotional experience in patients with mood disorder while also being effective 8. Parvizi J, Arciniegas D. B., in patients who have pathological Bernardini G. L., Hoffmann M. W., regulation of emotional experience is Mohr J. P., Rapport M.J., Schmahmann important.8 J. D., Silver J. M.,Tuhrim S. (2006) Mayo Clin Proc 81(11): 1482-1486. References 9. Oppenheim H, Siemerling E, 1. Bourgeois JA, Hilty DM, Chang Mitteilungen uber Pseudobulbarparalyse CH (2004) Poststroke neuropsychiatric und acute Bulbarparalyse. Berl Klin illness: an integrated approach to Wochenschr. 1886;46. diagnosis and management. Curr Treat Options Neurol 6:403-420. 10. Wilson SAK (1924) Some problems in neurology, II: pathological 2. Derex L, Ostrowsky K, laughing and crying. J Neurol Nighoghossian N, Trouillas P (1997) Psychopathol. 4:299-333 Severe pathological crying after left anterior choroidal artery infarct. 11. Parvizi J, Anderson SW, Martin Reversibility with paroxetine treatment. CO, Damasio H, Damasio AR. (2001) Stroke 28:1464-1466. 69. Pathological laughter and crying: a link to the cerebellum. Brain 124:1708-1719.
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12. McCullagh S, Moore M, Gawel 17. Ohkawa S, Mori E, Yamadori A. M, Feinstein A. (1999) Pathological (1989) Treatment of pathological laughing and crying in amyotrophic laughing with amitriptyline. Clin Neurol lateral sclerosis: an association with 29:1183-1185. In Japanese. prefrontal cognitive dysfunction. J Neurol Sci. 169;43-48. 18. Parikh Rm, Robinson RG, Lipsey JR, Price TR. (1989) 13. Jong S. Kim (2002) J Neurol Nortriptyline treatment of poststroke 249:805-810. emotional lability a double blind study. Neurology. 5(suppl 1):177. Abstract. 14. House Ao, Hackett ML, Anderson CS, Horrocks JA. (2004) 19. Anderaon G, Vestergaard K, Riis Pharmaceutical interventions for JO. (1993) Citalopram fro post-stroke emotionalism after stroke. Cochrane pathological crying. Lancet 342:837- Database of Systematic Reviews. Issue 839. 2. Art No.:CD003690. DOI: 10.1002/14651858. CD003690. pub2. 20. Poeck K (1969): Pathophysiology of emotional disorders 15. Burns A, Russell E, Stratton- associated with brain damage, in Powell H, Tyrell P, O’Neill P, Baldwin Handbook of Clinical Neurology, vol3, R. (1999) Sertraline in stroke-associated edited by Vinken PJ, Bruyn GW. lability of mood. Int J Geriatric Psych. Amsterdam, North-Holland, pp 343-367. 14:681-685. 21. Robinson G.B., Parikh R. M., 16. Brown K.W., Sloan R.L., Lipset J. R., Starkstein S.E., Price T. R. Pentland B. (2007) Fluoxetine as a (1993) Pathological laughing and crying treatment for post-stroke emotionalism. following stroke: Validation of a Acta Psychiatrica Scandinavica Vol98. measurement scale and a double-blind 6; 455-458. treatment study. Am J Psychiatry 150:2 pp286-193.
Corresponding address: Dr Amarpreet Kaur, Department of Psychological Medicine Faculty of Medicine, University of Malaya
Email:[email protected]
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BOOK REVIEW
ANTIEPILEPTIC DRUGS TO TREAT PSYCHIATRIC DISORDERS Edited by Susan L. McElroy, Paul E. Keck, Jr. and Robert M. Post Informa Healthcare USA, Inc. New York 2008, 224 pages
This book delves into the role of antiepileptics in psychiatric and neuro-psychiatric disorders which happen to be their most common area of “off label” use. We often associate antiepileptics with mood stabilization but we seemed not to realize that there are various other therapeutic benefits of this class of drugs as highlighted by the editors in the preface.
This book has 3 parts to it and there are numerous contributors to each chapter in each part and the contributors are all preeminent experts in psychiatry. The first part provides an overview of antiepileptics and its various uses in neuropsychiatric conditions. It contains one chapter that describes briefly the mechanism of action of these drugs as well as a summary about the first and second generation antiepileptics such as Felbamate, Topiramate, Gabapentin, Zonisamide, Pregabalin just to name a few. The author had also provided some information about the latest antiepileptics in the pipeline as well.
The second part consists of chapters describing antiepileptics in psychiatric disorders. It is made up of 10 chapters. The first chapter in described the treatment of acute manic and mixed episodes. This chapter highlights all the commonly prescribed antiepileptics in manic and mixed episodes with tabulated supporting evidence from randomized controlled trials which provides an excellent guide to those looking for evidence based literature with regards to this. This will be an important chapter especially for postgraduates as it provides useful information about drugs such as Oxcarbazepine, Phenytoin, Topiramate, Gabapentin as well as Lamotrigine as these are not commonly used in our clinical practice for manic or mixed episodes.
The second chapter in part 2 talks about the role of antiepileptics in long-term treatment of bipolar disorder. This is also an important aspect of bipolar disorder as we know that long-term management involves a complex and arduous process that can be very challenging even to the most experienced psychiatrist. Adequate evidence for safety, maintenance efficacy and practical guidelines for long-term use in bipolar disorder is presented in this chapter for all approved antiepileptics as well as those for which clear evidence indicates that they have secondary roles in bipolar disorder.
The third chapter in part 2 deals with antiepileptics in rapid-cyclers and bipolar depression. From a clinician’s point of view, rapid cyclers and patients with depressive episodes are more difficult to manage. Antiepileptics have traditionally been regarded as mood stabilizers and the rationale to support their use in bipolar disorder has primarily been derived from the treatment in mania. This chapter will review both these entities and
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simultaneously highlighting the results of randomized trials involving antiepileptics for them.
The fourth chapter in part 2 targets the role of antiepileptics in Major Depressive Disorder. The efficacy of antiepileptics in bipolar disorder has been well established over the past 30 years but that is not so in unipolar depression. In this chapter, some evidence is presented to suggest that some antiepileptics may have antidepressant effects in unipolar patients. The author had taken the effort to describe a few antiepileptics with regards to major depression and he had added a note on antiepileptics and suicidality as well which is always pertinent in this case.
The fifth chapter in part 2 deals with antiepileptics in the treatment of schizophrenia. The author highlighted the fact that when clinicians consider augmentation for inadequacy during monotherapy, prime candidates for combination with antipsychotics are agents with different mechanism of action. Antiepileptics and lithium are commonly used in combination with antipsychotics to treat schizophrenia. This chapter reviews the utilization patterns of antiepileptics in patients with schizophrenia, the evidence supporting this and some advice on how to consider augmentation with a specific antiepileptic for individual patients.
The sixth chapter in part 2 addresses the role of antiepileptics in the treatment of anxiety disorders. Antiepileptics as we know have been used widely in treating mood disorders and are considered first line treatment for bipolar disorder. Their success has led to investigation into their potential in other disorders, particularly anxiety disorders. This chapter attempts to review the small but emerging literature on the use of antiepileptics in anxiety disorders namely social phobia, PTSD, panic disorder, GAD, OCD and mixed anxiety states. Hence, this is again a very informative section that is superbly squeezed into one chapter to make it a very good read indeed.
The seventh chapter in part 2 concentrates on antiepileptics in treatment of alcohol withdrawal and relapse prevention in alcohol dependents. This is an interesting chapter that dwells on antiepileptics such as Carbamazepine/Oxcarbazepine, Divalproex, Topiramate, Gabapentin and Lamotrigine and their related literature describing their possible benefit in alcoholism. The eighth chapter extended the discussion to drug related disorders and how antiepileptics has been used to manage sedative-hypnotic withdrawal, stimulant dependence as well as treatment of drug dependence and co-morbid mood disorders. These 2 chapters collectively give a good account on management of alcohol and drug related disorders using antiepileptics.
The ninth chapter in part 2 gives an important insight into their use in impulsivity and aggression and impulse control and cluster B personality disorders. It covers a wide range of disorders from pathological gambling to borderline personality disorders and at the same time providing adequate literature on the various antiepileptics that had been studied in accordance with this. However, the tenth chapter concentrated solely on borderline personality disorder and this may provide an insight into the direction of how borderline personality is managed as it’s always a challenging disorder to handle.
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The last part deals with the potential psychotropic mechanisms of action of antiepileptic drugs. It contains only one chapter namely the psychotropic mechanisms of action of antiepileptic drugs in mood disorder. This is probably the most important chapter in the whole book as it gives a schematic account of the interpretation of which biochemical effects of the antiepileptic drugs may be related to their mood stabilizing and other psychotropic properties. For example, this chapter highlights some pertinent issues such as the fact that antiepileptics tend to act against seizures either immediately or as quickly as therapeutic blood levels can be achieved but in contrast, full antimanic and antidepressant effects are slower to achieve. The mechanisms of various antiepileptics are discussed here including some presumptive and theoretical mechanisms that will help the readers to understand them better. Also highlighted are the clinical implications of the mechanistic differences of the various antiepileptics as well as the potential neurotrophic and neuroprotective effects of lithium, valproate and the unimodal antidepressants. The author had added some information on ECT and vagal nerve stimulation in bipolar disorder as well.
In a nutshell, I think this is an excellent book and it provides valuable insight into the ever expanding role of antiepileptics in the management of psychiatric disorders and this book should dispel the myth that antiepileptics are confined only to epilepsy and bipolar disorder. This book is definitely a must have for trainees as well as psychiatrists.
Reviewed by: Dr. Koh Ong Hui, Lecturer, Department of Psychological Medicine, Faculty of Medicine, University Malaya.
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EDUCATION PAPER
MODEL ANSWER FOR CRITICAL REVIEW PAPER (PART 2 EXAMINATION): THE CONJOINT EXAMINATION FOR MASTER OF MEDICINE (PSYCHIATRY) AND MASTER OF PSYCHOLOGICAL MEDICINE ON FRIDAY, 4TH MAY 2007.
Model Answer prepared by Hatta Sidi, Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Center (UKMMC)
Are our postgraduate candidates having knowledge problems in basic sciences? – An experience with mock Multiple Choice Questions (MCQ)
Hatta Sidi , Fairuz Nazri AR. MALAYSIAN JOURNAL OF PSYCHIATRY, September, 2006 Vol.15, No.2.
Summary of Paper: This study aimed to assess the knowledge on basic sciences and clinical psychiatry (psychopathology and clinical syndromes) of the part I candidates on the mock MCQ paper.
Methodology and results:
The study is a descriptive and cross-sectional study and was carried out in a group of postgraduate students in psychiatry from Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM) and Faculty of Medicine, Universiti Malaya (UM) attending a series of revision course organized by the Department of Psychiatry, UKM. Revision course in psychiatry is an annual intensive course organized by the Department of Psychiatry, UKM to help young candidates preparing postgraduate psychiatry examination to refresh and consolidate their knowledge on basic sciences and clinical psychiatry. Candidates from various universities sitting for part 1 exam and completed their lectures and training in area of basic sciences are invited to attend this course which is held in The Department of Psychiatry, Hospital UKM.
A set of 40 item MCQ (a total of 200 statements) was randomly retrieved from a large MCQ mock examination question bank randomly, which consisted of a well balanced questions on neuroanatomy, neurophysiology, psychology, statistic and epidemiology, pharmacology, genetic, ethology, immunology and neuropathology. The mock MCQ was a modified version of the MRCPsych. examination MCQ paper which was repeatedly used by ongoing group of students participating in the revision course. 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 lecturer from the department of psychiatry, from year 2001 to 2004.
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All candidates participating in this revision course were informed that their answers in the MCQ paper would be graded, discussed and researched. All candidates had verbally given consent before they started answering the MCQ. Out of 17 candidates who attended this MCQ workshop during the above period and participated in this research, 11 candidates were from UKM, with the remaining from UM. No candidates from USM attended due to a short notice. All of them attempted all 40 questions given to them. The results of the study are shown in Table 1.………………………………………
Table 1. The profile of scoring marks in various domains of basic sciences in 17 candidates from UKM and UM. Forty MCQ items was asked. Each items scores minimum 0 and maximum 5 statement questions x 17 = 85 marks on 2nd last column from right. The last column scored individual percentage marks on each items.
Topic / areas Items number in Total Marks Percentage of MCQ exam paper (min.=0 ; max.= 85) scorings (%) 1 Neuroanatomy 1 45 53
2 40 47 3 45 53 5 40 47 Mean (SD)= A(B) ; Scoring marks = 50% 2 Neurophysiology 4 41 48 7 37 44
8 46 54
10 64 76
11 48 56 Mean (SD)= C(D) ; Scoring marks = 55.5% 3 Neurochemistry 6 35 41 9 42 49 Mean (SD)= E(F); Scoring marks = 45.3% 4 Neuropathology 12 32 38
13 25 29 Mean (SD)= G(H); Scoring marks = 33.5% 5 Psychology 14 36 42
15 41 48
16 43 51
17 36 42 18 37 44
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19 34 40 20 47 55
21 43 51 Mean (SD)=I(J) ; Scoring marks = 46.6%
6 Aetiology & 22 38 45 psychiatric genetics 23 39 46 Mean (SD) = K(L); Scoring marks = 45.3%
7 Stress & 24 30 35 immunology 25 35 41
Mean (SD)= M(N); Scoring marks = 37.6%
8 Psychopathology 26 24 28 27 30 35 28 29 34 29 45 53
Mean = 32 Scoring marks = 37.6%
9 Psychopharmacology 30 39 46 31 45 53
32 41 48 33 45 53
34 50 59 Mean (SD)= O(P); Scoring marks = 51.8%
10 Statistic 35 43 51
36 29 34 37 29 34 Mean (SD) = Q(R); Scoring marks = 39.6%
11 Epidemiology 38 42 49 39 34 40 40 35 41 Mean (SD) = S(T); Scoring marks = 43.5%
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QUESTIONS (Total marks: 20)
(MODEL ANSWER IS PROVIDED BELOW)
1. In this paper, basic statistical analysis was used to analyze the results of the mock MCQ examination conducted at the end of the Revision Course in UKM.
(a) Mean and standard deviation (SD) was used. Define mean and standard deviation of a given set of data? (2 marks) [ If x is the given value; X is the mean of the given values and N is the total samples/number of data, then SD = Σ [x –X]2/N]
(b) What types of descriptive statistics are they? (1 mark)
2. The researchers used the mean and SD to differentiate between the performance on each domains of basic sciences topic.
(a) Calculate the mean and SD for: (i) psychology, [I(J)] (ii) statistic, [Q(R)] and (iii) epidemiology [S(T)] (3 marks)
(b) Based on findings in 2(a), why is the value of SD for (i) Psychology less than for Statistics; and (ii) Epidemiology was very small? (2 marks)
3. Explain the meaning of confounding factors and give 1 example from this study? (2 marks)
4. Intervention was intended and a subsequent intensive revision course was attended by 10 postgraduate students while the rest (7 candidates) did self-learning. Out of 10 candidates attending revision course, 8 passed the final examination; whereas 7 candidates who did the self-learning, only 2 passed.
(a) Draw the 2 x 2 table (status of overall pass/fail outcome versus intervention for the postgraduate students). (2 marks)
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(b) Calculate the absolute benefit increase of revision course intervention over self- learning. Show your calculation. (2 marks)
(c) How many postgraduate students do you need to attend for a MCQ revision course in preventing one student from failing the exam? Show your calculation. (2 marks)
(e) Comment on the significance of the above result? (1 mark)
(f) Your junior colleague asked you to explain this statement:
“Two postgraduate students are needed to attend MCQ revision course in preventing one student from failing the exam, with 95% CI&: 1.8 – 4.5.” [confidence interval&]
He is asking you about the data and requested you to interpret the data to him. How are you going to explain to him? (3 marks) HS.29/01/2007.
MODEL ANSWER
1. (a) Mean = summation of total values or items divided by sample size, i.e. Mean = Σ [x1 + x2 + ….xn]/N
Standard deviation (SD) = standardized difference between the given values from the mean sample, in relation to the total sample size, ie. SD = Σ [x – X]2/N] (2 marks)
(b) Mean = measurement of central tendency; and SD = measurement of spread (or dispersion, or variation). (1 mark)
2. a) The mean and SD for:
(i) Psychology Data: 36,41,43,36,37,34,47 and 43; Total = 317 Mean = 317/8 = 39.6 Standard deviation = (36-39.6) 2 + (41-39.6) 2 + (43-39.6) 2 + (36-39.6) 2 + (37-39.6) 2 + (34-39.6) 2 + (47-39.6) 2 + (43-39.6)2/8 = 143.7/8 = 17.9 Mean (SD) for Psychology topic = 39.6 + 17.9
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(ii) Statistics Data: 43, 29 and 29; Total = 101. Mean = 101/3 = 33.7
Standard deviation = (43-33.7) 2 + (29-33.7) 2 + (29-33.7) 2/3 = 130.5/3 = 43.5 Mean (SD) for Statistics topic = 33.7 + 43.5
(iii) Epidemiology Data: 38,39 and 40; Total = 117. Mean = 117/3 = 39 Standard deviation = (38-39) 2 + (39-39) 2 + (40-39) 2/3 = 130.5/3 = 0.7 Mean (SD) for Epidemiology = 39 + 0.7 (3 marks)
(b) i. Sample size for Psychology is bigger than sample size for Statistics; ii Despite of the sample size for Epidemiology topic are small, the values are dispersed relatively close to the mean. (2 marks)
3. Confounding factors are other independent factors, which might account for any association. These could be risk or protective factor, e.g. past experiences in MCQ-style exam, how many times have he/she entering the exam, exposure of the exam-style before the revision course, effectiveness of teaching by the respective supervisors, etc. (2 marks)
4. (a) Draw the 2 x 2 table (status of overall pass/fail outcome versus intervention for the postgraduate students).
Status of Overall results MCQ results Pass Fail Total Interventions
Intensive revision course in 3 8 2 10 months time Self-learning 2 5 7
Total 10 7 17
(2 marks)
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(b) Absolute benefit increase (ABI) is a difference between the experimental event rate (EER) and control event rate (CER).
Passing rate for intensive revision course group, EER = 8/10 = 0.8 Passing rate for self-learning group, CER = 2/7 ≈ 0.3 ABI = EER – CER = 0.8 – 0.3 = 0.5. (2 marks)
(c) Numbers of postgraduate students that needed to attend for a MCQ revision course in preventing one student from failing the exam is based on the concept of numbers needed to treat, NNT; and NNT is a reciprocal of ABI.
NNT = 1/ABI = 1/0.5 = 2. (2 marks)
(d) Two students are needed to attend the MCQ revision course to prevent one student from failing the exam (2 marks)
(e) This result, NNT = 2 is significant, because it is < 10. The revision course was effective. (1 mark)
(f) “Two” students are needed to participate in the MCQ revision course in reventing one student from failing the exam, and I if I’m going to repeat this study 100 times, I’m 95 times confidence that the value of the NNT (i.e. 2 students) would ranged from 1.8 to 4.5, and the findings are statistically significant.” (3 marks) HS.29/01/2007.
Correspondence: Dr. Hatta Sidi, Professor and Senior Consultant Psychiatrist, Department of Psychiatry UKMMC, 56000 Cheras, Kuala Lumpur
Email: [email protected]
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