Dec 2008 Vol. 17 No. 2 CONTENTS - repository.um.edu.myrepository.um.edu.my/71755/1/MJP December 2008...

Dec 2008 Vol. 17 No. 2

CONTENTS

Editorial Amphetamine Type Stimulant (ATS) Induced Psychosis: A Rising Problems in Malaysia. 3-6

Ahmad Hatim S Original Paper Validation of the Bahasa Malaysia Version of the Coping Inventory for Stressful Situation.

7-16 Ramli M Mohd Ariff F Khalid Y Rosnani S

Social Anxiety Problem among Medical Students in Universiti Malaya Medical Center (UMMC) – A Cross-sectional Study.

17-22 Salina M Ng CG Gill JS Chin JM Chin CJ Yap WF

Student Learning Disability Experiences, Training and Services Needs of Secondary School Teachers.

23-36 Teoh HJ Cheong SK Woo PJ

Prevalence Of Obesity, Lipid and Glucose Abnormalities in Outpatients Prescribed Clozapine in University Malaya Medical Center, Kuala Lumpur.

37-46 Sharmilla T Ahmad Hatim S Jambunathan ST

Impact of Psychiatry Training on Attitudes of Undergraduate Medical Students.

47-54 Chandrasekaran R Srikumar P. S Joshua E Rasamy G

Cross-Cultural Adaptation and Validation of the Bahasa Malaysia Version of the Eating Disorder Examination Questionnaire (Ede-Q).

55-63 Ramli M Jamaiyah H Noor Azimah M Khairani O Adam B

The Prevalence of Depressive Symptoms and Potential Risk Factors That May Cause Depression among Adult Women in Selangor.

64-72 Sherina MS Rampal L Azhar MZ

MJP December 2008 Vol.17 No.2

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Review Paper Heroin Addiction: The Past and Future

73-78 Noor Zurani MHR Hussain H Rusdi AR Muhammad Muhsin AZ

Is There a Need for a Hospital Based Smoking Cessation Programme in Malaysia?

79-82 Noor Zurani MHR Mohammad Hussain H

Case Report Post Stroke Laughter – A Case Report. 83-87 Amarpreet Kaur Nor Zuraida Z Ng CG Aida SA

Book Review: Antiepileptic Drugs to Treat Psychiatric Disorders 88-90 Edited by Susan L. McElroy Paul E. Keck, Jr. and Robert M. Post Education Paper Are Our Postgraduate Candidates Having Knowledge Problems in Basic Sciences? – An Experience with Mock Multiple Choice Questions (MCQ). 91-97 Hatta Sidi Fairuz Nazri AR


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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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mailto:[email protected]

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 thoughts that people adopt to overcome the internal and external demands posed by a stressful encounter. The coping

mechanisms are determined by the types of personality of individuals other or apart from environmental factors. The effectiveness depends on the approach


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the individual takes. Coping can be divided into two dimensions: problem-focused coping, which addresses the stressful situation, and emotion-focused coping, which deals with the feelings and reactions to the stressful event [1]. Problem-focused coping refers to task orientation i.e. Strategies used to solve a problem, reconceptualise it or minimize its effects. Emotion-focused coping strategies refer to person orientation which basically includes emotional responses, self-preoccupation and fantasizing reactions [2]. In uncontrollable situation, emotional-focus coping style is effective in reducing stress. Problem-focused coping has been found to decrease emotional distress and is negatively related to depression, whereas emotion-focused coping increases emotional distress and is positively related to depression. In the long term, problem-focus or task-oriented coping style is most practical way reducing stress [3]. Recent tremendous increase in awareness and number of studies focused on the aspect of coping style related to personalities and other stressful situations triggered the initiative to translate and validate a questionnaire that can be used to Malaysian population. Various questionnaires are designed to measure coping styles such as adolescent coping scale [4], coping responses inventory [5], coping operations preference enquiry [6], ways of coping questionnaire [7], coping skills inventory [8] and coping inventory for stressful situations [9]. Apart from that we also have coping questionnaire related to certain condition; depression coping questionnaire [10] and pain coping questionnaire [11].

The CISS is a self-rated questionnaire and has multidimensionality in exploring coping styles [12]. The CISS 48-item has a great precision in predicting various types of coping mechanism. It has two versions; adult and adolescent. For both versions, they are able to classify coping styles into task-oriented (16 items), emotional-oriented (16 items) and avoidance-oriented (16 items). For avoidance, it can be further subdivided into 2 subscales; distraction (8 items) and social diversion (5 items) [9]. In this study the authors will focus on the effort of translating the CISS 48-item into Bahasa Malaysia (BM) and eventually to validate this version. Objectives The main objective of this study is to produce an acceptable CISS Bahasa Malaysia version through a sound translation process. The second main objective is to determine the validity of this version by looking at its confirmatory factor analysis among Malaysian population. Materials and Methods: Study Design This is a multi-center cross sectional study. This study had been reviewed and fully approved by the internal review board of University of Technology MARA. Special permissions from the original author of CISS (James D.A. Paker) and the authorized company (multi-health systems inc) were also acquired before commencement of this study. Informed consents of the participants were obtained after the nature of the procedure was fully explained.


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Translation Process of CISS Based on us census bureau guideline of translation, 2 forward and 2 back translations were done in parallel by medical and language experts. Two language experts would ensure the translated version would be grammatically and terminologically correct. The medical experts were to secure the meanings and contents of original CISS would be preserved. The two forward and back translations then had been reconciled and sentence-by-sentence revision was done with the help of two language experts from the academy of language studies University of Technology MARA (UITM). Good translations were reflected by production of 2 English backtranslations which almost similar to original English version. At the end of this process we produced a harmonized version of BM CISS before we proceed for pre-test. Harmonized BM version was tested to a small group of medical students before the authors embarked on real major validation study. Pre-test was done on 6 respondents with good background for both languages, English and Bahasa Malaysia. The objective of pre-test was to identify any flaws in the harmonized version which might affect the comprehension of the subjects during the actual field study. At the end of pre-test, we produced finalized BM version of CISS which then was used for real validation process. Validation Study The finalized BM version was tested for its reliability and validity among

Malaysian population from different backgrounds. Reliability in this study was determined by its internal consistency by looking at Cronbach’s alpha values and confirmatory factor analysis was used to ensure the validity of this BM-CISS by having acceptable factor loadings (>0.4). Selection of Respondents Study population of this study was the Malaysian general population with age range between 19 to 60 years. The age range was in tandem with a recommendation in CISS manual book for adult [9]. The subjects were selected from 3 government clinics in Klang Valley; Poliklinik Seksyen 7 Shah Alam, Poliklinik Tanglin and City Hall Clinic Kuala Lumpur. Permission was also obtained from relevant authorities. Patients who came to these clinics were from different backgrounds and ethnicity. After participants were briefed about this study they were given demographic and consent forms. Heterogeneous participants were taken care of in the aspects of age, gender, race and socio-economic class. Simple random sampling was done by taking every third patient registered at the clinic counter a total of 200 subjects with various age groups, ethnicity and socio-economic backgrounds were selected in this study. Composition of ethnic groups was tried to reflect the actual Malaysian population. Based on Malaysian statistic department, Malaysian population consists of Malays (54.1%), Chinese (25%), Indians (7.5%) and from other races (13.2%) [13].

Questionnaires 1) Demographic questionnaire -


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age, gender, ethnicity, level of education and types of occupation. 2) Finalized BM version of CISS. CISS is a self-rated questionnaire and it shall take at the most 15 minutes to complete. Steps Taken to Ensure the Accuracy of Responses During the course of BM CISS questionnaire administration, the subjects were left without any interference especially from facilitators of the project. If subjects raise any queries about the terminology, they should be explained as minimal as possible to maintain the objective of this study and it should be recorded. Inclusion and Exclusion Criteria 1) Inclusion criteria:jjjjjjjjjjjjjjjjj a) The age of the subjects was between 19 to 60 year.s…………. b) They must be proficient in Bahasa Malaysia. 2) Exclusion criteria: a) Subjects with learning disabilities and cognitive impairments. b) Subjects who were unable or refuse to give informed consent. c) Subjects who were illiterate and not proficient in BM and failed a short BM fluency test. BM Language Fluency Test. In this study a simple BM language

fluency test was administered and integrated at the end of the questionnaire form in order to have a reliable assessment about their language competency, it involved building up a short sentence based on 3 words. This test required good grammar and wide knowledge of BM vocabulary and grammar in order to create a good sentence. The subjects were considered passed this test if they were able to construct a good BM sentence based on 3 words given. Results Demographic analysis of the subjects showed that there was fairly equal diversity in the aspects of age, gender, educational and occupational status. The mean age of these subjects was with gender composition of 51% males and 49% females. Although the CISS is not recommended be used among people with only primary education, in this sample of population there was 7% of them came from this group and majority of them (63.3%) obtained secondary school as their highest level of education. Chinese (11%) was obviously underrepresented in this study as compared to actual Malaysian population (25%) [13]. Reliabilities of the CISS Bahasa Malaysia Version. The reliabilities (internal consistencies) of BM CISS were determined by looking at Cronbach’s alpha values. The overall Cronbach’s alpha value for all items was very good .91 (ci 95%). Furthermore, the BM version had very good Cronbach’s alpha values for all its 3 scales, .91, .89 and .85 respectively for task-, emotional- and avoidance-oriented. Task-oriented


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had among the best value with mean score .67 and standard deviation .11. Validity Test The construct validity was evaluated by using confirmatory factor analysis (CFA). Table-1 shows factor loadings for CFA of each BM CISS item by using varimax rotation. This table proves that BM CISS managed to delineate its items into 3 main entities (task-oriented, emotional-oriented and avoidance-oriented). Factor loadings of 0.4 or more were considered good. Among all 3 scales in CISS, task-oriented generally had the best value of CFA of all of its items. The lowest CFA value in this scale was item 1 “schedule time” (.41).

From all 48 items in CISS, four items had factor loadings less than .40. Among all items, item 28 (“wish that I could change what had happened or how I felt”) and 35 (“talk to someone whose advice I value”) had the poorest factor loading (.22 and .24 respectively). These items didn’t cross culturally sensitive to gauge emotional- and avoidance-oriented but rather had high factor loading for task-oriented; .51 and .60 respectively for item 28 and 35. Correlations (Spearman’s) between scales gathered from this study were between .20 to .35. Internal correlation between distraction and social diversion 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 Malaysia is a well known multi-racial country. Its population is composed of 3 major ethnic groups. According to Malaysian Statistic Department (2005) 54.1% were Malays, 25% were Chinese and 7.5% were Indians. Although much emphasis paid on the aspect of randomization in the selection of the subjects, this study had a limitation in its study population. Study population in this project didn’t reflect the actual Malaysian population. Chinese was underpresented as only 11% of this ethnic contributed to a total population as compared to 25% actual percentage [13]. The lack of Chinese percentage was replaced by Malays where Malay in this study was over presented (78%). Indians were roughly corresponded to actual percentage. Other aspect paid to ensure equal distribution of ethnic in the study population was the selection of participated clinics. The attendees of 3 selected clinics were good mixture of all ethnicities and represented the Malaysian population. There were a few explanations to this discrepancy. Randomization in the subjects selection managed to draw fairly good sample population according to ethnicity, however non-cooperation and refused to give consent had hindered the effort. We found there was quite substantial number of Chinese selected during randomization refused to give cooperation to participate in this study. There were about 20 Chinese subjects or if we translate into percentage, it was about 10% refused to give their consents. The number of Chinese who turned down their participations was replaced with other races during

randomization. The similar finding was also found in other studies in the past [14]. Internal consistency of new BM version of the CISS found in this study was quite comparable to the original English version. Original author recorded that internal consistencies for Task scale was between .87 to .92. Emotional scale .82 to .90 and Avoidance .85 to .76 [9]. These figures are quite similar to figures obtained in this study (.91, .89 and .85 respectively for Task-, Emotional- and Avoidance-oriented). We could also see a downward pattern of Cronbach’s alpha from Task-, Emotional- and Avoidance-oriented. The overall Cronbach’s alpha of all items in this study was .91. Generally most of items in the BM version of CISS 48-item were having good confirmatory factor analysis values except 2 items (28, 35) which may need to reexamine. The CFA of these items were not very bad but can be further improved either by altering the structure of the sentence or replacement. These items were not culturally bound to any specific ethnic groups. Possible explanation as to why it had poor CFA is Emotional- and Avoidance-oriented are mainly incline towards maladaptive coping style, whereas Task-oriented is adaptive [15]. Further analyzing of the items; item 28 “Wish that I could change what had happened or how I felt” or “Berharap agar saya dapat mengubah keadaan atau perasaan saya” and item 35 “Talk to someone whose advice I value” “Berbincang dengan seseorang yang pandangannya saya hargai” although these items were measuring emotional and avoidance but they are adaptive in nature. Comparing with the English version, there are a few


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similarities found in this study. First, in general Task-oriented had better CFA values as compared to other scales. Secondly among all items in Task-oriented, item 1 was the poorest item in this scale. Thirdly, item 35 was not stable both in the English version (from the manual) as well as the BM version in this study. It generated the lowest value when administered among undergraduate and general adults, and it shifted to task-oriented among psychiatric patients. Finally looking of pattern analysis of CFA by using Varimax rotation, the result of this study was more incline towards 3-factor solution as found in a few studies [9, 16, 17]. Authors identified a few items in Avoidance scale such as “Go for a party” or “See a movie” were expected to have low because it rather culturally bound. Not many Malaysian would go for a party or theater to watch movie in their daily activity as part of stress compensation mechanism. This item “go for party” had been extended and broadened the scope in its translation where the authors added to “religious gathering” (majlis keramaian) which was culturally significant. Due to this reason, both items yielded good CFA values. Correlations (intercorelation) between scales gathered from this study were between .20 to .35 as displayed in figure 1. These figures correspond with figures recorded in the CISS manual book .0 to 0.4. The low correlation between 3 scales implies that the 3 scales stand as different entities. There was moderate correlation between 2 subscales in Avoidance. The correlation between Distraction and Social Diversion

subscales was .44 which indicates that there is a moderate correlation. The present study provides a preliminary milestone for further establishment of this BM version. Future study need to look at the correlation and comparison with other coping questionnaire such as Coping Operations Preference Enquiry (COPE) which has been translated and used by various institutions [18,19]. The authors concluded that this version is adaptable to the Malaysian population but further study is needed and a few may need replacement of 2 poorest CFA which are item 28 and item 35. Acknowledgement We would like to express our gratitude and thanks to all subjects who had participated in this study for their kind consent. References 1. Latack JC, Kinicki AJ, Prussia GE. An integrative process model of coping with job loss. Academy of Management Review, 1995; 20:311-342. 2. Mitchell RE, Cronkite RC, Moos RH. Stress, coping, and depression among married couples. Journal of Abnormal Psychology, 1983; 92:119–133. 3. Endler NS. Stress, anviety and coping: The Multidimentional Interaction Model. Canadian Psychology, 1997; 38:136-153. 4. Frydenberg E, Lewis R. A replication study of the structure of the Adolescent Coping Scale: Multiple forms and applications of a self-report


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inventory in a counseling and research context. European Journal of Psychological Assessment, 1996; 12:224-235, 5. Moos, Rudolf H. Development and applications of new measures of life stressors, social resources, and coping responses. European Journal of Psychological Assessment, 1995; 11:1-13. 6. Schutz WC. Reliability, Ambiguity and Content Analysis. Psychological Review. 1952; 59:119-129. 7. Folkman S, Lazarus RS. Manual for the Ways of Coping Questionnaire. Palo Alto, CA Consulting Psychologist Press, 1988. 8. Jerabek I. Coping Skills Inventory. Plumeus Inc. 1996. http://www.psychtests.com/tests/career/coping_skills.html 9. Endler NS, Parker JDA. Coping Inventory for Stressful Situations (CISS): Manual (2nd ed.). Toronto, Canada: Multi-Health Systems. 1990. 10. Kleinke CL, Staneski RA, Mason JK. Depression Coping Questionnaire Journal of Clinical Psychology, 1982;44:516 – 526. 11. Reid GJ, Chambers CT, McGrath PJ, Finley GA. Coping with pain and surgery: Children's and parents' perspectives. International Journal of Behavioral Medicine. 1997; 4:339-363. 12. Endler NS, Parker JDA. The multidimensional assessment of coping:

A critical evaluation. Journal of Personality and Social Psychology, 1990b; 58:844-854. 13. Department of Statistics, State/District Data Bank, Malaysia; 2005. 14. Ramli M, Ariff MF, Zaini Z. Translation, validation and psychometric properties of Bahasa Malaysia version of the Depression Anxiety and Stress Scales (DASS). ASEAN Journal of Psychiatry, 2007; 8:82-89. 15. McWilliams LA, Cox BJ, & Enns MW. Use of the Coping Inventory for stressful situations in a clinically depressed sample: Factor structure, personality correlates, and prediction of distress. Journal of Clinical Psychology, 2003:59:423-437. 16. Furukawa T, Suzuki-Moor A, Saito Y, Hamanaka T. Reliability and validity of the Japanese version of the Coping Inventory for Stressful Situations (CISS): A contribution to the cross-cultural studies of coping. Seishin Shinkeigaku Zasshi, 1993; 95:602-620. 17. Cosway R, Endler NS, Sadler AJ, Deary IJ. The Coping Inventory for Stressful Situations: Factorial structure and association with personality traits and psychological health. Journal of Applied Biobehavioral Research, 2000; 5:121-143. 18. Zaidah A, Khairani O, Normah CD. Coping styles of Mother with disable Children at rural community rehabilitation centre in Muar, Malaysia. Medical Journal of Malaysia, 2004; 59:384-390.


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http://www.psychtests.com/tests/career/coping_skills.html

http://www.psychtests.com/tests/career/coping_skills.html

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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mailto:[email protected]

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 Studies conducted in the USA and Europe support the view that social anxiety disorder (social phobia) ranks among the most prevalent of the anxiety disorders in the general population (1). The National Co-morbidity Survey provides prevalence estimates of 12-month and lifetime DSM-IV social anxiety disorder as 7.1% and 12.1%, respectively, with higher prevalence in

females (2,3). Studies in other western nations (eg, Australia, Canada, Sweden) note similar prevalence rates as in the USA, as do those in culturally westernised nations such as Israel (4). Even countries with strikingly different cultures for example; Iran (5) note evidence of social anxiety disorder in their population. Social anxiety disorder has an early age of onset. It usually starts in childhood or


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early adolescence (6), where 50% begins by the age of 11 years old and by the age of 20 years old in about 80% of individuals (7). It has significant impact on the individual’s functioning such as reduced workplace productivity, increased financial costs, and reduced health-related quality of life (8) with negative impact on career progression (1). Social anxiety disorder can have negative impact on any profession including the medical profession. There are several studies being done in the West and other Eastern countries regarding social anxiety disorder in medical students (9), and it appeared that female students (10) and those without partners (11) had a higher risk of having social anxiety disorder. This study is conducted to look at the probability of having social anxiety disorder in medical students and the associated factors in developing social anxiety disorder. Method This is a cross sectional study involving University Malaya final year medical students. A self-administered questionnaire was given to the students who were willing to participate in the study. The medical students were approached after class in the clinical auditorium and the 167 medical students present were given the Social Phobia Inventory (SPIN). Additional variables such as gender, religion, number of sibling, having partner or not and type of school were included to assess whether these can be associated with developing social anxiety disorder.

Social Phobia Inventory (SPIN) is a 17 item self administered questionnaire with good sensitivity (73%) and specificity (84%) for social anxiety disorder where a SPIN score of > 19 distinguished subjects with and without social phobia, and good efficiency with diagnostic accuracy of 79% (12). Furthermore it has positive predictive value (PPV) of 81% and negative predictive value (NPV) of 77% (12). The results were analysed using of the Statistical Package for the Social Sciences (SPSS) version 13.0. Results Out of the 167 medical students, 101 of them filled the questionnaire. Table 1 shows the characteristics of the medical students involved in this study. There were more female respondents as compared to the male respondents, 74 students and 27 students respectively. There were 101 respondents; among them 2 did not answer the type of school question and 4 did not answer the question on religion. Overall, 56% of the medical students scored 19 or above in the Social Phobia Inventory indicating that they have a higher probability of possessing a diagnosis social anxiety disorder. The students whose SPIN score were more than 19 were offered further assessment to confirm the diagnosis by going to the psychiatric clinic and if need be treatment. After analyses, none of the variables (gender, type of school, partner status, religion and number of siblings) when tested against their score of >19 were significant. The results are summarized in Table 1.


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Table 1 – Characteristics of the medical students predicting social anxiety problem

Characteristic n(%) SPIN score > 19 (%)

Χ 2 Odds ratio (95% CI) P value

Sex Male Female

27 73

26 74

0.12

1.05 (0.43-2.55)

0.91*

Partner status With Without

34 66

30 70

1.10

0.68 (0.29-1.55)

0.35*

Type of school Mixed school Not mixed school

93 6

93 7

0.86

0.66 (0.12-3.80)

0.64*

Religion Muslim Non Muslim

46 54

50 50

0.22

0.65 (0.29-1.45)

0.29*

Number of sibling Only child Has siblings

19 81

16 84

0.78

1.57 (0.58-4.27)

0.38*

* P > 0.05 SPIN = Social Phobia Inventory CI = Confident Interval N (Number of medical students) = 101

Discussion In this study, 56% of the medical students screened scored above 19 in the Social Phobia Inventory (SPIN) suggesting that more than half of the medical students probably have a diagnosis of social anxiety problem. A similar study that was done previously, using Liebowitz Social Anxiety Scale (LSAS) found 4% of the students was diagnosed with social anxiety disorder with 85% showed some symptoms of avoiding behavior and 56% experienced somatic symptoms of social anxiety (9). This study also found that gender, number of siblings, type of school, religion or partner status was not significantly associated with the social anxiety symptoms the students had.

However, in the US Epidemiologic Catchment Area (ECA) study, the rates of social phobia were highest among women, persons who were younger (age, 18 to 29 years), less educated, single, and of lower socioeconomic class (10). This was further supported by other studies that found the prevalence is twice as high among women as men (11). One Canadian study found that religiousness was significantly associated to lower lifetime social phobia (13), however this was not replicated in this study. Social anxiety symptoms in medical students may influence their undergraduate clinical training, decrease their academic performance, affect their choice of future specialties, and may lead to other psychiatric co-morbidities such as


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depression and substance abuse especially alcohol abuse. Undergraduate medical training involves clinical and coursework. Any students with social anxiety symptoms may find clinical training difficult and this may lead to additional stress and anxiety. This may further decrease academic performance. There is also evidence to suggest that stress during undergraduate training may result in psychological or emotional impairment during professional life and therefore affect the quality of patient care (14). Patients with social anxiety disorder have a higher tendency to become dependent on alcohol (15). Alcohol serves as a form of self medication where the individuals can manage their symptoms (16) through its anxiolytic properties (17). One study using self-report questionnaire methods were interested in examining the relationship of social anxiety to alcohol problems in 116 undergraduates. The results demonstrated that that those classified as problem drinkers reported greater social anxiety and shyness, compared to those characterized as non-problem drinkers, confirming the significant positive relationship between social anxiety and problem drinking. (18). Social anxiety disorder frequently co-occurs with major depression and like other anxiety disorders it is a powerful risk factor for the subsequent onset of major depression (19,20). It was found that social anxiety disorder precedes major depression by at least 1 year in approximately 75% of patients with a lifetime diagnosis, which raises the question of whether social anxiety disorder is predictive of developing subsequent psychiatric disorders (21).

However, more prospective studies are required to look into this possibility. As one of the effects of social anxiety is the breakdown in social interactions, students with social anxiety disorder may choose specialties which are less stressful and has little involvement with people. The careers of students with social phobia might be significantly influenced by behaviors and decisions based on avoidance of stressful situations. However, a study looking into whether social anxiety disorder influences future career choices of medical students reported that there was no significant association among high stress, social phobia, and choice of least stressful specialties in them. Certain students, who indicated that stress was unfavorable, chose high-stress specialties (22). This study did not find any significant variables that could be associated with social anxiety symptoms found in the medical students. Given the high prevalence of social anxiety symptoms, more studies ought to be conducted to identify other factors that could play a role in the development of the disorder. This in turn would allow us to carry out a longitudinal study looking at the outcomes and possible interventions. This study has several limitations. It has no control group to allow for a more accurate comparison. Furthermore, an analysis of the individual social anxiety symptoms – fear, avoidance and physiological response with another instrument to assess quality of life would be of greater value. Other factors could have been looked at for example personality type, socioeconomic


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background and possible stressors giving rise to social anxiety in medical students. References 1) Wittchen, H-U, Fehm, L (2003). Epidemiology and natural course of social fears and social phobia. Acta Psychiatrica Scandinavica, 108 (Suppl. 417), pp 4–18. 2) Ruscio, AM, Brown, TA, Chiu, WT, Sareen J, Stein MB, Kessler RC (2008). Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychological Medicine, 35, pp15–28. 3) Kessler RC, Chiu WT, Demler O, Walters EE (2005). Prevalence, severity, and co-morbidity of 12-month DSM-IV disorders in the National Co-morbidity Survey Replication. Archives of General Psychiatry, 62, pp 617–27. 4) Iancu I, Levin J, Hermesh H, Dannon P, Poreh A, Ben-Yehuda Y, Kaplan Z, Marom S, Kotler M (2006). Social phobia symptoms: prevalence, sociodemographic correlates, and overlap with specific phobia symptoms. Comprehensive Psychiatry, 47, pp 399–405. 5) Mohammadi MR, Ghanizadeh A, Mohammadi M, Mesgarpour B. Prevalence of social phobia and its co-morbidity with psychiatric disorders in Iran (2006). Depression and Anxiety, 23, pp 405–11. 6) Chavira DA, Stein MB (2005). Childhood social anxiety disorder: from understanding to treatment. Child &

Adolescence Psychiatric Clinics of North America, 14, pp 797–818. 7) Stein, M. B., Stein, D. J (2008). Social anxiety disorder. Lancet, 371, pp 1115-1125. 8) Stein MB, Roy-Byrne PP, Craske MG, Michelle G, Bystritsky, A, Sullivan, G, Pyne, JM, Katon, W, Sherbourne, CD (2005). Functional impact and health utility of anxiety disorders in primary care outpatients. Medical Care, 43, pp 1164–70. 9) Raboch, J (1996). Prevalence of social phobia among medical students. European Psychiatry, 11 (suppl 4): pp 374. 10) Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM (1992). Social phobia. Comorbidity and morbidity in an epidemiologic sample. Archives of General Psychiatry, 49(4), pp 282-288. 11) Kessler RC (2003). The impairments caused by social phobia in the general population: implications for intervention. Acta Psychiatrica Scandinavica, 108 (Suppl. 417), pp 19–27. 12) Connor KM, Davidson JR, Churchill LE, Sherwood A, Foa EB, Weisler RH (2000). Psychometric properties of the Social Phobia Inventory (SPIN): a new self- rating scale. British Journal of Psychiatry, 176, pp 379–386. 13) Bowen R, Jones G, Koru-Sengul T, Baetz M (2006). How spiritual values and worship attendance relate to psychiatric disorders in the Canadian


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population. Canadian Journal of Psychiatry, 51 (10), pp 654-661. 14) Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR (1997). A longitudinal study of students' depression at one medical school. Academic Medicine, 72, pp 542–6. 15) Zimmermann P, Wittchen H-U, Hofler M, Pfister H, Kesslar RC, Lieb R (2003). Primary anxiety disorders and the development of subsequent alcohol use disorders: a 4 year community study of adolescents and young adults. Psychological Medicine, 33, pp1211–1222. 16) Brady KT, Lydiard RB (1993). The association of alcoholism and anxiety. Psychiatric Quarterly, 64, pp 135–149. 17) Morris EP, Stewart SH, Ham LS (2005). The relationship between social anxiety disorder and alcohol use disorders: a critical review. Clinical Psychology Review, 25 (6), pp 734-760. 18) Lewis B, O'Neill K (2000). Alcohol expectancies and social deficits relating.. to.. problem.. drinking.. among

college students, Addictive Behaviors, 25, pp 295–299. 19) Rush AJ, Zimmerman M, Wisniewski SR, Fava M, Hollon SD, Warden D, Biggs MM, Shores-Wilson K, Shelton RC, Luther JF, Thomas B, Trivedi MH (2005). Comorbid psychiatric disorders in depressed outpatients: demographic and clinical features. Journal of Affective Disorders, 87, pp 43–55. 20) Beesdo K, Bittner A, Pine DS, Stein MB, Höfler H, Lieb R, Wittchen H-U (2007). Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Archives of General Psychiatry, 64: pp 903–12. 21) Lecrubier Y (1998). Co-morbidity in social anxiety disorder. impact on disease burden and management. Journal of Clinical Psychiatry, 59 (Suppl. 17, pp 33–38. 22) Onady AA. Rodenhauser P. Markert RJ (1988). Effects of stress and social phobia on medical students' specialty choices. Journal of Medical 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 Learning disabilities is viewed with growing concern amongst educators. Much has been said about different kinds of learning disabilities and this has lead to attempts to create a suitable education environment for these children. However, despite these initiatives, there is still a lack of published research on the state of these services, along

suggestions on what needs to be focused on to enhance services. This research paper studies the observations of teachers of children with learning disorders. Defining Learning Disorders Before moving on, it is appropriate to review definitions of learning disabilities from various perspectives. Kirk’s


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earliest definition on learning disability states that a learning disability is “a retardation, disorder or delayed development in one or more areas of speech, language, reading, writing, arithmetic or school subjects due to possible cerebral dysfunction with or without emotional and behavioural disturbances”. However, this learning disability is not due to “mental retardation, sensory deprivation, or cultural and instructional factors” (1). In 2000, a redefinition of the term learning disability was proposed by the U.S Department of Education Office of Special Education Programs. Thus Bradley redefined the concept of learning disabilities, as specific learning disability (SLD). The “central concept to specific learning disability is disorders of learning and cognition which are intrinsic to individual, specific disorders that affect only a narrow range of academic and performance outcomes and not due primarily to other conditions such as mental retardation or behavioural disturbances” (2). Where the Malaysian Ministry of Education is concerned, special needs children are only categorised into three categories, those who are visually handicapped, or partially or fully deaf, or suffering from the disability to learn (3). In this present study, learning disability is defined in terms of behaviour characteristics that are observed and considered by the teacher as forms of learning problems such as being unable to read, poor comprehension, hearing problems and/or difficulty paying attention.

Prevalence of Learning Disorders in Schools in Malaysia, Across Countries The prevalence of learning disabilities among school children differs from country to country. This is largely dependent on the definition used to classify learning disabled children in each of the country. There are nearly 3 million school-age students in the United States identified with specific learning disabilities who are currently receiving special education services (4). This accounts for approximately 5.5% of students in the school years (ages 6 to 17) needing special education due to learning disabilities. However, this percentage reported may be slightly underestimated as it only consists of students identified by public schools without taking into account private schools (2). In a study by Komoula on 240 Greek students between 7 to 11 years old from urban and rural schools, it was found that prevalence of developmental dyscalculia among students were higher in rural schools than urban schools (5). Therefore, specific learning disabilities are prevalent in other countries, and may be especially more prevalent amongst rural school students. Where Asian countries are concerned, the National Statistics Office of Thailand in 1991 reported a prevalence rate of 10% for intellectual disability, 13.2 % for hearing impairment, 5.4 % for speech impairment and 1.9% of visual impairment (6). In Malaysia the Department of Special Education in 2002 reported 14, 535 children with learning disabilities in 700 schools nationwide (3). The statistics here includes children with visual


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impairment, hearing impairment and learning disabilities in special schools or integrated schools. Treatment of Children With Learning Disorders by Classmates School children with learning disabilities often lack of social support at school or at home. Pavri and Monda-Amaya studied 30 students with learning disabilities between 3rd to 5th grade and 60 general and special education teachers and reported that the students experienced less social support from parents, classmates and friends (7). However, they experienced a higher amount of support in certain areas such as companionship, self worth and self esteem, and instrumental assistance, from their teachers. Other findings also yield similar reports on support perceived by children with learning disabilities. In a study by Martinez on 120 middle school students with different degree of learning disabilities, it was found that students with multiple learning disabilities suffered from lower parent, classmate and friend support as compared to peers with a single learning disability or peers without learning disabilities (8). This is of concern given that support from parents, classmates and friends is an important element in children development. How Parents React to a Child With Learning Disorders Individuals respond to similar situation differently, thus knowing that one has a child with a learning disability may invoke feelings and reaction which may very based on the preparedness and

awareness of the parent for dealing with the situation. Most parents may encounter feeling of disappointment as they may have difficulty imagining their child’s future career, at least until they begin to develop an understanding of their new situation and to build new expectation for the child (9). Realising that a child has a learning disability may affect the parents relationship with the child and the entire family. Babb expresses that family relationships are often very different and complex when one child has a learning disability (10). Russell also indicated that many parents require emotional support to help them adjust to the new situation and intellectual support to help them learn new ways of handling their child (9). Families of children with learning disabilities may respond in various ways. Falik reported that the family either contains the information, or takes action to deal with the problem (11). Thus, the family either mobilises into effective action, flexibly adapting or freezes in varying degrees of rigid, ineffective reactions. Focusing on parental attitudes, Humphries and Bauman conducted research to identify the relationship between learning disabilities in children and maternal child-rearing attitudes (12). By comparing 42 children with disabilities and 42 normal achievers, they found that mothers of learning disabled children were more authoritarian and controlling in child rearing. At the same time, however, mothers of learning disabled children were less hostile and rejecting towards their children. Thus knowing that


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parenting attitudes on differ based in the child’s abilities is important for predicting how parents would reacts towards their child with learning disability. Services that are Available Most parents of children with disabilities express concern over services available to support their children and family. Leading from this, many countries have examined various strategies to provide for the need of these children and their families. In the US, early intervention services for infants and toddles and their families were authorised by the Individuals with Disabilities Education Act (IDEA). Three groups of children from birth to 3 years old were eligible for early intervention services – children with developmental delay, children with an identified physical or mental condition that carries a high probability of developmental delay and children who are medically or environmentally at risk for developmental delay if early intervention is not provided (13). When the child is ready to go to school, inclusion or exclusion education is prepared depending on the severity of the child’s condition. However, IDEA emphasises educating children with disabilities in less restrictive environment thus advocating more inclusion where possible. Inclusion education ranges from full time, complete membership of the child with disabilities in the general education classroom to part-time participation for non-academic subjects and activities (13).

Special education in Thailand has a history which dates back to 1951 when the government first introduced a specialised programme for deaf children. By 1999 the Thai government had advocated that all children be given similar rights to education, including those with disabilities, in an inclusion situation following the implementation of The Rehabilitation of Disabled Persons Act of Thailand in 1991. However, Carter reported that these phases had been implemented in a rapid pace thus leading to many logistical difficulties such as experiencing a lack of qualified educators and provisions for appropriate services for the programmes (6). Special education in Malaysia is governed by two departments, which are the Special Needs Department within Ministry of Education, and the Social Welfare Department, Ministry of National Unity and Social Development (14). The Malaysian government has set up specialised schools for children with visual and hearing impairment. Where other forms of disabilities are concerned, children are being placed into either special schools or integrated schools with special needs classes. In later years, the child may be enrolled in a technical or vocational schools to be further trained in a specific skill aimed at independent living. Services for children with learning disabilities are an area that still requires much attention. As there is very limited research conducted to evaluate the experiences of services for these children in developing countries, this research was designed to obtain information from the perspective of teachers.


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The research questions of this study are: (i)What is the observed prevalence of learning disorder in schools? (ii) How are children with learning disorders treated by their classmates? (iii) How do parents react towards their child with learning disorder? (iv)What types of facilities are available for children with learning disorders? (v) What are the perceived needs of teachers when it comes to assisting children with learning disorders? Methodology To answer the research question, a single survey was used to obtain the information from the subjects. The questionnaires were administered to participants who were attending a day workshop on children’s issues in schools. Subjects The sample consisted of a total of 107 subjects. Their ages ranged from 21 to 59 years, with a mean age of 39 years. There sample consisted of more female (95, 88.8%), as compared with male (12, 11.2%) teachers. The races consisted of Malays (42, 39.3%), Chinese (40, 37.4%), Indian (22, 20.6%) and Caucasians (3, 2.8%). Most of the subjects had undergraduate degrees (87, 81.3%), and the remaining possessed either Diploma (13, 12.1%) or 6th Form qualifications (7, 6.5%). The number of years of teaching experience ranged from 1 to 36 years, with mean of 13 years of experience. Most of the sample consisted of teachers (76, 71%), with the remainder being administrators (7, 6.5%) and counselors (24, 22.4%). They were from government national type (49, 45.8%), government Chinese type (8,

7.5%), private (47, 43.9%), and international schools (3, 2.8%). Subjects reported that they had all encountered students with learning disorders, and that the number of students that they had dealt with at any one time in a class ranged from 1 to 46 students (mean = 12, SD = 12), Measurement The questionnaire was developed by the staff of the Department of Psychology, Sunway University College. School Learning Disability Questionnaire The School Learning Disability Questionnaire is a self-report scale designed to measure the respondents observations on learning problems amongst school children. There are a total of 65 questions which were grouped into six categories which are demographics, prevalence of learning disability, treatment by classmates, peer reactions and actions, facilities, and teacher’s needs. All questions generally require the respondent to report on what they have observed and experienced with regards the issue of learning disorder at their respective schools. All the questions offered several answers ranging from two responses (i.e., “Yes”, “No”) to three responses (i.e., “Never”, “Occasionally”, “Very Often”). No validity data are available on the questionnaire. Results To answer the questions posed by the research hypotheses, a series of statistical analyses was conducted. The main analyses consisted of a series of


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frequency counts and percentages that compared the data sets of the prevalence

behaviours related to the issue of 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 off the margin.

56(52.3) 11(10.3)

Does not respond to what the teacher says. 72(67.3) 20(18.7) _____________________________________________________________________________ The subjects were asked about their observations of a variety of learning disorders within their schools (see Table 1). They reported that the most commonly

seen disorders involved difficulty paying attention (58.9%), difficulty learning a second language (49.5%), being fidgety and having difficulty sitting still (46.7%), 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 existence of negative treatment by students towards other students with learning disorders, the most common negative

treatment seemed to do with being made fun off (19.6%) (see Table 2). The least common form of negative treatment 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) ______________________________________________________________________________ There was also evidence of positive behaviours of classmates towards their other classmates with learning disorder

(see Table 3). The most reported positive behaviours were protection from bullies (16.8%), and trying to help their 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 educational potential

67(62.6) 2(1.9)

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’ reactions to their children with learning disorders (see Table 4). The most common reaction was to send the child for lots of tuition (23.4%), and to be very

frustrated with the child (21.5%). Some parents did neglect their children’s learning disorder (65.4%), and many did not seem to realize how serious the 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 special needs and learning disability.

48(44.9) 21 (42.9%) 1 (12.5%) 25 (53.2%)

1 (33.3%)

Special needs class within the school. 31(29.0) 11 (22.4%) 2 (25%) 18 (38.3%)

0 (0%)

Special needs class at a school nearby. 35(32.7) 18 (36.7%) 2 (25%) 15 (31.9%)

0 (0%)

Special one-to-one tutoring in school. 32(29.9) 11 (22.4%) 2 (25%) 17 (36.2%)

2 (66.7%)

Private after-school group tutoring at a nearby special needs centre.

28(26.2) 13 (26.5%) 1 (12.5%) 13 (27.7%)

1 (33.3%)

Private one-to-one tutoring. 38(35.5) 14 (28.6%) 2 (25%) 21 (44.7%)

1 (33.3%)

Books and manuals that teachers can refer to within the school.

51(47.7) 22 (44.9%) 2 (25%) 26 (55.3%)

1 (33.3%)

Regular talks and workshops, organized by the school or education ministry, that the teacher can attend.

64(59.8) 22 (44.9%) 4 (50%) 35 (76.6%)

2 (66.7%)

________________________________________________________________________ The prevalence of facilities within each group of type of school (i.e., Government National, Government Chinese, Private, International) was observed (see Table 5). It was noted that there was generally a larger number of Government National (42.9%) and Private schools (53.2%) with teachers or counselors trained in special needs or learning disability. When it came to special needs classes, Private schools (38.3%) seemed to report the largest number of classes available. International (36.2%) and Private (66.7%) schools both reported a much greater availability of one-to-one tutoring in their respective schools. In terms of resources, the Government National type (47.7%), Government Chinese type (44.9%) and Private (55.3%) schools reported a larger number of manuals and books that they

could refer to. Finally, all schools reported that there was a large number of talks and workshops organized to educate them on special needs issues (44.9% to 76.6%). When it came to the needs of teachers, the most common need that the teachers reported was to have the parents cooperate with them (72%) (see Table 6). Amongst the other more important needs that teachers had were support from the education authorities (66.4%), learning exercises and techniques for assisting the child (63.6%), receiving understanding and support from the school authorities (63.6%), and having more cooperation between the school authorities and professionals 62.6%).…………………….


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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 professionals (i.e., psychologists, paediatricians, speech therapists, occupational therapists, special needs tutors)

29(27.1) 67(62.6)

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 investigate the following on learning disability within the psychiatric community in Malaysia:

• What is the observed prevalence of learning disorder in schools?

• How are children with learning disorders treated by their classmates?

• How do parents react towards their child with learning disorder?

• What types of facilities are available for children with learning disorders?

• What are the needs of teachers when it comes to assisting children with learning disorders?

It was found that the most commonly seen learning problems in this study involved difficulty paying attention (58.9%), difficulty learning a second language (49.5%), being fidgety and having difficulty sitting still (46.7%), and having poor comprehension (43%). This is a much higher figure, when compared with

other countries. In the United States, it is estimated that the overall lifetime prevalence of learning disability for children age 18 years and below in year 2003 was 9.7% (15). In Nepal, the estimated national prevalence of learning disability in year 2001 was 1.63% while in Sri Lanka (16), it was reported that 10.6% of school aged children are disabled (17). In Korea, 2.71% of children aged between 6 -11 years old were disabled in year 2001 (18). There is generally a wide discrepancy in terms of prevalence of learning disability amongst children in each country. This variation could be due to the diversity of the procedural criteria and definition of learning disability used by various researchers and educational agencies. When the teachers were asked about the existence of negative treatment by students towards students with learning disorders, the most common negative treatment seemed to do with being made fun off (19.6%). The least common form of negative treatment appeared to be being 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 (19). They found that 17% of 46 students with learning disability were rejected by their peers, and 15% were neglected by their peers. Only 7% of children with learning disability were nominated as popular; indicating that their peers liked playing with them. In the present study, there was also evidence of positive behaviours of classmates towards their other classmates with learning disorder. The most reported positive behaviours were protection from bullies (16.8%), and trying to help their classmates understand by teaching (14%). It is frequently reported that children with learning disabilities have difficulties in social adjustment. This has been supported by a growing body of research that shows that children with learning disabilities exhibit significant behaviour problems or social skills deficits (20), and are often poorly accepted by peers who do not have learning disabilities (21, 22, 23). However, there are studies suggesting that having one or two good friends in class may serve as a buffer to negative effects such as loneliness and depressions in these children (24, 25, 26). In terms of parents’ reactions to their children with learning disorders, the most common reaction was to send the child for lots of tuition (23.4%), and to be very frustrated with the child (21.5%). Some parents neglected their children’s learning disorder (65.4%), and many did not seem to realize how serious the problem was (72%). These statistics indicate that there is a need to educate parents of learning disabilities and its consequences and ways to assist their children with learning problems. The prevalence of facilities within various types of school was observed (i.e., Government National, Government

Chinese, Private, International). It was noted that there was generally a larger number of Government National (42.9%) and Private schools (53.2%) with teachers or counselors trained in special needs or learning disability. When it came to special needs classes, Private schools (38.3%) seemed to report the largest number of classes available. International (66.7%) and Private (36.2%) schools both reported a much greater availability of one-to-one tutoring in their respective schools. In terms of resources, the Government National type (44.9%), Government Chinese type (25%) and Private (55.3%) schools reported a larger number of manuals and books that they could refer to. Finally, all schools reported that there were a large number of talks and workshops organized to educate them on special needs issues (44.9% to 76.6%). Despite having talks and workshops as well as special needs teacher and counselors in these schools, teachers still report a lack of support in assisting children with learning disability. The most common need that the teachers reported was to have the parents cooperate with them (72%). Amongst the other more important needs that teachers had were support from the education authorities (66.4%), learning exercises and techniques for assisting the child (63.6%), receiving understanding and support from the school authorities (63.6%), and having more cooperation between the school authorities and professionals (62.6%). In most schools, children with cognitive learning disability are usually grouped in the same classroom due to lack of special needs teachers and classroom resources. These children have very different learning disabilities ranging from reading difficulty (dyslexia), dyscalculia, autism, mental retardation, attention deficit, emotional problems, borderline intellectual capacity, lack of motivation


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and conduct disorders to name a few. This is a problematic phenomenon as the problems, intervention and teaching methods for each of these disabilities are very different. Moreover, children in each disability (i.e. autism) are individually different in terms of their severity as well as manifestation of symptoms and require individualized intervention programs. This then leads to another problem of the amount of time the special need teacher is required to spend with each children. Most of the time, special needs teachers are given additional responsibilities in school such as student counselors or extracurricular activities coordinator because they are perceive to have more time due to the small number of students in their classes. The lack of resources, time and support by educational authorities would have cause frustration amongst teachers involved with learning disability children. Teachers are often expected by parents and educational authorities to be able to help children with learning problems. However, in a study by Lambert, it was found that teachers typically were unable to identify students’ problem behaviours operationally, had a lack of knowledge of intervention strategies and relied primarily on global solutions, regardless of the nature of the presenting problem (27). In another follow up study by Wilson, Gutkin, Hagen and Oats on twenty general education teachers in the United States, they found that most teachers in their study demonstrated only a vague knowledge of classroom interventions (28). Prior research indicates that teacher knowledge of interventions are positively related to their use of classroom intervention (29). In addition, knowledge apparently influences teachers' sense of competence and willingness to work with mildly handicapped children (30). Hence, untrained teachers may not necessarily

have the adequate skills and knowledge in teaching children with learning disability. The results of this study are subject to several limitations. Given that this was a small sample of general education teachers, the results should be interpreted with caution. Additionally, although these teachers were encouraged to provide detailed retrospectives information on children with learning problems in their schools, time, fatigue, and memory factors may have limited the accuracy of the data. As this was a preliminary study to find out about information regarding learning disability amongst children in Malaysia, detail follow up studies on parents and children perspectives on learning disability should be gathered. In addition, more specific information on the knowledge and needs of teachers dealing with learning disability children needs to be investigated. Effectiveness of current intervention practices should also be investigated. Conclusions The present study indicates that there a lot that needs to be done in the area of services for children with special needs in Malaysia. There are many models that may be adopted within the school systems. These include team teaching, use of teacher consultants/school psychologists, building based on teacher support teams, multidisciplinary team meetings, regular scheduled screening examinations for general health status, visual and hearing acuity, intellectual potential, speech and language functioning, academic achievement and skills level and social and adaptive functioning. Formal referral procedures and guidelines for eligibility and placement of special needs could


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be shared with teachers and parents. Planning, material development, research support, teacher training, classroom organization, parental and community support are also much needed. Finally, teachers need considerable support such as information on the nature of children’s problems, the types of classroom intervention strategies available, training to develop individualized programs, and support from educational authorities in terms of time, physical resources and human resources. References 1. Kirk as cited in Kalave KA, Forness SR. What Definitions of Learning Disability Say and Don’t Say. Journal of Learning Disabilities 2000; 33: 241. 2. Bradley et al. as cited in Hallahan DP, Llloyd JW, Kauffman JM, Weiss MP, Martinez EA. Learning Disabilities: Foundations, Characteristics, and Effective Teaching. Pearson, Boston MA, 2005; 18. 3. Akta Pendidikan 1996 as cited in Manisah M, Ramlee M, Zalizan MJ. An empirical study on teachers’ perception towards inclusive education in Malaysia. International Journal of Special Education 2006; 21(3): 36-44. 4. The Advocacy Institute, Students with Learning Disabilities: A National Review, 2000. 5. Koumoula A, Tsironi V, Stamouli V, Bardani I, Siapati S, Graham A. et al. An Epidemiological Study of Number Processing and Mental Calculation in Greek Schoolchildren. Journal of Learning Disabilities 2004; 377-388.

6. Carter SL. The development of special education in Thailand. International Journal of Special Education 2006; 21(2): 32-36. 7. Pavri S, Monda-Amaya L. Social Support in Inclusive Schools: Student and Teacher Perspectives. The Council for Exceptional Children 2001; 67: 391-411. 8. Martinez RS. Social Support in Inclusive Middle Schools: Perceptions of Youth with Learning Disabilities. Psychology In the Schools 2006; 43: 197-209. 9. Russell F. The expectations of parents of disabled children. British Journal of Special Education 2003; 30(3): 144-149. 10. Babb C. Living with shattered dreams: A parent’s perspective of living with learning disability. Learning Disability Practice 2007; 10(5): 14-18. 11. Falik LH. Family patterns of reaction to a child with a learning disability: a mediational perspective. Journal of Learning Disabilities 1995; 28(6): 335-341. 12. Humphries TW, Bauman E. Maternal child rearing attitudes associated with learning disabilities. Journal of Learning Disabilities 1980; 13(8): 54-57. 13. Hunt N, Marshall K. Exceptional children and youth. (4th ed.). United States of America: Houghton Mifflin, 2006. 14. Kementerian Pelajaran Malaysia. Pengenalan kepada pendidikan khas. 2007, August. Retrieved from http://www. moe.gov.my 2007, October 23.


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15. Altarac M, Saroha E. Lifetime Prevalance of Learning Disability Among US Children. Pediatrics 2007; 119: 77 – 83. 16. NPC/UNICEF/New Era. A Situation Analysis of Disability in Nepal. National Planning Commission, UNICEF and New Era. 2001. 17. APEID. Sri Lanka country paper. In Proceedings of the Fourth APEID Regional Seminar on Special Education. Asia and Pacific Programme on Educational Innovation for Development, Yokosuka, Japan 1994. 18. Kim HJ. Educational supports for children with multiple disability in Korea. Journal of Special Education in the Asia Pacific 2005; 14- 20. 19. Junovan J, Bear G. Social adjustment of children with and without learning disabilities in integrated classrooms. Journal of Educational Psychology 1992; 84 (3): 322-330. 20. Bender WK, Smith JK. Classroom behavior in children and adolescents with learning disabilities: A meta-analysis. Journal of Learning Disabilities 1990; 23: 298-305. 21. Bursuck WD. A comparison of students with learning disabilities to low achieving and higher achieving students on three dimensions of social competence. Journal of Learning Disabilities 1989; 22: 188-194. 22. Stone WL, LaGreca AM. The social status of children with learning disabilities: A reexamination. Journal of Learning Disabilities; 1990: 23: 32-37. 23. Vaughn S, Hogan A, Kouzekanani K, Shapiro S. Peer acceptance, self-

perceptions, and social skills of learning disabled students prior to identification. Journal of Educational Psychology 1990; 82: 101-106. 24. Berndt TJ. The nature and significance of children's friendships. Annals of Child Development 1988; 5: 155-186. 25. Berndt TJ. Friendships in childhood and adolescence. In Damon W ed. Child Development Today and Tomorrow. San Francisco: Jossey-Bass: 1989 : 332-348. 26. Buhrmester D, Furman W. The changing functions of friends in childhood: A neo-Sullivanian perspective. In: Derlega VJ, Winstead BA eds. Friendship and Social Interaction. New York: Springer-Verlag, 1986: 41-62. 27. Lambert NM. Children’s Problem and Classroom Interventions from the Perspective of Classroom Teachers. Professional Psychology 1976; 7: 507-517. 28. Wilson CP, Gutkin TB, Hagen KM, Oats RG. General Education Teachers’ Knowledge and Self-Reported Use of Classroom Interventions for Working with Difficult-to-teach students: Implication for Consultation, Prereferral Intervention and Inclusive Services. School Psychology Quarterly 1998; 13 (1): 45-62. 29. Hall CW, Wahrman E. Theoretical orientations and perceived acceptability of Intervention strategies applied to acting-out behavior. Journal of School Psychology 1988; 26: 195-198. 30. Hannah ME, Pliner S. Teacher attitudes toward handicapped children: A review and synthesis. School Psychology 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 Schizophrenia has frequently been called a disease that decreases longevity (1). People with mental illness die 10-15 years earlier than the general population (2). Although individuals with Schizophrenia have increased mortality rates from cardiovascular and respiratory disorders many of these physical problems are not noticed by their psychiatrists. This may in part be due to

the attitude of the treating psychiatrists (3). It has also been noted that patient’s with Schizophrenia do not lead healthy lifestyles as compared to the normal population (4). The Schizophrenics tend to have a diet higher in fat and lower in fibre as compared to the general population (5). Numerous articles have been published about the association of Schizophrenia and physical illness. Research has shown that the risk of death from a large group of


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cardiovascular diseases is higher in Schizophrenia than in the general population (6). In 1899 Sir Henry Maudsley wrote in the Pathology Of The Mind, “ Diabetes is a disease that shows itself in families in which insanity prevail”(7). Also the relative risk is considerably greater in younger patients than in the older patients and those in the chronic stages of the disease (6). As we know risk factors for the development of cardiovascular diseases are obesity, diabetes mellitus, hypercholesterolemia, hypertension and cigarette smoking among many others. It has been shown that weight gain increases the risk of coronary heart disease (8). Weight gain also increases the risk of Type 2 Diabetes Mellitus and blood cholesterol levels and this in turn leads to an increased risk of coronary heart disease (9). An increase of 10% weight in men aged 35-44 is accompanied by a 38 % risk in the incidence of CHD and a 20% increase correspond with an 86% increase (9). This reflects the association between weight gain, higher blood cholesterol and glucose concentrations (9). Studies also show that impaired glucose tolerance, Diabetes Mellitus and insulin resistance may be more common among patients with psychiatric disorder such as Schizophrenia than in the general population (10). In one study by Muhkerjee et al ,the prevalence of diabetes was examined in 95 Schizophrenic patients in Italy aged between 45 to 74 years. The prevalence of diabetes was found to be 15.8%. These rates are higher than that reported in population surveys in Italy (10). A study conducted in Japan by Tabata et al among 248 Schizophrenic patients noted that the prevalence diabetes was 8.8%

but only 5% among 239 sedentary office workers (11). Schizophrenia is often associated with Type 2 diabetes mellitus and not Type 1 diabetes mellitus (12). A family history of Type 2 Diabetes Mellitus is found in as many as 18-19% of Schizophrenics further predisposing them to the development of this illness (12). In addition to this, it has come to light that many neuroleptic drugs induce hyperglycemia (13 ,14) . Among these, patients those who received atypical neuroleptics were 9% more likely to have diabetes than patients who received typical neuroleptics (15). Further complicating this picture is the fact that weight gain has been documented by almost all neuroleptics, both typical and atypical. (16) Both conventional and atypical antipsychotics are associated with weight gain (17). Long-term administration of typical and atypical antipsychotic drugs induces excessive weight gain which afflicts up to 50% of patients, impairs health and interferes with treatment compliance (18). Among newer antipsychotics mean increases in weight after 10 weeks were as follows; Clozapine 4.45 kg; Olanzapine 4.15kg; Sertindole 2.92 kg; Risperidone 2.10 kg and Ziprasidone 0.04 kg. The associated weight gain may affect patient’s health and also impede compliance (19). This is not helped by the fact that many Schizophrenics suffer from obesity themselves (20). Clozapine is currently regarded as the ‘gold standard’ in adults in terms of antipsychotic efficacy with regards to the management of treatment resistant Schizophrenia (21). Clozapine has been known to produce a response in 30% of


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treatment resistant Schizophrenics in a 6 week trial and up to 60% in 6 months (22). A study done by Kane and colleagues found Clozapine superior to doses of Chlorpromazine twice as large in patients with chronic Schizophrenia who had been unresponsive to treatment with up to 60 mg of Haloperidol a day before the start of the comparison trial (23). However the drug implicated in producing the greatest weight gain is Clozapine (19).It has been shown that after a 10 week treatment on a standard dose Clozapine produced a mean weight gain of about 4.45 kg(17). Leadbetter et al in 1992 reported that weight gain occurred in 67% of patients treated with Clozapine during a 16 week period (20). A study done on 26 patients in Ireland who were receiving Clozapine showed that 6 patients met the criteria for obesity and 12 met the criteria for overweight. Over half of the patients had lipid abnormalities (24). The fact that Clozapine appears to cause Diabetes Mellitus is suggested by a number of reports. The temporal relationship to the start of Clozapine treatment, the relatively young age of the affected patients and the immediate reversibility on withdrawal of the drug in some patients has also been noted (25). In a study by Koller et al most new- onset diabetes were documented within the first 6 months of therapy (25). 27 % were diagnosed in the first month of Clozapine initiation and 57% within the first three months. In a study done by Henderson et al it was noted that 30 out of 82 patients (36.6%) developed diabetes in a 5- year study (22). Not only has Clozapine been implicated as the drug with the greatest potential to produce weight gain and

Diabetes Mellitus but several studies have also linked it to the development of hyperlipidaemia in some patients with Schizophrenia (26). A study conducted by Ghaeli et al showed that subjects taking Clozapine had higher serum triglyceride levels than subjects taking typical antipsychotics. This was a difference that could not be accounted for by concurrent illnesses or medications, antipsychotic dosages ,or patient characteristics (27). Medical records of 222 men treated with Clozapine were reviewed by Gaulin et al, Clozapine treated men had significantly higher serum triglyceride levels at follow up than those treated with Haloperidol (28). Objective The primary objective of the study is to asses prevalence of diabetes mellitus, body mass index and serum cholesterol levels in the patients attending the Clozapine clinic at the University Malaya Medical Center. Method This is a descriptive cross sectional study of patients attending the Clozapine clinic at the University Malaya Medical Center. The University Malaya Medical Center is a Government Hospital serving the population of Selangor and Kuala Lumpur as well as referral cases from all over the country. The Clozapine Clinic was set up in 1998 for those patients who are on our psychiatric follow up and who had been prescribed Clozapine. All together 68 patients attend this clinic. For the first 18 weeks of treatment Full blood count is done weekly, after that it is done monthly. The full blood count is done routinely to look out for such side


39

effects such as leucopenia induced by Clozapine. The probability of the other side effects such as hyperglycemia, obesity and hypertriglyceridemia occurring has so far not been looked into. Only those patients who were reliable informants as to their fasting status or who were accompanied by reliable informants were used. Patients who were on Clozapine for 6 months or more were used in the study. Written informed consent was taken before the interview and blood taking. A total of 36 patients were eligible to take part in this study. A two- page questionnaire was used to record information about the patient. In this questionnaire such information as age, gender, race, height, weight , body mass index, duration of diagnosis of the illness in years, reason to start Clozapine, duration of treatment of Clozapine in months, past and family history of Diabetes Mellitus were recorded. Old notes were also looked into to verify the information. All this was done by the investigator herself. The height and weight were taken in order to calculate their body mass index (BMI) using the formula weight in kg/ height in metres. Patients were classified as overweight if their BMI was 25-30 and obese if the BMI was >30 (29). Fasting venous blood samples were taken from each patient for the estimation of lipid and glucose levels. Hypertriglyceridemia was defined as a fasting triglyceride level of >1.82 mmol/L. The normal level of serum tryglycerides was between 0.45-1.82 mmol/L. A serum level of 0.80-1.8 and

1.68-4.53 were considered to indicate normal levels of high- density lipoprotein and low -density lipoprotein respectively. Fasting blood glucose levels were classified as follows: 3.9 mmol/L-6.1mmol/L=normal, 6-7 mmol/L =impaired fasting glucose (IFG) and >7mmol/L=hyperglycemia (30). In our study we require one reading of impaired fasting glucose of more than 7 mmol/L in accordance to the criteria set by the American Diabetic Association to diagnose a patient to be suffering from Diabetes Mellitus. This recommendation is made in the interest of standardization and also to facilitate field- work, particularly where the Oral Glucose Tolerance Test (OGTT) may be difficult to perform and where the cost and demands on participants' time may be too much. This method will lead to slightly lower estimates of prevalence than would be obtained from the combined use of the Fasting Blood Glucose and Oral Glucose Tolerance Test. Results Important demographic characteristics of the participants are summarized in Table 1. 36 patients participated in this study with almost equal gender distribution. The mean age was 36.1 years (SD=9.9). The mean age of the male patients was 33.00 years (SD= 8.23) and the mean age of the female patients was 39.65 (SD=10.61) years. Most of the patients 28(77.77%) were single. The mean duration of illness was 14.64 years (SD=8.48). Most of the patients have been ill for between 11-20 years.


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Table 1. Demographic Characteristics Of Patients

Patient (%) N=36

Sex Male 19 (52.8%) Female 17 (47.2%) Age 16-25 4 (11.1%) 26-35 14 (38.9%) 36-45 9 (25%) 46-55 9 (25%) >55 0 (0%) Marital Status Single 28 (77.8%) Married 8 (22.2%) Race Malay 1 (2.8%) Chinese 29 (80.6%) Indian 5 (13.9%) Eurasian 1 (2.8%) Duration Of Illness 1-10 years 12 (33.3%) 11-20 years 14 (38.9%) 21-30years 8 (22.2%) 31-40 years 2 (5.6%) Duration Of Clozapine and BMI Table 2 shows the distribution of patients based on duration on Clozapine as well as the distribution of BMI. The mean (+/-SD) duration of being on Clozapine was 44.25 months (SD=26.57). 13 (36%) had family history of Diabetes Mellitus. Half of the patients have been on Clozapine for less than 2 years. Most of the patients (52.78%) are in the normal range. Out of the 36 patients 10(27.77%) were

overweight and 5 (13.89%) were obese. 2 (5.56%) were underweight. Of the five patients who were obese the average duration in months they were on Clozapine was 45.4(3.78 years) Of the two patients who were underweight one of the patients was on Clozapine for 25 months (2.08 years) and the other for 12 months. The mean BMI was 24.63 ( SD= 4.44). Table 2 :- Distribution of patients based on duration of Clozapine as well as the BMI.

Patient (%) N=36

Duration On Clozapine 0-24 months 12 (33.3%) 25-48 months 6 (16.7%) 49-72 months 11 (30.6%) 73-96 months 7 (19.4%) BMI BMI Less than 18.5 2 (5.6%) BMI 18.5-<25 19 (52.8%) BMI 25-30 10 (27.8%) BMI <30 5 (13.9%’) Fasting Blood Sugar and Fasting Serum Lipid The mean (+/- SD) fasting blood sugar was 5.37 (SD=0.68 ) mmol/L. Out of the 36 patients 5(13.89%) had impaired fasting glucose (IFG). However on subsequent assessment of those 5 patients, two of the readings were normal, two continued to have IFG and one patient had hyperglycemia with a value of 7.1 mmol/L and was therefore diagnosed to have Diabetes Mellitus. The mean (+/-SD) value for Hba1c was 5.10 (SD=0.4). There was no correlation between the duration of being on Clozapine and the fasting blood sugar.


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The mean (+/-SD) values for HDL, LDL, and triglycerides were 1.28 (SD=0.33), 3.25 (SD= 0.86) and 2.22 (SD=1.63) respectively. 14(38.89%) patients had hypertriglyceridemia. The number of patients in whom there was presence of family history of Diabetes Mellitus was 13 (36.11%). The number of patients who had no family history of Diabetes Mellitus was 23 (63.89%). The number of patients who had fasting blood sugar less than 3.9 mmol/L is 1(2.78%) . The number of patients who had their blood sugar in the normal range was 30(83.33%) The number of patients who had fasting blood sugar more than 6.1% at the first testing was 5(13.89%) On subsequent testing 2 patients continued to have impaired fasting blood sugar but did not exceed the level of 7 mmol/L and one had hyperglycemia 7.1 mmol/L. Therefore by our criteria which are similar to that recommended by the American Diabetic Association, only 1 patient was diagnosed to have Diabetes Mellitus. There were no patients who had serum triglyceride levels less than 0.45%. There were 22 (61.11%) patients who had their serum triglycerides in the normal range i.e. between 0.45-1.82% There were 14 (38.89%) of patients who had their serum triglycerides more than normal i.e. 38.89%. The number of patients who had serum HDL levels less than normal was 1 (2.75%). The number of patients who had serum HDL levels in the normal range was 31 (86.11%) The number of patients who had serum HDL levels more than normal was 4(11.11%.)

There were no patients who had serum LDL levels less than normal. There were 32 (88.89%) patients who had serum LDL levels in the normal range i.e. between 1.68- 4.53. There were 4 (11.11%) patients who had serum LDL levels more than normal. Discussion The main purpose of our study was to assess the adverse effects of Clozapine on our patients so that steps may be taken in future to counteract it. Even though our findings are based on a limited sample size a significant number of them were classified as obese or overweight. From this study we see that the mean BMI is 24.63. This is at the upper range of normal value for BMI of the general population. The mean BMI of the general population is only 22.48 (29). Also the prevalence of obesity is 13.89%, which is much higher than the general population of only 4.4% (29). The prevalence of overweight is 27.8% compared to the national value of 16.6%. The percentage of underweight is much less 5.5% as compared to the general population of 25.2% (29). Similar findings have been noted in various other studies. In a study by Homel P et al the (31) body mass index (BMI; kg/m2) and the prevalence of overweight and obesity among Schizophrenic versus non-Schizophrenic individuals among nationally representative samples of the US adult population were evaluated. This study was carried out between the 1987 to 1996, a period during which the use of novel/atypical agents increased. Results showed that mean BMI (body


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mass index) for individuals with Schizophrenia is significantly higher than individuals who are not schizophrenic. Another study done by Hummer M et al showed that weight gain induced by Clozapine is much more than that induced by Haloperidol (32). In the study done by Hummer M et al on 81 patients it was also noted that 35.7 % of the patients treated gained weight. If patients gained weight this side effect was noted within the first 12 weeks of therapy (32). Also weight gain was not influenced by gender, and the weight gain may continue till the 46 month from the start of therapy with Clozapine (22). The values of increased BMI among Schizophrenics may be accounted for by the medication the patient is on or it may also be due to the illness itself. Either way measures have to be taken to safeguard against excessive weight gain among patients. Studies also show that weight gain is more among those who were underweight initially. Due to the cross-sectional nature of the study it is not known to what extent Clozapine is responsible for these findings. Although Clozapine is known to be frequently associated with substantial weight gain it is important to highlight that obesity is a common concomitant of Schizophrenia. Whether the cause of obesity is due to the illness or the drug, psychiatrists need to address the issue of obesity amongst their patients who are prescribed Clozapine. Unfortunately, some of the cognitive and motivational deficits associated with Schizophrenia may limit these patients from benefiting from weight loss programmes. The prevalence of Diabetes Mellitus in our study is 2.78% which is the less than that of the national population of 8.3%

(29). This may be due to the fact that the mean age of our patients is only 36.1 years with an age range of 29 –54 years. Studies have shown that the risk of developing Diabetes Mellitus increases with age. In addition we used the criteria of one reading of IFG (Impaired Fasting Glucose) to diagnose Diabetes Mellitus when IGT (Impaired Glucose Tolerance) will diagnose a greater percentage of people from suffering from Diabetes Mellitus. This also may have contributed to a lower prevalence value for Diabetes Mellitus. Since we have no baseline BMI (body mass index) values we cannot ascertain if the Diabetes Mellitus occurred with or with out weight gain. The prevalence of hypertriglyceridemia is 38.89 %. However no figures are available for comparison with the general Malaysian population. Also we did not take into account if patients were on lipid lowering agents when conducting our study. This finding may be attributable to either the illness, medication or may be due to the weight- gain induced by the medication. The fact that Clozapine causes an elevation in serum triglyceride levels has been replicated in many studies (22, 33). Although these findings are preliminary annual monitoring of fasting blood sugar and serum lipid concentrations may be prudent in those patients receiving Clozapine. From the above results it is evident that Clozapine may contribute to the occurrence of cardiovascular disease. While these are important findings with potential clinical significance, these results must be viewed with caution due to certain limitations of our study.


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Some of the limitations of the study are listed below. As this is a cross sectional study the temporal relationship between the initiation of Clozapine treatment and the onset of the side effects cannot be studied. Prospective, case controlled studies may be better. The prevalence of Diabetes and hypertrigyceridemia may have been affected by the treating clinician’s knowledge of the side effects of the medication and of having avoided prescribing Clozapine to those patients who already had Diabetes Mellitus and hypertriglyceridemia. This may have contributed to the low prevalence of Diabetes Mellitus in our study. Reference 1. Allebeck P. Schizophrenia: A Life Shortening Disease. Schizophr Bull. 1989; 15(1):81-90. 2. Marder SR, Essock SM, Miller AL, et al. Physical Health Monitoring Of Patients With Schizophrenia. Am J Psychiatry. 2004; 161:1334-1349. 3. Lambert TJ, Velakoulis D, Pantelis C. Medical Comorbidity In Schizophrenia . Med J Aust .2003; 178 (9 Suppl): 67-70. 4. Davidson S , Judd F ,Hocking B, Thompson S ,Hyland B. Cardiovascular Risk Factors For People With Mental Illness. Aust N Z J Psychiatry . 2001; 35(2):196-202. 5. Brown S, Birtwistle J, Roe L,Thompson C. The Unhealthy Lifestyle Of People With Schizophrenia. Psychol Med 1999; 29(3): 697-701.

6. Baldwin J .A. Schizophrenia And Physical Disease. Psychol Med. 1979; 9 : 611-618. 7. Mukherjee M, Schnur D and ReddyR. Family History Of Type Two Diabetes In Schizophrenic Patients. The Lancet. 1989; 495. 8. Silverstone T, Smith G and Goodall E. Prevalence Of Obesity In Patients Receiving Depot Antipsychotics. Br J Psychiatry. 1988 ;153: 214-217. 9. The Health Consequences Of Overweight And Obesity. J Of The Royal College Of Physicians Of London. 1983; 17 (1); 6-17. 10. Mukherjee S, Decia P, Bocola V, Saraceni F and Scapicchio P.L . Diabetes mellitus In Schizophrenic Patients. Compr Psychiatry. 1996; 37(1): 68-73. 11. Tabata H, Kikuoka M, Kikuoka H, Bessho H ,Hirayama J, HanabusaT et al. Characteristics Of Diabetes Mellitus In Schizophrenic Patients. J Med Assoc Thai. 1987; 70(2): 90-93. 12. Finney G. Juvenile Onset Diabetes and Schizophrenia? The Lancet; 1989. 13. Hagg S, Joelsson L , Mjorndal T, Spigset O, Oja G and Dahlqvist R. Prevalence of Diabetes And Impaired Glucose Tolerance In Patients Treated With Clozapine Compared With Patients Treated With Conventional Depot Antipsychotics. J Clin Psychiatry. 1998; 59 (6): 294-299.


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14. Haupt DW , Newcomer JW. Hyperglycemia And Antipsychotic Medications. J Clin Psychiatry. 2001; 62 Suppl 27:15-26. 15. Michael S, Douglas L, Renato D, Miklos F and Rosenheck R. The Association Of Diabetes Mellitus With Use Of Atypical Neuroleptics In The Treatment Of Schizophrenia. The Am J Psychiatry 2002; 159(4): 561-566. 16. Bustillo J, Buchanan R, Irish D and Brier A .Differential Effect Of Clozapine On Weight: A Controlled Study. The Am J Psychiatry. 1996 ; 153: 817-819. 17. Allison D, Mentore J , Heo M, Chandler L ,Cappelieri J, Infante M and Weiden P. Antipsychotic Induced Weight Gain: A Comprehensive Research Synthesis. Am J Psychiatry 1999; 156:1686-1696. 18. Baptista T . Body weight gain induced by antipsychotic drugs: mechanisms and management. Acta Psychiatr Scand. 1999; 100(1): 3-16. 19. Hong, Chen- Jee ab, Ching Hua c, Younger W-d , Chang, Su Chenc, Wang, Shu- Ying a; Tsai, Shih-Jen ab. Genetic Variant Of The Histamine- 1 Receptor And Body Weight Change During Clozapine Treatment. Psychiatr Genetics 2002: 12 (3): 169-171. 20. Leadbetter R, Shutty M, Pavalonis D ,Vieweg V, Higgins P and Downs M. Clozapine Induced Weight Gain: Prevalence And Clinical Relevance. Am J Psychiatry 1992; 149:68-72.

21. Baldessarini R.J and Frankenburg F. Drug Therapy. A Review Article. N Eng J Med. 1991; 324 (11) : 746-754. 22. Henderson D ,Cagliero E, Gray C, Nasrallah R, HaydenD, Schoenfeld D and Goff D. Clozapine, Diabetes Mellitus, Weight Gain, and Lipid Abnormalities: A five –year Naturalistic Study. Am J Psychiatry. 2000; 157: 975-981. 23. Kane J, Honingfeld G, Singer J, Meltzer H. Clozapine For The Treatment Resistant Schizophrenic: A Double Blind Comparison With Chlorpromazine. Arch Gen Psychiatry. 1988; 45:789-796. 24. Peter L, Brown S, Hailey A. Prevalence Of Obesity, Lipid and Glucose Abnormalities In Outpatients Prescribed Clozapine. Irish Med J. 2002; 95 (4 ): 1-4. 25. Koller E, Schneider B, Bennet K, Dubitsky B. Clozapine Associated Diabetes. American J Medicine. 2001; 111 (9):716-723. 26. Brian C, Lund; Paul J. Perry; John M Brooks; Stephen Ardnt. Clozapine Use In Patients With Schizophrenia And The Risk Of Diabetes Mellitus , Hyperlipidaemia And Hypertension : A Claims Based Approach. Arch Gen Psychiatry. 2001; 58(12): 1172-1176. 27. Ghaeli P, Dufresne R L. Serum Triglyceride Levels In Patients Treated With Clozapine. Am J Health –Syst Pharm. 1996; 53: 2079-2081.


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28. Gaulin B D, Markowitz J S , Caley C F ,Nesbit LA and Drufesne RL. Clozapine- Associated Elevation In Serum Triglycerides. Am J Psychiatry. 1999; 156(8): 1270- 1272. 29. Report Of The Second National Health And Morbidity Survey Conference. Nov 1997. Published By Ministry Of Health Malaysia: Nutritional Status Of Adults. 30. Report Of The Expert Committee On The Diagnosis And Classification Of Diabetes Mellitus (American Diabetes Association: Clinical Practice Recommendations 2003: Committee Report) Vol. 26 supp.1January 2003.

31. Homel P, Casey D, Allison DB .Changes In Body Mass Index For Individuals With And Without Schizophrenia, 1987-1996. Schizophr Res. 2002; 1;55(3):277-284. 32. Hummer M, Kemmler G, Kurz M, Kurzthaler I, Oberbauer H, Fleischhacker WW. Weight Gain Induced By Clozapine. Eur Neuropsychopharmacol. 1995; 5(4):437-440. 33. Meyer JM,. MD. Novel Antipsychotics and Severe Hyperlipidemia. Journal Of Clin Psychopharmacology. 2001; 21(4): 369-374.

Address for Correspondence: Dr. Sharmilla Thanasan, Department Of Psychological Medicine, Pusat Perubatan University Malaya, Lembah Pantai. 59100 Kuala Lumpur.


46

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 Failure to attract sufficient residents to specialize in the field of psychiatry is a growing concern in many countries (1). This trend is partly attributed to the negative attitudes of medical students towards psychiatry. Some of the factors

that contribute to this negative attitude include lack of scientific rigor in the discipline, non efficacy of treatment, low social status among other disciplines and poor financial returns (2). In addition the misconceptions about psychiatry may also arise from negative social stigma that


47

prevails towards the profession in general, psychiatrists and patients (3). There is some evidence to support that psychiatric education in medical school may change the opinions of students in a favorable direction, though one is not certain whether the changes remain permanent (4). Though the impact of clerkship, in general, has been found to be positive, a recent study failed to bring out any significant change in the attitudes of students following the clerkship (3). It is also realized that the quality of medical education is a crucial factor in motivating students to choose psychiatry as a career (5). Training that focuses on knowledge acquisition, usefulness of psychiatric interventions, direct contact with patients and liaison activity with other medical departments is likely to yield better results (6). If positive attitudes are built it is expected that more students would opt for specialization in psychiatry (7). But this has not been confirmed (8). This shows that positive opinions need not lead to an action. It is also possible that the improvement may be temporary and the desire to specialize in psychiatry may wane following exposure to other medical disciplines. In spite of various constraints, the social image and general opinion towards psychiatry is improving (9). The objective of this study is to assess the impact of psychiatry training program on the attitude towards psychiatry of undergraduate medical students. It is hypothesized that exposure to the subject may cause positive changes in attitudes of students. Methods The AIMST University, Malaysia offers a

six week structured psychiatry training program for medical undergraduates. Out of a total of 181 hours, 120 hours are devoted to clinical practice rotation and 15 hours for lecture classes. The remaining 46 hours are used for symposia, problem-based learning, tutorial classes and directed self-learning activity. The subjects who participated in this study were medical undergraduates at AIMST University who received training in psychiatry from July 2007 to Nov 2007. The only selection criterion applied was that they should have attended both theoretical and clinical training classes in psychiatry during the term. In this study, a modified version of Balon’s questionnaire (10) was used. The questionnaire explores six main areas: i) overall merits, ii) efficacy, iii) role definition of functioning of psychiatrists, iv) possible abuse and social criticism, v) career and personal reward and vi) specific medical school factors. Twenty three questions falling under main areas (i) to (v) were chosen for administration. Area (vi) was felt inappropriate to administer as it is concerned with the outcomes after the training, and students would not be in a position to respond at the start of the program making it inconsistent with the before-after design of this study. A written explanation of the purpose of the study preceded the main questionnaire. Students completed the same questionnaire before and after completion of their training. Students were assured of anonymity of responses and failure to participate in the study did not involve academic and /or social risks. In view of these conditions, returning a questionnaire was considered to be indicative of informed consent.


48

3

Compliance was reasonably good and only a small number of questionnaires had missing data. Statistical analysis was performed using SPSS Version 13. The data was converted to relative percentages excluding the missing answers. Wilcoxon test for proportions was used for comparison. Results The index group consisted of 116 students of which 91 participated in the initial assessment and 89 returned the

questionnaire after the completion of training. These two were considered dropouts. Participants included 43 male and 46 female respondents. As shown in Table 1, positive opinions regarding the overall merits of psychiatry got further strengthened following the training. They more strongly supported the view that psychiatry is a rapidly expanding frontier of medicine and psychiatric research has made good strides in advancing care of major mental 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 disorders

25. 8

58.3

13.9

2.0

46.9

42.5

6.7

3.8

3.8

0.0001

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 imprecise

7.9 36.0 38.3 17..8 2.6 24.5 41.1 31.8 3.45 0.0005

SA –Strongly agree, MA –Moderately agree, MD –Moderately disagree, SD- Strongly disagree The students’ opinion concerning efficacy also changed. Table 2 indicates that the students agreed that psychiatric consultation may be more helpful for medical and surgical patients.

However there was a negative shift in the belief that psychiatric treatment in general is helpful to most people who receive it.

Table 2: Efficacy Before training After training

No Question SA MA MD SD SA MA MD SD Z sig

4

If someone in my family was very emotionally upset and the situation did not seem to be improving ,I would recommend a psychiatry consultation

74.2

19.9

5.3

0.6

69.4

25.4

3.4

1.7

-1.2

ns

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 people who receive it.

27.4 60.0 11.3 1.3 11.3 58.4 28.3 1.9 -1.9 0.05

SA –Strongly agree, MA –Moderately agree, MD –Moderately disagree, SD- Strongly disagree


49

There were not very significant changes in the attitude of students regarding the role definition and functioning of a psychiatrist.

After the training a greater proportion of students regarded psychiatrists as clear and logical thinkers. (Table 3)

Table 3: Role definition and functioning of psychiatrist Before training After training

7 Psychiatry is not a genuine and valid

branch of medicine 2.6 7.9 23.2 66.3 2.9 6.5 24 66.4 0.46 ns

8 Most psychiatrists are clear and logical thinkers

7.3 55.6 27.8 9.3 26.8 55.8

15.6 2.3 3.21 0.001

9 With few exceptions, clinical psychologist and social workers are just as qualified as psychiatrist to diagnose and treat emotionally disturbed persons

30.5 43.7 15.2 10.6 28.0 40.6 18.2 13.2 -0.9 ns

10 Among mental health professionals psychiatrist have the most authority and influence

38.4 24.7 26 11.3 39.8 22.6 29.0 8.6 0.51 ns

11 Psychiatrist are too frequently apologetic while teaching psychiatry

6.8 26.1 37.4 29.7 5.5 22.2 39.7 32.6 0.40 ns

12 Psychiatry is too biologically minded and not attentive enough to patients personal life and psychological problems

38.4 24.7 26 11.3 39.8 22.6 29.0 8.6 -0.4 ns

13 Psychiatry is to analytical, theoretical, and psychodynamic and not attentive enough to patients physiology

7.7 25.2 54.5 12.6 5.8 24.5 49.5 20.1 -0.5 ns

After completion of training students were less inclined to believe that psychiatrists make as much money as

most other doctors. No change in attitude was noticed regarding abuse of power. (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 against their will

6.4

14.3

35.0

44.3

5.2

15.5

32.1

47.2

-0.3

ns

15 On average ,psychiatrists make as much money as most other doctors

11.1 51.3 28.2 9.4 9.3 39.4 36.6 14.7 -2.3 .05




50

At the end of clerkship, the students reported a more favorable attitude concerning the prestige enjoyed by the discipline among the general public. The fear of being branded as odd or neurotic for the interest in psychiatry became significantly less after the training. But training did not seem to have improved

the status of psychiatry as compared to other medical disciplines. Students at the end of training also felt that the family exerted a significant negative influence in the choice of psychiatry as a specialty. (Table 5)

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

the general public

24.5 39.8 22.4 13.3 10.3 10.1 39.6 39.6 -3.3 .001

17 Psychiatry has high status among other medical disciplines

3.6 16.1 53.2 28.1 4.4 18.0 39.6 37.9 0.51 ns

18 Many people who could not obtain a residency position in other specialties eventually enter psychiatry

2.9 19.7 39.4 38.0 3.8 26.3 37.4 32.6 0.43 ns

19 Psychiatry is a discipline filled with international medical graduates whose skills are of low quality

3.6 15.1 53.2 28.1 4.4 18 39.6 37.9 0.23 ns

20 My family discouraged me from entering psychiatry

5.7 9.2 17.7 67.4 10.3 15 25.3 49.4 2.27 0.05

21 Friends and fellow students discourage me from entering psychiatry

6.3 14.1 14.1 65.5 6.3 26.7 30.5 30.4 0.36 ns

22 If a student expresses interest in psychiatry, he or she risks being associated with a group of other would be psychiatrists who are often seen as odd, peculiar or neurotic

6.5

35.0

33.5

24.9

6.2

17.8

28.0

48.0

-3.3

.001

23 I feel uncomfortable with mentally ill patients

5.5 27.4 36 31.1 4.8 25.4 38.2 31.6 0.52 ns

SA –Strongly agree, MA –Moderately agree, MD –Moderately disagree, SD- Strongly disagree Discussion The results show that some of the attitudes have changed in a favorable direction. Psychiatry has long been carrying an image that it is imprecise and unscientific. This study shows that training in psychiatry leads to

appreciation that the discipline does not lack scientific basis and it has far more to offer in terms of research. The training appears to have strengthened the views in a positive direction. These findings are supported in other studies indicating opinions on psychiatry have improved. (3, 11)


51

The opinion of students regarding efficacy of treatment appear uncertain. While conceding that psychiatry referrals for medical and surgical patients are often helpful, they were not certain about the efficacy of treatment in general. The training program organized for the students could have considerably influenced the opinion on this aspect. The students have no liaison experience with other medical specialties and minimal exposure to non psychotic conditions such as panic disorder, depression and obsessive compulsive disorder. While treating chronic psychotic illnesses unlike other medical illnesses, the therapeutic gains are slow and barely visible and this may very well explain the nihilism expressed by the students. A significant proportion of students have changed their opinion and regarded psychiatrists as clear and logical thinkers. The undergraduate psychiatry education over the years has undergone several changes and evidence based medicine has brought in clinical algorithms adding more clarity to teaching the subject. The mysticism surrounding the subject over the years has been replaced by empiricism. A significant change concerning income prospects was observed before and after training. Following training they were less likely to think that psychiatrists make as much money as most other specialist doctors. The training in psychiatry is sandwiched between ophthalmology and orthopedics in this medical school. Choice of surgical specialities has been significantly correlated with better income prospects. This reality might have influenced the opinion of the students regarding income prospects. There is a significant positive change about the

social prestige of the discipline. Students were inclined to view that psychiatry enjoyed a respectable image among the general public. It has been amply demonstrated in other studies that a perceived low social prestige can be altered by educational experience. (12) Despite improvement in its general standing, many believed that psychiatry does not enjoy a high status among other disciplines and this trend persisted during the training. This brings into focus the role of practical integration of psychiatry with other disciplines in the form of liaison work. If an essential role of a psychiatrist is built into an interdisciplinary team approach to medical and surgical cases, it is bound to enhance the image of psychiatry among other disciplines. There is a significant change in the way the students perceived the family’s reaction for considering psychiatry for further specialization. The level of discouragement expressed by the family was perceived to be greater following the completion of training. The reason is not very clear although it can be presumed that it is due to the stigma attached to psychiatry as a profession. Peer pressure, on the contrary, seemed to have lessened following the training proving that exposure to scientific training can induce more balanced views. Expressions such as odd, peculiar and neurotic were less used in reference to psychiatrists. This study has some limitations. The data has been obtained from one batch of students from a single medical school. This limits the generalization of the findings.


52

A little less than 25% of the students did not participate in the study. Among the strengths of the study, barring two students, all others participated in the evaluation before and after the training. This adds support to the findings of the study. The training program is highly structured with minimal chances for deviation. Conclusions The students of today will be (non) psychiatrists tomorrow and they will be in a position to influence the attitudes of their own students. In this context education in psychiatry needs to undergo revision. The focus should be on a bio-psychosocial model and this is to be accomplished through liaison activity with other disciplines. The psychiatrist may be required to be an effective role model to alter the image of psychiatry among other medical professionals. Acknowledgements The authors thank Batch 5&6 medical students of AIMST University for their participation in the study. References 1. Sierles FS,Taylor MA. Decline of U.S medical student career choice of psychiatry and what to do about it. Am J Psychiatry1995;152:1416-1426 2. Bulbena A,Pailhez G,Coll J,Balon R. Changes in the attitude towards psychiatry among Spanish medical students during training in psychiatry. Eur J Psychiatry 2005; 19:79-87

3. Fischel T, Mana H, Krivoy A, Lewis M, Weizman A. Does a clerkship in psychiatry contribute to changing medical students’ attitudes to psychiatry? Acad Psychiatry 2008; 32:147-150 4. Wilkinson DG,Greer S, Tone BK Medical students’ attitudes to psychiatry. Psy Medicine1983 ; 13:185-192 5. Nielsen AC. Choosing psychiatry: The importance of psychiatric education in medical school .Am J Psychiatry 1980;137:4 6. Alexander DA,Eagles JM. Changes in attitudes towards psychiatry among medical students: correlation of attitude shift with academic performance. Medical Education 2003:37:447 7. McParland M, Noble LM, Livingstone G, McManus C. The effect of a psychiatric attachment on students’ attitudes to and intention to pursue psychiatry as a career. Med Edu 2003;37:447-454 8. Sivakumar K, Wilkinson G, Tonne BK, Greer S. Attitudes to psychiatry in doctors at the end of their first post-graduate year: two year follow-up of a cohort of medical students. Psy Medicine 1986; 16:457-460 9. Pailhez G, Bulbena A, Coll J Ross S, Balon R. Attitudes and views on Psychiatry: A comparison between Spanish and U.S. medical students. Academic Psychiatry 2005;29: 82-91 10. Balon R, Franchini GR, Freeman PS, Hasenfeld IN, Keshavan MS et al. Medical students attitudes and views of psychiatry: 15 years later.Academic psychiatry1999; 23: 30-36


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11. Garryfallos G, Adamopoulu A, Lavrentiadis G, Giouzepas J, Parashos A et al.. Medical students’ attitudes towards 12. Psychiatry in Greece: An eight-year comparison. Acad Psychiatry 1998;

22: 92-97, Feifel D, Moutier CY, Swerdlow NR. Attitudes toward psychiatry as a prospective career among students entering medical school. Am J Psychiatry 1999:156:1397-1402.

Corresponding author: Dr. Chandrasekaran Ramamurthy , MD Professor , School of Medicine, AIMST UNIVERSITY, Jalan Bedong, Semeling , Kedah 08100

Phone no: 0164138739 Email: [email protected]


54

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 The prevalence of eating disorders such as anorexia and bulimia nervosa is low; that is between 1-2% of the worldwide

population and these conditions are rarer in Asia than it is in the west1. The presence of these disorders is more significant in certain groups of community such as in athletes, young


55

females and those in the higher socioeconomic society 2, 3. In Malaysia, there is insufficient data on the prevalence of eating disorders especially among adolescents and children. Even studies related to eating habits are scarce due to unavailability of screening or measuring tools. Thus it is crucial that a well-validated and culturally-accepted questionnaire for the Malaysian population is developed. Constructing a locally adapted questionnaire would establish a path for future studies on eating habits and indirectly inculcate better mental health services for children and adolescents in general. The characteristics of a good tool are convenient yet comprehensive in which it should be able to measure various aspects related to eating habits such as anorexic and bulimic behaviours and body disfigurement. There are several questionnaires designed to analyse abnormal eating habits such as the Eating Attitudes Test (EAT–26) 4, the Eating Disorder Inventory (EDI-2) 5, the Three Factors Eating Questionnaire (TFEQ) 6, the SCOFF questionnaire, the Eating Disorder Examination (EDE) interview7 and the Eating Disorder Examination Questionnaire (EDE-Q) 8. Studies had shown that there is a good level of agreement between the interview version of Eating Disorder Examination (EDE) and Eating Disorder Examination Questionnaire (EDE-Q) except in behavioural binge eating 9,10. The EDE-Q is a self-report version of a 36-item questionnaire derived from and scored in the same way as the interview schedule6 As the EDE interview schedule requires training and can be

time consuming, it is not practical and quite costly to administer to a big group of people. Alternatively, as the EDE-Q is a self-administered questionnaire, it requires little training, is relatively inexpensive and is less time consuming. It can be administered in a group format 11. As the self-administered EDE-Q is more feasible for epidemiological study, it was chosen to be validated in this study. This 36-item instrument generates four subscale scores (i.e. Dietary Restraint, Eating Concern, Shape Concern and Weight Concern) as well as a global score which is the mean of the four subscales. Each subscale item is rated on a seven point system (0–6), with higher scores indicating greater frequency or severity. Objective The main objective of this study is to conduct a cross-cultural adaptation of the EDE-Q and to assess the reliability and validity of the Bahasa Malaysia version in Malaysian population. Methods Study Design: This study was funded by the Ministry of Health Malaysia (MOH) under the MOH grant. It was a multi-centred, cross-sectional study, involving four secondary schools (i.e. SMK Taman Maluri, SMK Puteri Titiwangsa, SMK Seri Titiwangsa, SMK Setapak Indah). Within each school, the participants were selected by stratified quota sampling to represent the Malaysian population with ratio of race, gender and academic performance as main


56

considerations. The study population consisted of adolescents, aged 12 to 17 years old that fulfilled the inclusion criteria. Consent was obtained from parents and participants. The study commenced in June 2006 and ended in December 2007. The full protocol was approved by the Ethics Committee of Clinical Research Centre Kuala Lumpur Hospital. All parents and subjects that participated in the study were asked to provide informed consent. The schools were selected based on the student distribution which should reflect the actual Malaysian population. Vernacular schools or schools with one predominant ethnic group were excluded. Study Process The study was divided into four phases. Phase 1 was the translation process where two forward and two backward translations of the original EDE-Q English version were carried out. One arm consisted of two independent bilingual medical experts while the other arm comprised of two blinded bilinguistic experts. This process was carefully done in order to ensure that there would be no alteration in the meaning, removal or addition in the sentences of the original English EDE-Q. The BM version at this phase was labelled as Pre-final BM EDE-Q. Phase 2 was intended to check for equivalence between the original English EDE-Q and pre-final BM EDE-Q. The product at the end of this process underwent pre-test using a probe technique. This pre-test

was conducted on eight bilingual first-year medical students based on a focused group discussion. Phase 3 was an expert panel review. Pre-final BM EDE-Q 2 was reviewed by an expert panel to further improve the BM version of the EDE-Q and to evaluate the clarity, understandability, naturalness and adequacy of wording. Phase 4 was the reliability and validation process. For validation of the final BM version of EDE-Q, construct validity was done. The reliability of the instrument was examined using internal consistency looking at the Cronbach’s alpha values. The participants’ recruitment was integrated with the validation effort of the Family Environment Scale (FES) questionnaire. Results A total of 298 students from four schools were selected in this study and we managed to attain reasonably heterogeneous subjects to fit the socio-demographic profiles. Majority of the respondents were Malays (63.4%), followed by Chinese (28.2%) and Indians (6.7%), which corresponded to the Malaysian population (i.e., Malays – 54.1%; Chinese – 25%, Indians – 7.5% and from other races – 13.2%; as based on the 2005 census of the Department of Statistics, Malaysia)12. Statistically significant differences were noted for the global score of the EDE-Questionnaire with regards to gender, ethnicity and religion but not for the other variables (Table 1).


57

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 14-15 16-17

21(7.0)

173(58.0) 104(34.9)

Race Malays Chinese Indians & others

189 (63.4) 84(28.2) 25 (8.4)

10.7 7.9

13.7

8.1 8.4 7.1

< 0.001

Gender Male Female

141 (47.3) 157 (52.7)

7.9

11.9

7.4 8.5

< 0.001

Religion Islam Christian Hinduism Buddhism Others

195 (65.4) 11 (3.7) 17 (5.7)

73 (24.5) 2 (0.7)

10.8 8.9

13.5 7.5

8.1

12.4 7.3 7.7

< 0.001

Academic achievement Excellent Average Poor

36 (12.1) 225 (75.5) 37 (12.4)

19.2 10.1 12.8

9.4 9.5

10.2

0.373

Parents’ Marital status Married/living together Divorced/separated No answer

267 (89.6) 24 (8.1) 7 (2.3)

9.9 11.4

8.3 8.6

0.253

Parents’ Income < RM 1000 RM 1001-5000 > RM 5000 Don’t know

75 (25.2) 117 (39.3) 30 (10.1) 76 (25.5)

11.5 11.4 11.0

9.1 8.1 7.4

0.700

Mother’s Educational level Primary school Secondary school Tertiary education Don’t know

20 (6.7)

120 (40.3) 54 (18.0) 104 (34.9)

13.0 10.7 9.8

8.5 9.3 7.5

0.226

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 Secondary school Tertiary education Don’t know

19 (6.4)

95 (31.9) 71 (23.8) 113 (37.9)

10.9 11.1 9.8

7.3 9.5 7.5

0.871

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 The Bahasa Malaysia version was found to have a high internal consistency with global Cronbach’s alpha of 0.879. The participants were highly consistent in their responses throughout the questionnaire. The version was further evaluated based on its original four sub-scales. A greater consistency was found in Shape Concern domain (0.874), followed with Weight Concern (0.775),

Eating Concern (0.655) and Restrain (0.635). Validity test

The construct validity was evaluated by using confirmatory factor analysis (CFA). The Keiser value of 0.890 with cumulative variances of 59.9% was yielded.

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

1 Restrain

Factor 2 Shape concern

Factor 3 Eating concern

Factor 4 Weight 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 analysis of all items managed to draw four unforced factors. Table 2 shows that all items except items 9, 21, 22, 24 and 25 had CFA values of more than 0.3 for their original subscales. The confirmatory factor analysis with eigenvalues over 1 and unforced factor managed to draw 4 domains.

Discussion In general this study achieved its general objective of testing the cross-cultural adaptation of the BM version of the EDE-Questionnaire to the Malaysian teenage population. The constitution of participants represented the Malaysian population with respect to gender and racial distribution based on the 2005 census of the Department of Statistics, Malaysia12. A balance between the subjects in this study and the actual Malaysian population was achieved as schools’ student distribution and subjects’ selection were taken into consideration. Schools with multiracial students and quota sampling on subjects were based on ethnic groups. However we advocate the effort of future validation efforts of this BM version among the general adult group.

The BM version of EDE-Q produced at the end of this project had very good reliability in which the global internal consistency for the BM EDE-Q was high with all the subscales showing consistently good results. The Cronbach’s alpha ranged from 0.63 to 0.87 which were comparable to other studies which had values between 0.70 and 0.93 based on various types of community. 9, 13, 14

The translation process was conducted

with extreme care according to a strict guideline. Responses from participants during pre-test and validation phase were favourable as the terms and sentences used were clear. Nevertheless confirmatory factor analysis yielded modest favourable results as only five items had CFA values below than 0.3 for their original subscales. Items 22, 24, 25 were clearly measuring weight but the result showed these items to have had better factor loading for Shape and Restrain subscales. Minor discrepancies in comparison to the results garnered by the original author 11 may be attributed to various reasons.

Firstly, the original English EDE-Q itself is still in expansion stage. Of late, more studies were done to explore the psychometric behaviours of EDE-Q. Based on the EDE-Q brief preliminary report, item 8 belonged to two subscales (i.e. Shape Concern and Weight Concern). Item 10 (fear weight gain) clearly involves issue pertaining to weight but it belongs to Shape Concern subscale. Therefore results of this study would add more value to the behavioural aspect of all items particularly related to the Asian context.

Secondly, the variation of certain items belonging to different subscales as compared to the original version was most likely due to the differences in the socio-cultural nature of the Malaysian and Caucasian populations. In particular, people’s view and concept about patterns of eating habits may be different from one culture to another. This is evidenced by the different prevalence in eating disorders among various populations 15, 16. In different health care systems, the definition and the importance given to health and diseases


60

vary and this is linked to the cultural setting. Inter-country comparisons should use standard measures in assessing health status equivalently rather than identically over cultural differences 13.

Thirdly, the subjects in this study were Malaysian adolescents and this group may respond differently to the BM translated version of the EDE- Questionnaire than adults.

Nevertheless the original EDE-Q is suitable and has been tested on a young adolescent population17. Other favourable feature that we found in this study is that the construct validity reproduced and confirmed that there are four factors or subscales in this questionnaire. This is in line with results from other studies where consistent findings of four factors were found 17,18.

Further research may help us to entrench our understanding of the psychometric values of this version particularly with different groups of subjects. Studies on the consistency and level of agreement between self-rated questionnaire and clinical interview have high psychometric value in making it more colloquial to the general Malaysian population.

Conclusion

The translation and validation efforts produced quite acceptable outcomes. The different socio-cultural background of the studied population could explain the non-identical subscales of the BM version in comparison with the original EDE-Questionnaire. As a result of the distinct multi-racial as well as the different socio-culture in comparison

with the Caucasian population, an equivalent questionnaire would perhaps be more appropriate than an identical questionnaire.

Acknowledgement

We extend our heartfelt gratitude to the Clinical Research Centre, Ministry of Health Malaysia for grant conferment and for providing dedicated research assistants; Ms. Norwani, Ms Gunavathy Selvaraj, Ms. Husna and Ms. Azdayanti who had given their endless kind cooperation.

References

1. Markey CN, Markey PM. Relations between body image and dieting behaviours: An examination of gender differences. Sex Roles. 2005; 53(7/8):519-530.

2. Bulik CM, Reba LBA, Siega-Riz AM, Kjennerud RT. Anorexia nervosa: Definition, epidemiology, and cycle of risk. International Journal of Eating Disorders. 2005; 37(1):2-9.

3. Dotti JC. Eating Disorders, Fertility, and Pregnancy: Relationships and Complications. Journal of Perinatal & Neonatal Nursing. 2001; 15(2):36-48.

4. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine. 1982; 12:871-878.

5. Garner DM, Olmsted MP, Polivy J. Development and validation of a multidimensional Eating Disorder Inventory for anorexia nervosa and bulimia. International Journal of Eating


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Disorders. 1983; 2:15–34.

6. Yeomans MR, Tovey HM, Tinley EM, Haynes CJ. Effects of manipulated palatability on appetite depend on restraint and disinhibition scores from the Three-Factor Eating Questionnaire International Journal of Obesity. 2004; 28(1):144-151.

7. Fairburn CG. Cooper Z. The Eating Disorder Examination (12th ed.). In C.G.Fairburn & G.T. Wilson (eds.), Binge eating: Nature, assessment and treatment 1993; 317-360. New York: Guilford Press.

8. Kristine H. Luce, Janis H. Crowther. The reliability of the eating disorder examination - Self-report questionnaire version (EDE-Q) International Journal of Eating Disorders. 1999; 25(3):349–351.

9. Luce KH, Crowther JH. The reliability of the eating disorder examination – self report questionnaire version (EDE-Q). International Journal of Eating Disorder, 1999; 25:349-351.

10. Black CMD, Wilson GT. Assessment of eating disorders: Interview vs. questionnaire. International Journal of Eating Disorders, 1996; 20:43–50.

11. Fairburn CG, Beglin SJ. The assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders. 1994; 20:43-50.

12. Department of Statistics, State/District Data Bank, Malaysia; 2005.

13. Mond JM, Ha P J, Rodgers B, Owen C, Beumont PJV. Validity of the eating disorder examination questionnaire (EDE-Q) in screening for eating disorders in community samples. Behaviour Research and Therapy. 2004; 42(5):551-567.

14. Rizvi SL, Peterson CB, Crow SJ, Agras WS. Test-retest reliability of the Eating Disorder Examination. International Journal of Eating Disorders. 2000; 28:311–316.

15. Rosen DS. Eating disorders in children and young adolescents: Etiology, classification, clinical features, and treatment. Adolescent Medicine. 2003; 14:49–59.

16. Engström I, Kroon M, Arvidsson CG, Segnestam K, Snellman K. Eating disorders in adolescent girls with insulin-dependent diabetes mellitus: A population-based case-control study. Acta Paediatrica. 1999; 88:175–180.

17. Carter JC, Stewart DA, Fairburn CG. Eating disorder examination questionnaire: norms for young adolescent girls. Behaviour Research and Therapy. 2001; 39:625-632.

18. Mond JM, Hay PJ, Rodgers B, Owen C, Crosby R, Mitchell JE. Use of extreme weight control behaviors with and without binge eating in a community sample of women: Implications for the classification of bulimic eating disorders. International Journal of Eating Disorders. 2006; 39:294–302.


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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


63

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 The life expectancies of women in both developed and developing countries are increasing with improved health services and living conditions. The life expectancy of Malaysian women was 75.2 years in 2001 compared to 65.6 years in 1970. 1,2 Today, women are exposed to large amounts of stress. 3 The stress of taking care of young children, having an unstable marriage, or working full time while still being responsible for the house and family. 3 Women are usually the primary caretakers for both young and old, often under financial strain or outright poverty. Many women focus so much on caring for others that they do not attend to themselves. Their own well-being takes a distant second to the needs of others. All these affect the mental health status of women making them vulnerable to develop mental health problems, namely depression. 4 Poor mental health status is a major health problem that occurs more commonly in women. 5 Over the course of a lifetime, depression, which is a common mental health disorder occurs in approximately 20% of women compared to 10% of men. This statistic is the same regardless of country or race or economics. 5 Married women have higher rates of depression than unmarried women, with rates peaking during the childbearing years. Depression occurs most frequently in women 25-44 years of age. Reasons why women are at increased risk for poor mental health status are biological factors such as hormonal changes and genetics, physiological factors such as body weight, and social factors such as

stresses from work, family responsibilities and poverty. 6 Studies in Malaysia have shown that the prevalence of mental health problems, which consists mainly of depression are higher in women than in men. 7 However, not many studies have been done on mental health status of women despite women nowadays being very much exposed to stress. This study hopefully can provide information on the mental health status of women in Malaysia, as well as make recommendations for the improvement of mental health. The objective of this study was to determine the prevalence of depressive symptoms among adult women in Selangor, as well as to identify the potential risk factors that may cause depression. Method This community based cross sectional study was conducted in Selangor in July 2004, for a duration of 4 weeks. All districts were included. Multi stage stratified proportionate to size sampling method was used to select households in each district. All women aged 20-59 years old in the selected households were included in this study and were contacted via home visit. This age group was chosen so that only adult women were included in this study, and not children, adolescents and elderly. Non-Malaysian citizens were excluded from this study. A standardized pre-tested structured questionnaire was used by trained personnel to collect data from the respondents via face-to-face interview.


65

The questionnaire consisted of 4 parts which consisted of questions on socio demography (age, ethnicity, religion, education level, occupation and monthly income), marriage profile, obstetrics and gynaecology history, and the Patient Health Questionnaire (PHQ-9) which was used to determine the presence or absence of depressive symptoms. The Patient Health Questionnaire (PHQ-9) was developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke and colleagues. It was developed from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ). It is a self-report questionnaire and consists of 9 questions that identify depressive symptoms. The PHQ Depression Severity Index score is used to calculate for the presence of depressive symptoms. 8 The questionnaire was translated and validated in Bahasa Malaysia. Pre-

testing was done in another location not included in the study. Data was analyzed using the computer program “Statistical Package for the Social Sciences” (SPSS) version 11.5. Descriptive statistics were used for all the variables studied. Pearson Chi-square, Odds ratio (OR) and 95% Confidence Interval (CI) were used to test the association and risk between each factor and depressive symptoms. Further analysis using multivariate logistic regression was also done to study the predictor outcome of the potential risk factors. Results Out of 1032 women, 972 agreed to participate in this study, giving a response rate of 94.2%. Age of the respondents ranged from 20-59 years old. The mean age was 37.91±10.91 and median was 38.00 (95% CI=37.22-38.60). The profile of the respondents is shown in Tables 1A and 1B.

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


66

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 depressive symptoms based on the PHQ-9 scores, giving a prevalence of 8.3%

among adult women aged 20 to 59 years old ..in.. this ..study.


67

Table ..2 shows. the association of depressive symptoms and socio demographic factors. Depressive symptoms were significantly associated

with education level (p=0.036), race (p=0.004) and religion (p= 0.001) of the respondents.

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 education had significantly higher prevalence of depressive symptoms compared to respondents who had formal education (p=0.036). The prevalence of depressive symptoms were highest among the Indians (13.2%) followed by other races (11.8%), Malays (7.9%) and Chinese (3.6%). Further

analysis found that the difference was significant between Malay vs Chinese (p=0.043), Malay vs Indian (p=0.021) and Chinese Vs Indian (p=0.001). The prevalence of depressive symptoms were also highest among the Hindus (14.6%) followed by Muslims (7.9%), Christians (4.5%) and Buddhist (3.0%). Further analysis found that the difference was


68

significant between Muslim vs Buddha (p=0.030), Muslim vs Hindu (p=0.005) and Buddha vs Hindu (p<0.001). Depressive symptoms were significantly associated with history of having a miscarriage within the last 6 months (p = 0.001) and difficulty in getting pregnant (p = 0.049). Other findings such as menstrual history and problems with mood (before and after menstrual periods) were not significant (p > 0.05).

Further… analysis… using ..multivariate logistic regression to study the association between depressive symptoms and selected associated factors found that history of having a miscarriage within the last 6 months and absence of formal education were potential risk factors for depressive symptoms among the respondents (Table 3).

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 Discussion This study found that the prevalence of depressive symptoms among adult women aged 20 to 59 years old was 8.3%. This finding is slightly lower compared to the study by Ialongo N et al who found that the prevalence of depression was about 11.4% among African-American adult women from years 1999-2000. 9

Depressive symptoms in this study were significantly associated with education level (p=0.036). The odd of having depressive symptoms was two times higher for women with no formal education compared to women who had formal education. Absence of formal education was also found to be a potential risk factor for depressive symptoms among women in this study. This finding is supported by a study done by Berenson et al (2003) who


69

found that women were at increased risk of moderate to severe symptoms of depression if they had not graduated high school. 10 Educational status determines the socio-economic level of a person and is significantly linked with occupational and financial status. Other studies in Malaysia have confirmed that low socio-economic status which is associated with no or low educational levels, unemployment, low income and financial problems are significantly associated with poor mental health status and depression. 11,12 This study also found that depressive symptoms was significantly associated with race (p = 0.004) and religion (p = 0.001), where the prevalence was highest among the Indians (13.2%) compared to other races, and Hindus (14.6%) compared to other religions. A study by Radziszewska et al (1996) among 3993 students in Los Angeles County and San Diego County found that ethnicity was significantly associated with depressive symptoms, with Asians having the highest prevalence of depressive symptoms, followed by Whites, Hispanics and African-Americans. The findings of this study highlighted the variation in the prevalence of mental disorders as a function of ethnicity and socioeconomic status. The data suggested that lower levels of socioeconomic status increase the risk for mental disorder. However, the link between SES and prevalence of mental disorder varies by the type of disorder and by ethnicity. 9 There was a significant association between depressive symptoms and history of having a miscarriage within the last 6 months in this study. The odds of having depressive symptoms was 5

times higher for women who had suffered a miscarriage within the last 6 months compared to women who did not suffer from any miscarriage. This was also found to be a potential risk factor for depressive symptoms among women in this study. Although there was also a significant association between depressive symptoms and difficulty of getting pregnant, further analysis did not find that infertility was a potential risk factor for depressive symptoms in this study. Studies have found that in women’s childbearing life, problems such as infertility and miscarriage are fairly common. Both are stressful and can make some women more vulnerable to depression.5 Swanson (2000) found that the women most at risk for depressive symptoms after miscarriage include women who do not conceive or give birth by 1 year after the loss. 13 Brier (1999) has described the risk of intense and long-lasting distress following miscarriage as higher if the woman strongly desired the pregnancy, waited a long time to conceive, or has no living children. 14 In conclusion, the findings of this study show that the prevalence of depressive symptoms among adult women aged 20 to 59 years old in Selangor was 8.3%. Factors found to be significantly associated with depressive symptoms were race, religion, education level, history of having a miscarriage within the last 6 months and difficulty in getting pregnant. Potential risk factors for depressive symptoms in these women were history of having a miscarriage within the last 6 months and the absence of formal education. The lower prevalence of depressive symptoms in this study could be due to


70

the higher socio-economic status and education level of the respondents in Selangor. Other studies in different states in Malaysia need to be done to obtain the overall prevalence of depressive symptoms among women in Malaysia. This result can then be compared to studies done in other countries. The characteristics of the groups with statistically higher prevalence of depressive symptoms also need to be further studied to assess their contribution to the burden of illness amongst these women. The main limitation of this study was that the questionnaire used (PHQ-9) had not been validated in the Malaysian setting. At present there are very limited questionnaires on depression which have been specifically validated in the Malaysian community. However, as a follow-up to this study, there is another study currently being conducted on the validation of depression questionnaires in government primary care clinics in Malaysia, and this includes the PHQ-9. As women are exposed to large amounts of stress due to the multiple roles they have to play as wife, mother daughter, employee or employer and so forth, factors associated with depressive symptoms among these women should be identified. It is important that depressive symptoms and its associated factors be identified early as depression can have severe effects on the sufferer’s quality of life if left untreated for extended periods. Acknowledgement This study was conducted using the Fundamental Research Grant from The Research Management Centre of Universiti Putra Malaysia.

References 1. Department of Statistics. Year Book of Statistics Malaysia 1999. Kuala Lumpur, 1999. 2. Department of Statistics. Vital Statistics Time Series Peninsular Malaysia 1911-1985, Kuala Lumpur, 1991. 3. Alexander JL. Quest for Timely Detection and Treatment of Women With Depression. Journal of Managed Care Pharmacy 2007;13(9):S3-S10. 4. Subhash CB, Shashi KB. Depression in Women: Diagnostic and Treatment Considerations. American Academy of Family Physicians, 1999. 5. Department of Mental Health and Substance Dependence, World Health Organization. Depression in Women (Part 2). Women’s Mental Health: An Evidence Based Review, World Health Organization, Geneva, 2000. 6. National Mental Health Association. Clinical Depression and Women. Alexandria, VA: National Mental Health Association,2000. http://www.nmha.org/ccd/support/factsheet.women.cfm 7. Report of the Second National Health and Morbidity Survey Conference, Kuala Lumpur,1997. 8. Spitzer RL, Kroenke K, Williams JB. Validation and utility of self-report version of PRIME-MD: the PHQ primary care study. JAMA 1999;282:1737-1744.


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9. Ialongo N, McCreary BK, Pearson JL, Koenig AL, Schmidt NB, Poduska J, Kellam SG. Major depressive disorder in population of urban, African-American young adults: prevalence, correlates, comorbidity and unmet mental health service need. J Affect Disorders 2004;79:127-136. 10. Berenson AB, Breitkopf CR, Wu ZH. Reproductive Correlates of Depressive Symptoms Among Low-Income Minority Women. Obstet & Gynecol 2003; 102:1310-1317. 11. Institute of Public Health (IPH). The.. .Second... National… Health... and Morbidity Survey 2006 (NHMS II), Vol 16. Kuala Lumpur: Ministry of Health Malaysia, 1999.

12. Wan Mohd Rushidi WM, Shakinah S, Mohd Jamil Y. Postpartum Depression: A Survey of the Incidence and Associated Risk Factors among Malay Women in Beris Kubor Besar, Bachok, Kelantan. Malaysian Journal Of Medical Sciences 2002; 9(1): 41-48. 13. Radziszewska B, Richardson JL, Clyde W, Flay BR. Parenting Style and Adolescent Depressive Symptoms, Smoking, and Academic Achievement: Ethnic, Gender, and SES Differences. J Behav Med 1996;19(3):289-305. 14. Freda MC, Devine KS. The Lived Experience of Miscarriage After Infertility. MCM, Am J MCN 2003;28(1):16-23.

Corresponding Address: Sherina Mohd Sidik, Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia. Email: [email protected]


72

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 Substance abuse has been prevalent in Malaysia for more than a century. In the early 20th century, the main drug of abuse was opium which was mainly consumed by Chinese immigrants who were introduced by the British colonialist to work in Malaya. In the later part of the 20th century,

consumption patterns changed where heroin became the abused substance of choice and Malays were the main ethnic group involved in heroin abuse compared to other ethnic groups (1, 2). By the later part of the 20th century, the prevalence of heroin abused increased substantially and this made the Malaysian government consider heroin


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addiction as a threat to national security. Early government response included: the formation of the national anti-drug task force to control trafficking and to rehabilitate heroin addicts, and legislation where mandatory death sentence was implemented for those who smuggled more than 15 grams of heroin (3). It is mandatory for heroin addicts found to be drug positive to undergo compulsory rehabilitation for two years (4). Up to 28 government drug rehabilitation centres, costing approximately RM 50 million were established, where each center accommodated up to 500 inmates at any one time (5). The centres, managed on a total abstinence philosophy however produced poor results. Reports showed that as high as 85% of heroin addicts relapsed after completing their rehabilitation at these centres (4, 6). In response to the poor results, substitute treatment with methadone was recently introduced as part of treatment programme for heroin addicts (7).……………………………. Challenges to treating heroin addiction in Malaysia- the past Heroin misuse contributes to complicated health and social problems to our country. Despite three decades of managing these problems, outcomes are unpromising and poor. Among the reported contributory factors are: (i) treatment policy which had been confined to a single treatment modality- the regimental rehabilitation programme, (ii) despite strong published evidence that addiction to drugs is a medical condition, earlier approach had totally ignored the medical therapeutic approach. The medical profession was

only recently invited to review the policy of treatment for heroin addiction in Malaysia (iii) the stigma of the illness and rehabilitation treatment which resulted in heroin users hesitant of seeking early treatment. Heroin users were reported to fear rejection by the community and of losing their freedom once they entered a rehabilitation programme (6-8). Thus, as a consequence of ineffective treatment approach, there has been a continually increasing number of infectious diseases among heroin users and an escalating incidence of HIV and/or AIDS in Malaysia (8). The Ministry of Health, Malaysia reported that the cumulative number of HIV infections up to December 2005 was 71,000 cases, where more than 10% cases were AIDS positive. Most of the HIV infected persons are males (82 %) aged 20-40 years (6). One of the requirements of rehabilitation was that a heroin addict needed to be placed as in-house resident for two years (3). This resulted in majority of heroin addicts being forced to resign or losing employment. At the end of 2 years, by the time they leave the centres, they lose the opportunity to work (2). This could be one reason why many of rehabilitation inmates resort to crime once discharged from in-house rehabilitation centres. Some heroin addicts reported that they perpetrated crime in order to support themselves and their families. However this is partially truthful as it was observed that many perpetrated crime to support their addictive heroin habit. This is because forced abstinence while in the rehabilitation centres do not cure the heroin addiction. Once discharged from


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the centres, and without strict abstinent enforcement, they relapse to their previous heroin usage (6-8). The types of crimes commonly perpetrated by heroin addicts included snatch theft, selling drugs, fraud and house breaking (9). The involvement of heroin addicts in crime may result in imprisonment. Thus, another problem and another second stigma is added. In this case, imprisonment further confirms the community’s view that heroin addicts are criminals and should be alienated, hence resulting in total rejection from the community and from their families (2). The resulting alienation may cause depression and loss of hope. This emotional state will worsen their heroin addiction, making it challenging for the therapist and clinician to motivate them for treatment (8). The combined rejection by the community and family limits the heroin addict to confide in their peer heroin addicts. Ultimately, the heroin addict’s condition will get worse, and this is the time when they may start sharing needles. This could explain the whole cycle of addictive behaviour and how it correlates with HIV and AIDS. It is very unfortunate that in the past, the medical community dealt with these heroin addicts after they had already contacted these horrendous complications (6, 8). The sharing of needles by heroin addicts’ also exposes their spouses at risk of HIV and AIDS (6). There were many instances where husbands, who were heroin addicts with AIDS transmited the disease to their spouses and children (7). This is another disaster, which could have been prevented if the addiction cycle was

intervened with appropriate medical treatment. The consequence of failed rehabilitation treatment not only affect heroin addicts but also their family members (4). More than 50% of heroin adicts who underwent rehabilitation programmes were the breadwinners of their family. For the family, the loss of their sole breadwinner to two year rehabilitation programme caused loss of financial and emotional support. This caused family stress which further disrupted the family system. This could be one explanation why the children of heroin addicts are at more risk of social and mental problems and of becoming heroin addict themselves. Both professionals and the public have expressed concern about the failure of the in-house rehabilitation treatment programme in tackling heroin addiction in Malaysia (4, 8). It is therefore timely for the government to look at the process of how to maximise the cost benefit of the rehabilitation programmes. For instance, the duration and the type of heroin addict who needs such treatment should be reviewed. One of the suggestions is that the duration of stay should be shortened to less than 6 months. The advantages of shorter rehabilitation include: firstly, this maintains the heroin addicts within the community without depriving them of their employment potential or maintaining as breadwinners of the family. The second advantage would be the cost saving to the government. It was reported that each addict cost RM3, 000 per month to rehabilitate. Thus reducing in-house rehabilitation to less than six months will


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incur less than a quarter of the total cost spent at present. Nonetheless, the most expensive cost is still borne by the heroin addicts’ family who suffer at being left to fend for themselves mentally and financially. This loss is of course is unquantifiable in Ringgit and Cents (7).……………………………….. Medical treatment- the future Managing heroin addiction can only be taken seriously as a medical issue once everyone is convinced that heroin addiction is an illness (7). Latest literature confirms that addiction is a brain disorder and categorised as a mental disorder (1). Thus, effective intervention for heroin addiction is only complete when combined with medical input (8). ……………………………../ Understanding medical treatment for heroin addiction is not limited to whether there is medication that could cure heroin addiction. For the present, no reports could offer promise of a medication to cure heroin addicts (7). However, the same argument could be used for conditions such as schizophrenia and diabetic mellitus, as there is also no medication that promises cure for such conditions. Hence, as there is no medicine which can cure addiction at present, the next objective is to find medication which can minimise the harm caused by heroin addiction. This situation is similar to diabetic mellitus, where drugs such as insulin and other hypoglycemic agents are prescribed to minimise the harm caused by the disease. A New Era of Managing Heroin Addiction

The national drug substitution task force materialised after the realisation that the occurrence of HIV/AIDS among heroin addicts was out of control (6, 7). Although the initial suggestion was in 2000, it was only fully implemented in 2005. The objective of this task force was to review and determine the role of drug substitution treatment in order to prevent the spread of HIV among heroin addicts. Its successful implementation was mainly due to the combined efforts of the Ministry of Health, Malaysia, the universities and non-governmental organisations (NGOs) which ensured urgent implementation of the programme (7). A pilot national methadone maintenance treatment study was conducted on 1200 heroin addicts. Methadone treatment was offered free by selected government and private clinics. While on methadone, the patients also attended regular counselling sessions provided by the national anti-drug task force (AADK). This was the first arrangement nationally that combined the resources of clinicians, NGOs and AADK in treating heroin addicts (5, 7). At review, the results showed that methadone maintenance therapy improved compliance to treatment programmes (7). Compliance to treatment was observed to reach as high as 80% (5). The advantages of this treatment were not confined to the retention rate only, but also in ensuring patients maintain their occupation and quality of life. Many heroin addicts reported the ability to both maintain their social and family responsibilities. The cost of treating heroin addicts using 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 addict with drug substitution therapy. On the other hand, it cost approximately RM 3000 per patient per month to manage heroin addicts for in-house rehabilitation. Another major cost would be incurred if the heroin addicts had contracted hepatitis, HIV or AIDS. For example, the cost of treating heroin addicts with hepatitis C was approximately RM 15,000 per month. As most of the heroin addicts could not afford to pay, there is a possibility that the cost would have been transferred to the government and this would have been a financial burden to the nation. The other advantage of methadone substitution programme was that it ensured that the heroin addicts were ready for training and counselling (7). They were offered a choice of programmes to suit their needs. They could choose to opt for either psychological counselling or spiritual based counselling. Some were also offered employment placement/training. On the other hand, it was also observed that the absence of withdrawal symptoms or intoxicating effects of heroin made the heroin addicts ready for counselling and able to concentrate on their rehabilitation programme. Conclusion In recent years, the approach to heroin addiction in Malaysia has undergone various processes. In-house rehabilitation programmes were first introduced; however the reported success rates were negligible. At present, the government has introduced new policies involving medical professionals that offer more treatment options to deal

with heroin addiction. The new policy involving methadone substitution therapy and counselling have been proven to be effective in treating heroin addiction and would need support and cooperation from all parties involve. Reference 1. Chawarski, M.C.M., M..Schottenfeld, R.S., Heroin dependence and HIV infection in Malaysia. Drug Alcohol Dependence, 2006. 82: p. 39-42. 2. Navaratnam, V.F., L., Natural history of heroin addiction and adjunctive use, in Research Report Series. No. 16. 1988, National Drug Research Centre, University Science Malaysia: Penang. 3. National Narcotics Report. Kuala Lumpur, M.O.H. Affairs, Editor. 1998, National Narcotic Agency. 4. Navaratnam, V.F., K.. Kulalmoli, S., An Evaluation Study of the Drug Treatment and Rehabilitation Programme at Drug Treatment Centre, in Centre for Drug research UN/WHO/IFNG Research and Training Centre University Science Malaysia. 1992: Penang. 5. www.adk.gov.my. (cited) 6. Chawarski, M.C.M., M.. Schottenfeld, R.S., Behavioral drug and HIV risk reduction counseling (BDRC) with abstinent-contigent take-home buprenorphine: A pilot randomised clinical trial. Drug and Alcohol Dependence, 2007.


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7. Mazlan, M.S., R.S..Chawarski, M.C., New challenges and opportunities in managing substance abuse in Malaysia. Drug Alcohol Dependence, 2006. 25: p. 473-478. 8. Habil, H., Managing heroin addicts through medical therapy. 2001:

University Malaya Press. 9. Karofi, U.A., Drug Abuse and Crimical Behaviour in Penang, Malaysia. A Multivariate Analysis. Bangladesh e-journal of Sociology, 2005. 2(2): p. 1-26.

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]


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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 Smoking is a major public health concern in Malaysia. The prevalence of cigarette smoking in Malaysia is still one of the highest in South East Asia despite the on-going public health campaigns to encourage smoking cessation [1]. Smoking thus presents the single most important preventive measure to reduce morbidity and premature mortality in Malaysia. Thus designing and implementing successful smoking

cessation interventions is of urgent public health importance. Smokers who stop smoking have been shown to have reduced risk of morbidity and mortality from cardiovascular disease even after the onset of clinical illness. Even those who stop after an attack of myocardial infarction were observed to have a lower reinfarction rate and survived longer than those who continued to smoke [2].


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Smoking cessation programmes have been available for more than 2 decades in Malaysia. However, these efforts have mainly focused on outpatient settings, usually at primary care practices. Much less attention has been paid to in-patient settings that deliver more acute medical care e.g. hospitals, despite the opportunities that they present for changing behaviour. It is well documented that illness, especially a tobacco related illness such as myocardial infarction, lung cancer and stroke, increases a smoker's motivation to stop smoking [3, 4]. This is probably because illnesses increased a smoker's perceived vulnerability to the health hazards of tobacco use. In addition, a medical problem or illness also brings a smoker in contact with the hospital setting and providing an opportunity to encourage smoking cessation [5]. Promoting smoking cessation during a hospital stay also provides a special incentive for implementing the no smoking policy in conjunction with the government’s policy which prohibits smoking in hospitals. Being hospitalised also meant that a smoker is prevented from smoking and have access to multiple health personnel who could provide smoking cessation assistance [3, 4, 6]. The importance of hospital based smoking cessation has been demonstrated over the past two decades. Studies have shown that a hospital stay can effectively initiate smoking cessation even in the absence of intervention. This was especially noted in patients with cardiovascular and pulmonary disease and in patients having surgery [3-5, 7-9].

Why is a hospital-based smoking cessation programme needed in Malaysia? For a start, Malaysian hospitals are smoke-free zones. These smoke-free zones provide a conducive environment for a smoker to start a cessation attempt away from the cues of smoking. In addition, procedures such as cardiac angioplasty or bronchoscopy provide a good opportunity to uncover a smokers’ denial of the contributory risk smoking has on cardiovascular and respiratory diseases. Hospital-based smoking cessation programmes have also been reported to have many advantages. Among them are: 1. An admission to hospital provides an opportunity for smokers to obtain help and stop smoking. At this time, smokers are more open to advice at a time of perceived vulnerability. 2. Smoker’s may also find it easier to stop smoking in an environment where smoking is restricted and prohibited. 3. Hospitalisation provides a teachable moment for smokers housed in a temporary smoke-free environment. 4. Hospital personnel, e.g. nurses constitute the largest number of health care worker in a hospital and have a vital role in promoting smoking cessation [3, 4]. Which hospital-based smoking cessation programme works? Among the programmes reported in the 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 programs showed patients who were post-myocardial infarction had double the smoking cessation rate compared to other smokers. The cessation rates reported were as high as 60-70% at one year [10, 11]. Even research who had focused on a broader target population such as all in-patient hospitalized smokers regardless of diagnosis produced good results, (2) By type of intervention, interventions with highest frequency of contact and longer duration of follow up showed the highest cessation rates [3, 4], (3) when compared, the addition of counselling as part of post-discharge program were also reported to increase smoking cessation rates after hospital discharge when compared with usual care [3-5] and (4) the inclusion of pharmacological treatments such as nicotine replacement therapy and bupropion increases cessation rates [3, 4]. Elements of effective hospital-based smoking cessation programmes Among the reported characteristics of an effective hospital-based smoking cessation programmes are: 1) systematic identification of smokers at (or shortly after) admission; 2) a bedside counselling session by a nurse or specially trained counsellor and supplemented by written or audiovisual material; 3) continuous physician advice to stop smoking and follow-up contact, usually by telephone, for at least three months after discharge [3-5]. Implications for Malaysian hospitals

The Malaysian Clinical Practice Guidelines on Treating Tobacco Dependence 2003 had clearly endorsed the concept of hospital based smoking intervention. Thus a hospital based smoking cessation programme should be especially attractive to hospital administrators because comparatively they are more cost effective than smoking programs for outpatients [12]. For example, hospital based smoking cessation programs have been shown to achieve higher cessation rates than outpatient programs and reducing the cost per patient cessation. Furthermore it is also reported that the cost incurred in treating a smoker was justified by reductions in the cost of medical care for patients with chronic medical disease than for ambulatory patients. Challenges to implementing a hospital based smoking cessation programme The reported challenges faced by dedicated smoking cessation physicians were how to implement the model intervention programs into existing hospital delivery systems. Among the issues that needed to be addressed were: (1) adapting the hospital information and registration system to routinely identify patients' smoking status at admission, (2) training, maintaining and retaining experienced staff to provide the smoking counselling, both in the hospital and after discharge and (3) the coordination of inpatient and post-discharge service. It is suggested that this problem may be reduced by integrating a hospital based smoking intervention as part of the general disease management for all patients [3-5, 13].


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Conclusion There is a need to develop a hospital based smoking cessation programme to tailor to our Malaysian setting. This review suggests that the combination of hospital-based smoking cessation interventions with follow up support after discharge increase the success of smoking cessation. With an estimated 5 million smokers in Malaysia, a hospital based smoking cessation program has the potential to reach many smokers and yield substantial clinical and public health benefits. References 1. Morrow, M. and S. Barraclough, Tobacco control and gender in Southeast Asia. Part I: Malaysia and the Philippines. Health Promotion International, 2003. 18(3): p. 255-64. 2. Rea, T.D., et al., Smoking status and risk for recurrent coronary events after myocardial infarction. Ann Intern Med, 2002. 137(6): p. 494-500. 3. Munafo, M., et al., Interventions for smoking cessation in hospitalised patients: a systematic review. Thorax, 2001. 56(8): p. 656-63. 4. Rigotti, N.A., et al., Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev, 2001(2): p. CD001837. 5. MacKenzie, T.D., R.I. Pereira, and P.S. Mehler, Smoking abstinence after hospitalization: predictors of success. Prev Med, 2004. 39(6): p. 1087-92.

6. Rigotti, N.A., II. Smoking cessation in the hospital setting-a new opportunity for managed care. Introduction. Tob Control, 2000. 9 Suppl 1: p. I54-5. 7. Glasgow, R.E., et al., Changes in smoking associated with hospitalization: quit rates, predictive variables, and intervention implications. Am J Health Promot, 1991. 6(1): p. 24-9. 8. Perkins, K.A., Maintaining smoking abstinence after myocardial infarction. J Subst Abuse, 1988. 1(1): p. 91-107. 9. Rigotti, N.A., et al., Smoking cessation following admission to a coronary care unit. J Gen Intern Med, 1991. 6(4): p. 305-11. 10. Taylor, C.B., et al., Smoking cessation after acute myocardial infarction: effects of a nurse-managed intervention. Ann Intern Med, 1990. 113(2): p. 118-23. 11. DeBusk, R.F., et al., A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med, 1994. 120(9): p. 721-9. 12. Krumholz, H.M., et al., Cost-effectiveness of a smoking cessation program after myocardial infarction. J Am Coll Cardiol, 1993. 22(6): p. 1697-702. 13. MacKenzie, T.D., Hospitalised smokers: characteristics, treatment, and transition to ambulatory care. Tob 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 The post-stroke patient is at significant risk for various psychiatric syndromes. The most commonly reported of these in the literature are Post-stroke Depression (PSD) and Post-stroke Dementia (PSDem) (1). Integrating assessment for psychiatric symptoms into the care of post-stroke patients is especially critical in the first 6 months following a stroke, a period of high risk for psychiatric complications. Psychiatric and substance abuse history, past treatment with psychopharmacologic agents, family

psychiatric history, and personal and family history of suicidal behavior are important items to bear in mind. Careful attention to caregivers' and family members' behavioral observations is necessary, especially in patients with cognitive impairment or other neurologic barriers to communication, such as residual aphasia. Other Post-stroke Psychiatric Syndromes less frequently seen include pathologic crying, pathologic laughter, apathy, and isolated fatigue (1). These are coded as mental disorder due to a general medical condition not otherwise specified.


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Pathologic laughter and crying are sometimes grouped as pathologic emotions (PE) with sudden paroxysms of either laughter or crying, irrespective of the ambient mood state. Post stroke PE is a distressing and socially disabling problem. It affects 16 to 29% of all stroke survivors. (2) PE can be triggered by non-specific stimuli or by a low-threshold emotive stimulus. Curiously, the PE do not themselves induce a mood change other than during the affective display, and they are not under voluntary control. Some literature recommends the use of antidepressants for PE; lithium and anticonvulsants are alternatives. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRls), have been increasingly recognized as the treatment of choice for pathologic crying (PC) (2) . However, little is known about etiologies and other treatment options for various clinical manifestations of PLC. This case report illustrates a case of post stroke laughter, highlighting the journey that brought her there. Case This is a case of a 32 year old Indian lady with no past medical history, who presented with a sudden onset of giddiness, followed by altered consciousness for one day. She was brought immediately to Kajang Hospital, where she developed a fever and neck stiffness, conscious level dropping to Glasgow Coma Scale of 7/15. A computed tomography (CT) scan of the brain done to investigate and elicit causal factor of illness, showed a massive left cerebellar infarct. She was treated as having meningitis and given a course of antibiotics. She was intubated

for cerebral protection. Cerebral resuscitation was commenced and completed after 48 hours. She was transferred to University Malaya Medical Centre (UMMC) for further management of her condition. In UMMC, physical examination showed evidence of tetraparesis. Supported ventilation continued. Unfortunately she developed sepsis secondary to a nosocomial infection. A CTV brain scan was done and a conclusion of an extensive cerebellar and brainstem infarct with no evidence of venous sinus thrombosis was made. Subsequently, a tracheostomy was done and she was weaned off from supported ventilation the next day. The patient had dysarthria and difficulty communicating with others. While in the ward, screening for possible factors that could have precipitated the infarct, such as connective tissue disease and a thrombophilic screen were done, however results were negative. The patient was reviewed by the psychiatric team a month later, after the primary treating team noted that she had sudden crying spells. Based on the history and presentation gathered, a diagnosis of Major Depressive Disorder was made and she was started on Escitalopram 10mg daily. With subsequent observations, a week later she was then noted to have labile mood, characterized by crying spells as well as bouts of laughter. In the meantime, her communication had improved as she was now able to write on an alphabet board to convey information. She was discharged from ward after having been admitted for two months.


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Subsequent reviews in the psychiatric clinic showed that her mood had improved. Her antidepressant was stopped. However, her family members noted that the crying spells recurred. Antidepressant medication was commenced again three months later. Upon review from December 2007 onwards, the patient had continuous inappropriate laughter. She was not able to explain why she was laughing. She denied feeling elated but felt that her laughter was beyond her control. There were no other accompanying symptoms to suggest mania or hypomania, nor were there any psychotic symptoms. Discussion Sudden, uncontrollable episodes of emotional display or pathological laughing or crying (PLC) were recognized after the occurrence of a stroke.3,4 The prevalence of this morbid condition has been reported to range from 15% to 18%.5,6,7 The episodes either do not have an apparent motivating stimulus or are triggered by a stimulus that would not have elicited such an emotional response before the onset of their neurological disorder. Various terms have been used to describe this condition. These terms are pseudobulbar affect, pathological laughter and crying, emotional lability, emotionalism, emotional dysregulation, forced crying, involuntary crying, pathological emotionality and emotional incontinence.8 The authors use PLC in this report as we believe is a precise descriptive term for the condition. In clinical setting, PLC is often unrecognized. The condition can be often be misdiagnosed as a mood disorder. Patients with PLC exhibit the

emotional display in the absence of a pervasive and sustained depressed or elated mood. PLC occurs only paroxysmally and is uncontrollable and involuntarily. Such episodes may even occur in the absence of any congruent changes in the mood of the patient.11 Three primary features were emphasized by Poeck: 1) sudden loss of voluntary emotional control; 2) occurrence in response to “non specific”, often inconsequential stimuli; and 3) lack of clear association with prevailing mood state.20 Several scales are available to identify and characterize PLC. One of them is Pathological Laughter and Crying Scale.21 It is commonly used in clinical research. PLC is a disorder of emotional expression rather than a primary disturbance of feeling. The laughter or crying behaviours (e.g. the facial expression, the tears etc) in PLC is identical with regular laughter or crying but no associated feeling of happiness or sadness. In the past, it was proposed that the impaired emotional regulation resulted from disinhibition of a presumed brainstem center for laughing and crying due to lesions of the voluntary motor pathways in the descending corticobulbar pathways.9,11However, this explanation has several limitations like patients do sometimes response contradictory to the emotional valence of the triggering stimulus, lack of typical features of pseudobulbar palsy and no clear evidence of single brainstem center for laughing and crying.11 Based on current studies, other structures like prefrontal cortices9, cerebellum12 and globus pallidus13 are suggested to be associated with PLC. A thorough understanding of the pathophysiology of PLC is needed.


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Although there is lack of understanding regarding the exact etiologies of PLC, the condition was found improved markedly with the administration of antidepressants14 like sertraline15, fluoxetine16, amitriptyline17, nortriptyline18 and citalopram.19 The possible explanation for the beneficial affect of selective serotonin reuptake inhibitor (SSRI) and other antidepressants would be that by altering the operation of higher order cortical areas involved in cognitive processing, the drugs would alter the cognitive context enough to raise the threshold at which stimuli engage the system in PLC, reducing, in short, emotional lability.11 It is important to note that even though the antidepressant is helpful in treating PLC, does not necessary imply a causal relationship between the agent and the condition. However, understanding how serotonergic substitution can improve emotional experience in patients with mood disorder while also being effective in patients who have pathological regulation of emotional experience is important.8 References 1. Bourgeois JA, Hilty DM, Chang CH (2004) Poststroke neuropsychiatric illness: an integrated approach to diagnosis and management. Curr Treat Options Neurol 6:403-420. 2. Derex L, Ostrowsky K, Nighoghossian N, Trouillas P (1997) Severe pathological crying after left anterior choroidal artery infarct. Reversibility with paroxetine treatment. Stroke 28:1464-1466. 69.

3. Ghika-Schmid F, Bogousslavsky J (1997) Affective disorders following stroke. Eur Neurol 38:75-81. 4. Dark FL, McGrath JJ, Ron MA (1996): Pathological laughing and crying. Aust NZ J Psychiatry 30:472-479. 5. Huse A, Dennis M, Molyneux A, Warlow C, Hawton K (1989) Emotionalism after stroke. Br Med J 298:991-994. 6. MacHale SM, O’Rourke SJ, Wardl0aw JM, Dennis MS (1998) Depression and its relation to lesion location after stroke. J Neurol Neurosurg Psychiatry 64:371-374. 7. Morris PLP, Robinson RG, Raphael B (1993) Emotional lability after stroke. Aust NZ Psychiatry 27:601-605. 8. Parvizi J, Arciniegas D. B., Bernardini G. L., Hoffmann M. W., Mohr J. P., Rapport M.J., Schmahmann J. D., Silver J. M.,Tuhrim S. (2006) Mayo Clin Proc 81(11): 1482-1486. 9. Oppenheim H, Siemerling E, Mitteilungen uber Pseudobulbarparalyse und acute Bulbarparalyse. Berl Klin Wochenschr. 1886;46. 10. Wilson SAK (1924) Some problems in neurology, II: pathological laughing and crying. J Neurol Psychopathol. 4:299-333 11. Parvizi J, Anderson SW, Martin CO, Damasio H, Damasio AR. (2001) Pathological laughter and crying: a link to the cerebellum. Brain 124:1708-1719.


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12. McCullagh S, Moore M, Gawel M, Feinstein A. (1999) Pathological laughing and crying in amyotrophic lateral sclerosis: an association with prefrontal cognitive dysfunction. J Neurol Sci. 169;43-48. 13. Jong S. Kim (2002) J Neurol 249:805-810. 14. House Ao, Hackett ML, Anderson CS, Horrocks JA. (2004) Pharmaceutical interventions for emotionalism after stroke. Cochrane Database of Systematic Reviews. Issue 2. Art No.:CD003690. DOI: 10.1002/14651858. CD003690. pub2. 15. Burns A, Russell E, Stratton-Powell H, Tyrell P, O’Neill P, Baldwin R. (1999) Sertraline in stroke-associated lability of mood. Int J Geriatric Psych. 14:681-685. 16. Brown K.W., Sloan R.L., Pentland B. (2007) Fluoxetine as a treatment for post-stroke emotionalism. Acta Psychiatrica Scandinavica Vol98. 6; 455-458.

17. Ohkawa S, Mori E, Yamadori A. (1989) Treatment of pathological laughing with amitriptyline. Clin Neurol 29:1183-1185. In Japanese. 18. Parikh Rm, Robinson RG, Lipsey JR, Price TR. (1989) Nortriptyline treatment of poststroke emotional lability a double blind study. Neurology. 5(suppl 1):177. Abstract. 19. Anderaon G, Vestergaard K, Riis JO. (1993) Citalopram fro post-stroke pathological crying. Lancet 342:837-839. 20. Poeck K (1969): Pathophysiology of emotional disorders associated with brain damage, in Handbook of Clinical Neurology, vol3, edited by Vinken PJ, Bruyn GW. Amsterdam, North-Holland, pp 343-367. 21. Robinson G.B., Parikh R. M., Lipset J. R., Starkstein S.E., Price T. R. (1993) Pathological laughing and crying following stroke: Validation of a measurement scale and a double-blind 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 MCQ exam paper

Total Marks (min.=0 ; max.= 85)

Percentage of scorings (%)

1 45 53

2 40 47

3 45 53

40 47

1 Neuroanatomy

5

Mean (SD)= A(B) ; Scoring marks = 50% 4 41 48

7 37 44

8 46 54

10 64 76

48 56

2 Neurophysiology

11 Mean (SD)= C(D) ; Scoring marks = 55.5%

6 35 41

42 49

3 Neurochemistry

9 Mean (SD)= E(F); Scoring marks = 45.3%

12 32 38

25 29

4 Neuropathology

13

Mean (SD)= G(H); Scoring marks = 33.5% 14 36 42

15 41 48

16 43 51

17 36 42

5 Psychology

18 37 44


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19 34 40

20 47 55

43 51

21

Mean (SD)=I(J) ; Scoring marks = 46.6%

22 38 45

39 46

6 Aetiology & psychiatric genetics

23 Mean (SD) = K(L); Scoring marks = 45.3%

24 30 35

35 41

7 Stress & immunology

25

Mean (SD)= M(N); Scoring marks = 37.6%

26 24 28

27 30 35

28 29 34

45 53

8 Psychopathology

29

Mean = 32 Scoring marks = 37.6%

30 39 46

31 45 53

32 41 48

33 45 53

50 59

9 Psychopharmacology

34

Mean (SD)= O(P); Scoring marks = 51.8%

35 43 51

36 29 34

29 34

10 Statistic

37

Mean (SD) = Q(R); Scoring marks = 39.6%

38 42 49

39 34 40 35 41

11 Epidemiology

40

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 Interventions

Pass

Fail

Total

Intensive revision course in 3 months time

8 2 10

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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