The objectives of this study were to determine the risk factors and life stressors that are prevalent among the acetaminophen deliberate self-poisoning (DSP) cases, to identify gender differences in the associated factors, and to determine the prevalence of psychiatric diagnosis and the patterns and types of psychotherapeutic interventions provided by psychiatrists.
OBJECTIVES: Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes.
METHODS: The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41 (85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness.
RESULTS: ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy.
SCOPE OF THE PROBLEM: The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses.
INTERVENTIONS: It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions.
CONCLUSIONS: Adherence problems are complex and multidetermined. The experts recommended customized interventions focused on the underlying causes.
Instruments to measure mental health and well-being are largely developed and often used within Western populations and this compromises their validity in other cultures. A previous qualitative study in Singapore demonstrated the relevance of spiritual and religious practices to mental health, a dimension currently not included in exiting multi-dimensional measures. The objective of this study was to develop a self-administered measure that covers all key and culturally appropriate domains of mental health, which can be applied to compare levels of mental health across different age, gender and ethnic groups. We present the item reduction and validation of the Positive Mental Health (PMH) instrument in a community-based adult sample in Singapore.
Woodbrige Hospital had 2,257 patients in 1975. Of these 75 percent were suffering from Schizophrenia. This pattern was similar to that of developing countries like Padistan and Malaya. A study was carried out on all new admissions in 1975. There were 1,068 patients whose age ranged from 10 to 89. Schizophrenia which constituted 62% of the cases was analysed in detail. They were mainly in the age range 10-29 (64%). The sex ratio was 3 males to 2 females. Their distribution by their type of housing was similar to that of the general populations. They were better educated. The most common presentation were reports of aggressive, violent, disturbed, abnormal or withdrawn behaviour. The 10 most common symptoms were paranoid ideas, hearing of voices, talking to oneself, insomnia, aggression, abnormal behaviour, laughing to oneself, disturbed behaviour, crying to oneself and withdrawn behaviour. The most common drugs used were trifluoperazine (47%) and chlorpromazine (45%). Electroconvulsive therapy was given to 25% of the patients. Most of the patients (63%) stayed less than 20 days.
A major challenge in the refugee field is to ensure that scarce mental health resources are directed to those in greatest need. Based on data from an epidemiological survey of 959 adult Rohingya refugees in Malaysia (response rate: 83%), we examine whether a brief screening instrument of functional impairment, the WHO Disability Assessment Schedule (WHODAS), prove useful as a proxy measure to identify refugees who typically attend community mental health services. Based on estimates of mental disorder requiring interventions from analyses of epidemiological studies conducted worldwide, we selected a WHODAS cutoff that identified the top one-fifth of refugees according to severity of functional impairment, the remainder being distributed to moderate and lower impairment groupings, respectively. Compared to the lower impairment grouping, the severe impairment category comprised more boat arrivals (AOR: 5.96 [95% CI 1.34-26.43); stateless persons (A20·11 [95% CI 7.14-10); those with high exposure to pre-migration traumas (AOR: 4.76 [95% CI 1.64-13.73), peri-migration stressors (AOR: 1.26 [95% CI 1.14-1.39]) and postmigration living difficulties (AOR: 1.43 [95% CI 1.32-1.55); persons with single (AOR: 7.48 [95% CI 4.25-13.17]) and comorbid (AOR: 13.54 [95% CI 6.22-29.45]) common mental disorders; and those reporting poorer general health (AOR: 2.23 [95% CI 1-5.02]). In addition, half of the severe impairment grouping (50.6%) expressed suicidal ideas compared to one in six (16.2 percent) of the lower impairment grouping (OR: 2.39 [95% CI 1.94-2.93]). Differences between the severe and moderate impairment groups were similar but less extreme. In settings where large-scale epidemiological studies are not feasible, the WHODAS may serve as readily administered and brief public health screening tool that assists in stratifying the population according to urgency of mental health needs.
Alzheimer's disease (AD) has become recognised as a major cause of morbidity and mortality in the ageing population worldwide. Over 20 million people worldwide are affected by AD, which ensures that the disease imposes a major economic burden. Alzheimer's disease is a progressive neurodegenerative disorder with characteristic clinical and neuropathological features. Neurofibrillary tangles, neuritic plaques and amyloid angiopathy occur in varying severity in brains of patient's with Alzheimer's disease. Biological markers of AD allowing an early definitive premorbid diagnoses are currently not available. Memory loss for recent events is invariable and often the earliest prominent symptom. Language disorders, difficulties with complex tasks, depression, psychotic symptoms and behavioral changes are other common manifestations of AD. Diagnosis involves the early detection of cognitive decline and ruling out other causes of dementia like vascular dementia, Lewy body dementia, fronto-temporal degeneration or reversible causes like hypothyroidism. Acetylcholinesterase inhibitors have shown to be effective in mild to moderate AD in improving the cognitive function of patients in clinical trials. Caregiver intervention programs have considerable potential to improve both the caregiver and patient quality of life.
A rare case of complex partial seizure (psychomotor epilepsy) with varying shades of psychiatric manifestations is presented. The highlights are multiplicity of its manifestation in the same case, its interchanging pattern and the variable durations. This gray area of psychiatry and neurology is discussed with special reference to diagnosis and management.
INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) has dramatically affected global healthcare systems. We aimed to determine the response of our paediatric surgical fraternity to a disease that overwhelmingly affects adults.
MATERIALS AND METHODS: We conducted a cross-sectional questionnaire-based study over 6 weeks during a federally mandated lockdown. Using snowball sampling, we recruited paediatric surgeons, trainees and medical officers from paediatric surgical units in Malaysia. The anonymous online questionnaire covered sociodemographic information, changes in patient care, redeployment, concerns regarding family members, and impact on training. Mental well-being was assessed using the Depression, Anxiety and Stress Scale (DASS-21). Kruskal-Wallis, ANOVA and multiple regression analysis was used, with significance level 0.05.
RESULTS: Of the 129 eligible participants, 100(77%) responded. Junior doctors had clinically higher levels of depression, anxiety, and stress. Age <30 years was significantly associated with anxiety. Junior doctors believed that redeployment led to loss of surgical skills (p<0.001) and trainees felt that clinical application of knowledge had reduced (p<0.020).
CONCLUSION: Specific to our paediatric surgical community, this study highlights areas of concern, particularly among junior doctors. It is likely that recurrent cycles of the pandemic will occur soon. These issues must be addressed to preserve the mental and emotional well-being of all health care workers.
Although family violence perpetrated by juveniles has been acknowledged as a potentially serious form of violence for over 30years, scientific studies have been limited to examining the incidence and form of home violence. The present study examined the prevalence of family aggression as perpetrated by youths; we examined groups drawn from clinic-referred and forensic samples. Two audits of case files were conducted to systematically document aggression perpetrated by referred youths toward their family members. The purpose of the first audit was fourfold: i) to identify the incidence of the perpetration of family aggression among clinical and forensic samples; ii) to identify whether there were any reports of weapon use during aggressive episodes; iii) to identify the target of family aggression (parents or siblings); and iv) to identify the form of aggression perpetrated (verbal or physical). The second audit aimed to replicate the findings and to show that the results were not due to differences in multiple deprivation indices, clinical diagnosis of disruptive behavior disorders, and placement into alternative care. A sampling strategy was designed to audit the case notes of 25 recent forensic Child and Adolescent Mental Health Service (CAMHS) cases and 25 demographically similar clinic-referred CAMHS cases in the first audit; and 35 forensic cases and 35 demographically similar clinic-referred CAMHS cases in the second audit. Using ordinal chi-square, the forensic sample (audit 1=64%; audit 2=82.9%) had greater instances of family violence than the clinical sample (audit 1=32%; audit 2=28.6%). They were more likely to use a weapon (audit 1=69%; audit 2=65.5%) compared to the clinical sample (audit 1 and 2=0%). Examining only the aggressive groups, there was more perpetration of aggression toward parents (audit 1, forensic=92%, clinical=75%; audit 2, forensic=55.17%, clinical=40%) than toward siblings (audit 1, forensic=43%, clinical=50%; audit 2, forensic=27.58%, clinical=30%). Based on these findings, we would urge professionals who work within the child mental health, particularly the forensic area, to systematically collect reports of aggression perpetrated toward family members.
In a prospective study of fifty consecutive outpatients (30 men and 20 women) attending the Behaviour Therapy Clinic at a general hospital, the commonest conditions were obsessive compulsive disorders (n = 16), phobic disorders (n = 11) and generalised anxiety disorders (n = 9). Three-quarters of the referrals were from psychiatrists and family physicians. The patients received between 2 to 10 sessions of behaviour treatment; most had 4 to 6 sessions with a mean of 4.7, SD 1.82. The commonest behavioural techniques administered were exposure therapy with response prevention and relaxation therapy. Initially, treatment was therapist-aided, but subsequently self-help was encouraged with regular reviews of the patient's homework. After one month, 42 patients (84%) were assessed to have improved somewhat, with 20 (40%) showing moderate improvement. After three months, 41 (82%) continued to improve, with 33 (66%) showing moderate to great improvement. Nine patients were considered to have failed in therapy-six defaulted and three were non-responders. The reasons for defaulting treatment were unwillingness to bear with the discomfort involved in exposure therapy, lack of motivation or returning to own hometown in Malaysia. Sixteen patients (n = 32%) were treated solely with behavioural techniques while the rest had a combination of behaviour therapy and drugs, especially anxiolytics and antidepressants. However, at the end of treatment, the dosages of most medications were reduced or else discontinued completely.
Study site: Behavior therapy clinic at a general hospital
OBJECTIVE: Translation of developmental-behavioral screening tools for use worldwide can be daunting. We summarize issues in translating these tools. METHODS: Instead of a theoretical framework of "equivalence" by Pena and International Test Commission guidelines, we decided upon a practical approach used by the American Association of Orthopedic Surgeons (AAOS). We derived vignettes from the Parents' Evaluation of Developmental Status manual and published literature and mapped them to AAOS. RESULTS: We found that a systematic approach to planning and translating developmental-behavioral screeners is essential to ensure "equivalence" and encourage wide consultation with experts. CONCLUSION: Our narrative highlights how translations can result in many challenges and needed revisions to achieve "equivalence" such that the items remain consistent, valid, and meaningful in the new language for use in different cultures. Information sharing across the community of researchers is encouraged. This narrative may be helpful to novice researchers.
The unprecedented inclusion of culture-bound syndromes in DSM-IV provides the opportunity for highlighting the need to study such syndromes and the occasion for developing a research agenda to study them. The growing ethnic and cultural diversity of the U.S. population presents a challenge to the mental health field to develop truly cross-cultural approaches to mental health research and services. In this article, the authors provide a critique of previous analyses of the relationship between culture-bound syndromes and psychiatric diagnoses. They highlight the problems in previous classificatory exercises, which tend to focus on subsuming the culture-bound syndromes into psychiatric categories and fail to fully investigate these syndromes on their own terms. A detailed research program based on four key questions is presented both to understand culture-bound syndromes within their cultural context and to analyze the relationship between these syndromes and psychiatric disorders. Results of over a decade of research on ataques de nervios, a Latino-Caribbean cultural syndrome, are used to illustrate this research program. The four questions focus on the nature of the phenomenon, the social-cultural location of sufferers, the relationship of culture-bound syndromes to psychiatric disorders, and the social and psychiatric history of the syndrome in the life course of the sufferer.
Mental illnesses and mental health have, out of ignorance and fear, evoked a low priority in healthcare systems the world over. The concept that all mental illnesses were synonymous with madness has its origins in the beginnings of ignorance and fear. To a large extent, these have contributed to the marginalization of psychiatry and neglect of the mentally ill. The kings of old, seeing the ill-treatment of the mentally ill, built asylums for them, but again, the prejudice soon was overwhelming and care of the mentally ill was often given to those who were not the best administrators and carers. The long and controversial tradition of mental asylum care for the mentally ill was also brought about by the lack of specific treatments for mental illnesses. With the advent of chlorpromazine in the 1950s and other psychotropics afterwards, the need for incarceration in asylums became largely redundant. However, what also became obvious soon after was the fact that the psychotropics only helped to control symptoms and not to cure diseases of the mind. Although considerable research has gone into attempts at correcting supposed defects in neurotransmission, the cure of mental illness seems some way off. The need for rehabilitating or re-housing those with mental illnesses especially those needing long-term care and those whose cure seems difficult has been recognized for a long time. It was Phillipe Pinel who almost 200 years ago unchained the mental patients at an asylum in Paris and proposed work therapy and humane care. Psychosocial rehabilitation of the mentally ill is not, therefore, a new concept. The need for methods of changing the behavior, thinking and functioning of those with severe mental illnesses using psychological, social, occupational, behavioral and medical methods is called psychosocial rehabilitation. This method, although developed in stages over the past two centuries, has undergone changes and deterioration and development in different parts of the world with different priorities and emphasis.
An important risk factor for suicide assessment is the suicide precipitant. This study explores suicide attempt precipitants across the lifespan. Three years of medical records related to suicide attempters who were admitted to the emergency department of a large teaching hospital in Singapore were subjected to analysis. These cases were divided into three age groups: Adolescence, Early Adulthood, and Middle Adulthood. A total of 540 cases were examined (70.9% females; 63.7% Chinese, 13.7% Malays, 15.9% Indians), whose ages ranged from 12 to 62. There were eight cases above the age of 65 years which were excluded from the analysis. Significant differences were found in precipitants for suicide attempts across the lifespan. Middle adults had relatively fewer relationship problems, and adolescents had comparatively fewer financial and medical problems. The models to predict medically severe attempts across the age groups using suicide precipitants were not significant. The findings were discussed in regards to implications in suicide assessment and primary prevention in Singapore, as well as limitations and recommendations for future research.
During a psychiatric survey in Sarawak, subjects demonstrating latah were examined separately, both clinically and with a questionnaire. Latah occurred only in females, mainly Malays, occasionally Ibans, and never Chinese. Fifty latah subjects were examined, seven were firmly diagnosed as being mentally ill, and another 13 demonstrated mild psychiatric disorders. Dream content indicated an overt sexual component
In an attempt to discover how the phenomenon of amok is viewed within its indigenous culture, the authors studied and interviewed 21 subjects in West Malaysia who were labeled as amok. This investigation showed that both the subjects and the Malay culture view amok as psychopathology, that amok cases are disposed of in line with this view, and that the behavior of the amok person conforms to social expectations of the phenomenon. Despite cultural proscriptions, however, the act is purposive and motivated and is subtly sanctioned by Malay society.
Recent Australian Government initiatives have emphasised problems with service provision to the ethnic mentally ill. This study aims to address the paucity of contemporary data describing the disposition of the ethnic mentally ill in hospital settings.