Journal of the College of Psychiatry of Ireland by Peter Mas-Mollinedo

Irish Journal of Psychological Medicine Vol. 29, Issue 2, September 2012 ISSN 0790- 9667

Editor–in-Chief: Brendan Kelly, Senior Lecturer in Psychiatry, Department of Adult Psychiatry, UCD Mater Misericordiae University Hospital, Dublin 7 Deputy Editor: Niall Crumlish, Consultant Psychiatrist, St James’s Hospital, Dublin 8 Consulting Editor: Larkin Feeney, Consultant Psychiatrist, Cluain Mhuire Services, Blackrock, Co. Dublin Founding Editor: Mark Hartman Associate Editor: Ted Dinan (Cork)

Editorial 3

Original Papers 6

Situational and Psycho-Social Factors Associated with Relapse Following Residential Detoxification in a Population of Irish Opioid Dependent Patients Kevin Ducray, Catherine Darker, Bobby P Smyth

Suicide on the Isle of Wight: A Case-study of 35 Suicides Among Mental Health Service Users between 2006 and 2008 Homayun Shahpesandy, Ad van Heeswijk

Patients’ Satisfaction with a Psychiatric Day Hospital in the West Galway Catchments Area Inam Ul-haq

Psychiatrists: An Endangered Species? Navroop Johnson, Declan Lyons

Decreased Verbal Learning but not Recognition Performance in Alcohol-Dependent Individuals During Early Abstinence Isolde Daig, Richard Mahlberg, Julia Stethin, Franziska Schroeder, Jana Wrase, Nina Knoll, Tom Bschor, Guenter Esser, Andreas Heinz, Thorsten Kienast

Post-Traumatic Stress Disorder (PTSD) Symptoms in Adults with Psychiatric Disorders Muhammad Tahir Khalily, Anna Paulina Wota, Brian Hallahan

Child and Adolescent Mental Health Services in Laois/Offaly: A One Year Perspective of Services (July 1, 2008 to June 30, 2009) Heather Church

Administrator: Sibéal Farrell Editorial Board: Brian A Lawlor (Dublin), Patricia Casey (Dublin), Stephen Cooper (Belfast), Michael Fitzgerald (Dublin), Brian Leonard (Galway), Roy McClelland (Belfast), Brian O’Shea (Wicklow), Ian Pullen (Edinburgh), John Waddington (Dublin), Richard Williams (Victoria) Submissions and Correspondence to: The Editor College of Psychiatry of Ireland 5 Herbert Street Dublin 2, Ireland Tel: 00 353 1 6618450 Fax: 00 353 1 6629677 Email: sfarrell@irishpsychiatry.ie Website: www.ijpm.ie Publisher: Irish Medical Information Fir Tree Lodge Craddockstown Road Naas Co. Kildare

The Challenge of Managing Severely Ill Patients with Anorexia Nervosa in Ireland Caroline Maher, Izu Nwachukwu

Brief Reports 47

The Vron – an Early Intervention In-Patient Recovery Unit Rob Macpherson, Pradeep Peddu, Chris David

Knowledge and Attitude of Basic Psychiatric Trainees in Ireland to the Clinical Indemnity Scheme Nnamdi Nkire, Oluwatosin Akinsola, Annette Kavanagh

Experience of an Inter-Regional Research Symposium for Higher Psychiatric Trainees in Scotland Ashleigh C Duthie, Allen J Shand, Seonaid M Anderson, Ross J Hamilton

Case Report 59

Delayed Onset of Neuropsychiatric Events Associated with Montelukast Fintan Byrne, Bolarinwa Oluwole and Vanessa Whyte, Sabina Fahy and Delia McGuinness

Clinical Audit 62

Benzodiazepine and Z-drug Prescribing for Elderly People in a General Hospital: A Complete Audit Cycle Catherine Dolan, Sami Omer, Deirdre Glynn, Michelle Corcoran, Geraldine McCarthy

Opinion 66

Threshold Concepts and Teaching Psychiatry: Key to the Kingdom or Emperor’s New Clothes? Seamus Mac Suibhne

Book Reviews 69

A Practical Guide to Cluster Randomised Trials in Health Services Research. Sandra Eldridge and Sally Kerry. Reviewed by Richard Duffy

The Language of Mental Health: A Glossary of Psychiatric Terms. Narriman C. Shahrokh, Robert E. Hales, Katharine A. Phillips, Stuart C. Yudofsky. Reviewed by Eric Kelleher

Trinity’s Psychiatrists. From Serenity of the Soul to Neuroscience. Marcus Webb Reviewed by Dermot Walsh

Health Equity, Social Justice and Human Rights. Ann Taket. Reviewed by Brendan D. Kelly

Letters to the Editor

This paper meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper)

Exploring Health in Census 2011 Frank Houghton, Sharon Houghton

The Dissociative Experiences Scale: A Welsh Translation Christopher Alan Lewis, Martin J. Dorahy, Julie Brake, Mary Jane Lewis

Guidelines for Authors

EDITORIAL

The Challenge of Managing Severely Ill Patients with Anorexia Nervosa in Ireland Caroline Maher, Izu Nwachukwu Ir J Psych Med 2012; 29 (2): 69-71

Abstract

Quantifying the scale of the problem

Anorexia Nervosa (AN) has the highest rates of morbidity and mortality of any psychiatric disorder. Psychiatrists in Ireland have reported difficulties in managing patients with AN, particularly those with severe levels of illness. This paper explores these management difficulties, including the financial and organisational impediments to service provision, and the legal and ethical dilemmas involved in dealing with those patients who refuse treatment.

The only study looking at incidence or prevalence rates for eating disorders in Ireland was reported by Shinkwin & Standen in 2001.3 Their research identified an incidence rate of 4 per 100,000 for AN, although the authors reported significant methodological difficulties with data collection. However, their findings were broadly comparable to studies from the rest of Europe, although the reported incidence rates vary widely between 0.1 and 12 per 100,000.4 The European prevalence rate appears to be approximately 0.3%.5 It is estimated that 200,000 people suffer from an eating disorder in Ireland, with 400 new cases and approximately 80 deaths per year.6

Key words: Anorexia Nervosa, legal and ethical difficulties, coercive feeding

Introduction

In attempting to quantify the numbers of patients with more severe levels of illness, we looked at data from the National Psychiatric In-Patient Reporting System (NPIRS) and the Hospital In-Patient Enquiry (HIPE) that show psychiatric and medical admissions respectively.

A session at the inaugural conference of the new College of Psychiatry in Ireland (March 2009) highlighted the paucity of Government-provided services for the management of patients with eating disorders in Ireland, particularly those who are severely ill with AN. Several psychiatrists reported difficult experiences while trying to treat such patients on general medical wards in environments that were both physically and psychologically unsuitable. Others commented on the problem of accessing appropriate specialist care for eating disorder patients, especially for those with severe illness. This paper seeks to explore some of the issues that currently make caring for such patients so challenging, and to consider the service developments that need to be implemented in order to address the needs of this group of patients.

Number of admissions per year Year 2004 2005 2006 2007

*correspondence

HIPE (Medical)** 152 168 154 163

* NPIRS includes public and private admissions, but does not distinguish between AN and BN. ** HIPE data is for AN alone, but only includes public admissions.

In their study, Shinkwin and Standen identified data retrieval as a significant problem. There is certainly a marked lack of accessible, accurate information on patients with AN. For example, the NPIRS does not distinguish between AN and BN, whilst HIPE does. Thus, there remains considerable uncertainty with regard to how many patients with AN are treated annually, in what facilities, and at what financial cost. The problem of data access is highlighted further by a recent Freedom of Information enquiry. A request was made to elicit information on how many patients with AN have received publicly funded specialist treatment in either public or private facilities in Ireland between 2004 and 2009, and at what cost. The response to the request was that this information would be almost impossible to deliver, as there is no department, or specified person, with the responsibility of tracking this data.7 Service planning clearly becomes very difficult if appropriate data is unavailable.

Although facilities to treat Bulimia Nervosa (BN) are equally deficient in Ireland, we have chosen to focus on AN in this paper. Patients with AN present the added challenge of low body weight with the attendant risk of significant physical consequences and serious medical events, although the risk of death may be similar in both groups.1,2 There is also the problem of how and where to manage patients with severe AN, especially those who refuse treatment. The possible need for coercive feeding of these patients creates legal and ethical complications that remain without clarification from Irish legislative or regulatory bodies. In attempting to outline the barriers to the provision of efficient and effective care to patients with severe AN in Ireland we will briefly consider three issues: (1) the absence of reliable data on the scale of the problem; (2) impediments to service development; and (3) the legal/ethical dilemma of coercive treatment.

*Caroline Maher Consultant Psychiatrist to the Eating Disorder Programme, Elm Mount Unit, St. Vincentâ&#x20AC;&#x2122;s University Hospital, Elm Park, Dublin 4, Ireland. Email C.Maher@st-vincents.ie

NPIRS (Psychiatric)* 175 182 178 147

Izu Nwachukwu Consultant Psychiatrist, North Sector, Wexford Mental Health Services, Ireland

Submitted 3rd August 2010 Accepted 18th February 2011

Developing services to manage patients with eating disorders

Despite this, there appears to be an emerging international trend with regard to the use of coercive re-feeding, although this is not universal. In England and Wales, the courts have held that AN is a mental disorder, and that patient consent is “not required for any medical treatment administered by a responsible medical officer for a mental disorder under the Mental Health Act 1983 s.63”. Naso-gastric feeding is regarded as a “medicine and an integral part of the treatment for anorexia nervosa”.17 Thus, English common law recognises forced feeding as a psychiatric treatment in the context of severe and life threatening AN. Similarly, in 1999 in Australia, following the Mental Health Tribunal hearing of a case concerning a 19 year-old severely-ill patient, New South Wales legislation recognised AN as a mental disorder thereby bringing NSW into line with other Australian states. Prior to this, clinicians had resorted to certain provisions under the Guardianship Act 1997 to treat patients with AN, a process that was described as being fraught with many practical difficulties.18 In Germany, where there is evidence of direct and imminent danger to the patient’s life, detention and involuntary treatment are permitted under federal state law or by invoking civil law guardianship. In 2004, doctors treating a patient with AN were fined for accepting her refusal of any kind of feeding or intravenous drip.19 In Israel, under the Mental Health Act 1991, theoretically it is not possible to involuntarily hospitalise a patient with a diagnosis of AN. However, involuntary detention and treatment does take place, usually through the mechanism of appointing a legal guardian for the patient’s body.12

When A Vision for Change set out the plan to provide comprehensive services to treat patients with eating disorders nationally, it was agreed that adults, adolescents and children would initially all be managed at primary care level. Those patients who required more intensive treatment would be referred to their local general Community Mental Health Teams. For more complex cases, adults would be referred for specialist treatment to one of four six-bedded units, attached to a general hospital mental health unit. These would be placed in each of the four HSE regions (six beds per million population, with 24 in total), and staffed by a Multi-Disciplinary Team (MDT). Children and adolescents would have access to a National Centre for Eating Disorders based at a main children’s hospital and also staffed by a MDT. However, there has been effectively no progress on national service provision in the intervening period.8 From the HIPE and NPIRS data (above) it is clear that, given that there are only three designated adult eating disorder public beds, the majority of patients with AN are managed in general medical or general psychiatric hospitals, mostly without access to specialist involvement. There are a number of reasons for this lack of progress. Firstly, there has been a shortage of available funding for the development of services for the treatment of eating disorders. Secondly, an equally significant barrier to the provision of a coherent and comprehensive national service appears to be a lack of strategy on how, and where, to spend any available funds. In 2007, Minister Brendan Smith pledged €750,000 of funding for the development of designated eating disorder services in the Dublin and South areas.9 This pledge was subsequently withdrawn. However, it is apparent that some funding was made available, but on a piecemeal basis. For example, since 2006, €699,519.35 has been spent on fourteen patients who were sent abroad for treatment.10 There have also been monies provided to fund treatment of individual patients in privately owned specialist eating disorder facilities in Ireland, although the amount is uncertain.7 It is arguable that such monies might have been more efficiently used if invested in the development of the national strategy that is outlined in A Vision for Change.

The situation in Ireland is rather complex. Uncertainty exists as to whether re-feeding can be considered a psychiatric treatment under the Mental Health Act (Ireland) 2001. The problems encountered by psychiatrists in the treatment of severe AN, made more difficult through the shortage of treatment facilities, are further compounded by a lack of clarity on the legal status of coercive treatment. A Vision for Change, whilst setting out the plan as to how to develop services for patients with eating disorders, is silent on the legal and ethical challenges posed by the management of AN. The Mental Health Act (MHA) although not specifically excluding AN as a mental disorder, does not address whether admitting such a patient under the Act for re-feeding is an acceptable psychiatric treatment. Legal opinion has indicated that this issue needs to be clarified by the courts before it can be assumed. Should re-feeding not be accepted as an appropriate psychiatric treatment, it will not be possible to invoke the MHA to detain and coercively feed patients with AN. Alternatively, should forced re-feeding be permissible, the lack of appropriate facilities where this could take place could limit the implementation of the Act.

Legal and ethical issues in treating severely ill patients with AN In patients with severe AN, cooperation with treatment can diminish to the extent that their life becomes seriously threatened. In such cases the question of the introduction of forced nasogastric feeding may be raised, a scenario that is medically, ethically and legally contentious.11

Moreover, there remains the question of whether a patient who refuses re-feeding in a clinically appropriate context should always be coercively fed. This raises issues of competence and capacity. The effect of AN on competence in particular, and the decisionmaking process in general, remains poorly understood and problematic.14,20 It is to be hoped that the Mental Capacity Bill currently passing through due legislative process in Ireland will clarify some of these uncertainties when finally enacted.

Legal provisions for the use of coercive approaches in the treatment of AN differ considerably across jurisdictions.12 Pertinent issues leading to this variance include: (1) disparities in the conceptualisation of AN as a mental disorder,13,14 (2) a lack of clarity apropos the medico-legal concepts of competence and capacity in patients with AN;15 and (3) socio-cultural differences which influence the legislative provisions for the use of coercive approaches in the treatment of AN.16 These differences tend to be influenced by the views and attitudes of medical professionals, legal experts, the lay public and media regarding AN.

Conclusions In conclusion, the significant levels of morbidity and mortality in patients with eating disorders are well reported,21, 22 as are the benefits of early and effective intervention.23 It is clear that there 70

is a compelling need to implement the recommendations of A Vision for Change to equip clinicians with the appropriate facilities to treat all eating disorder patients, and particularly those with severe levels of illness. However, without a detailed plan on how this would be achieved, it is difficult to see how meaningful progress can be made. In addition, the legal uncertainties surrounding the management of patients who refuse treatment need to be clarified, both in relation to the MHA, and the new Mental Capacity Bill. Finally, our ability to record and collate data must be improved as, without this, appropriate service provision cannot effectively be achieved.

References: 1. Papadopoulos FC, Ekbom A, Brandt L, Ekselius L. Excess mortality, causes of death and prognostic factors in anorexia nervosa. Br J Psychiatry 2009; 194: 10-7. 2. Crow SJ, Peterson CB, Swanson SA et al. Increased Mortality in Bulimia Nervosa and Other Eating Disorders. Am J Psychiatry 2009; 166: 1342-1346. 3. Shinkwin R, Standen PJ. Trends in anorexia nervosa in Ireland: A register study. European Eating Disorders Review 2001; 9: 263-76. 4. Hoek HW, van Hoeken D. Review of the Prevalence and Incidence of Eating Disorders. International Journal of Eating Disorders 2003; 34: 383-396. 5. Hoek, HW. Review of the epidemiological studies of eating disorders. International Review of Psychiatry 1993; 5: 61–74. 6. Department of Health & Children. A Vision For Change. Report of the Expert Group on Mental Health Policy. The Stationary Office, Dublin, 2006. Annex 15.5. 7. Telephone conversation with Health Service Executive Lead Mental Health Officer. October 2009. 8. Barry S, Murphy P. A Gloomy View: Rhetoric or reality in relation to the advancement of A Vision for Change. College of Psychiatry of Ireland, 2009. 9. Parliamentary Debates v639, 17 October, 2007. Adjournment Debate - Eating Disorders.http://historical-debates.oireachtas.ie/D/0639/D.0639.200710170029.html. [Cited 2009 July 30]. 10. Freedom of Information response. P. O’Connor, Contracts and Utilisation, National Hospitals Office, Health Service Executive. 15th June 2009. 11. Carney T, Tait D, Saunders D, Touyz S, Beumont P. Institutional options in management of coercion in anorexia treatment: The antipodean experiment? International Journal of Law and Psychiatry 2003; 26: 647-75. 12. Melamed Y, Mester R, Margolin J, Kalian M. Involuntary treatment of anorexia nervosa. International Journal of Law and Psychiatry 2003; 26: 617-26. 13. Beumont P, Carney T. Conceptual issues in theorising anorexia nervosa: Mere matters of semantics? International Journal of Law and Psychiatry. 2003; 26: 585-98 14. Russell GFM. Involuntary treatment of anorexia nervosa. Psychiatric Clinics of North America 2001; 24: 337-49. 15. Vandereycken W. Whose Competence Should We Question? European Eating Disorders Review 1998; 6: 1-3. 16. Klump K, Bulik C, Kaye W, Treasure J, Tyson E. Eating disorders are serious mental illnesses. International Journal of Eating Disorders 2009; 42: 97–103. 17. South West Hertfordshire HA v KB [1994] 2 FCR 1051. 18. Beumont PJV. Compulsory treatment in anorexia nervosa. British Journal of Psychiatry 2000; 176: 298-9. 19. Thiels C. Forced treatment of patients with anorexia. Current Opinion in Psychiatry 2008; 21:495-8. 20. Tan J, Hope T, Stewart A. Competence to refuse treatment in anorexia nervosa. International Journal of Law and Psychiatry. 2003; 26: 697-707. 21. Sullivan PF. Mortality in anorexia nervosa. American Journal of Psychiatry. 1995; 152: 1073-4. 22. Birmingham CL, Jenny S, Julia AH, Elliot MG, Min G. The mortality rate from anorexia nervosa. International Journal of Eating Disorders 2005; 38: 143-6. 23. Le Grange D, Loeb KL. Early identification and treatment of eating disorders: Prodrome to syndrome. Early Intervention in Psychiatry 2007; 1: 27–39.

Conflict of interest None

Addendum Since this paper was written, the provision of eating disorder services in Ireland has been included as one of the priorities of the HSE Clinical Care Programmes in Mental Health. In addition, there is a review of the Mental Health Act 2001 being conducted by the Mental Health Commission. These initiatives are very welcome, and it is hoped that they will adequately deal with the issues raised in this paper, and address the challenges of caring for these patients.

O R I G I N A L PA P E R

Situational and psycho-social factors associated with relapse following residential detoxification in a population of Irish opioid dependent patients Kevin Ducray, Catherine Darker, Bobby P Smyth

Ir J Psych Med 2012; 29 (2): 72-79

Abstract

Irish national treatment protocols for opioid dependence have recently undergone a major external review8 resulting in an increased accent on opioid detoxification9 as a treatment goal for this typically chronic and relapsing condition.10 The 2009 Irish Comptroller and Auditor General’s Report8 notes that levels of detoxification and follow-on rehabilitation treatment are very low, equating to about 1.25% of those receiving methadone substitution treatment per annum. This scenario is likely to change as goals arising from recent Irish National Drug Strategies now include an increased commitment to opioid dependent patients being directed to eventual drug-free lifestyles and the provision of increased residential detoxification services to facilitate greater levels of rehabilitation.11,12 Similarly, a major objective of the recently published external review9 of the Department of Health and Children’s Report of Methadone Treatment Services Review Group (1998) was to consider the provisioning of treatments such as detoxification.

Aims: To identify and describe the context and factors involved in the opioid lapse process following discharge from an Irish inpatient opioid detoxification treatment programme. Design, participants, setting: Prospective follow-up study of consecutive detoxified opioid dependent patients treated in a specialist inpatient drug dependency unit. Measurements: The Maudsley Addiction Profile and a structured interview were administered to 109 patients, 18–36 months after discharge. Findings: Of 109 people interviewed at follow-up, 102 (94%) reported at least one episode of opioid use after leaving the residential treatment programme. Eighty eight patients (86% of the lapsers) identified more than one major factor contributing to their recidivism. The median number of factors identified as having a major role in the lapse was four. The most frequently reported major contributors to lapse were low mood (62%), difficulties with craving (62%), ease of access to heroin (48%) and missing the support of the treatment centre (43%). Conclusions: Early lapse was common following inpatient treatment of opioid dependence. Lapse tended to result from a number of common, identifiable, high-risk situations, feelings and cognitions which may assist clinicians and patients develop lapse prevention strategies to anticipate and interrupt this process.

As relapse is the most common outcome following treatment for a range of psychological and substance use problems13-17 moves towards increased opioid detoxification are not without risks related to lapse, overdose and mortality.18,19 An onus will be placed on treatment centres offering detoxification to assist service users in anticipating and avoiding contexts associated with lapse, a potentially perilous scenario when opioid tolerance is low. As opioid detoxification treatments are likely to increase in Ireland there is a clinical imperative to better understand relapse precipitants in detoxified patients.

Key Words: Lapse, relapse, opioids, heroin, relapse- prevention, psychological, drug, addiction, abstinence, social.

1. Background Factors associated with lapse have been broadly categorised into interoceptive or intrapersonal determinants (mood states or cognitions) and external or interpersonal precipitants (drug availability, drug-related cues and contact with drug using peers). Across all addictions, factors most frequently linked to relapse were found to be negative emotional states, interpersonal conflict and social pressure.20 According to Donovan21 the most frequent generic situations associated with relapse include social or peer pressure, a wish for interpersonal inclusion, negative emotional states and an absence of time structure; as well as anger and resentment, normally arising from interpersonal conflict.

Over the past four decades the major misused opioid in Ireland has been heroin.1 Methadone substitution treatment, a harmreduction strategy, is currently the dominant intervention for opioid dependence.2 Despite the robust evidence that methadone maintenance treatment (MMT) reduces mortality, drug use and associated criminal behaviour,3 there is increasing international pressure4 to provide recovery orientated treatments which may include medically supported opioid detoxification. Detoxification is the general term referring to the structured process whereby patients aspiring to live ‘drug free’ lives are medically weaned from either illicit or prescribed opioids. Opioid detoxification completion is higher where treatment is residential or inpatient.5-7

*Kevin Ducray, The Drug Treatment Centre Board, 30-31 Pearse Street, Dublin 2, Ireland Email kducray@dtcb.ie

Early models of relapse20 were characterised by hierarchical

Bobby P Smyth, The Drug Treatment Centre Board, 30-31 Pearse Street, Dublin 2, Ireland Department of Public Health and Primary Care, Trinity College, Dublin 2, Ireland

Catherine Darker, Department of Public Health and Primary Care, Trinity College, Dublin 2, Ireland *correspondence

Submitted 23rd July 2010 Accepted 2 November 2011

classifications of risk factors and a reliance on linear statistical methods. Critiques of earlier static, taxonomic models of relapse, led to the proposal of revised dynamic models.14, 22- 24 Witkiewitz and Marlatt24 have noted that the characteristics of alcohol are most amenable to the development of relapse prevention models. Within this research tradition there has been recent interest in incorporating the mechanism by which social variables impact upon the internal (efficacy, expectancies, negative affect, craving, motivation) and behavioural factors (coping and alcohol use) salient to alcohol relapse.25 These writers have suggested the existence of a dynamic, reciprocal feedback loop between social network and intra-individual factors, noting that social network and interpersonal variables probably moderate alcohol treatment outcomes by impacting upon the co-varying, intra-individual cognitive, affective and behavioural mechanisms of change.

follow up 18-36 months later. Abstinence was significantly associated with completion of the full six-week treatment programme, attendance at aftercare and not having an opioid dependent sibling. A related study34 which sought to identify factors associated with early relapse found that this process was significantly predicted by general demographic or patient characteristics such as younger age, greater heroin use prior to treatment, history of injecting and a failure to enter aftercare. Those who completed a full six-week inpatient treatment programme also had a significantly delayed relapse. In a 2010 review Veilleux et al35 argued that physicians and drug abuse treatment facilities must work alongside researchers to better understand the mechanisms that influence treatment retention and develop interventions to overcome barriers to abstinence. As national and international pressure mounts to direct heroin dependent patients towards abstinence based treatments and detoxification from opioids, it will be incumbent upon treatment providers to better understand the opioid relapse trajectory as well as strategies which may prevent this outcome. As noted by Bradley et al26 by learning how detoxified individuals return to drug use, it may be possible to identify strategies to minimise the risk, impact and scale of this ubiquitous treatment hazard. Our study, by investigating the situational, psychological and social factors implicated in individual lapse processes attempts to further extend the understanding of the more clinically accessible and modifiable determinants of the heroin lapse process following residential treatment within the Irish milieu. This investigation finds its relevance in the scantiness of Irish research on this topic and the anticipated increased shift towards opioid detoxification as a treatment objective. Resultant findings would be of particular salience given the generally unsatisfactory results of abstinence-directed treatments,13,35 the recent counsel to robustly embed national detoxification efforts in a psycho-social context9 and the fact that periods following detoxification are associated with an increased risk of death.36 In light of the danger posed by relapse in the initial perilous period following treatment, enhancing relapse-related coping skills during treatment and aftercare is seen to be vital13. Given the prospect of increased levels of opioid detoxification treatment in Ireland, the primary aim of the current study was to revisit earlier gathered data to identify factors associated with lapse following discharge from a residential detoxification treatment service among the same cohort of patients previously investigated by Smyth et al elsewhere.33, 34

Witkiewitz and Marlatt24 have encouraged scientist-practitioners to incorporate the idiosyncrasies of particular substances such as heroin in the modification and development of drug specific relapse prevention procedures. Focussing specifically on opioid-dependent patients, Bradley et al,26 identified 11 different factors associated with lapse following inpatient detoxification. Cognitive factors, mood factors and external events were the factors most frequently associated with initial lapse. Social pressure, drug availability and priming rarely contributed to initial lapse. Cognitive, mood and external events as well as withdrawal symptoms were the factors most strongly associated with continued use of opioids following initial lapse. This contrasts with the findings of Marlatt20 who noted the important role of social pressure as a relapse precipitant for heroin addicts. Social pressure, negative emotional states and interpersonal conflict were found to be the most frequent relapse situation among this cohort. Westermeyer27 found social factors such as arguments and the loss of supportive relationships to be associated with the probability of relapse. Gossop et al28 found most lapses to heroin use occurred in the company of other drug users or in social scenarios associated with drug taking. Unnithan, Gossop & Strang,29 found that drug-related cues and interpersonal events were the most important factors in lapses amongst opioid-dependent individuals. The significance of cues, particularly amongst heroin users, was also noted by Heather, Stallard, and Tebbutt30 who found temptations or urges in the presence of substance cues were regarded by heroin users to be the most important factor precipitating their last relapse. Maulik, Tripathi and Pal31 similarly found observing others using and then subsequently wanting to use were the predominant reasons for an initial lapse to heroin use. Westphal, et al32 conclude that whilst the high-risk situations which may lead to opioid use relapse are too plentiful to list, the empirical literature has indicated interactions with other drug users, exposure to drugs and drug cues and use of other substances are major categories of high-risk situations.

2. Aim As medically supported detoxification from opioids is likely to become an increasingly common treatment activity in Ireland, the aim of this study was to identify and describe the context and factors involved in the opioid lapse trajectory following discharge from an inpatient opioid detoxification programme, thus further extending an understanding of those clinically accessible and therapeutically malleable factors within Irish, and similar, milieus.

There has been a paucity of published research investigating the situational, contextual and psycho-social factors associated with the lapse process following residential detoxification of Irish opioid dependent patients. Little information is known about the potentially modifiable lapse catalysts among this population. A recent study by Smyth et al33 examining the medium-term outcome of Irish opioid dependent patients admitted for opioid detoxification found that 23% of patients were neither using opiates nor on methadone maintenance when interviewed at

3. Method The methods involved in this study are largely described in the related paper by Smyth et al.33 3.1 Participants Respondents were recruited from Cuan Dara which is a residential detoxification treatment centre in Dublin. The standard treatment 73

episode during this period involved a six-week admission with a medically assisted opioid detoxification taking place during the first two weeks of the admission. The treatment provided during admission is described in more detail elsewhere.33 Of 144 opioid dependent patients admitted to Cuan Dara with the goal of abstinence, 109 were interviewed 18-36 months after discharge. Five of the 40 patients not interviewed had died during the intervening period. A further six had relocated. There were twenty individuals still living in Dublin who were not interviewed because they either could not be contacted or because they refused to participate. There was insufficient information available to initiate the interview process with the remaining 11 patients.

Table 1. Demographic and drug use factors cited by the 102 opioid dependent patients who reported a lapse episode post residential detoxification treatment.

3.2 Measures When interviewed, respondents completed the Maudsley Addiction Profile37 to provide detailed information on patterns of drug use and other relevant behaviours in the month before interview, the findings of which have already been reported.33 Those patients who had lapsed also completed a modified structured questionnaire, based upon the factors associated with relapse as identified in Bradley et al.’s initial qualitative study of opiate users.26 Whilst this questionnaire was specially developed for this study, reflecting a move from a qualitative to quantitative methodology, no comment regarding the psychometric properties or robustness of this instrument can be presented. The purpose of this structured questionnaire was to fully explore the circumstances of their first lapse to opioid use, as follows.

% Median

Admission demographics Median admission age Median period of past opioid use (years) Heroin the main reported opioid used Reporting a history of injecting In a relationship with another opioid user Has an opioid dependent sibling Working at time of admission Male

N/A N/A 90 82 29 41 4 66

N/A N/A (89) (80) (28) (40) (4) (65)

Lapse data Lapsed within one week of discharge

(71)

Opioid used during first lapse Heroin alone Methadone alone Morphine Sulphate Heroin and Methadone Other combination Unknown

89 5 2 3 2 1

(87) (5) (2) (3) (2) (1)

26 72 4 36 35 27

(25) (71) (4) (35) (34) (27)

65 26 10 50 16

(64) (26) (10) (49) (16)

Social and other context of first lapse Company when first lapsed Lapsed alone Lapsed with another drug user Unknown social context Lapsed in own home Lapsed in home of another drug user Lapsed under influence of another substance Mood when first lapsed Lapsed when mood worse than usual Lapsed when mood better than usual Lapsed under normal mood Injected on first lapse occasion Injected when alone on first lapse occasion

3.3 Procedures From lapsed respondents information was obtained regarding their location and company when lapse occurred, the type of drug used and method by which the drug was taken. For each potential relapse related factor, participants were asked whether or not this had been relevant to their own lapse. If it was a relevant factor they were asked to categorise it as having either a major or minor role in the lapse episode. Following completion of this list, patients were asked to identify the main factor(s) involved in the lapse, taken from the list presented. 3.4 Data Analysis Descriptive statistics were collated to examine the percentage frequency of factors reported by participants as being pertinent to their relapse.

22 4

lapse episodes. The next most important factors were “ease of access to heroin, due to living with a heroin user for example” and “missing the support of Cuan Dara”, each of these being identified as a major factor by more than 40% of respondents. The factors which had the smallest role in lapse were “being under the influence of another substance” and “knowledge that they could re-access methadone treatment if they became ‘strung out’ again”, these being involved in 16 and 17 cases respectively.

4. Results The demographic and the other drug use factors reported by the 102 opioid dependent patients who reported a lapse episode following residential detoxification treatment are recorded in Table 1. Sixty six (72%) of respondents who used heroin (either by itself or in combination with methadone) reported being in the company of another drug user during their first lapse. Forty seven (51%) of this group injected during their first lapse and 15 (65%) of the subset of 23 who were alone during heroin re-initiation engaged in this most risky route of drug administration.

A total of 88 (86%) people identified two or more major factors contributing to their lapse. The median number of factors identified as having a major role in the lapse was four (IQR 2 – 6). Patients rated the quality of their recall regarding the circumstances of the initial lapse as very good in 77% of cases and fairly good in 13% cases, although 10% reported having relatively poor recollection of details. The interviewers rated the patients recall as being very good in 72% of cases and fairly good in 18% of cases.

As shown in Table 2, it emerged that the most important issues involved in the lapse were low mood and difficulties with cravings, with each of these being the main factor in one third of cases, while each had either a major or minor role in three quarters of 74

Table 2. Factors involved in first lapse following a period of residential detoxification treatment amongst 102 opioid dependent patients

Simply made a decision to start using again Thought that I could just try it once again Mood was bad and wanted a lift Mood was good Wasn’t sleeping or felt ‘sick’ Upset at prospect of meeting partner/family/friends Met someone and offered opioids Missed support of Cuan Dara Ease of access to opioids e.g. living with a user Knew that I could get on a methadone programme if ended up ‘strung out’ again Under the influence of alcohol or another drug Drug-related cues e.g. saw someone stoned or found ‘works’ Cravings were too much

Identified as the main precipitating factor

Identified as a major precipitating factor

Identified as a minor precipitating factor

N 11 8 27 3 8 4 9 9 11

(%) (11) (8) (27) (3) (8) (4) (9) (9) (11)

N 29 40 63 16 31 25 37 43 48

(%) (28) (39) (62) (16) (31) (25) (37) (43) (48)

N 15 16 12 11 10 4 4 14 11

1 3

(1) (3)

13 11

(13) (11)

4 5

8 30

(8) (30)

23 63

(23) (62)

6 10

5. Discussion

drug cues (which may imply ease of access) together with the consumption of other drugs are significant categories of high-risk situations and associating with other drug users is a strong predictor of relapse. Social pressure has been found to be the most significant relapse precipitant for heroin addicts.30 Unnithan et al29 found interpersonal factors and drug-related cues as being most strongly associated with opioid use lapses. In this study the cited lapse precipitant ‘ease of access’ is a broad construct that may encapsulate the ready availability of drugs, access to other drug users and exposure to other drug cues. All these risk factors may be amenable to cognitive behavioural interventions. Beck et al41 argue that as exposure to high-risk situations is inevitable, careful, planned and graded exposure assignments or ‘inoculation’ to such cues are a clinically sound strategy leading to increased self efficacy. The need to specifically identify the deleterious impact of social interactions; prepare clients for peer or social risk factors; anticipate related intrinsic drug-use cues and their impact on intra-individual functioning under such situations, as well as to harness the potentially beneficial elements of social networks in facilitating desired change is thus strongly recommended as a treatment activity.

Our finding that the majority of lapses occurred during the first week after leaving treatment confirms Gossop et al’s findings as to the general alacrity of initial opioid lapse28, 38 and the notion of a ‘critical period’ of extraordinarily high-risk immediately after leaving residential treatment during which the best possible support should be provided. Connors et al39 similarly highlighted the importance of preventing relapse immediately following treatment as the prognosis for ongoing abstinence are significantly better once an initial period of abstinence has been attained. We have discussed issues salient to the rapidity of lapse amongst this patient population in more detail in a related paper.34 Our findings that half of lapsing heroin users injected on their first lapse occasion and that nearly two-thirds of those who were alone during their first lapse episode injected, reflects scenarios with a high risk potential which need to be proactively addressed when preparing clients for discharge. Such findings underscore the current National Institute for Clinical Excellence (NICE) guideline36 that it is imperative that detoxification treatments include wider psychosocial support as well as education on post-detoxification vulnerability to relapse and to overdose.

The factors low mood, cravings, ease of access to opioids, missing the supports offered in treatment, cognitive factors and meeting someone and being offered opiates were similarly ordered in the aforementioned hierarchy of importance, when cited either as ‘the main’ precipitant to lapse or as ‘a major’ factor contributing to lapse.

Our determination that a large percentage of respondents lapsed in the company of another drug user confirms Gossop et al’s28 observation that most opioid lapses occur in the company or home of other users and emphasises the detrimental role played by certain drug-related peer group influences and social contexts in precipitating opioid use lapses. Having examined social networks and alcohol use disorders, McCrady40 notes that the impact of social networks on problem drinking may be positive, negative or mixed. Hunter-Reel et al,25 recognising the impact of social network influences in predicting drinking outcomes, have proposed a model of alcohol relapse in which social variables have a reciprocal influence on drinking outcomes by altering those intraindividual factors and processes salient to alcohol use relapse. Westphal et al32 have similarly argued the empirical literature indicates encounters with other drug users, exposure to drugs and

More than six times as many respondents reported their mood was worse than usual during first lapse than those who reported lapsing under normal mood. Examining a range of addictive behaviours, Cummings et al42 found most lapses were associated with factors such as negative emotions, social forces and interpersonal discord. Marlatt20 found negative emotional states were the intrapersonal factor most highly linked with relapse amongst heroin users and that negative emotional states and interpersonal conflict were associated with a resumption of 75

substance use in more than half of such cases.43 Bradley et al26 found dysphoric mood states to be the second-most common factor associated with relapse. Negative emotional states have been found to be a pervasive relapse predictor across the majority of studies investigating relapse precipitants.14 Consistent with the dynamic models14, 22-25 discussed earlier, Unnithan et al29 suggests negative mood states be viewed as a chronic background factor which enhances the risk of relapse when linked with other specific relapse precipitants.

reformulated relapse models14, 22-24 to describe the interpersonal factors that may interrelate with intrapersonal characteristics and processes to produce change. Given the accepted convention and ubiquitous nature of alcohol consumption in Ireland against the fact heroin users are often a much more marginalised group with multiple morbidities53 the interplay between inter and intra personal factors within these populations may be dissimilar. Notwithstanding this, our findings confirm the potential salience of social networks in the development of a model reflecting the lapse idiosyncrasies of recently detoxified opioid dependent persons.

Our finding as to the role of negative mood states as a lapse precipitant underscores the importance of clinicians being sensitive to the existence of possible co-morbid depressive disorders, a distal relapse precipitant according to Shiffman’s22 model. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) regards such conditions as being underestimated and under diagnosed and suggest that about 80% of patients with a drug dependency diagnosis also have co-morbid psychiatric diagnoses. They cite European data to highlight the anomaly that whilst co-morbid depression ranges from 5% to 72% and that suicide attempts occur in around 50% of drug dependent patients, treatment teams commonly fail to spot patients with such psychiatric co-morbidity.44, 45

The above underscores the importance of social interventions which either positively impact upon intrapersonal processes supporting positive change, or reinforce abstinence through interpersonal relationships. A review of social network variables in Alcoholics Anonymous (AA) by Groh et al54 found not only was support from others in AA to be of great value to recovery but also that individuals with harmful social networks benefited the most from AA involvement. Gossop et al55 found that predominantly heroin-addicted patients in the UK who regularly attend 12-step groups after residential treatment have been more likely to sustain abstinence from alcohol and opiates. These writers suggest the effectiveness of treatment services may be enhanced by systems that lead to increased involvement and engagement with groups such as Narcotics Anonymous (NA) and AA which have proven to be valuable aftercare resources. Conversely this study’s finding that ease of access to drugs, for example living with a user, was the third most influential main risk factor and that 40% of this group had an opioid dependent sibling or intimate partner illustrates the inherent complexities in motivating changes in social networks as a treatment strategy. The synergistic impact of social network influences on intrapersonal variables28 when living with another opioid user, together with the influence of classically conditioned drug-use or cravings cues49, 56 in such intimate relationships are likely to produce a blend of post detoxification risk scenarios that are challenging to address.

Craving has been described as the most widely studied yet poorly understood topic in the domain of drug addiction.46 Niaura47 argues that whilst the role of craving has been given a position of prominence in many current theories of relapse, debate remains as to the motivational significance of craving in drug-use behaviours. Westphal et al32 note too the weak empirical relationship between craving and relapse and the contradictory role played by this construct in the area of opioid use. Marlatt and Witkiewitz48 similarly assert a common finding of contemporary addiction research is the absence of a strong association between craving and relapse. We found that cravings were the most commonly cited ‘main’ lapse precipitant and together with ‘a mood worse than usual’ the most commonly cited “major” factor associated with an opioid lapse. This is of import given Siegel’s precipitating factor treatise on cues and cravings. According to his thesis, based upon the Pavlovian conditioning paradigm, the treated addict’s experience of cravings are elicited by exposure to exteroceptive (e.g. social settings, the company of friends, paraphernalia) or interoceptive (cognitions, memories, emotions) situations previously paired with drug use. This study’s finding as to the significance of cravings as an opioid lapse precipitant confirms the importance of addressing factors associated with this phenomenon early in treatment.50, 51

Other factors intermediately ranked as having a major role in a first lapse included thinking one could just try it once again, simply making a decision to start using again, meeting someone and being offered opioids, exposure to cues (e.g. saw someone stoned or found ‘works’) and being upset at the prospect of meeting significant others. Whilst cognitive factors such as “simply made a decision to start using again” or “I thought I could just try it once again” were only of moderate importance as ‘main’ or ‘major’ relapse precipitants, they were the most frequently cited ‘minor’ lapse precipitating factors. This finding contrasts with Bradley et al’s26 determination as to the importance of cognitive factors in relapse. According to Beck et al41 exposure to high-risk triggers activate a chain of cognitive, behavioural and internal experiences potentially culminating in drug-use behaviours. In response to cravings and urges the individual may experience permissive cognitions (e.g. “I thought I could just try it once again”) thus activating drug-seeking behaviour. Treatment strategies may include assisting patients in understanding how these transient thoughts about drug use may be elicited by antecedent cues and be proactively managed through cognitive behavioural coping skills. Interventions41, 50, 51 to manage attractive thoughts about drug use and reduce positive drug expectancies are regarded as a primary active ingredient of cognitive-behavioural treatments57 and

A number of writers25, 40, 48 cite a raft of research to indicate that whilst positive social support is highly predictive of abstinence across a number of addictive behaviours, other social interactions are conversely linked to impeded therapeutic change and an increased risk of relapse. We found missing the support offered by Cuan Dara was ranked fourth, both as the most commonly identified lapse antecedent and the most commonly cited ‘major’ precipitant. Hunt and Azrin’s52 Community Reinforcement Approach is based on the operant learning principal that substance use is a behaviour determined by arrangements of contingencies and specifically influenced by patterns of reinforcers either lost or received. Working with alcohol use disorders and utilising a social network perspective Hunter-Reel et al25 have extended 76

are readily available to clinicians preparing patients to cope with such challenges. Consistent with the work of Hunter-Reel25 many of the other aforementioned factors (e.g. upset at prospect of meeting a significant other, being offered opiates, exposure to drug-related cues such as seeing someone stoned or finding works) are socially or inter-personally mediated, highlighting the adverse impact of certain social network influences on intrapersonal experiences.

abusers under the influence of drugs.59 The design of the questionnaire based on Bradley et al’s26 work also predated the emergence of more systemic, non-linear and dynamic models of relapse14, 22-25 as well as research highlighting the relevance of coping skills in preventing opioid relapse.60 As the data for this study was gathered more than a decade ago and prior to the development of more dynamic models of relapse, it is thus predisposed towards linear lapse processes and proximal determinants whilst paying less attention to the synergy between these and intermediate, background and distal factors, including the role of social networks. Ideally further research should meet the challenge of both prospectively examining the opioid relapse process and integrating the impact of tonic or underlying background risk factors with clinically relevant phasic proximal factors (such as coping skills, motivation, self efficacy and drug and outcome expectancies) in an effort to develop a systemic and dynamic understanding of the opioid relapse process. Such a focus should include the interaction between environmental, social network and intra-individual factors.

Our finding as to the relatively small roles played by postdetoxification and discharge symptoms such as sleep difficulties or feeling “sick” in precipitating opioid lapses are consistent with Bradley et al’s26 verdict that ‘withdrawal symptoms’, including sleep difficulties, were not dominant factors associated with relapse. Whilst Unnithan et al29 noted a high prevalence of symptoms of feeling unwell (either because of withdrawals or because of other health problems) amongst responders, they found no significant difference between opiate lapsers and non-lapsers in terms of either withdrawal symptoms or feeling unwell. Thus residual symptoms of illness or feeling unwell, when experienced after detoxification has been completed and patients have been discharged, may act only as a modest intermediate or contextual background risk factors, compromising abstinence when superimposed with other acute or proximal relapse precipitants. Such findings may provide some consolation to suggestible, alarmist or highly anxious patients and serve as a tool for clinicians wishing to therapeutically normalise the perceived hazard of these physical experiences.

On a positive note these findings, taken together with the earlier work of Smyth et al33, 34 suggest specific areas of focus for those clinicians hoping to support detoxified patients to recognise, anticipate and avoid where possible and better manage clearly identified threats to their newfound drug-free status. The National Institute for Clinical Excellence’s guideline on opiate detoxification36 records that whilst a number of psycho-social treatment models exist, interventions can be unfocussed and both therapist and client may not have a clear understanding of the therapeutic goals of treatment. This body notes too that evidence for adjunctive psychosocial interventions, such as relapse prevention cognitive behavioural therapy is sparse. It is thus hoped this examination of the opioid lapse process, specifically categorising the specific situational and psychosocial hazards recovering patients should anticipate and psychologically prepare for, has contributed to establishing helpful mechanisms of intervention. These findings furthermore neatly interlock with the practical cognitive and behavioural strategies that Wanigaratne et al61 have argued are fundamental to dealing with relapse triggers. These include recognising high-risk conditions and triggers for craving; developing strategies to minimise exposure to these high-risk situations; learning skills to manage cravings and other distressing emotions without recourse to drug use; learning to control lapses; learning to identify, contest and manage unhelpful or dysfunctional thoughts about drug use; developing emergency plans to manage high-risk situations when other skills are not effective; generating enjoyable sober activities and relationships; constructing a life worth living and attaining a balanced lifestyle.

That 88 (86%) people in this study identified two or more factors contributing to their lapse and with four being the median number of factors identified as having a major role in the lapse, suggests that the majority of respondents have insight to both the compound nature of their own lapse episodes and an intuitive understanding that multiple interacting risk factors precede and impact upon their lapse. Bradley et al26 noted relapse factors occur in systemic clusters and argued that a complete model of lapse should encompass the interactions between external events, cognitions and affect in explaining renewed drug use. As has been suggested14, 22-24 relapse may thus be best conceptualised as a consequence of a complex nonlinear interaction of background, physiological state, cognitive and coping-skill related factors or similarly as a consequence of the reciprocal dynamic between the individual’s social network and their internal cognitive, affective and behavioural processes.25 Future research examining relationships between these factors should provide exciting data for those seeking to develop a systemic model explaining the relapse process following successful opioid detoxification.

6. Conclusion

Limitations of this study include the reliance on a retrospective assessment of relapse precipitants and the static model of assessment. These features of the methodology bring with them the risks of recall bias and inaccurate identification of true precipitants.21 The fact that in most instances relapses occurred close to discharge is however likely to have assisted patients in accurate recall. Previous studies report too that drug users are capable of valid self-reports regarding their drug use in environments where social desirability does not play a major role58 As also noted, whilst retrospective responding has the potential for selectivity in recall, such questioning is often the only practical option given the challenges of engaging relapsing substance

In Ireland, as in other jurisdictions, lapse following the inpatient treatment of opioid dependence is typically alacritous. Lapse following detoxification tends to follow key, identifiable high-risk situations, feelings, and cognitions. Identification of these components may be useful for Irish treatment providers facing an increased expectation to provide detoxification-based treatment models and goals. Such findings highlight the need to ensure resources are made available for clinicians to develop and implement contextually relevant treatment strategies which prepare clients to anticipate, interrupt and better manage likely lapse precipitants. 77

References 1. Comiskey C, Cox G. ROSIE baseline data report. Dublin: National Advisory Committee on Drugs; 2007. 2. Callon C, Wood E, Marsh D, Li K, Montaner J, Kerr T. Barriers and facilitators to methadone maintenance therapy use among illicit opiate injection drug users in Vancouver. J Opioid Manag 2006 Jan-Feb; 2(1):35-41. 3. Marsch LA. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis. Addiction 1998 Apr; 93(4):515-32. 4. McKeganey N. The challenge to UK drug policy. Drug-Educ Prev Policy 2007; 14 (6):559-571. 5. Hubbard RL, Craddock SG, Anderson J. Overview of 5-year follow up outcomes in the drug abuse treatment outcome studies (DATOS). J Subst Abuse Treat 2003 Oct; 25(3):125-34. 6. Strang J, McCambridge J, Best D, Beswick T, Bearn J, Rees S, Gossop M. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. BMJ 2003 May; 326(7396):959-60. 7. Day E. Opiate detoxification in an inpatient setting. London: National Treatment Agency for Substance Misuse, 2005. 8. Comptroller Auditor General VFM Report 64. Drug Addiction Treatment & Rehabilitation. Dublin: Office of the Comptroller Auditor General, 2009. 9. Farrell M, Barry J. The introduction of the opioid treatment protocol. Dublin: Health Service Executive, 2010. 10. Van den Brink W, Haasen C. Evidence-based treatment of opioid-dependent patients. Can J Psychiatry 2006 Sep; 51 (10): 635-46. 11. National Drugs Strategy 2001-2008: Building on Experience. Dublin: Department of Tourism, Sport and Recreation, 2001. 12. National Drugs Strategy (interim) 2009-2016. Dublin: Department of Community, Rural and Gaeltacht Affairs, 2009. 13. Haug NA, Sorensen JL, Gruber VA, Song JS. Relapse prevention for opioid dependence. In: Marlatt GA, Donovan DM, editors. Relapse Prevention. 2nd ed. New York: Guilford Press; 2005. P 151- 78. 14. Witkiewitz K, Marlatt GA. Modeling the complexity of post-treatment drinking: it’s a rocky road to relapse. Clin Psychol Rev 2007 Jul; 27(6):724-38. 15. Ockene JK, Emmons KM, Mermelstein RJ, Perkins KA, Bonollo DS, Voorhees CC, Hollis JF. Relapse and maintenance issues for smoking cessation. Health Psychol 2000 Jan; 19(1 Suppl):17-31. 16. Litman GK, Stapleton J, Oppenheim AN, Peleg M, Jackson P. Situations related to alcoholism relapse. Br J Addict 1983 Dec; 78(4):381-9. 17. Amato L, Minozzi S, Davoli M, Vecchi S, Ferri M, Mayet S. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev 2008 Oct; (4): CD005031. Review. 18. Fugelstad A, Stenbacka M, Leifman A, Nylander M and Thiblin I. Methadone maintenance treatment: the balance between life-saving treatment and fatal poisonings. Addiction 2007; 102(3): 406-412. 19. Naderi-Heiden A, Gleiss A, Bäcker C, Bieber D, Nassan-Agha H, Kasper S, Frey R. Mortality and employment after in-patient opiate detoxification. European Psychiatry: the journal of the Association of European Psychiatrists 2010 July: 0924-9338. 20. Marlatt, GA. Relapse Prevention: Theoretical rational and overview of the model. In: Marlatt GA, Gordon JR, editors. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press; 1985. p 3- 70. 21. Donovan, DM. Assessment of addictive behaviors for relapse prevention. In: Donovan DM, Marlatt GA, editors. Assessment of addictive behaviors. New York: Guilford Press; 2005.p 1- 48. 22. Shiffman S. Conceptual issues in the study of relapse. In: Gossop M, editor. Relapse and addictive behaviour. London: Routledge; 1989. p 149- 79. 23. Donovan DM. Marlatt's classification of relapse precipitants: is the Emperor still wearing clothes? Addiction 1996 Dec; 91 Suppl: S131-7. 24. Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. Am Psychol 2004 May-Jun; 59(4):224-35. 25. Hunter-Reel D, McCrady B, Hildebrandt T. Emphasizing interpersonal factors: an extension of the Witkiewitz and Marlatt relapse model. Addiction 2009; 104: 1281– 1290. 26. Bradley BP, Phillips G, Green L, Gossop M. Circumstances surrounding the initial lapse to opiate use following detoxification. Br J Psychiatry 1989 Mar; 154: 354-9. 27. Westermeyer J. Nontreatment factors affecting treatment outcome in substance abuse. Am J Drug Alcohol Abuse 1989; 15(1): 13-29. 28. Gossop M, Green L, Phillips G, Bradley B. Lapse, relapse and survival among opiate addicts after treatment. A prospective follow-up study. Br J Psychiatry 1989 Mar; 154: 348-53. 29. Unnithan S, Gossop M, Strang J. Factors associated with relapse among opiate addicts in an out-patient detoxification programme. Br J Psychiatry 1992 Nov; 161: 654-7. 30. Heather N, Stallard A, Tebbutt J. Importance of substance cues in relapse among

Acknowledgements: The authors would like to thank Dr. Alan Kelly, Senior Statistician in Bio-Statistics, Department of Public Health & Primary Care, Trinity College Dublin for his advice on statistics.

Conflict of interest None.

Addendum Since the submission of this paper Prof. J Strang (2011) has published Recovery-oriented drug treatment. An interim report. This National Treatment Agency document, heralding a new direction in UK clinical guidance for treating heroin addicts recommends that clinicians should promote abstinence; helping more heroin users recover and break free of opioid dependence. Professor Strang notes that in focussing more on helping patients overcome their dependence clinicians must guard against relapse and that by drawing upon layered and phased psychosocial and pharmacological approaches this threat, together with associated risks, can be minimised.

31. 32.

33.

34. 35.

36.

37.

38.

39.

40.

41. 42. 43. 44.

45.

46. 47. 48.

49. 50.

51. 52. 53. 54. 55.

56. 57. 58.

heroin users: comparison of two methods of investigation. Addict Behav 1991; 16(12): 41-9. Maulik PK, Tripathi BM, Pal HR. Coping behaviors and relapse precipitants in opioid dependence: a study from North India. J Subst Abuse Treat 2002 Apr; 22(3): 135-40. Westphal J, Wasserman DA, Masson C L, Sorenson JL. Assessment of opioid use. In: Donovan DM, Marlatt GA, editors. Assessment of addictive behaviours. 2nd ed. New York: Guilford; 2005. p 215- 47. Smyth BP, Barry J, Lane A, Cotter M, O'Neill M, Quinn C, Keenan E. In-patient treatment of opiate dependence: medium-term follow-up outcomes. Br J Psychiatry 2005 Oct; 187:360-5. Smyth BP, Barry J, Keenan E, Ducray K. Lapse and Relapse Following Inpatient Treatment of Opiate Dependence, IMJ 2010 June; 103(6): 176- 79. Veilleux JC, Colvin PJ, Anderson J, York C, Heinz AJ. A review of opioid dependence treatment: pharmacological and psychosocial interventions to treat opioid addiction. Clin Psychol Rev 2010 Mar; 30(2):155-66. National Institute for Clinical Excellence (NICE): Drug Misuse: Opioid detoxification. The NICE guideline. London: National Institute for Health and Clinical Excellence, 2008. Marsden J, Gossop M, Stewart D, Best D, Farrell M, Lehmann P, Edwards C, Strang J. The Maudsley Addiction Profile (MAP): a brief instrument for assessing treatment outcome. Addiction 1998 Dec; 93(12):1857-67. Gossop M, Marsden J, Stewart D, Treacy S. Change and stability of change after treatment of drug misuse: 2-year outcomes from the National Treatment Outcome Research Study (UK). Addict Behav 2002 Mar-Apr; 27(2):155-66. Connors G J, Donovan DM, Diclemente C C. Substance Abuse Treatment and the stages of Change: Selecting and Planning Interventions. New York: Guilford Press; 2001. McCrady B. S. To have but one true friend: Implications for practice of research on alcohol use disorders and social networks. Psychology of Addictive Behaviors 2004; 18: 113-121. Beck AT, Wright FD, Newman, CF, Liese BS. Cognitive Therapy of Substance Abuse. New York: Guilford Press; 1993. Cummings C, Gordon J R, Marlatt GA. Relapse: Prevention and prediction. In: Miller WR, editor. The addictive behaviours. Oxford: Pergamon Press; 1980. p 291- 321. Marlatt GA. Taxonomy of high-risk situations for alcohol relapse: evolution and development of a cognitive-behavioral model. Addiction 1996 Dec; 91 Suppl: S37-49. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Selected issue 3: Co-morbidity in Annual Report 2004: The state of the drugs problem in the European Union and Norway. Luxembourg: Office for Official Publications of the European Communities, 2004. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Drugs in focus issue 14. Co-morbidity - drug use and mental disorders. Lisbon: European Monitoring Centre for Drugs and Drug Addiction, 2005. Drummond DC, Litten RZ, Lowman C, Hunt WA. Craving research: future directions. Addiction 2000 Aug; 95 Suppl 2: S247-55. Niaura RS. Cognitive social learning and related perspectives on drug craving. Addiction 2000; 95:S155â&#x20AC;&#x201C;S164. Marlatt G A, Witkiewitz K. Relapse prevention for alcohol and drug problems. In: Marlatt GA, Donovan DM, editors. Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. 2nd ed. New York: Guilford Press; 2005. p 1- 44. Siegel, S. Drug Tolerance, Drug Addiction, and Drug Anticipation. Current Directions in Psychological Science 2005 Dec; 14: 296-300. Kadden R, Carroll K M, Donovan D, Cooney N, Monti P, Abrams D, Litt M, Hester R. Cognitive-behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1992. Carroll, KM. A Cognitive Behavioural Approach: Treating Cocaine Addiction. Rockville, MD: National Institute on Drug Abuse, 1998. Hunt GM, Azrin NH. A community-reinforcement approach to alcoholism. Behav Res Ther 1973 Feb; 11(1): 91-104. Gossop M. Treating drug misuse problems: evidence of effectiveness. London: National Treatment Agency for Substance Misuse, 2006. Groh DR, Jason LA, Keys CB. Social network variables in alcoholics anonymous: a literature review. Clin Psychol Rev 2008 Mar; 28(3): 430-50. Review. Gossop M, Stewart D, Marsden J. Attendance at Narcotics Anonymous and Alcoholics Anonymous meetings, frequency of attendance and substance use outcomes after residential treatment for drug dependence: a 5-year follow-up study. Addiction 2008 Jan;103(1):119-25. Ludwig AM, Wikler A. "Craving" and relapse to drink. Q J Stud Alcohol 1974 Mar; 35(1):108-30. Moos RH. Theory-based active ingredients of effective treatments for substance use disorders. Drug Alcohol Depend 2007 May; 88(2-3): 109-21. Langendam MW, van Haastrecht HJ, van Ameijden EJ. The validity of drug users' self-

reports in a non-treatment setting: prevalence and predictors of incorrect reporting methadone treatment modalities. Int J Epidemiol 1999 Jun; 28(3):514-20. 59. Hammerbacher M, Lyvers M. Factors Associated with Relapse among Clients in Australian Substance Disorder Treatment Facilities. Journal of Substance Use 2006 11:6, 387- 394. 60. Gossop M, Stewart D, Brown N, Marsden J. Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses. Addiction 2002; 97: 1259- 1267. 61. Wanigaratne S, Davis P, Pryce K, Brotchie J. The Effectiveness of Psychological Therapies on Drug-Misusing Clients. London: NTA; 2005.

O R I G I N A L PA P E R

Suicide on the Isle of Wight: A Case-study of 35 Suicides among Mental Health Service Users Between 2006 and 2008 Homayun Shahpesandy, Ad van Heeswijk

Ir J Psych Med 2012; 29 (2): 80-84

Abstract

The suicide rate for men in the South Central region is significantly lower than the England average. Hampshire PCT has the lowest rate in the region, falling significantly below the regional and national averages. The Isle of Wight and Oxfordshire have the next lowest rates, while Southampton, Buckinghamshire and Berkshire West have the highest rates (Department of Health (DoH), 2002). Since the publication of the Government’s suicide prevention strategy (DoH, 2002), suicide has become a key focus for psychiatric services in the UK.

Aims: To identify the sociodemographic, clinical and service delivery risk factors for suicide in psychiatric patients in a limited geographic area. Method: A retrospective case study of 35 patients who died as a result of suicide between January 2006 and December 2008. Results: Male gender, unemployment, living alone, basic education and significant life events were identified as sociodemographic factors. A history of previous psychiatric admission, previous suicide attempt, suffering from depression, co-morbidity of another psychiatric disorder (mainly stress-related symptoms and alcoholism), and contacting the services prior to suicide were found as typical clinical factors. Hanging was the most common method of suicide in both men and women. Most men died in spring and summer, while the majority of females died in autumn.

The present study focuses specifically on the Isle of Wight (IOW). The IOW is a small island (380km2) 4 miles off the British south coast, separated from the mainland by the Solent. The only connections with the mainland are maintained through ferries from Portsmouth, Southampton and Lymington. The IOW has a resident population of around 130,000. Apart from national and international tourism, small-scale electronic industry and shipbuilding, the island has a mainly rural character (258km2 is farmland). The island’s healthcare services are organised in one single NHS Primary Care Trust, providing general as well as mental healthcare in the island’s only hospital and in the community. Although the Trust aims at providing comprehensive healthcare, due to the island’s small size patients have to travel to the mainland for certain specialist physical and mental health treatment. The Trust’s Care Group Mental Health and Learning Disabilities provides Adult Mental Healthcare (including inpatient acute services, community mental healthcare and psychological therapy services), Older People’s Mental Healthcare (including inpatient and community dementia care), Substance Misuse Services, a Child and Adolescent Mental Health Service, and Learning Disability Services. Patients who need specialist inpatient treatment for e.g. forensic problems, eating disorders, substance misuse rehabilitation, or child and adolescent psychiatric problems have to be transferred to mainland specialist hospitals. For patients as well as their relatives and visitors, this often means a journey of several hours both ways, as well as being taken out of their familiar surroundings.

Clinical implications: As in similar studies, mental disorders could be identified as the strongest risk factor for suicide. Almost 70% of suicides were conducted by people suffering from a mental disorder. Treating mental disorders and identifying certain sociodemographic and clinical characteristics of people suffering from mental disorders and addressing them is the key in suicide prevention strategies. Key words: suicide, service users, risk factors, mental disorders, sociodemographics.

Introduction Suicide is a major public health problem. Approximately one million lives worldwide are lost to suicide each year. According to the World Health Organization (WHO) statistics, an increase of approximately 49% in suicide rates in males and 33% in females can be observed between 1950 and 1995. The highest suicide rates for both men and women are found in Europe, more particularly in Eastern Europe (Bertolete & Fleischmann, 2005).

Aims of the study The aim of this study was to identify sociodemographic, clinical and service delivery risk factors in a sample of patients who were under the care of the local mental health services.

Suicide is the sixth most common cause of death in the general population of the United Kingdom; in the 15-44 year-old age group, it is the third most common cause of death (Baldwin & Hirschfield, 2005).

*Homayun Shahpesandy, Consultant Psychiatrist Tees, Esk and Wear Valleys NHS Foundation Trust, Roseberry Park, Middlesbrough TS4 3AF Email shahpesandy@hotmail.com *correspondence

Inclusion Criteria: 1. Any individual who received services of the local mental health facilities within two years prior to their death, and who died between

Ad van Heeswijk, Lead Clinical Psychologist Acute & Recovery Community Mental Health Service, Chantry House, 29-31 Pyle Street, Newport, Isle of Wight PO30 1JW, United Kingdom

Submitted 2nd December 2010 Accepted 6th July 2011

January 1st 2006 and December 31st 2008 as a result of suicide. 2. Death resulted from ‘intentional self-harm’ as defined and classified in the ICD-10 (WHO 1992; codes X60-X84), and had been confirmed by the coroner’s verdict as suicide or as an ‘open verdict’, the circumstances of death indicating a probable suicide.

women than men had financial (30% vs 8%); work-related (20% vs 8%), and bereavement issues (10% vs 4%). On the other hand, relationship problems (32% vs 20%), judicial problems (24% vs 10%), housing problems (20% vs 10%); and illness of a family member (12% vs 0%) were more frequent in men than in women (Table 1).

Exclusion criteria: 1. Death resulted from ‘accidental death’ or ‘drug overdose’ (according to the coroner’s verdict). 2. Non-service users, i.e. individuals not using the local mental health services within the two years prior to their death.

Table 1. Demographic and socio-economic factors

Data collection: Data were collected from medical case notes (including postmortem examination and coroners’ reports), and were recorded under the following headings: 1. Demographic and socio-economic characteristics: a. Marital status, b. Education, c. Employment, d. Psychiatric admissions, and 2. Psychiatric diagnosis, using the ICD-10 (WHO, 1992); 3. Adverse life events (ALEs) that were taken from the audited files, and grouped in nine cogent categories. 4. Attendance at accident and emergency (A&E) within a year prior to suicide; 5. Contact with mental health services; 6. Previous suicide attempts, and 7. Circumstances of suicide (method, place, day and month of suicide) There were 51 suicides (13 women and 38 men) of Isle of Wight residents, of whom 49 died on the island and two on the mainland. 35 individuals (10 women, with an average age of 41.9 years, age range 17- 63 and 25 men, with an average age of 43.5 years, age range 21-76 years) were found to fulfil the inclusion criteria, nine in 2006, eight in 2007 and 18 in 2008 respectively.

Family status Single Married Engaged Divorced Separated Widow/widowers

Women (n-10) No. % 4 40 2 20 0 0 2 20 1 10 1 10

Men (n-25) No. % 9 36 9 36 2 8 0 0 5 20 0 0

All (n-35) No. % 13 37.1 11 31.4 2 5.7 2 5.7 6 17.1 1 2.9

Education Academic Basic Unknown

1 9 0

10 90 0

3 21 1

12 80 4

4 30 1

11.4 85.7 2.9

Employment Employed Unemployed Retired Disabled Unknown

3 7 0 0 0

30 70 0 0 0

11 10 2 1 1

44 40 8 4 4

14 17 2 1 1

40 48.5 5.7 2.9 2.9

Previous suicidal attempts

77.1

Previous psychiatric admission 7

62.8

No. 7 2 1 2

% 70 20 10 20

No. 21 8 1 2

% 84 32 4 8

No. % 28 80 10 28.5 2 5.7 4 11.4

0 3 1 1 2

0 30 10 10 20

3 2 5 5 4

12 8 20 24 16

3 5 6 6 6

Adverse Life Events Any adverse event Relationship Bereavement Work-related Illness of a family member Financial Housing Judicial Physical illness

Results With regards to family status 37.1% were single; 37.1% lived in a marriage (31.4%) or other form of engagement (5.7%); 22.8% were either divorced (5.7%) or separated (17.1%); and 2.9% were widowed. In terms of education, 11.4% of all cases had an academic education and 85.7% had a basic education (until the age of 16). In 2.9% of cases it was impossible to find out their level of education.

8.6 14.2 17.4 17.4 17.4

Depressive disorders were diagnosed in 34.3%, followed by alcohol-related disorders (28.6%); polysubstance abuse (14.3%); bipolar affective disorder (8.6%); ‘neurotic’ and stress-related disorders; schizophrenia spectrum disorders (equally 5.7%) and organic mental disorders (2.9%). Mental and behavioural disorders due to use of substances (42.8%),and mood disorders (42.8%) were the most common primary diagnoses. On the other hand, stress-related (31.4%) and personality disorders (31.4%) were the most common co-morbidities. Drug related and affective disorders were the next most common co-morbid disorders each diagnosed in 14.3% of the cases. (Table 2).

Of the cases, 48.5% were unemployed; 40% employed; 5.7% retired; and 2.9% registered disabled. In 2.9% of the cases, it was impossible to identify their employment status. More than 77% of individuals had a history of previous suicide attempts, and almost 63% a history of previous psychiatric admission. Furthermore, 80% of the individuals had some adverse life event within the year prior to suicide. As the results indicate more 81

Table 2. Diagnoses Diagnoses

Organic mental disorders Alcohol use disorders Multiple substance use disorders Schizophrenia spectrum disorders Bipolar affective disorder Depressive disorders “Neurotic” and stress-related disorder Personality Disorders

Table 3. Circumstances related to suicide Primary (n-35) Number %

Secondary (n-35) Number %

1 10

2.9 28.5

0 0

14.3

2 3 12

5.7 8.6 34.3

0 0 5

0 0 14.3

2 0

5.7 0

11 11

31.4 31.4

Circumstances of the suicide

Suicide by hanging was the most common method (76% of men and 50% of women). In terms of the place of suicide, 51.4% of the cases died in their homes, 34.3% in a public place; 8.6% in their relatives houses, and 5.7% in prison. With regard to the day of suicide, 34.3% of all suicides were committed on Wednesday; 14.3% on Monday; equally 11.4% on Saturday, Tuesday and Thursday. 8.6% died on Friday; 5.7% on Sunday, and in 2.9% we could not identify the day of their death. No women died during the weekend and in 10% of women it was impossible to find out the exact day of their suicide. Twenty percent of women died in spring; 10% in summer; 60% in autumn; and 10% in winter. On the other hand, 32% of men died in spring, 24% in summer; 20% in autumn and 24% in winter. Sixty percent of the individuals contacted the services within two weeks prior to their death (37% within one week and 22.8% within two weeks). Exactly 20% contacted the services within three months, 5.7% within six months, and the remaining 14.3% >1 year. Women contacted the services earlier than men; 90% of them contacted services within two weeks; of whom 50% within a week of death (Table 3).

Women (n-10) No. %

Men (n-25) No. %

All (n-35) No. %

Method of suicide Hanging Drug overdose Drowning Jumping Gun shot Exsanguinations

5 4 1 0 0 0

50 40 10 0 0 0

19 1 2 1 1 1

76 4 8 4 4 4

24 5 3 1 1 1

68.5 14.3 8.6 2.9 2.9 2.9

Place of suicide Home Public place Relative’s house Prison

5 4 1 0

50 40 10 0

13 8 2 2

52 32 8 8

18 12 3 2

51.4 34.2 8.6 5.7

Day of suicide Monday Tuesday Wednesday Thursday Friday Saturday Sunday Unknown

1 2 2 2 2 0 0 1

10 20 20 20 20 0 0 10

4 2 10 2 2 4 1 0

16 8 40 8 8 16 4 0

5 4 12 4 4 4 1 1

14.3 11.4 34.3 11.4 11.4 11.4 2.9 2.9

Season of suicide Spring Summer Autumn Winter

2 1 6 1

20 10 60 10

8 6 5 6

32 24 20 24

10 7 11 7

28.5 20 31.4 20

48 28 8 16

21 7 2 5

60 20 5.7 14.3

Contact with services prior to suicide ≤2 weeks 9 90 12 ≤3 months 0 0 7 ≤ 6 months 0 0 2 > 1 year 1 10 4

Discussion and 25% by women (DoH, 2002). Furthermore, our findings support data of international authors reporting the risk ratio for men compared to women being 3:1 (Keown et al, 2007).

During the three-year period of the review, there were 51 suicides by Isle of Wight residents, of whom 68.6% (35 individuals, 10 women and 25 men) were local mental health service users.

In our study, 60% of individuals were single, divorced or separated which is consistent with the Wessex Suicide Audit (King, 2001), the North Staffordshire suicide study (Boardman et al, 1999) and is in support of previous studies indicating that living alone and being single are associated with a higher risk of suicide (Qin, Agerbo & Mortensen, 2003).

As far as ethnicity is concerned, all cases were of white British origin, which is at variance with the Wessex in-patient suicide study (King et al, 2001a,b), and with national (Crawford et al, 2005) and international (Joe, Marcus and Lewis, 2007) studies indicating that suicide risk is higher in ethnic minorities. However, the Isle of Wight population consists mainly of white British residents, and with a non-white population of only 1.3% (ONS, 2007).

In terms of education, more than 85% of the individuals had only basic education, which supports statements that those with lower education are at higher risk of suicide (Fergusson; Beautrais & Harwood, 2003).

Of the individuals who died from suicide, 71.4% were men and 28.6% were women. This is almost identical to previous data on suicide on the Isle of Wight and Hampshire, where during the fiveyear period of 1999 to 2003, 75% of suicide cases were by men

With regard to employment status, we have found that 48.5% of 82

all cases were unemployed. In addition, we found that unemployment was strikingly higher in women (70%) than in men (40%). These findings are consistent with the Wessex Suicide Audit (King, 2001) and the Wessex in-patient suicide study (King et al, 2001a,b); North Staffordshire suicide study (Boardman et al, 1999) that found a significant connection between unemployment and suicide. An international comparison study by Yip et al. (2000) even emphasizes that proportion of unemployed is overrepresented in the suicide population.

Our results are also in concordance to findings of studies (Brooks & Watson, 2006, Secretary of State, 1999) that reported hanging as the commonest method of suicide in men and poisoning in women.

Eighty percent of the individuals had some adverse life event within the year prior to suicide. This is consistent with the Wessex suicide Audit (King, 2001); the Wessex in-patient suicide study (King et al, 2001a,b), the North Staffordshire suicide study (Boardman et al, 1999), and other studies reporting adverse life events being one of the most common risk factors of suicide (Gunnel & Lewis, 2005).

With regard to the day on which suicides took place, more than 34% died on a Wednesday. Moreover, no women died during the weekend. This is in contrast with data provided by the ONS (2005), which found that the largest number of suicides took place on Mondays. Furthermore, our findings contradict studies reporting that public holidays were associated with higher suicide rates (Johnson et al, 2005).

In terms of diagnosis, depressive disorders were diagnosed in more than 34% of cases (70% of women and 20% of men), which is again consistent with the Wessex suicide audit (King, 2001), the Wessex in-patient suicide study (King et al, 2001a, b) and others (Coryel & Young, 2005) indicating that between 36% and 90% people who die as a result of suicide suffer from depression. Schizophrenia was diagnosed in about 6% of cases, which supports studies estimating a lifetime suicide risk of approximately 5% in people with schizophrenia (Hor and Taylor, 2010). Nevertheless, our findings are in contrast to an Australian study of suicide (Burgess et al, 2000), which found schizophrenia and schizoaffective disorders being the most common diagnoses.

In terms of seasonal fluctuation of suicide, more than half of men died during the spring and summer seasons. This finding is consistent with studies showing an increase in the incidence of suicide in spring and early summer (Petridou et al, 2002). Although the majority of previous European studies have shown a spring or summer peak in suicide, studies from the UK in the recent past have not. In particular, two studies (Simkin et al, 2003, Yip, Chao & Chiu, 2000) that used ONS data for England and Wales between 1982 and 1999 found no – or very little – evidence of a seasonal effect.

In terms of the location, more than half of the cases died in their homes, which is roughly similar to Gunnell & Lewis’s study (2005), which reported approximately three-quarters of cases took place in the person’s home.

In total contrast to this, 60% of women died in autumn, which is in line with one of the recent studies, which reported no spring or summer peak in suicide (Page, Hajat & Kovats, 2007).

We found that 31.4% of individuals also fulfilled criteria for stress-related disorders. This supports studies that demonstrated a positive association between adverse life events and suicide (Sareen et al, 2005). Alcohol use disorders were diagnosed in 36% of men and 10% of women. This is consistent with studies that found alcoholism in one-third (Beglund, & Ojehagen, 1998) to 54% (Lonnqvist, 2000) of people who died due to suicide. We found personality disorders in 31.4% of all cases which is consistent with Henriksson et al. (1993) who found axis-II diagnosis in 31% of suicide victims and Lonnqvist (2000) who diagnosed personality disorders in 5-44% of people who died as a result of suicide.

In our study, 90% of women and 48% of men contacted services within 14 days prior to their death. This is in line with the Wessex suicide audit (King, 2001), which found that 40% of men and 60% of women who died had seen a medical practitioner in the four weeks prior to their death. Furthermore, our data are concordant with Bessant, King and Peveler (2008) who performed an audit of 278 suicides in Hampshire and the Isle of Wight over a two-year period (2002-2004) to determine the characteristics of those who died by suicide and had been in recent contact with NHS Direct. Significantly more females than males had contacted NHS Direct in the two weeks before death.

Our data are in contrast to the North Staffordshire suicide study (Boardman et al, 1999), which linked the increased risk of suicide with a diagnosis of bipolar affective disorder. In our study, bipolar affective disorder was diagnosed in less than 9% of cases.

In addition, our data support the results of the National Confidential Inquiry (DoH, 2001) into suicides reporting that a quarter of suicides are preceded by mental health service contact during the year prior to death. Moreover, our results are in line with findings of Luoma et al. (2002) who concluded that over half of those completing suicide had made contact with a primary care professional in the month before death, and around three-quarters had contact within one year prior to suicide.

In terms of methods of suicide, hanging was the most common. 76% of men and 50% of women died as a result of hanging. The second most common way was drug overdose; 40% of women but only 4% of men died by this method. Previous data of suicides on the Isle of Wight (DoH, 2003), compiled in the five-year period of 1999 to 2003, found that hanging was also the most common method (42% of male deaths, 17% of female deaths). Strikingly, our study shows that the number of both men and women who died by hanging has doubled. Furthermore, the number of women who died from an overdose has also increased (from 33% to 40%). In contrast to this, the number of male suicides by an overdose has plummeted (from 19% to 4%).

Most individuals (77%), who died as a result of suicide, had a history of previous suicide attempts. This also supports findings of the North Staffordshire suicide study (Boardman et al, 1999), which found that the risk of death due to suicide is associated with past history of deliberate self-harm, and of the Wessex in-patient suicide study (King et al, 2001a, b) that found that individuals who died due to suicide were significantly more likely to have attempted suicide in the previous six months. Moreover, this is 83

consistent with an Australian study (Burgess et al, 2000), which found that 67% patients who died by suicide had previously attempted suicide.

Crawford, MJ, Nur, U, McKenzie, K, Tyrer, P. Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey. Psychol Med 2005; 35: 369-77. Department of Health. Compendium of Clinical and Health Indicators 2002. June 2003. Department of Health. National Suicide Prevention Strategy for England. London: Department of Health, 2002. Department of Health. Safety First: Five-year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. London: Department of Health 2001. Fergusson, D.M, Beautrais, A and Harwood, L.J. Vulnerability and resiliency to suicidal behaviours in young people. Psychological Medicine 2003; 33: 61-73. Gunnell, D, and Lewis G. Studying suicide from the life course perspective: implications for prevention. Br J Psychiatry 2005; 187: 206-208. Henriksson, MM Aro, HM Marttunen, MJ Heikkinen, ME Isometsa, ET Kuoppasalmi KI and Lonnqvist JK. Mental disorders and comorbidity in suicide. Am J Psychiatry 1993; 150:935-940. Hor, K and Taylor, M. Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of Psychopharmacology, 2010; 24 (11) Supplement 4: 81-90. Joe, S, Marcus, S, C, Kaplan, MS. Racial differences in the characteristics of firearm suicide decedents in the United States. Am J Orthopsychiatry 2007; 77: 124-30. Johnson, H, Brock, A, Griffiths, C. et al. Mortality from suicide and drug-related poisoning by day of the week in England and Wales, 1993-2002. Health Statistics Quarterly 2005; 27: 13 -16. Keown, P, Tacchi, MJ, Niemiec, S, and Hughes J. Changes to mental healthcare for working age adults: impact of a crisis team and an assertive outreach team. Psychiatric Bulletin 2007; 31: 288-292. King, EA, Baldwin DS, Sinclair JM, Baker, NG, Campbell MJ, Thompson C. The Wessex recent in-patient suicide study, 1. Case-control study of 234 recently discharged psychiatric patient suicides. Br J Psychiatry 2001a; 178:537-42. King, EA, Baldwin DS, Sinclair JM, Campbell MJ. The Wessex recent in-patient suicide study, 2. Case-control study of 59 inpatient suicides. Br J Psychiatry 2001b; 178:531-6. King, EA. The Wessex Suicide Audit 1988-1993: A study of 1457 suicides with and without a recent psychiatric contact. International Journal of Psychiatry in Clinical Practice 2001; Vol. 5; 2: 111-118. Lรถnnqvist, J.K. Psychiatric aspects of suicidal behaviour: depression. In The International Handbook of Suicide and Attempted Suicide (eds K. Hawton & K. Van Heeringen), 2000; 107-120. Chichester: John Wiley. Luoma, J, Martin, C and Pearson, J. Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry 2002; 159: 909916 Morgan HG, Priest P. Suicide and other unexpected deaths among psychiatric inpatients. The Bristol confidential inquiry. Br J Psychiatry 1991; 158:368-74. Office for National Statistics 2005. UK Suicides Reach 30 Year Low in 2003. http://www.statistics.gov.uk/pdfdir/suicide0305.pdf. Office for National Statistics 2007. http://www.statistics.gov.uk. Page, LA, Hajat, S and Kovats, SR. Relationship between daily suicide counts and temperature in England and Wales. Br J Psychiatry 2007; 191: 106-112. Petridou, E, Papadopoulos, F, Frangakis, C, et al. A role of sunshine in the triggering of suicide. Epidemiology 2002; 13: 106-109. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socio-economic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry 2003; 160:765-72. Rutz W, von Knorring L, Walinder J. Frequency of suicide on Gotland after systematic postgraduate education of general practitioners. Acta Psychiatr Scand 1989; 80:151-4. Sareen, J, Houlahan, T, Cox, BJand Asmundson, GJ. Anxiety disorders associated with suicidal ideation and suicide attempts in the national co morbidity survey. J Nerv Ment Dis 2005; 193: 450-454. Secretary of State for Health. Saving Lives: Our Healthier Nation. London: Stationery Office 1999. Simkin, S, Hawton, K, Yip, PS, et al. Seasonality in suicide: a study of farming suicides in England and Wales. Crisis 2003; 24: 93 -97. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. World Health Organization, Geneva, 1992. Yip, P, Chao, Chiu, C. Seasonal variation in suicides: diminished or vanished. Experience from England and Wales, 1982-1996. Br J Psychiatry 2000; 177: 366 -369. Yip, PSF, Callanan, C, and Yuen, HP. Urban/rural and gender differentials in suicide rates: East and West. Journal of Affective Disorders, 2000, 57: 99-106.

Conclusion Comparing our data, of a study in a small geographical area, with those of studies worldwide appears to indicate that there are many similarities in the circumstances and conditions that are conducive to suicide, as well as in the parameters of the suicides themselves. It cannot be denied that people with mental health problems are at greater risk of suicide. More than two-thirds of completed suicides had a severe depressive episode at the time of the act of suicide, however, this is not always recognised, and if identified it is not always treated effectively (King, 2001). Moreover, factors such as gender, social isolation, polymorbidity and recent adverse life events can strongly contribute to the decision-making process of people who take their lives. Furthermore, particularly from the geographical point of view, it seems that lack of opportunities, lower education and mainly, unemployment, are relatively common in rural areas and play an important role in suicidal behaviour worldwide (Yip et al., 2000). From a preventive perspective, suicide prevention programmes therefore should focus on the treatment of psychiatric illnesses, in particular depressive disorder. There is a large body of evidence that early recognition and adequate treatment of depression is one of the essential ways of suicide prevention (Rutz, von Knorring & Walinder, 1989). At the same time, it is crucial to be aware of the vital role of psychosocial support of vulnerable individuals. Misleading clinical improvement in the absence of corresponding alleviation of situational problems, as well as patient alienation appear to be important hazards (Morgan & Priest, 1991). Our results along with findings of several other studies (King, 2001) support the suggestion that there are certain sociodemographic and clinical characteristics, which can predict a high risk of suicide; and they may be generally applicable for the majority of mentally disordered individuals.

Conflict of interest None. References Baldwin and Hirschfield. Depression. Fast Facts, second edition. Health Press 2005. Beglund, M and Ojehagen, A. The influence of alcohol drinking and alcohol-use disorders on psychiatric disorders and suicidal behaviour. Alcoholism: Clinical and Experimental Research 1998; 22: 333S-345S. Bertolete JM, Fleischmann A. Suicidal behaviour prevention: WHO perspectives on research. Am J Med Genet C Semin Med Genet 2005; 133:8-12. Bessant, M, King, EA and Peveler, R. Characteristics of suicides in recent contact with NHS Direct. Psychiatric Bulletin 2008; 32: 92-95. Boardman AP, Grimbaldeston AH, Handley C, Jones PW, Willmott S. The North Staffordshire Suicide Study: a case-control study of suicide in one health district. Psychol Med; 1999; 29(1): 27-33. Brooks, P and Watson, J. A profile of suicide mortality in South East. South East England Public Health Observatory 2006. Burgess P, Pirkis J, Morton J, Croke E. Lessons from a comprehensive clinical audit of users of psychiatric services who committed suicide. Psychiatr Serv. 2000; 51(12): 1555- 60. Coryell, W, Young, EA. Clinical predictors of suicide in primary major depressive disorder. J Clin Psychiatry 2005; 66: 412-416.

O R I G I N A L PA P E R

Patients’ Satisfaction with a Psychiatric Day Hospital in the West Galway Catchments Area Inam Ul-haq Ir J Psych Med 2012; 29 (2): 85-90

Abstract

building, as recommended by the mental health policies, Planning for the Future and A Vision for Change.1,2

Aim: To evaluate patients’ satisfaction with a psychiatric day hospital in the West Galway Catchments area.

Patient satisfaction is considered an important factor in the development and evaluation of services, and no assessment had been carried out before to ascertain patients’ satisfaction with the services at the surveyed day hospital. In order to get appropriate resources for the development of the day hospital services, it was considered important to assess patients’ satisfaction with this kind of services.

Study design: This is a cross-sectional study. Methods: This study was undertaken by using a 33-items questionnaire for 44 patients who attended the day hospital. SPSS version-12 was used for collecting and applying tests to the data, Fisher’s exact test was used to analyse the data as sample size is small and P<0.05 was considered statistically significant. Results are also presented in the form of descriptive analysis including percentages and frequencies.

Day hospitas were invented in Russia in the 1930s, introduced to America and Europe in the 1940s and 1950s, and reached their peak in the 1970s, when they provided the main alternative to hospital admission.3

Results: Only 37 out of the 44 patients returned the questionnaires. Among the participants were 61% (n=22) male and 38% (n=15) female. The patients were mostly satisfied with the services available at the day hospital, except the waiting period for a first appointment. There was no significant (P=0.11) gender difference in terms of patients’ satisfaction with the day hospital service. The age group, 45 years and above, were less satisfied (P=0.02) with the availability of a comfortable room for counselling, as compared to the younger age group. The patients did not like to tell others that they were attending the day hospital. The results were comparable with previous published patient satisfaction surveys using the same questionnaire by the Health Research Board, except that the patients in the present survey were more satisfied with the waiting area and availability of counselling.

The information services of NHS Scotland characterise a day hospital as a hospital, or a specified area within a hospital, which provides services on a regular daytime basis for specific patient/client groups, for example, the elderly, mentally ill or learning disabled. Services normally provided are assessment, rehabilitation, maintenance of function and clinical treatment. A person attending a day hospital is called a day patient. The principal purpose of a day hospital is to assist people to remain living in the community while getting acute mental health treatment.4 The West Galway day hospital provides an alternative to inpatient acute mental health services to people who live in the community. All patients who are living in the Galway catchment’s area and under the care of General Adult Psychiatric services are eligible for admission to the day hospital. Assessment appointments are arranged within three weeks for routine and five working days for urgent referrals. Following assessment the day hospital programme is discussed with patients and individualised programme is agreed. The day hospital provides a variety of therapeutic group and individualised interventions delivered by a multidisciplinary team. The Galway day hospital has different educational, social and therapeutic groups such as an anxiety management group, selfesteem group, stress and coping group, psychosis education group, mood disorder group, personal development group etc. Two sessions of yoga, art and horticulture are also organised for patients in the day hospital on weekly basis.

Conclusions: Patients are mostly satisfied with the West Galway day hospital services. The older patients (45 years and above) are not satisfied with the counselling room, and therefore further investigations are needed to ascertain their requirements for a counselling room. Patients are more satisfied with the waiting area and availability of counselling compared to the findings of other similar studies conducted in Ireland. Resources are needed to be allocated to the day hospital services. Key words: patients’ satisfaction, psychiatric day hospital, mental health services.

Services that may otherwise require inpatient service, such as alcohol detoxification, benzodiazepine discontinuation, initiation of Clozapine and outpatient electroconvulsive treatment, are also provided in the day hospital.

Introduction and literature review The surveyed psychiatric day hospital in the West Galway catchments area was supposed to move from its old premises based in the acute psychiatric unit to its new community-based

*Inam Ul-haq, Consultant Psychiatrist in Learning Disability Services Sligo/Leitrim Mental Health Services, Cloonamahon Learning Disabilty Services, Collooney, Co Sligo, Ireland Email: drinamulhaq@gmail.com *correspondence

Submitted 22nd November 2010 Accepted 15th July 2011

At the time of the survey there was one clinical nurse manager, three nursing staff, one occupational therapist and one psychologist, working in the day hospital. The day hospital had access to the patients’ social workers and other agencies related to their care. Two doctors, one junior trainee and one senior registrar were also working full time in the day hospital. The consultant psychiatrists from the West Galway mental health services visit the day hospital weekly to discuss their patients with multidisciplinary team members. The total number of patients registered at one time in the West Galway day hospital usually doesn’t exceed 35. These patients attend from one to five days per week depending on their needs and care plan. Usually the number of patients attending the day hospital per day doesn’t exceed 20.

in a safe environment for one-to-one treatment. Accordingly if a day hospital can be combined with outreach services for patients who fail to attend and short-term crisis beds for those temporarily too ill to be at home, then it could offer a powerful alternative model to home-based care.10 Patients’ satisfaction with a service is defined as “the reaction of the service user to the context, process and result of his/her treatment”.11, 12 Satisfaction with services is considered important in mental health services research, as it represents outcome measures from a consumer perspective and, in the process of care, can influence other outcomes.13,14 In Ireland, through the appointment of the Head of Consumer Affairs, the Health Services Executive (HSE) has committed to ensure that services provided by the HSE are consumer-focused. The present Irish mental health policy document, A Vision for Change, recognises the importance of patients’ satisfaction in the delivery of client–centred, community-based mental health services.2

The length of the stay at the day hospital is usually from eight to ten weeks. Discharge planning is organised in the weekly multidisciplinary team meeting in consultation with patients. After discharge from the day hospital, patients are followed up in community by the community mental health teams.

The assessment of satisfaction with mental health services has been relatively neglected due to the view that patients with severe mental illness lack capacity.15 However, recent studies have shown that severity of mental illness does not compromise the ability of patients to express their views about a service.16,17,18 Patients’ satisfaction depends on various factors, such as the quality of care, previous service experience and service expectations, and it is influenced by clinical and socioeconomic characteristics of the service users.13, 19

With the shift from hospital-based care to community-based mental health care, the importance of day hospitals is increasingly recognised and is considered an important part of the Community Mental Health Centre, which is the hub of mental health care delivery in A Vision for Change.2, 5 Day hospitals are considered superior to the inpatient setting in several important ways with higher expectation for patients‘ functioning, lower tolerance for deviance and more choice, allowing for more continuity of patients’ on-going community involvement.6 Day hospital treatment is cheaper than inpatient treatment despite the increased costs associated with additional travelling costs and community psychiatric nurse time for day patients.7

Effectiveness of the treatment is considered the most important factor in satisfaction with mental health services, irrespective of the diagnosis and length of the treatment.20 However, satisfaction with interpersonal life and housing also affects the level of satisfaction with mental health services.21

Day hospital services, also known as partial hospitalisation, aim to treat people with acute severe episodes of mental illness who would otherwise be admitted to hospital, and are distinct from day centre services which provide rehabilitation to patients with longer-term illnesses. Day hospitals can be used to prevent inpatient admissions, and the inpatient stay can be shortened by transferring the patients to day hospital facilities before they are fully recovered from their illness.8

In the EPSILON (European Psychiatric Services: Inputs Linked to Outcome Domains and Needs) study conducted in five European sites, low satisfaction is associated with being unemployed, having a high number of hospital admissions, having a high level of psychopathology, having a high number of unmet needs and having a poor quality of life.22 All published studies of patients’ satisfaction with day hospitals have reported that the majority of patients are satisfied with day hospital services.

Some studies have indicated that 30-40% of acute patients can be managed in the day hospital but in practice, nine to 13% of day hospital places are used for acute illness as an alternative to inpatient admission.9

Patients’ satisfaction with the efficacy of different care programmes offered in a day hospital and inpatient services may be comparable, but patients attending day hospital have far better social functioning compared to inpatient hospitalisation.23 The only published study in Ireland was carried out by the Health Research Board across two health boards in 2003, which looked into patients’ satisfaction with day hospitals. This study revealed that most of the patients were satisfied with the services provided by the day hospitals in these health boards. Over 80% of patients were satisfied with treatment, staff, activities and food provided.24 Another recent day hospital review in Co Sligo in February 2010, commissioned by the local health office, revealed that most of the patients were very satisfied with the day hospital. This review is yet to be published and has assessed patient satisfaction both quantitatively and qualitatively. However, day hospital staff were

Since 1980 in the UK, the home-based acute care has been the preferred alternative to hospital admission and day hospital care. However, home-based care has two problems. Firstly, concerns for staff safety mean that clinicians cannot visit patients at home on their own, so that two or more clinicians end up caring simultaneously for the same patient. Secondly, these small groups of clinicians are obliged to drive through congested towns and cities, spending time bumper to bumper that could have been spent in face-to-face contact with patients.10 By contrast, a day hospital, accessible by bus or hospital transport, seems a model of efficiency. Here, comparatively small numbers of nurses can maintain a high level of input to substantial numbers of patients, 86

less satisfied with the day hospital services compared with patients’ levels of satisfaction with the same services of the same day hospital.

Methods This cross-sectional survey was undertaken in the day hospital using a 33-item questionnaire (see appendices). All adults (18 years and over), male and female patients who were attending the hospital were offered to participate in the study over a period of one month. Although the maximum number of people registered in the day hospital at one time is not more than 35, during the one month periods some were discharged and new patients were admitted, therefore 44 were given the questionnaire to participate in the study. An explanatory note was issued to each patient to explain that participation in the study was voluntary and would not influence their treatment in the day hospital. Nursing staff at the day hospital distributed the questionnaires to the patients and addressed any concerns or questions patients had. Patients were free to fill the questionnaire in the day hospital or at home. To reduce the bias the study was made anonymous, confidentiality was assured and patients were asked to return the questionnaire to a secure box with a slot for the questionnaire. The questionnaire uses Likert scale,25 which is a five-point scale from strongly agree to strongly disagree, to measure quantitatively the satisfaction with the services available at the day hospital. The items of the questionnaire closely represent the services delivered in the day hospital, and the questionnaire has been previously used in Ireland for the purpose of measuring day hospital satisfaction.

counselling, information about the availability of different treatment options, and good and bad effects of the treatments. In addition, the patients were satisfied with the following environmental factors: food, premises (the reception and dining areas), communication with other patients and transportation to the day hospital. However, with regards to waiting times, 39% (n=15) agreed they have to wait a long time when they have an appointment, compared with 36% (n=15) who were satisfied with the waiting period, while 24% (n=9) were not sure.

Copyright authorisation was granted to use the questionnaire by Shropshire’s Mental Health NHS Trust. The patient sample and the questionnaire were discussed with the data-coordinator for the appropriate number of participants and appropriate statistics before the survey was commenced. SPSS-version 12 was used for collecting and applying tests to the data for the survey. Fisher’s exact test was used to analyse the data as the sample is small and P< 0.05 was considered as statistically significant. Results are also presented in the form of descriptive analysis including percentages and frequencies.

Fifty-one (n=19) percent of the day hospital patients did not like to tell others that they attend the day hospital. Premises A substantial proportion of patients were satisfied with aspects of the day hospital’s premises. Seventy-nine percent (n=29) agreed that the reception area is nice to wait in, 85% (n=32) who ate at the day hospital felt that the dining area was nice to eat in, and 67% (n=25) felt that they were counselled in a comfortable room.

Results Forty-four patients participated in this survey, but only 37 returned the questionnaire.

Staff Most patients displayed a positive attitude towards staff. Eighty-six (n=32) percent of the patients felt that staff took their problem seriously, 79% (n=29) considered they were treated with respect, 85% (n=31) believed the staff were competent, and 82% (n=30) felt staff were interested in their view regarding their treatment. With regards to the availability of staff, 82% (n=30) of patients agreed they were always able to speak to a staff member in private within working hours. Ninety-one percent (n=34) agreed staff were available when they wanted to speak to them, and 61% (n=23) were always able to see/contact the staff member when they wanted to speak to them within working hours.

A higher proportion of males (n=22, 61%) compared with females (n=15, 38%) attended the day hospital, but there was no significant (P=0.11) gender difference in terms of their satisfaction with the day hospital. A higher proportion (27%) of patients were aged 25-34 years (see Graph B in Appendices) who attended the day hospital, and there were no significant (P=0.12) differences in satisfaction with the day hospital in terms of age group, except the older age group (45 years and above) was significantly (P=0.02) less satisfied with the availability of a comfortable room for counselling.

Treatment Mostly the patients were satisfied with the treatment in the day hospital. Sixty-nine percent (n=26) of patients considered the

All of the patients were satisfied with the following clinical variables: treatment, staff and availability of staff, availability of 87

Table 1. Findings

Staff take the problem seriously Patient treated with respect Staff available on request Have to wait a long time when have appointment Were not told about the good and bad effects of treatment Individual counselling useful Liked the food Costs too much to travel to the day hospital Rooms dirty and untidy Waiting area is nice to wait in

Health Board A (n=78) 92% 85% 88%

Health Board B(n=104) 94% 92% 78%

The present day hospital (n=37) 86% 79% 91%

44%

33%

39%

19% 13% 69%

10% 18% 86%

32% 76% 80%

25% 24% 10%

17% 14% 14%

12% 17% 79%

The findings in the present study were compared with that of previous day hospital satisfaction survey in Ireland using the same questionnaire conducted by Health Research Board across two health boards

treatment to be good, and 54% (n=20) felt they had a say and choice about the treatments they received. Seventy-nine percent (n=29) agreed they knew why they were attending the day hospital, and 61% (n=23) of the patients believed they were told about all the treatments available to them at the day hospital.

room. The physical environment of the counselling room is an important factor in the successful outcome of counselling.26 Most of the patients were satisfied with staff, but it was not clear from the questionnaire what they specifically meant by ‘staff’ – i.e. doctors, nurses or domestic staff?

Seventy-six percent (n=26) of patients considered the individual counselling to be useful, and 68% (n=25) felt their medications were useful.

The questionnaire used in this study was considered appropriate because of its face and content validity; however, there was no provision for the patients to express their views. The lack of provision for patients to express their views in quantitative study may influence the results of a satisfaction survey but using qualitative analysis may also be biased as patients may say what the doctor wants to hear, and not necessarily what the patients want to say.27,28, 29

A substantial proportion of patients (n=14, 39%) agreed that they always had to wait for a long time when they have an appointment. Activities and other items Seventy percent (n=27) liked the activities they did in the day hospital, and 68% (n=26) found the activities offered worthwhile. Eighty percent (n=30) liked the food at the day hospital, and 67% (n=25) liked talking to other patients in the day hospital. Sixty-six (n=24) percent agreed there is sufficient transport to the day hospital, 80% (n=31) disagreed that it costs too much to travel to the day hospital, and 73% (n=28) disagreed that the day hospital was too far from where they were living.

In the present study, patients were happy to attend the day hospital, but they did not like to tell others that they were attending the psychiatric day hospital. The most probable reason for not telling others is the stigma of using mental health services, and stigma itself can influence the patient satisfaction and recovery from the illness.30,31 Although the number of participants in the present study is much smaller compared to the previous study conducted by the Health Research Board on day hospital satisfaction in Ireland across two health boards (A&B), the findings of the present study are somewhat comparable to the findings of the Health Research Board study, using the same questionnaires in both studies as shown in Table 1.

Discussion Like other satisfaction studies done in UK and Ireland, an overwhelming majority of the patients are satisfied in this present study with most of the services provided in the day hospital in the West Galway area. However, there are certain points that are worth considering based on this current research, particularly when planning the new day hospital premises/services.

The proportion of patients who felt that individual counselling is useful was higher (76%) in the present study of Galway day hospital compared with 18% in Health Board A and 13% in Health Board B. In addition to these results, a higher proportion (79%) thought that the waiting area is nice in the present day survey compared with 10% and 14% in Health Boards A and B respectively. The nice décor is appreciated by the patients who perhaps as a result feel valued. The importance of nice décor in patients’ satisfaction has been recognised in other studies.32

The older age group (45 years and above) were not happy with the availability of a comfortable room for counselling, as compared to the younger age group. Although it was not clear from the study as to why they were less satisfied with the counselling room, it is important to consider their needs and find out what the requirements of this age group are for a comfortable counselling

Conclusion

21. Prince, Jonathan D. Life Contentment and Mental Health Care Satisfaction. Research on Social Work Practice 2005; 15(6): 564-567. 22. Ruggeri M, Lasalvia A, Bisoffi G et al. Satisfaction With Mental Health Services Among People With Schizophrenia in Five European Sites: Results from the EPSILON Study. Schizophrenia Bulletin 2003; 29(2):229-245. 23. Kallert TW, Priebe S, McCabe R, et al. Are day hospitals effective for acutely ill psychiatric patients? A European multicenter randomized controlled trial. J. Clin Psychiatry 2007; 68: 278–287. 24. Hickey T, Moran R, Walsh D. The Purposes and Functions of Psychiatric Day Hospitals and Day Centres: A Study In Two Health Boards; Heath Research Board publication 2003. 25. Likert R. A Technique for the Measurement of Attitudes. Archives of Psychology1932; 140: 1–55. 26. McLeod J, Machin L; The context of counselling: A neglected dimension of trainings research and practice. British Journal of Guidance and Counselling 1998; 3:325-336. 27. Elbeck M, Fecteau G. Improving the validity measures of patient satisfaction with psychiatric care and treatment. Hosp Community Psychiatry 1990; 41(9):998-1001. 28. Kalman TP. An overview of patient satisfaction with psychiatric treatment. Hosp Community Psychiatry 1983; 34:48-54. 29. Svensson, Bengt, Hansson Lars, A user participation approach: Satisfaction with mental health services. Nordic Journal of Psychiatry 2006; 60(5):365-371. 30. Corrigan, Patrick. How stigma interfere with mental illness. American Psychologist 2000; 59(7): 614-625. 31. Rosenfield S. Labeling Mental Illness: The Effects of Received Services and Perceived Stigma on Life Satisfaction, American Sociological Review 1997; 62:660-672). 32. Lovell K. User Satisfaction with In-patient Mental Health Services. Journal of Psychiatric and Mental Health Nursing1995;2: 143-150.

• Patients are highly satisfied with the West Galway day hospital services. • The age group, 45 years and above, are not satisfied with the counselling room. Therefore, further investigations are needed to ascertain their specific requirements for a counselling room. • Patients are more satisfied with the waiting area and availability of counselling compared to the findings of other similar studies conducted in Ireland. • More importance and resources need to be given to the day hospital services, which provide patients’ favourite and cost-effective mental health services.

Conflict of interest None. References 1. Department of Health & Children. The Psychiatric Services – Planning for the Future. Government Stationary Office: Dublin, 1984. 2. Expert Group on Mental Health Policy. A Vision for Change: Report of the Expert Group on Mental Health Policy. Government Stationary Office: Dublin, 2006. 3. Pang J. Partial hospitalization: an alternative to inpatient care. Psychiatr Clin North Am 1985; 8: 587–95 4. NHS National services of Scotland, Information division. http://www.datadictionaryadmin.scot.nhs.uk/isddd/2197. 5. Malone D, Marriott S, Newton-Howes G, Simmonds S, Tyrer P. Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality. Cochrane Database of Systematic Reviews 2008; Issue3. 6. Davidson L, Tebes J, Rakfeldt J, Sledge W. Differences in social environment between inpatient and day hospital – crisis respite settings. Psychiatric Services 1996; 47: 714720 7. Creed F, Mbaya P, Lancashire S ,Tomenson B , Williams B, Holme S . Cost effectiveness of day and inpatient psychiatric treatment: results of a randomised controlled trial. BMJ 1997; 314: 1381 8. Weldon E, Francis A. The Day Hospital: Structures and Functions. Psychiatric Quarterly 1977; 49 (4): 338–342. 9. Mbaya, P., Creed, F., Tomenson, B. (1998) The different uses of day hospitals. Acta Psychiatrica Scandinavica, 98, 283–287. 10. Marshal M. Acute Psychiatric Day Hospital. BMJ 2003; 327:116 11. Hoff R A., Rosenheck RA, Meterko M,Wilson NJ. Mental illness as a Predictor of Satisfaction With Inpatient Care at Veterans Affairs Hospitals. Psychiatr Serv 1999; 50:680-685. 12. TysonP, Ayton A, Al Agib AO, Bowie P, Worrall–Davies A, Mortimer A. A comparison of the service satisfaction and intervention needs of patients with schizophrenia and their relatives. International Journal of Psychiatry in Clinical Practice 2001; 5: 263– 271. 13. Svensson B, Hansson L. Patient satisfaction with inpatient psychiatric care: The influence of personality traits, diagnosis and perceived coercion. Acta Psychiatr Scand 1994; 90:379– 84 14. Ruggeri M. Patients’ and relatives’ satisfaction with psychiatric services: The State of the Art of its Measurement. Soc Psychiatry Psychiatr Epidemiol 1994; 29:212–27. 15. Fitzpatrick R. Surveys of Patients Satisfaction; Important General Consideration. BMJ 1991; 302: 887-889 16. Noble L, Douglas B, Newman S. What do patients want and what do we know? A review of patients requests of psychiatric services. Acta Psychiatrica Scandinavia 1999; 100(5): 321-327. 17. Noble L, Douglas B. What do patients expect of psychiatric services? A systematic & critical review of empirical studies. Social Sciences & Medicine 2001; 52(7): 985-998. 18. Hill S, Niall T, Barry S, O'Callaghan E. Client satisfaction among outpatient attending an Irish community mental health service. Irish Journal of Psychological Medicine 2009; 26(3): 127-130 19. Barker DA, Shergill SS, Higginson I, and Orrell MW. Patients' views toward care received from psychiatrists. British Journal of Psychiatry 1996; 168:641- 646. 20. Betts, William Robert. Conjoint analysis: A new approach to satisfaction with mental health treatment; Dissertation Abstracts International: Section B: The Sciences and Engineering 2006; 66(12-B):6914.

SERVICE SATISFACTION QUESTIONNAIRE Instructions: Tick the number which shows if you agree or disagree with the statement. Suppose that you agreed with the statement “I like the food at the day hospital.” Then you would tick number 4 Day Hospital Name:________________________________ Age: 16-19 20-24

Male 35-44

25-34

Female 45-54

55-64

Your answers will be treated confidently. Please Complete the Whole Form. 1. Strongly Disagree; 2. Mildly Disagree; 3. Unsure; 4. Mildly Agree; 5. Strongly Agree; 6. Not Applic. 1. The staff at the Day Hospital take my problems seriously

2. The treatments are good

3. I have a say and choice about the treatments I receive

4. If I have an appointment, I always have to wait a long time

5. I am always able to speak to a member of staff in private

N/A

within working hours 6. I like the things that I do at the Day Hospital 7. The rooms are dirty and untidy

8. I can always see/contact the staff member I want to speak

to within working hours 9. I find the activities offered to me at the Day Hospital worthwhile

10. There is sufficient transport to get to the Day Hospital

11. I like talking to other patients who go to the Day Hospital

12. I like telling people that I go to the Day Hospital

N/A

13. The staff are available when I want to speak to them

14. It costs too much to travel to the Day Hospital

15. I have been told about the good/bad effects of my treatment

16. Staff are interested in my views about the treatments I receive

17. I like the food at the Day Hospital

18. I feel that I am treated with respect

19. I have been told about all the treatments available to me

20. I know what I am attending the Day Hospital for

21. I am counselled in a comfortable room

N/A

22. I was concerned about not being given a choice of a male

N/A

23. It is not easy to move about the Day Hospital if you are disabled

24. The reception area is nice to wait in

25. The staff know what they are doing

N/A

at the Day Hospital

or female therapist

26. The dining area is nice to eat in

27. I feel I can turn treatment down if I don’t want it

28. The individual counselling is useful

N/A N/A

29. My medication is useful

30. I cannot have one to one counselling if I want it

31. The reception staff are welcoming

32. The Day Hospital is too far from where I live

33. I am not worried about breaking the rules at the Day Hospital

You have now finished the questionnaire. Thank you for you help. © 1995 Shropshire’s Mental Health NHS Trust Adapted from Turpin and Sturmey (1988) by Newnes, Ashman, Holmes, Waltho, Community Link and Shropshire Advocacy Forum.

N/A

65+

O R I G I N A L PA P E R

Psychiatrists: An Endangered Species? A Study to Observe Attitude of Fifth Year Medical Students to Psychiatry and to Compare Change in Same after a Psychiatry Posting During Medical School Navroop Johnson, Declan Lyons Ir J Psych Med 2012; 29 (2): 91-95

Abstract

Introduction

Objective: This study was conducted to gauge the attitude of fifth year medical students to psychiatry as a potential career choice and to determine if an eight-week clinical attachment had any impact on this.

Recruitment of medical graduates to the discipline of psychiatry is of great relevance in terms of maintaining existing services and expansion to meet future needs. Concern about the low numbers of medical graduates entering psychiatric training in the United States and Europe has existed for some.1,2 Although research from the US did reveal a general increase in the proportion of psychiatrists per million population (from 23 per million in 1949 to 142 per million in 1992), the numbers of medical graduates entering psychiatry has peaked at 6.9% in 1969 and steadily declined thereafter to as low as 3.1% by 1988.1,3 The UK has also witnessed a similar decline.2

Methods: We surveyed a cohort of fifth year medical students from Trinity College Dublin. A purpose designed, self-completed questionnaire was used to establish a number of variables and was given to students on the first and last day of their attachment in psychiatry. Participation was optional and responses were confidential. Questionnaires were distributed following an explanation of the purpose of the study.

A recent Canadian study suggested that psychiatry was the least preferred specialty amongst first year medical students.4 To replenish and expand psychiatry in Canada, it was estimated that 6.6% of all medical graduates would be required to train in the specialty – a significantly higher percentage than the 2.9% who expressed such an interest. Internal medicine by contrast was selected by 28.9% of students as a preferred career choice, above its ‘replacement level’ of 24.7%.4

Results: The survey was applied to 118 fifth year medical students. The most significant finding of the study was the increase in number of students choosing psychiatry (17%) as a possible career upon completion of the attachment as compared to before (4%). The majority of the students considered psychiatry as a mainstream specialty with little change in this perception pre and post attachment. Almost all of the students believed that a psychiatry posting would improve their communication skills when dealing with patients.

Previous surveys in an Irish context have reflected on the subject of the career choice favoured by medical students and the likely impact on psychiatry services.5,6 It has been suggested that a proportion of medical students may enter medical school with preconceived negative attitudes towards psychiatry training.5 Such views were quite strongly held by some in a recent survey, whereas other opinions appeared to be more modifiable through direct exposure to and education in psychiatry.10

Approximately half of students chose medical subspecialties as career choice prior to their psychiatry posting but this declined afterwards. There was a small increase in the number of students wanting to become GPs and those who were undecided about their potential career choice. With regards to deterrents to doing psychiatry, the principal one was the belief that psychiatry was too depressing and stressful. Lack of interest, adverse career prospects and financial considerations featured in a minority of student answers.

We wished to ascertain the impact of structured undergraduate teaching on the career preferences of fifth year medical students. We also hoped to elucidate the general perceptions of psychiatry before and after a teaching module as well as elicit other career options preferred by respondents. We asked students to rate perceptions of their own academic ability and asked respondents to endorse or otherwise, factors that might represent deterrents to pursuing psychiatry.

Conclusions: The findings of this study suggest that psychiatry remains less attractive to students as a career compared to some other specialities but a clinical attachment may be an important means of raising interest in psychiatry as a career. Key words: attitudes, medical students, undergraduate, psychiatry career, psychiatry posting.

*Navroop Johnson, Senior Registrar in General Adult Psychiatry, North East Kildare Sector, Naas General Hospital, Naas, Co. Kildare, Ireland Email navsuchi@gmail.com

*correspondence

Declan Lyons, Consultant Psychiatrist, St. Patrick's University Hospital, James' Street, Dublin 8, Ireland

Submitted 12th April 2010 Accepted 27th January 2012

Methodology

of the study were the principal investigators but were not involved in the teaching of the students during the rotation. Participation in the study was left optional and the questionnaires were self-completed in contrast to interviewer-assisted to minimise observer effect. Students were asked not to collude when answering the questions but no formal method was devised to negate this. To maintain anonymity students were not asked for their names or date of births. No other indicator on the questionnaires could identify the responders. Students were asked to rate their subjective academic ability as either superior, above average, average and below average but were specifically asked not to provide any objective grades or marks in order to further protect their identity. The students were instructed to leave the questionnaires in a box left in the classroom to maintain anonymity. These questionnaires were collected separately at the start and the conclusion of teaching by the secretarial staff.

The authors surveyed fifth year students in Trinity College Dublin University (TCD) to ascertain a career interest in psychiatry before and after an eight-week clinical attachment in psychiatry. A purpose designed questionnaire was used for establishing a number of variables. Participants A total of 118 fifth year medical students from TCD were asked to participate in the study. The questionnaire was distributed before commencement of the psychiatry rotation and on its final day. There was a female preponderance (over 60%) among the students who participated in the study and the majority were in the age group of 20-24 years (70%). Structure of clinical rotation in Psychiatry at TCD Three groups of approx 40 students attend teaching at the Department of Psychiatry for a period of eight weeks in one academic year. These students are assigned between three different hospitals namely, St. Patrick’s University Hospital (SPUH), St. James’s Hospital (SJH) & The Adelaide and Meath Hospital, Dublin Incorporating the National Children's Hospital, Tallaght (AMNCH). The students participate in introductory didactic lectures for the first week of the rotation and additionally commence a six-week attachment with a general psychiatry team. Through observational learning, patient interviews and case presentations, general psychiatry skills in history taking and mental state examination are acquired. Students subsequently undertake a two-week specialty placement to conclude their rotation. Throughout their placement students continue to attend twice-weekly lectures in SPUH and participate in recorded interviews with patients, the grading of which is counted towards their final assessment mark. Students undertake a viva exam at the end of the rotation based on their observing a prerecorded patient interview.

Data in the form of aggregate scores was processed using SPSS Version 17 for Windows. Fisher’s exact test of independence was applied to ascertain statistical significance as the sample numbers were small.

Results The survey was applied to 118 fifth year medical students. The response rate was 74.5% before commencing the clinical attachment which rose to 84% after. There were more female students (62%), who participated in the study as compared to males (38%). The majority of the students who participated in our study considered psychiatry as a mainstream specialty with little change in this perception pre (70.45%) and post (68.7%) clinical attachment. A large proportion of students believed that a psychiatry posting would improve their general communication skills in dealing with patients (84% of students prior to attachment and 91% after). The most significant finding of the study was that 17.2% students selected psychiatry as a possible career after finishing their posting in psychiatry compared to only 4.5% expressing such a preference before, which was statistically significant (p=0.012). Almost half of students (45%) chose Internal Medicine as a career choice prior to the clinical attachment but this declined to 26% after, which was again statistically significant (p=0.016). The number of students who chose A&E as a prospective career also fell from nine to 1 percent (p=0.014) although the absolute number still remained small. Approximately 70% of the students who chose psychiatry as a possible career after the posting were females and 86% rated themselves as average academically.

Study design Although the survey was deemed not to require full ethics committee approval, oversight of the survey was provided by the academic staff at the TCD department of Psychiatry, who were made aware of the survey at the outset and its findings upon conclusion of the project. An identical purpose-designed questionnaire was circulated at the start and conclusion of the psychiatry teaching. The questionnaire was a Likert Scale type questionnaire eliciting positive or negative responses to a series of statements and probed various attitudes such as: interest in psychiatry prior to attending medical school, interest in psychiatry as a career, deterrents to choosing a career in psychiatry, worth of psychiatry as an undergraduate subject, belief in whether psychiatry was a mainstream scientific branch of medicine, comparison of teaching in psychiatry with other attachments and whether experience of psychiatry was likely to help with communication skills or otherwise, etc. The questionnaire was facevalidated prior to use in the study by the authors and other tutors for the medical students but no other form of validity was sought.

Interestingly, the percentage of students aspiring to enter General Practice rose slightly from 15.9% to 19.2% but this wasn’t statistically significant. The number of students who were undecided about their career choice rose from 13.6% to 23.2%, again without reaching statistical significance. Students were also asked to rate their subjective perception of academic ability ranging from superior, above average, average and below average. The authors decided to use this measure instead of objective grades so that the identity of the participants

The questionnaires were distributed following an explanation of the purpose of the study in a prepared statement read out by the secretarial staff. Students were assured that their responses would not determine their success in the clinical attachment. The authors

Table 1. Demographics of participants in the study Before Clinical Attachment 88 30 (34.1%) 58 (65.9%) 58 (65.9%) 22 (25.0%) 8 (9.1%)

Total no. of responses Males Females Age= 20-24 Age= 25-29 Age >30

After Clinical Attachment 99 42 (42.4%) 57 (57.6%) 74 (74.8%) 20 (20.2%) 5 (5.0%)

Table 2. Preferred career choice of participants (* statistically significant result) Preferred career choice Psychiatry Internal Medicine Surgical incl. O&G A&E GP Undecided

Before Clinical Attachment 4 (4.5%) 40 (45.4%) 10 (11.4%) 8 (9.1%) 14 (15.9%) 12 (13.6%)

After Clinical Attachment 17 (17.2%) 26 (26.3%) 13 (13.1%) 1 (1%) 19 (19.2%) 23 (23.2%)

P-Value p=0.012* p=0.016* p=0.802 p=0.014* p=0.754 p=0.627

Table 3. Perceived subjective academic ability as rated by the participants Perceived subjective academic ability Superior Above average Average Below average

Before Clinical Attachment 4 (4.5%) 16 (18.2%) 62 (70.4%) 6 (6.8%)

After Clinical Attachment 1 (1.0%) 19 (19.2%) 72 (72.8%) 7 (7.0%)

Before Clinical Attachment 22 (25.0%) 2 (2.3%) 2 (2.3%) 34 (38.6%) 18 (20.4%) 10 (11.4%)

After Clinical Attachment 19 (19.2%) 8 (8.1%) 1 (1.0%) 47 (47.5%) 18 (18.2%) 6 (6.0%)

Table 4. Deterrents for psychiatry as a career

No interest Poor career prospects Financial considerations Too depressing/stressful Wouldn't be deterred Multiple reasons

our paper in contrast demonstrated a more positive and more fluid view of psychiatry as a potential career choice after medical students had acquired some practical experience of the discipline.

could be kept secret. Most of the students rated themselves as average and above average. The authors did not find any correlation between perceived academic ability and psychiatry as a potential career choice.

In relation to those affirming psychiatry as a potential career, previous research has yielded a common trend across different healthcare settings. It is apparent that expressed interest is high during the first and second years but declines after the first clinical placement in hospitals, only to rise after the clinical psychiatry module or attachment but then steadily declines until the completion of medical school.7,8,14 The timing of our survey was in close proximity to completion of a psychiatry attachment and at a time when these students would be more likely to endorse psychiatry as a potential career. It would be relevant and of interest to conduct similar surveys at different years of medical school training to observe any changes or decay in interest in psychiatry in accordance with patterns evident from other surveys.

In relation to deterrents to pursuing psychiatry, the negative perception most endured by the students was the view that psychiatry was too depressing and stressful. This perception increased from 38.6% to 47.5% following the posting, which though not being a statistically significant difference, is somewhat concerning for those who strive to portray a positive image of psychiatry as a career. Lack of interest, career prospects and financial considerations featured in a minority of student answers.

Discussion From perusal of literature in respect of medical students’ attitudes towards psychiatry, it is clear that negative perceptions of psychiatry predominate irrespective of which year of medical school training the surveys were conducted.10,11,12 The results of

The increase in “expressed interest” in psychiatry was the most significant of all specialties, rising from 4.5% to 17.2% and the

magnitude of this increase is consistent with similar previously conducted studies.8,9 Distinctive findings in our survey included the increase in those undecided about their career choice increasing from 13.6% to 23%, and the fall in expressed interest in Internal Medicine and A&E as potential careers - the latter finding being unusual and not resonating with the previous literature.6 This suggests that ultimate career choice is an evolving process and one of considerable fluidity, yet the challenge must be to foster, encourage and maintain interest in psychiatry beyond the eight-week placement. Whether university departments of psychiatry have the resources to offer ongoing mentorship to students is a moot point but doing so could be a prudent investment in terms of enhancing the numbers and quality of graduates who ultimately pursue psychiatry as a career.

consultants see teaching as a time-consuming duty or are they aware of their potential ambassadorial role? A more proactive and energetic mentorship, combined with novel teaching methods highlighting the different and unique aspects of our specialty could be the greatest driver of increased recruitment to psychiatry in years to come.

Conclusions As evident by our results one could argue that psychiatry still remains the â&#x20AC;&#x2DC;Cinderellaâ&#x20AC;&#x2122; amongst other medical and surgical specialties. The majority of students on the verge of deciding their career paths would shun psychiatry in favour of other seemingly more stimulating, more lucrative and less stressful medical specialties. The implications of this negative attitude towards psychiatry may become apparent in the future when the demand for psychiatrists exceeds the numbers of medical graduates willing to enter postgraduate training.

The results of our survey resonate with previous literature which suggests that medical students hold contrasting opinions about psychiatry. It is often perceived as a challenging and interesting specialty with favourable hours and working conditions, but simultaneously also regarded as a lower status discipline with poorer earning potential and being more stressful to practice compared with other disciplines.11,13 It has also been previously inferred that medical students were deterred from pursuit of a psychiatric career on the basis of a perception that psychiatry had less prospects for scientific advancement compared to other specialties.10,14 Our survey did not reflect this as a majority of respondents (approximately 70%) believed psychiatry to be a mainstream specialty with scientific foundation. The participants also believed that a clinical attachment in psychiatry would benefit them in terms of enhanced communication skills irrespective of their ultimate career choice. Perhaps exposure to psychiatry also promotes career selection in the direction of medical specialties that have emphasis on interpersonal communication, extended patient contact and reflection as opposed to more technically driven specialties. We noted, for example, an increase in the number of students opting for General Practice at the conclusion of a psychiatry module.

The most positive finding from our survey however was that a clinical attachment is an important opportunity and means of raising the profile of psychiatry. As practitioners of psychiatry we all have an obligation to review the structure and content of our teaching, to improve efforts to dispel the negative attitudes towards psychiatry and incorporate new and diverse teaching methods highlighting the unique and positive attributes of our specialty. These efforts may be assisted by the promotion of a number of dynamic and charismatic psychiatrists as ambassadors of psychiatry in general, in order to portray a more balanced and more positive image of psychiatry in the media and amongst the lay public. The opportunity to tackle the issue of stress associated with psychiatry is also salient and the promotion of lifelong mental health and professional well-being is a message that could be imparted to medical students, perhaps uniquely by psychiatrists who are also well placed to offer more general vocational and career advice and support.

Limitations of this study include a potential positive response bias inherent in this type of questionnaire and the lack of qualitative information from respondents, particularly about teaching methods that were preferred by students or that facilitated interest in psychiatry. Ascertaining what teaching methods are favoured by students of psychiatry could be a fruitful avenue for further research. Studies to ascertain the preferred teaching methods for students would be highly relevant (such as the utility of clinical exposure, didactic teaching or interview teaching) as would comparisons with other undergraduate specialties in terms of their educational interventions. A focus and emphasis on the subgroup of students who in the wake of a clinical attachment initially favour psychiatry as a career choice, but subsequently change their mind, could yield important information about the decision-making process in selecting a career and the impediments to training in psychiatry. Novel ways to incentivise and stimulate medical studentsâ&#x20AC;&#x2122; interest in psychiatry could be undertaken, such as making available brief rotations in hospitals and psychiatric facilities outside term or having more informal contact with mentors (consultants and trainees alike) at earlier stages of undergraduate training. Surveying the attitude of consultants towards teaching medical students could also be illuminative. Do

Conflict of interest None.

References: 1. Brockington I, Mumford D. Recruitment into psychiatry. Br J Psychiatry 2002; 180: 307312. 2. Cutler JL, Alspector SL, Harding KJ, Wright LL, Graham MJ: Medical Students’ Perceptions of Psychiatry as a Career Choice. Academic Psychiatry 2006;30: 144-149 3. Sierles FS & Taylor MA. Decline of U.S. medical student career choice of psychiatry and what to do about it. Am J Psychiatry 1995; 152:1416-1426 4. Scott IM, et al. Whether or wither some specialties: a survey of Canadian medical student career interest. BMC Med Educ 2009, 9:57 5. Glynn S, et al. Attitudinal change toward psychiatry during undergraduate medical training in Ireland. Ir J Psych Med 2006; 23(4): 131-133. 6. Finucane P & O’Dowd T. The career plans of Irish interns: Results of a national survey. Ir Med J 2004; 97(5): 149. 7. Maidment R, Livingston G, Katona C, et al: Change in attitudes to psychiatry and intention to pursue psychiatry as a career in newly qualified doctors: a follow-up of two cohorts of medical students. Med Teach 2004; 26:565–569 8. Creed F, Goldberg D. Students’ attitudes toward psychiatry. Med Educ 1987; 21: 227234. 9. Bulbena A, et al. Changes in the attitudes towards psychiatry among Spanish medical students during training in psychiatry. Eur J Psychiat. 2005 Vol. 19, No. 2: 79-87. 10. Feifel D, et al. Attitudes Toward Psychiatry as a Prospective Career Among Students Entering Medical School. Am J Psychiatry 1999; 156:1397–1402. 11. Nielsen AC, Eaton JS: Medical students’ attitudes about psychiatry: implication for psychiatric recruitment. Arch Gen Psychiatry 1981; 38:1144–1154 12. Yager J, LaMotte K, Nielson A III, Eaton JS Jr: Medical students’ evaluation of psychiatry: a cross-country comparison. Am J Psychiatry 1982; 139:1003–1009 13. Goldacre MJ, Turner G, Fazel S, et al: Career choices for psychiatry: national surveys of graduates of 1974–2000 from UK medical schools. Br J Psychiatry 2005; 186:158– 164 14. Eagles PF, Marcos MD. Factors in medical students’ choice of psychiatry. Am J Psychiatry 1980; 137: 423-427.

O R I G I N A L PA P E R

Decreased Verbal Learning but not Recognition Performance in Alcohol-dependent Individuals During Early Abstinence *Isolde Daig, Richard Mahlberg, Julia Stethin, Franziska Schroeder, Jana Wrase, Nina Knoll, Tom Bschor, Guenter Esser, Andreas Heinz, Thorsten Kienast Ir J Psych Med 2012; 29 (2): 96-101

Abstract

Introduction

Objective: Alcoholism ultimately leads to impairment of memory and other cognitive functions. This can interfere with treatment, if cognitively impaired alcohol-dependent individuals have difficulties recalling and implementing skills acquired during therapy. We investigate if alcohol-dependent individuals without clinically apparent withdrawal symptoms may still be impaired in higher-order cognitive functions.

Clinical evidence shows that chronic alcohol consumption as well as early alcohol withdrawal leads to long-term cognitive impairment, decreased memory function and later on even to higher psychiatric morbidity.1,2,3 Cognitive deficits related to alcohol consumption can be found in several domains, including problem solving, verbal and non-verbal abstraction learning, memory consolidation1,2 as well as verbal recall and recognition performance (a synopsis of articles investigating verbal recall and recognition performance in alcohol-dependent individuals are shown in table 1). Most of these studies indicate that alcohol-dependent individuals perform relatively worse in recall than in recognition tasks.2,4-7 Only one study has focussed on the memory dimension of verbal recall and revealed impairments in partially medicated alcohol-dependent individuals only on the first day but not to a later time point of acute alcohol withdrawal.6

Methods: Thirty-four alcohol-dependent patients and 20 matched healthy controls were tested with the Verbal Learning and Memory Test which includes seven measurement points. The test comprises free recall, free recall after distraction and after 30 minute delay, and a word recognition task. Testing was performed between day seven and day 10 after the beginning of abstinence, when clinical withdrawal symptoms had ceased. Results: Compared to healthy controls, alcohol-dependent patients performed worse in free recall after delay, but not in word recognition. Healthy controls showed a more linear progression of improvement in verbal memory performance. Overall, alcohol-dependent individuals showed reduced verbal learning efficiency. The extent of impaired recall after distraction was positively associated (one-tailed test) with history of delirium (r=0.34, p=0.04), seizures (r=0.46, p=0.01), and years since diagnosis for alcohol dependency (r=0.39, p=0.01).

The pattern of greater deficits in recall than in recognition memory in alcohol-dependent patients is itself evocative of the initiationretrieval difficulties of patients with subcortical dysfunction.8 Alcohol dementia patients seem to be more impaired in free recall, though they do not differ from controls in verbal recognition memory, in contrast to patients with Alzheimer’s disease, who also had impaired recognition memory.9 New acquired memories are normally retained in a fragile state, and then consolidate over time.10 This slow consolidation of memory may serve as an adaptive function, enabling the contribution of physiological processes modulating memory strength.10,11 It is this consolidation process, rather than retrieval, which may be disturbed in alcoholdependent individuals.12

Conclusions: Our results provide evidence that unmedicated alcohol-dependent patients without obvious withdrawal symptoms had impaired verbal recall, but normal recognition performance, at seven to 10 days after onset of abstinence. This deficit may deteriorate treatment outcomes due to poorer implementation of skills newly-learned during this time period.

A number of studies have been investigating the neuropsychological performance of intoxicated alcohol-dependent individuals, or as a function of duration of abstinence (see also table 1). As to our knowledge, there are no available data on verbal recall and recognition performance of alcohol-free, drug

Key words: alcoholism, withdrawal, verbal memory, cognitive function, recall, recognition.

*Isolde Daig a, Richard Mahlberg b, Julia Stethin c, Franziska Schroeder c, Jana Wrase d, Nina Knoll a, Tom Bschor e, Guenter Esser c, Andreas Heinz d, Thorsten Kienast d a Institute of Medical Psychology, Charité – University Medical Center, Berlin, Luisenstraße 57, 10117 Berlin, Germany b Clinic of Psychiatry, Addiction, Psychotherapy and Psychosomatics, Klinik am Europakanal, Erlangen, Am Europakanal 71, 91056 Erlangen, Germany c Department of Psychology, University of Potsdam, Karl Liebknecht Straße 24/25, 14476 Potsdam OT *correspondence

Golm, Germany d Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité – University Medical Center, Berlin, Charitéplatz 1, 10117 Berlin, Germany e Department of Psychiatry and Psychotherapy, Jewish Hospital Berlin, Heinz Galinski Straße 1, 13347 Berlin, Germany *Correspondence: Isolde Daig, Institute of Medical Psychology, Charité – University Medical Center Berlin, Luisenstraße 57, 10117 Berlin, Germany, Email: isolde.daig@charite.de

Submitted February 4th 2011 Accepted July 29th 2011

Table 1. Synopsis of articles about verbal learning in alcohol dependent patients

Author/year

Tivis et al. 1995

sample 1: 143 alcoholdependent individuals

Interval of abstinence Current medication before testing

Type of verbal learning test

Verbal memory impairment

Wechsler Memory Scale (immediate and delayed recall)

impaired verbal performance and deficits in memory for the majority of alcohol-dependent individuals

3-6 weeks

not specified

3-6 weeks

not specified

Sullivan 1997 52 alcohol-dependent individuals 66 controls 27 schizophrenic

4 weeks

not specified

Adapted version of the Wechsler Memory Scale

impairment in order recognition for verbal material

Parsons 1998 sample 1: 143 alcoholdependent individuals sample 1: 97 controls

>=3 weeks

not specified

Wechsler Semantic Immediate and Delayed (Russel, 1975)

more time for completion of test batteries, poorer performance in test batteries (♀=♂)

Mean 17.8 days, SD 29.4 days

none

impariment in verbal short-term memory, Auditory Verbal Learning Test (adapted from the AVLT by Rey, 1964), significant improvements at 2nd measurement point, but difference remains to controls Logical Memory Subtest (adapted from subtest 4 of the Wechsler Memory Scale, 1945)

not specified

California Verbal Learning Test (CVLT, Delis et al., 1987)

polysubstance abuse group had greater deficits on recall than on recognition memory compared to the alcoholic group

not specified

Brown-Peterson distractor tests (Brown, 1958), WMS (Wechsler & Stone, 1945)

abstainers scored better than relapsers on delayed recall of drawings, visuospatial function, attention, gait, and balance

sample 1: 97 controls sample 2: 130 alcoholdependent individuals sample 2: 83 controls

Mann et al. 1999

49 alcohol-dependent individuals

greater recall deficits, but no difference in recognition memory

49 controls Bondi et al. 1998

70 alcohol-dependent individuals 80 polysubstance abuse individuals

Sullivan et al. sample 1: 20 abstinent alcohol-dependent 2000 individuals sample 1: 22 alcoholic relapsers sample 2: 90 alcoholdependent individuals

Mean 32.5, SD 3.9 days

not specified >= 3 weeks

not specified

less accuracy, more time for completion of tests, lower levels of efficiency, deficit performances in tests (♀=♂)

sample 2: 65 controls Sullivan et al. 43 alcohol-dependent individuals 2002

Mean 3.6 months, SD not specified 3.1 months

Wechsler Memory Scale (Wechsler, 1987), Warrington's Recognition Test (Warrington, 1984)

verbal, working memory was severely affected

Immediate and delayed recall of three word lists (Daum et al, 1994), Rivermead behavioral memory test (Wilson, Coekburn & Baddeley, 1985)

impairments of alcohol-dependent individuals in free and delayed recall (no difference between depressed and non-depressed alcoholdependent individuals) free recall and verbal fluency deficits for depressive

47 controls Uekermann et al. 2003

30 alcohol-dependent individuals

Mean 1.98 months, SD 1.56 months

Yes

28 depressive 28 controls Seifert et al. 2003

29 alcohol-dependent individuals

Measure points at days 1, 3, 7, 14 after last drink

Yes (19 out of 29)

recall impairment on 1st day, recognition Wortliste Nürnberger Altersinventar based on the Wechsler Memory Scale impairment on day 1 and day 3 (♀=♂) for the group with carbamazepine treatment

31 controls Davies et al. 2005

43 alcohol-dependent individuals 58 controls

>= 6 weeks

not specified

Wechsler memory scale (Wechsler, 1987)

worse performance on the verbal memory task

Pitel et al. 2007

40 alcohol-dependent individuals

Mean 11.57 days, SAW 12.82 days

none

Free and Cued Selected Reminding Test (FCSRT, Grober & Buschke, 1987), Spontaneous deep test (“Spondee”, Pitel et al., 2007)

impairment in learning abilities, encoding processes, retrieval processes, no gender difference, no difference in storage capacities (delayed and cued recall)

55 controls

free and non-medicated, alcohol-dependent individuals in an early condition of withdrawal, just after cessation of acute withdrawal symptoms. This time point is of critical interest, because these patients are often discharged from intense treatment, but have to implement their newly learned strategies for maintaining abstinence, in spite of possible memory deficits. A study regarding admissions to a psychiatric ward reported that patients with alcohol or substance abuse were spending shorter periods of time in the hospital than other patient groups.13

In patients reporting history of seizures or delirium during previous withdrawal, medication was administered when AWS scores were six to eight. As well as the anti-seizure medications, some patients received haloperidol for the treatment of visual hallucinations, and/or clonidine for the treatment of high blood pressure. Once a treatment was started, the medication was reduced stepwise during the following days. Twelve of the 34 patients reported having had delirium, and 12 reported having had seizures during previous withdrawals. Of these patients, two reported having had delirium but no seizures, whereas one patient reported having had seizures but no delirium. During our inpatient program, there were no cases of delirium or seizures. The day before the assessments of cognitive function, no patient showed clinical symptoms of alcohol withdrawal syndrome. Only patients without medication or those who at least discontinued four half-lives before study began were included in the study.

The objective of this study was to investigate the extent of verbal memory deficits during the first days of abstinence in unmedicated alcohol-dependent individuals. Because the cognitive deficits found in alcohol-dependent individuals typically manifest in tasks of higher-order cognitive function,14,15 we selected a task that measures the ability to recall and recognise words without a specific context (VMLT 16). We tested the hypothesis that the prediction performance of this learning task would be impaired in a group of alcohol-dependent individuals during early abstinence in comparison with healthy controls, especially in the more complex task of free recall versus the lower order cognitive task of word recognition.

The comparison group comprised 20 (13 male) healthy subjects with no lifetime psychiatric diagnosis, no clinically significant medical or neurological history, no acute medication and no history of alcohol abuse or alcohol dependency according to DSM-IV and ICD-10. The mean age was 44.4 years (SD=13.1), with mean school education of 10.0 years (SD=1.5). After school, 12 participants had finished vocational education, five had finished their academic studies, two had started attending university; one volunteer did not respond to this question. The comparison group was collected among healthy acquaintances of other, non substance dependent or psychiatric patients, and was matched for age, sex, schooling and vocational education.

Method Study population and diagnostic procedures The local ethics committee approved the study according to the declaration of Helsinki and written informed consent was provided by all participants after the procedures had been fully explained. All patients were inpatients, recruited at the psychiatric ward of the Charité - University Medical Center in the St. Hedwig Hospital as well as in the Jewish Hospital in Berlin. Patients who were included in the study fulfilled DSM-IV criteria for alcohol dependency, had no other axis I disorder or reported any other drug consumption except smoking. Furthermore, participants had no active medical or neurological disorder of substantial nature.

Assessment of verbal memory Participants were tested with the Verbal Learning and Memory Test (VLMT16), which is a test for serial word learning, encompassing two word lists: a learning list and a distraction list. The VLMT is designed for assessing different parameters of declarative verbal memory, such as learning efficacy and long-term encoding, as well as decoding processes. The assessment with the VLMT comprises seven measurement points. The first five measurement points represent aspects of the learning phase. The number of correct recalls is noted for each of the five runs. After the fifth run a list with the distraction words is presented. The subject is asked first to recall the distraction list, and then the learning list (sixth measurement point). The subject is then engaged for 30 minutes in non-stressful personal interactions, before being asked to recall the original learning word list (seventh measurement point, i.e. delayed memory). Immediately after the seventh run a blended list of 35 words is presented, and the participant is asked to indicate the words from the original learning list. The test takes 50 to 55 minutes to complete. Table 2 explains the different VLMT scores. In our study, we focus on four main outcomes: total learning efficiency, recall performance after distraction, recall performance after delay, and recognition.

The alcoholic group included 34 (28 male) alcohol-dependent inpatients of mean age 44 years (SD=8). The mean extent of school education was 10.0 years (SD=1.4), 27 participants had completed vocational education, five had finished academic degrees, and one had started attending university. One patient did not respond to the question about education history. Patients reported having had their first drink at a mean age of 14.9 years (SD=3.9), and their first intoxication which needed medical treatment at a mean age of 23.5 years (SD=9.1). Nine patients reported no previous hospitalisation, whereas the remaining 25 patients reported a mean of 8.6 (SD=9.7) prior detoxications in an inpatient setting. Patients had a mean of 18.4 years (SD=10.0) since diagnosis with alcohol dependence. The mean pure ethanol intake during the past five years was 219 kg (SD=172) alcohol per patient. All patients underwent acute alcohol detoxication including complete alcohol abstinence in an inpatient setting starting 7-10 days before entry into the study. Severity of acute alcohol withdrawal symptoms was measured up to a maximum of 12 times a day with the alcohol withdrawal scale (AWS 17). Withdrawal was supported by medication in those with an AWS score of 10 or higher. At admission, patients had a mean AWS score of 7.5 points (SD=3.2); 20 patients exceeded the AWS cut-off score, and were consequently treated with diazepam, clomethiazole, or carbamazepine for a mean of 4.7 days (SD=3.9).

Statistical analysis Data were analyzed using SPSS Version 15.0 for Windows. Data from the memory test were analyzed using a repeated measures analysis of variance (ANOVA), with ‘time’ as the repeatedmeasures factor and “group” (patients-controls) as the between subjects factor. A total N of 54 was reduced to 52 with the deletion of a case missing a score in the sixth session, and one who withdrew after the fourth session. The first step in the ANOVA was 98

Table 2. Labels and descriptions for the different VLMT scores Label learning efficiency total learning efficiency recall performance after distraction recall performance after delay loss after distraction loss after delay recognition efficiency

Description number of correctly recalled words after the fifth learning session sum of correctly recalled words including the first five (learning) sessions number of correctly recalled words directly after the distraction phase (sixth measurement point) number of correctly recalled words after a delay of 30 minutes (seventh measurement point) difference of the amount of correctly recalled words between fifth and sixth measurement point difference between the fifth run (learning efficiency) and the correctly recalled items after 30 minute delay (seventh run) number of correctly recognised words from the blended list

to perform the Mauchly test for sphericity. To correct for violation of sphericity, we used the Huynh-Feldt correction, which alters the degrees of freedom, thereby altering the significance value of the F-ratio. This test is appropriate for small sample sizes. Univariate post-hoc tests were conducted with Bonferroni correction. The effect-size for the ANOVA is partial eta squared (partial Îˇ2). Furthermore, correlations were conducted with one-tailed Spearman Rho for non parametric tests among the four main outcome variables (total learning efficiency, recall performance after distraction, recall performance after delay, recognition), as well as the factors of former delirium, seizures, years of being diagnosed for alcohol dependency, and the number of prior detoxications. Figure 1: Means (SE) of the verbal memory test, shown for alcohol-dependent individuals compared to healthy controls

Results

Note: 1st run: reproduction after first learning cycle; 5th run: reproduction after fifth learning cycle; distractionlist: reproduction of distraction list; 6th run: reproduction of learning list after distraction; 7th run: reproduction after 30min delay; recall: number of recognised words; n.s. indicates a non significant group difference; ** indicates a significant group difference with p<.01; *** a significant group difference with p<0.001

Group differences in verbal memory ANOVA was performed with â&#x20AC;&#x2DC;correctly recalled wordsâ&#x20AC;&#x2122; as the dependent variable, measurement points as the repeated measure factor, and group as the between-subject factor. Because of a significant Mauchly test for sphericity (W=0.27, approximate chisquare=62.65, df=20, p<0.001), we used the Huynh-Feldt correction. Results showed that verbal learning memory (correctly recalled words) increased with the number of learning cycles (see figure 1; F=144.44, df=4.23, p<0.001, partial eta squared=0.74). A time by group interaction was found (F=3.37, df=4.24, p=0.01, partial eta squared=0.06), i.e. healthy controls showed a more linear progression of improvement in verbal memory performance, and had better free recall scores compared to alcohol-dependent individuals (F (1,50)=14.28, p<0.001, partial eta squared=0.22).

b) for loss after distraction, and c) for loss after delay (see figure 1). Furthermore, no group difference appeared for the dependent variables recognition efficiency and correctly reproduced words of the distraction list. Reproducing words of the distraction list is a similar task to reproducing the learning list for the first time (first run), in which there was likewise no group difference. Even after correction for the covariate short-term memory (based upon recall after the first run), performance in free recall was poorer in the alcoholic group (F(1, 49)=16.68, p<0.001, partial eta squared=0.25).

Univariate post-hoc tests with Bonferroni correction were computed for each measurement point. There was a significant group difference for learning efficiency (fifth run; (F (1, 52)=12.09, p<0.001, partial eta squared=0.19) as well as total learning efficiency (sum of the recalled words from the first to fifth run; F(1,52)=14.17, p<0.001, partial eta squared=0.21). Alcoholdependent patients recalled significantly fewer words of the learning list than healthy controls after five learning cycles. In addition, alcohol-dependent individuals recalled fewer words in total than healthy controls. Furthermore, a significant group difference appeared for recall performance after distraction (sixth run; F(1,52)=9.73, p=0.003, partial eta squared=0.16) as well as for the recall performance after delay (seventh run; F(1,52)=11.07, p=0.002, partial eta squared=0.18). Compared to alcoholdependent individuals, healthy controls were able to recall significantly more words at these two measurement points. No significant group differences appeared a) at the first learning cycle,

Comparing the verbal learning memory performance between alcohol-dependent individuals with a past medical history of seizures or delirium (n=10) and those without such history (n=24), univariate post-hoc tests with a family-wise Type-I Error corrected significance level at p<0.006 indicated only in one domain a significant difference between these two subgroups of alcoholdependent individuals, i.e. patients with history of seizures/delirium did perform worse only in recall after distraction (sixth run; F(1,32)=8.51, p<0.006, partial eta squared=0.21). Associations between severity of alcohol dependence and verbal memory In the 17 of 20 alcohol-dependent patients for which information was available, the one-tailed Spearman Rho showed that loss after distraction was positively associated with history of delirium (n=12, r=0.34, p=0.04), seizures (n=12, r=0.46, p=0.01), and years since 99

diagnosis for alcohol dependency (r=0.39, p=0.01). The loss after delay was correlated positively with a history of seizures (r=0.34, p=0.04). There was no significant association between number of prior detoxications and verbal memory performance.

of the learning curve was steeper for healthy controls than for alcohol-dependent individuals. Furthermore, we found that loss after distraction was positively associated with history of delirium, seizures, and years since diagnosis of alcohol dependency. In contrast, loss after delay was associated only with a history of seizures during previous detoxications. It has been argued that decreased hippocampal volume imparts an increased risk for alcohol-related seizures in alcohol-dependent individuals.23 If so, present findings suggest that loss after delay is particularly sensitive to hippocampal pathology in alcohol-dependent individuals. The decline of cognitive performance and a decrease of memory function during early alcohol abstinence may be either pre-existent or due to the confluence of a number of neurobiological processes occurring during acute withdrawal.24-29 The cognitive decline might also be due to smoking effects. A study of 229 older smokers compared to 98 people who had never smoked showed that smoking causes cognitive decline and loss of gray matter tissue in the brain over time.30 Another study on 92 alcohol-dependent patients showed an association between greater smoking chronicity and poorer performance in neuropsychological tests after control for alcohol consumption.31 Chronic smoking seems to add an additional negative effect to neurocognitive function in patients with alcohol dependence.31

Discussion To our knowledge, this is the first study that has shown within a narrow time frame that unmedicated alcohol-dependent patients showed decreased verbal memory performance specifically in recall, but not in recognition during early withdrawal compared to healthy controls. Furthermore, our data indicate that verbal memory consolidation increased as a function of the number of learning sessions in all participants. This result is in accordance with findings of Pitel and colleagues,7 who had included patients with a larger interval of alcohol abstinence than 10 days as in the present study. Yet a previous study has shown that consolidation of newly-learned declarative items is time-dependent.10 It has been suggested that the memory deficits in alcohol-dependent individuals may arise from inferior acquisition processes, rather than inferior retrieval12 which we were not presently able to confirm. Our results corroborate an earlier finding that alcoholic and control groups did not differ in scores for word recognition efficiency.18 We found that word recognition (retrieval) scores were significantly higher than free recall scores, in both alcoholdependent individuals and healthy controls. It may be that the cognitively less complex recognition performance is an unfit indicator of memory consolidation, which is better indicated by the individuals’ ability for free recall.10

Nevertheless, it occurs that impaired memory function may negatively affect the ability of alcohol-dependent individuals to transfer their psychotherapeutic intervention into daily routine, thus increasing their risk for relapse.30-32 Results indicate that engagement in the behavioural intervention process appears to depend on cognitive abilities, although commitment to abstinence is given.33 Some authors suggest using a screening instrument for excessive drinking to identify actual excessive drinking episodes.34 In future studies, the cognitive status in alcohol-dependent individuals could be briefly assessed with an instrument35 for measuring the change in cognitive ability during different withdrawal specific phases. Interventions could than be tailored via the cognitive state of the patient. In addition, future studies should also investigate the links between memory deficits of alcohol-dependent individuals and their episodic and executive deficits, not only with correlational patterns but also with behavioural and imaging experiments. Kelleher and O’Brien13 suggest an implementation of outpatient detoxication programmes that also would have an impact on admission patterns.

Our findings showed that the basal ability of word acquisition and immediate retrieval, revealed by recall after the first run, may be less affected in alcohol-dependent individuals during early withdrawal. However, we found a difference between alcoholdependent individuals and healthy controls in the performance of a test of memory consolidation, as revealed by impaired free memory reproduction between run two and seven in the alcoholic group. Contradictory findings have been reported for verbal memory acquisition and retrieval capacity in alcohol-dependent individuals during early abstinence.6,7,12,19,20 These discrepant results may be explained by divergent study designs with differences in severity of alcoholism, medication status during the study, and the variable time period defined for early withdrawal. Müller and Pilzecker’s21 pioneering preservation-consolidation theory of memory dating back 1900 postulates that retention of recall of newly learned information will be disrupted by the subsequent learning of new information soon after the original learning. In accordance with this, we found a decrease of verbal memory recall performance in all subjects in both interfering conditions. Setting the learning efficiency (assessed by recall after the fifth run), of the two present study groups to 100%, we find that the alcoholic group showed a relatively larger decrease of reproducible words at run six and seven. This effect may be due to an impairment of memory consolidation processes in alcoholdependent individuals which may be withdrawal-induced. However, there was no group difference for word reproduction after the first learning session, and for reproduction of the distraction list. This lack of difference suggests that the efficacy of working memory is similar in both groups, consistent with the results of previous studies.18,22 However, we found that the slope

A limitation of our study is the time-dependency of group differences in recall. Improvement in memory depends on temporal conditions, but the neuropsychological recovery from alcoholism is not only time-dependent, but also experience-dependent.35 It also remains uncertain if the deficits were withdrawal-induced or pre-existing. Furthermore, although patients and controls negated the possibility of any further comorbid recreational drug consumption which might have independent effects on memory performance36,37 we did not measure urine control status.

Conflict of interest None.

100

29. Heinz A, Siessmeier T, Wrase J, Buchholz HG, Gründer G, Kumakura Y, et al.. Correlation of alcohol craving with striatal dopamine synthesis capacity and D2/3 receptor availability: a combined [18F]DOPA and [18F]DMFP PET study in detoxified alcoholic patients. Am J Psychiat 2005; 162: 1515-20. 30. Almeida OP, Garrido GJ, Alfonso H, Hulse G, Lautenschlager NT, Hankey GJ, Flicker L. 24-month effect of smoking cessation on cognitive function and brain structure in later life. Neuroimage 2011; 55(4): 1480-1489. 31. Durazzo TC, Fryer SL, Rothlind JC, Vertinski M, Gazdzinski S, Mon A, Meyerhoff DJ. Measures of learning, memory and processing speed accurately predict smoking status in short-term abstinent treatment-seeking alcoholics. Alcohol Alcohol 2010; 45(6): 507-513. 32. Miller WR, Wilbourne PL, Hettema JE.. What works? A summary of alcohol treatment outcome research. In R. K. Hester & W. K. Miller (Eds.), Handbook of alcoholism treatment approaches: effective alternatives, Vol. 3. Boston: Allyn and Bacon, 2003: 213-36. 33. Aharonovich E, Amrhein PC, Bisaga A, Nunes EV, Hasin DS. Cognition, Commitment Language, and Behavioral Change Among Cocaine-Dependent Patients, Psychol Addict Behav 2008; 4: 557-62. 34. Sinha R. The role of stress in addiction relapse. Curr Psych Rep 2007; 9: 388-95. 35. James A, Edwards E.. Screening for excessive drinkers in a Hampshire general practice. Ir J Psych Med 2002; 19(1): 13-15 36. Godding PR, Fitterling JM, Schmitz JM, Seville JL, Parisi SA. Discriminative Utility of a Brief Cognitive Status Assessment With Alcoholics and the Impact of Cognitive Status on Acquisition of Treatment-Relevant Information. Psychol Addict Behav 199; 6(1): 34-40. 37. Mann K, Günther A, Stetter F, Ackermann K. Rapid recovery from cognitive deficits in abstinent alcoholics: a controlled test-retest study. Alcohol Alcoholism 1999; 34: 567-74.

References 1. Parsons OA. Neurocognitive Deficits in Alcoholics and Social Drinkers: A Continuum? Alcohol Clin Exp Res 1998; 22: 954-61. 2. Davies SJC, Pandit SA, Feeney A, Stevenson BJ, Kerwin RW, Nutt DJ, et al. Is there cognitive impairment in clinically “healthy“ abstinent alcohol dependence? Alcohol Alcoholism 2005; 40: 498-503. 3. Johnson I. Outcome of Alcoholism in Old Age. Ir J Psych Med 2001; 18(4): 125-28. 4. Tivis R, Beatty WW, Nixon SJ, Parsons OA. Patterns of cognitive impairment among alcoholics: are there subtypes? Alcohol Clin Exp Res 1995; 19: 496-500. 5. Uekermann J, Daum I, Schlebusch P, Wiebel B, Trenckmann U. Depression and cognitive functioning in alcoholism. Addiction 2003; 98: 1521-29. 6. Seifert J, Seeland I, Borsutzky M, Passie T, Rollnik JD, Wiese B, et al. Effects of acute alcohol withdrawal on memory performance in alcohol-dependent patients: a pilot study. Addict Biol 2003; 8: 75-80. 7. Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007; 31: 1169-78. 8. Bondi MW, Drake AI, Grant I. Verbal learning and memory in alcohol abusers and polysubstance abusers with concurrent alcohol abuse. J Int Neuropsych Soc 1998; 4: 319-28. 9. Saxton J, Munro CA, Butters MA, Schramke C, McNeil MA. Alcohol, dementia, and Alzheimer's disease: comparison of neuropsychological profiles. J Geriatr Psych Neur 2000; 13: 141-49. 10. McGaugh JL. Memory-a century of consolidation. Science 2000; 287: 248-51. 11. Nielson KA, Powless M. Positive and negative sources of emotional arousal enhance long-term word-list retention when induced as long as 30 min after learning. Neurobiol Learn Mem 2007; 88: 40-47. 12. Sherer M, Nixon SJ, Parsons OA, Adams RL. Performance of alcoholic and braindamaged subjects on the Luria Memory Words test. Arch Clin Neuropsych 1992; 7: 499–504. 13. Kelleher M, O’Brien S. An audit of admissions to an acute psychiatric unit. Ir J Psych Med 2001; 18(4): 132-36 14. Noel X, Paternot J, Van der Linden M, Sferrazza R, Verhas M, Hanak C, et al. Correlation between inhibition, working memory and delimited frontal area blood flow measure by 99mTc-Bicisate SPECT in alcohol-dependent patients. Alcohol Alcoholism 2001; 36: 556-63. 15. Moselhy HF, Georgiou G, Kahn A. Frontal lobe changes in alcoholism: a review of the literature. Alcohol Alcoholism 2001; 36: 357-68. 16. Helmstaedter C, Lendt M, Lux, S. Verbaler Lern- und Merkfähigkeitstest. Göttingen: Beltz Test GmbH, 2001. 17. Wetterling T, Kranitz RD, Besters B, Fischer D, Zerfass B, John U, et al. A new rating scale for the assessment of the alcohol-withdrawal syndrome (AWS scale). Alcohol Alcoholism 1997; 32: 753-760. 18. Sullivan EV, Marsh L, Mathalon DH, Lim KO, Pfefferbaum A. Relationship between alcohol withdrawal seizures and temporal lobe white matter volume deficits. Alcohol Clin Exp Res 1996; 20: 348-54. 19. Nixon SJ, Kujawski A, Parsons OA, Yohman JR. Semantic (verbal) and figural memory impairment in alcoholics. J Clin Exp Neuropsychol 1987; 9: 311-22. 20. Sullivan EV, Shear PK, Zipurksy RB, Sagar HJ. Patterns of Content, Contextual, and Working Memory Impairments in Schizophrenia and Nonamnesic Alcoholism. Neuropsychology 1997; 11: 195-206. 21. Müller GE, Pilzecker A. Experimentelle Beiträge zur Lehre vom Gedächtnis. Zeitschrift für Psychologie und Sinnesphysiologie (Ergänzungsband) 1900; 1: 1-300. 22. Hildebrandt H, Brokate B, Eiling P, Lanz M. Response shifting and inhibition, but not working memory, are impaired after long-term heavy alcohol consumption. Neuropsychology 2004; 18: 203-11. 23. Sullivan EV, Rosenbloom MJ, Pfefferbaum A. Pattern of motor and cognitive deficits in detoxified alcoholic men. Alcohol Clin Exp Res 2000; 24: 611-21. 24. Tsai GC, Gastfriend DR, Coyle JT. The glutamatergic basis of human alcoholism. Am J Psychiat 1995; 152: 332–40. 25. Inder WJ, Joyce PR, Ellis MJ, Evans MJ, Livesey JH, Donald RA. The effects of alcoholism on the hypothalamic-pituitary-adrenal axis: interaction with endogenous opioid peptides. Clinical Endocrinology (Oxford) 1995; 43: 283-90. 26. Abi-Dargham A, Krystal JH, Anjilvel S, Scanley BE, Zoghbi S, Baldwin RM, et al. Alterations of benzodiazepine receptors in type II alcoholic subjects measured with SPECT and [123I]iomazenil. Am J Psychiat 1998; 155: 1550-55. 27. Oscar-Berman M, Marinkovic K. Alcoholism and the brain: an overview. Alcohol Res Health 2003; 27: 125-33. 28. Kiefer F, Wiedemann K.. Neuroendocrine pathways of addictive behaviour. Addiction Biol 2004; 9: 205-12.

101

O R I G I N A L PA P E R

Post-Traumatic Stress Disorder (PTSD) Symptoms in Adults with Psychiatric Disorders Muhammad Tahir Khalily, Anna Paulina Wota, Brian Hallahan Ir J Psych Med 2012; 29 (2): 102-106

Abstract

associated with the stressor and exhibit symptoms of increased physiological arousal (e.g. hypervigilance, exaggerated startle response) and may be unable to recall some aspects related to the stressor. PTSD may follow a protracted course,2 with significant deleterious effects on the individuals’ quality of life.3 The presence of ‘a specific traumatic event’ is currently essential for a diagnosis of PTSD.1,4 However, some have challenged this requirement because conditions such as long-term or terminal illness are associated with symptoms similar to those that occur in PTSD.4,5

Objective: This study explores unrecognised symptoms related to post-traumatic stress disorder (PTSD) in individuals with a range of psychiatric disorders in the absence of traumatic events. We also examine the association between PTSD symptoms, social interaction with peers and therapeutic alliance with mental health professionals. Method: A purposive sample of 120 adults consecutively referred to the psychology department from September 2008 to September 2010 was included in this study. We used the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) to ascertain the presence of PTSD symptoms, social interaction levels and treatment alliance with health professionals.

If a traumatic event is not the individuals’ presenting complaint or is not specifically enquired about during the initial patient assessment; a diagnosis of PTSD is frequently not elicited by the clinician.6, 7 Most research in PTSD continues to be based solely on individuals who present following traumatic events,8 however PTSD is significantly more prevalent in those who fulfil diagnostic criteria for other DSM-IV diagnostic disorders.9, 10 The increased rate of PTSD in individuals with other psychiatric disorders suggests a multifaceted causal relationship between PTSD and these conditions.11 For example, individuals with psychiatric disorders are more likely to be interpersonally victimised,12 which may increase their vulnerability and likelihood of developing PTSD. Furthermore, a diagnosis of PTSD is associated with symptoms such as hypervigilance, persistent disturbing memories, anger and mistrust, which can impact negatively on the relationship with mental health professionnals.13,14 In addition, when PTSD is not diagnosed and treated appropriately, other co-morbid psychiatric conditions may be affected; with increased symptom severity, a greater risk of relapse, and increased social isolation.10,15,16

Results: Individuals previously undiagnosed with PTSD, referred without any noted traumatic event had high levels of symptoms related to PTSD, as measured by the PK scale of the MMPI-2. The PK scale was significantly correlated with several MMPI-2 clinical scales, the Social Introversion Scale (Si) and the Treatment Alliance Scale (TRT) (p < 0.001). Conclusion: This study demonstrated the presence of symptoms related to PTSD in individuals with a range of psychiatric disorders despite the absence of reported trauma. The presence of symptoms related to PTSD may be associated with an indirect negative impact on social contacts and a poorer therapeutic alliance with mental health professionals. Investigating symptoms of PTSD during a psychological assessment even when trauma is not the presenting complaint is merited in most cases.

In this study, we aimed to assess symptoms of PTSD when ‘a traumatic event’ was not the presenting problem. We wanted to explore the frequency of unrecognised PTSD symptoms in a cohort of consecutively referred patients, diagnosed with other psychiatric disorders who did not present with or report exposure to traumatic events and who did not have a previous diagnosis of PTSD. We further wanted to ascertain if symptoms of PTSD, either alone or in conjunction with other psychiatric pathology, would have a negative impact on social isolation and treatment alliance with mental health professionals.

Key words: PTSD, MMPI, PK, assessment, absence of traumatic event.

Introduction Post-traumatic stress disorder (PTSD) is a common psychiatric disorder, occurring after a traumatic event of significant severity to cause pervasive distress in almost anyone.1 It is characterised by persistent reliving of the stressor in the form of intrusive flashbacks, vivid memories or recurrent dreams, or experiencing distress on exposure to circumstances resembling or associated with the stressor. In addition, individuals prefer to avoid circumstances

*Muhammad Tahir Khalily, Senior Clinical Psychologist, Psychology Department Roscommon Mental Health Services and Clinical Supervisor for D.Psych.Sc School of Psychology, National University of Ireland, Galway, Galway, Ireland Email khalily64@gmail.com

Brian Hallahan, Consultant Psychiatrist, Department of Psychiatry, Roscommon County Hospital, Roscommon and Honorary Research Fellow, Clinical Science Institute, National University of Ireland, Galway, Galway, Ireland

Anna Paulina Wota, Programme Department of Psychology, University of Bielefeld, Bielefeld, Germany. *correspondence

102

Submitted 30th November 2010 Accepted 14th February 2012

Method

2. MMPI Post-Traumatic Stress disorder scale (PK) The PK sub-scale was developed in 1984 for the assessment of PTSD symptoms and was developed after contrasting war veteran groups with and without a diagnosis of PTSD.21 It has been shown to be highly sensitive (82%) in diagnosing individuals with PTSD.25 The items on the PK scale assess re-experiencing symptoms (“once in a while I think of things too bad to talk about,” “I have nightmares every few nights”), effortful avoidance (“I am so touchy on some subjects that I can’t talk about them”), and hyperarousal (“At times I feel like smashing things”). It also assesses worry, anxiety, depression, guilt, sleep disturbance and unwanted and disturbing thoughts. Caution has been suggested in utilising this scale for the diagnosis of PTSD particularly as it does not specifically assess traumatic events,26 however the PK scale has been shown to differentiate PTSD from other psychiatric disorders,26 and its diagnostic utility is particularly applicable for individuals requiring treatment for PTSD.27,28 Furthermore, the MMPI-PK scale has demonstrated good sensitivity in the classification of individuals with disorder,29 and has shown superior validity in the prediction of PTSD compared to other clinical scales such as the Restructured Clinical Scale (RCS) and Clinical Scale (CS).30 A strong correlation (r=0.77) has been demonstrated between the PTSD Checklist (PCL) and PK scale of the MMPI-2.31

Subjects: Subjects included 162 consecutively received new referrals to the department of psychology, adult mental health services, Roscommon between September 2008 and September 2010. All 162 individuals were adults (>18 years of age) without an intellectual disability (Intelligence Quotient > 70) and included both in-patients and out-patients. All were referred by consultant general adult psychiatrists attached to the department of psychiatry, Roscommon County Hospital for diagnostic assessment or psychological treatment. Each individual referred had received a diagnosis using ICD-10 diagnostic criteria by a consultant general adult psychiatrist. Thirteen individuals did not attend and four individuals had a diagnosis of PTSD or were referred for assessment after a traumatic event and thus were excluded from the study. Of the remaining 145 individuals, 120 individuals completed the MMPI-2 in entirety (answered 567 items) and were included in the study. Nine individuals refused to have the MMPI-2 administered and 16 individuals failed to complete the entire assessment. Informed verbal consent was obtained during the administration of MMPI-2 as part of their initial psychological assessment. Ethical approval was attained from the ethics committee of Roscommon County Hospital.

In this study, we utilised the MMPI-PK scale to examine individuals with symptoms of PTSD rather than ascertain a diagnosis of PTSD as we only assessed individuals who did not report traumatic events. Whilst the MMPI-PK scale has demonstrated good sensitivity in the classification of individuals with PTSD,29 we believe that care should be utilised in the interpretation of scores above the threshold for PTSD on this scale, as a range of related anxiety conditions including adjustment disorders and acute stress disorders could potentially be present rather than PTSD.

Demographic data including age, gender, employment and relationship status was collected from the client dossiers, with diagnostic information attained from the treating general adult psychiatrist.

Instruments 1. Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) The MMPI-2 is a broadband inventory devised to measure a number of key elements of personality and assess psychological disorders. The MMPI was originally developed in 1943, with the revised version (MMPI-2) published in 1989, based on a larger and more racially and culturally diverse normative community comparison group. The MMPI-2 includes four validity scales, nine basic clinical scales (Hypochondriasis (Hs), Depression (D), Hysteria (Hy), Psychopathic Deviate (Pd), Masculine and Feminine (Mf), Paranoia (Pa), Psychasthenia (Pt), Schizophrenia (Sc), Mania (Ma)) and a Social Introversion scale (Si). The MMPI-2 can contribute in the assessment of psychiatric disorders in a wide variety of clinical settings with the scales providing symptom related information that can be used as an adjunct but not solely for the diagnosis of psychiatric disorders.17 In addition, numerous content and supplementary scales have been developed, including the Posttraumatic disorder Scale (PK), which is widely utilised for clinical and research purposes.18 These sub-scales possess external validity,19 and are recognised as being valid in describing and predicting personality variables.20

3. MMPI-Negative Treatment Indicators (TRT) This scale assesses negative attitude towards doctors and other mental health professionals. High scores indicate that individuals have difficulty discussing their issues with health professionals, are resistant to change, and preferentially avoid rather than face crises.17

Analysis All MMPI-2 answer sheets were hand scored. Statistical analysis was performed using the Statistical Package for Social Sciences 15.0 for Windows (SPSS Inc., Chicago, Illinois, and USA). We utilised the student-t test for parametric data and the Chi Square (x2) test for non-parametric data where appropriate. We used the Pearson’s Product Moment Correlation (r) to determine the correlation between the MMPI-2 clinical scales and the Si, PK and TRT scales.

Results

We previously have utilised the MMPI-2 as a psychometric tool both alone and in conjunction with the schema mode inventory (SMI) for the assessment of psychiatric symptoms in individuals with a large range of mental health disorders in a number of studies carried out in Ireland.22-24

Demographic data is detailed in Table 1. There were equal numbers of males and females in the study and both genders were of similar age (the mean age of females was 35 (SD=10) and the mean age of males was 34 (SD=12)). The most common diagnoses in order of frequency were recurrent depressive disorder (n=45), dependence on, or harmful use of, alcohol (n=30) and anxiety disorders (n=24).

103

examining partial correlations between the PK and TRT scales, a significant but lower positive correlation remained (r=0.253, p=0.008) when controlling for all clinical scales and the social introversion scale. The Sc and Pt scales contributed most significantly to this reduction in correlation between the PK and TRT scales. Findings for the three diagnostic sub-groups (recurrent depressive disorder, dependence or harmful use of alcohol and anxiety disorders) were virtually identical to those presented for the entire group.

Table 1. Demographic and clinical data Variable

(%)

Gender Male Female

60 60

(50.0) (50.0)

Employment Status Employed Unemployed In full-time education Housewife Retired

60 29 14 15 2

(50.0) (24.1) (11.7) (12.5) (1.7)

Relationship Status Single* Married Separated/Divorced

71 39 10

(59.0) (32.5) (8.3)

Psychiatric Diagnosis** Schizophrenia Bipolar Disorder Recurrent Depressive Disorder Anxiety Disorder Obsessive Compulsive Disorder Eating Disorder Unspecified Dependence or Harmful use of alcohol

5 9 45 24 4 3 30

(4.1) (7.5) (37.5) (20.0) (3.3) (2.5) (25.0)

Discussion Symptoms of PTSD were present at high rates (66% of individuals) in a clinical population with a range of psychiatric disorders including schizophrenia, bipolar disorder, recurrent depressive disorder, dependence or harmful use of alcohol and anxiety disorders (general anxiety disorder, panic disorder and obsessivecompulsive disorder) despite these individuals previously not being diagnosed with PTSD. Our studies confirm previous reports that PTSD symptoms may be over-looked in individuals with other psychiatric disorders when trauma is not the presenting complaint.6,7 Social introversion was significantly positively correlated with symptoms of PTSD. This correlation was similar to that seen with depression, schizophrenia and psychasthenia and was greater than all other clinical disorders, suggesting that PTSD symptoms may be associated with significant social isolation from oneâ&#x20AC;&#x2122;s peers. A negative treatment alliance was correlated to a greater extent with PTSD symptoms than with symptoms of other clinical disorders, suggesting that the presence of PTSD may have significant deleterious effects for therapeutic rapport with mental health professionals. Other conditions, in particular psychasthenia and schizophrenia, also had significant negative effects on treatment alliance. In addition to the significant morbidity that is associated with PTSD, these findings suggest that individuals may be slow to look for or accept treatment for their PTSD symptoms.

*Twenty-one of these individuals were in a relationship. **Only the principal diagnosis is described above.

In Table 2, we present MMPI-2 data for the group as a whole, and also for individuals with recurrent depressive disorder, dependence or harmful use of alcohol, and anxiety disorders. MMPI-2 scores above the threshold indicative of psychopathology included Depression (D), Paranoia (Pa) and Post-Traumatic Stress disorder (PK) for the entire group; D, Pa, Social Introversion (Si) and PK for individuals with recurrent depressive disorder; D, Pa and PK for individuals with dependence or harmful use of alcohol and D for individuals with anxiety disorders. In the entire group, 79 individuals (65.83%) scored above the threshold on the PK scale for PTSD. Thirty-two individuals (71.11%) with recurrent depressive disorder, 16 individuals (53.37%) with dependence or harmful use of alcohol and 15 individuals (62.5%) with anxiety disorders similarly scored above the threshold for PTSD on the PK scale.

There are a number of limitations with this study. Firstly some caution should be exercised in interpreting that a high score on the PK scale of the MMPI-2 is definitively associated with a diagnosis of PTSD. Nevertheless, this scale has proven validity and reliability for measuring PTSD symptoms. However, several anxiety conditions such as adjustment disorders, and acute stress disorder have symptoms similar to PTSD, and in the absence of traumatic events, it is possible that the MMPI-PK scale is not alone in measuring symptoms of PTSD but is also measuring symptoms from these conditions. Furthermore, individuals in withdrawal states from psycho-active substances and individuals with depression may also have some symptoms that may be elucidated by the PK scale. Secondly, all individuals were diagnosed with ICD10 criteria after lengthy and in most cases several interviews with consultant general adult psychiatrists, however no formal diagnostic schedules, such as the Structured Clinical Interview for DSM-IV (SCID) were utilised in this study. Thirdly, it should be remembered that 34% of individuals in this study, scored below the cut-off for PTSD using the PK scale of the MMPI-2, and that scores below the cut-off, even if high, may indicate general distress rather than PTSD symptom severity.32 Fourthly, although no individuals reported traumatic events during their interviews with their clinical team, it is possible that a number of individuals had

In Table 3, we present correlation data between the MMPI-2 clinical scales and the Si, PK and Negative Treatment Indicators (TRT) scales. A significant positive correlation (p < 0.001) was found between the PK scale and all clinical scales of MMPI (except Hypomania (Ma)), the Si and TRT scales. The PK scale showed most correlation with the Psychasthenia (Pt), Schizophrenia (Sc) and TRT scales. A significant positive correlation (p < 0.001) was demonstrated between the Si scale and all clinical scales of the MMPI-2 (except Hypomania (Ma)), the PK scale and the TRT scale. This correlation was greatest for the Psychasthenia (Pt) and Depression (D) scale. The TRT scale showed most correlation with the PK and Pt scales, but was significantly positively correlated with all scales except the Masculinity â&#x20AC;&#x201C; Femininity (MF) scale. On

104

Table 2 MMPI - Clinical scales raw mean scores MMPI -2 (Range)

Hs (5-40) Mean (SD)

D (10-55) Mean (SD)

Hy (10-50) Mean (SD)

Total group

12.3 (6.849)

29.8 (8.464)

27.0 23.5 (7.545) (6.476)

30.0 14.6 (6.377) (4.957)

Recurrent depressive disorder

13.3 (6.652)

30.8 (8.342)

27.9 22.8 (7.079) (5.963)

Dependence or harmful 11.8 use of alcohol (6.913)

28.0 (8.438)

Anxiety disorders

28.2 (8.917)

11.4 (6.351)

Pd (15-50) Mean (SD)

Mf (20-55) Mean (SD)

PA (5-30) Mean (SD)

Pt (20-55) Mean (SD)

Sc (15-65) Mean (SD)

Ma (10-40) Mean (SD)

Si (10-65) Mean (SD)

Pk (5-45) Mean (SD)

Trt (5-25) Mean (SD)

25.1 25.8 (10.720) (13.962)

18.8 (5.648)

36.1 20.8 11.5 (10.756) (11.041) (6.177)

30.5 14.8 (6.162) (4.802)

26.2 26.3 (10.789) (13.380)

17.4 (5.813)

37.7 21.5 11.8 (10.789) (11.210) (6.425)

26.3 26.6 (7.281) (6.763)

28.3 15.0 (6.599) (5.415)

26.1 28.5 (9.982) (13.752)

20.9 (4.963)

34.3 22.5 11.4 (11.525) (10.634) (6.425)

24.7 20.2 (6.150) (5.371)

29.4 13.0 (5.892) (4.298)

22.2 22.0 (11.014) (13.917)

18.7 (3.917)

36.0 17.5 10.5 (11.282) (10.576) (6.336)

The range of scores possible for each clinical scale is provided in parentheses under their heading. The cut off score suggesting pathology for each of the MMPI scales are: Hs = 18, D = 25, Hy = 27, Pd = 29, Mf = 34, Pa = 14, Pt = 33, Sc = 35, Ma = 25, Si = 37, PK= 20, TRT= 12 Hs = Hypochondriasis; D = Depression; Hy = Conversion Hysteria; Pd = Psychopathic Deviate; Mf = Masculinity-Femininity; Pa = Paranoia; Pt = Psychasthenia; Sc = Schizophrenia; Ma = (Hypo)mania; Si = Social Introversion; PK= Post-traumatic stress disorder; TRT= Negative Treatment Indicators

Table 3 Correlation between MMPI clinical scales and the PK, Si and TRT scales Scales

PK Si TRT

0.733** 0.511** 0.641*

0.686** 0.683** 0.612**

0.510** 0.737** 0.274* 0.347** 0.382** 0.588**

0.214** 0.234* 0.108

0.712** 0.422** 0.611**

0.923** 0.702** 0.819**

0.920** 0.655** 0.821**

0.414* -0.023 0.366**

0.641** 0.660**

.846*** 0.641** .660** 0.846** -

experienced traumatic events but not revealed this to their treating clinician. Lastly, and most pertinently, a large set of correlational analyses were undertaken and results of such analysis should be interpreted with caution. In particular, some scale items share items which may give falsely high correlations between scales and this may be of particular relevance to the PK and Pt scales of the MMPI2 and may explain some of the high correlation noted in this study between these scales.

Trt

psychological assessment, should be investigated for possible symptoms of PTSD even if a traumatic event is not the presenting problem. This will help the treating team to both understand the patientsâ&#x20AC;&#x2122; difficulties and optimise their management plan.

Conflict of interest None.

Conclusion In individuals fulfilling diagnostic criteria for a range of psychiatric disorders, we found that 66% of individuals scored above the threshold on the PK scale of the MMPI-2, despite not presenting with a traumatic event or previously having a diagnosis of PTSD. This suggests that many individuals have symptoms of PTSD or similar anxiety conditions (adjustment disorders/acute stress disorders) and we suggest that individuals referred for

105

References 1. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-1V). Washington, DC: APA. 2. Kessler RC, Sonnega A, Brmet E, Hughes M, Nelson CB. Post-traumatic stress disorder in the National Co-morbidity Survey. Arch Gen Psychiatry 1995; 52: 1048-1060. 3. Holbrooke TL, Galarneau MR, Duye JL, Quinn K, Dougherty AL. Morphine use after combat injury in Iraq and Post-traumatic stress disorder. N Engl J Med 2010; 362: 110117. 4. Saskia, SL, Arntz A, Metsemakers JFM. Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study. Br J Psychiatry 2005; 186: 494-499. 5. Scott MJ, Stradling SG. Post-traumatic stress disorder without the trauma. Br J Clin Psychol 1994; 33: 71-74. 6. Carey PD, Stein DJ, Zungu-Dirwayi N, Seedat S. Trauma and post-traumatic stress disorder in an urban Xhosa primary care population: Prevalence, co-morbidity and service use patterns. J Nerv Ment Dis 2003; 19: 230-236. 7. Mkize DL. Post traumatic stress disorder in a psychiatric population not presenting with trauma: a preliminary study. Afr J Psychiatry 2008; 11:51-53. 8. Davidson J, Smith R. Traumatic experience in psychiatric out patients. J Trauma Stress 1990; 3: 459-475. 9. Levin A. PTSD not most common disorder that develops after trauma. Psychiatric News 2010; 45: 8- 24. 10. Mueser KT, Goodman LB., Trmbetta SL, et al. Trauma and post traumatic stress disorder in severe mental illness. J Consult Clin Psychol 1998; 66: 493-499. 11. Blanchard EB, Hicking EJ, Taylor AE. Loos W. Psychiatric morbidity associated with motor vehicle accidents. J Nerv Ment Dis 1995; 183: 495-504. 12. Goodman LA, Fallot R. HIV risk behaviours and poor urban women with severe mental disorders: Association with childhood physical and sexual abuse. Am J Orthopsychiatry 1998; 68: 73-83. 13. Roessler TA, McKenzie N. Effects of childhood trauma on psychological functioning in adult sexually abused as children. J Nerv Ment Dis1994; 182: 145-150. 14. Solomon P, Draine J, Delaney MA. The working alliance and consumer case management. J Ment Health Adm 1995; 22: 126-134. 15. Cresswell CM, Kuipers L, Power MJ. Social networks and support in long term psychiatric patients. Psychol Med 1992; 22:1019-1026. 16. Breslau N, Davis GC, Andreski P. Risk factors for PTSD-related traumatic events: A prospective analysis. Am J Psychiatry 1995; 152: 529-535. 17. Penk WE, Rierdan J, Losardo M, Robinowitz R. The MMPI-2 and Assessment of Posttraumatic Stress Disorder (PTSD). In J.N. Butcher (Ed.) 2006 MMPI-2: A Practitionerâ&#x20AC;&#x2122;s Guide. Washington, D.C.: American Psychological Association. 18. Butcher JN, Graham JR, Ben-Porath YS, et al. Manual for administration, scoring, and interpretation. Revised Edition, MMPI-2 2001. University of Minnesota, Press Minneapolis. 19. Hase HD, Goldberg LR. Comparative validity of different strategies of constructing personality inventory scales. Psychol Bull 1967; 67: 231-248. 20. Burisch M. Approaches to personality inventory construction: A comparison of merits. Am Psychol 1984; 39: 214-227. 21.Wetzel RD, Murphy GE, Simons A, et al. What does the Keane PTSD Scale of the MMPI measure? Repeated measurements in a group of patients with Major Depression. Psychol Rep 2003; 92, 781-786. 22. Khalily T M. Neuropsychology and its relevance to clinical psychology in the nonspecialist Adult Mental Health setting. Ir J Psychol Med 2009; 26: 131-133 23. Khalily TM, Wota.A, Hallahan B. Investigation of schema modes currently activated in clients with psychiatric disorders. Ir J Psychol Med 2010 ;28: 76-81 24. Khalily TM, Hallahan, B. Occurrence of neurological symptoms in alcohol misusers. Ir J Med Sci 2012; in press (DOI 10.1007/s11845-011-0801-6). 25. Keane TM, Malloy PF, Fairbanks JA. Empirical development of an MMPI subscale for the assessment of comate-related post-traumatic stress disorder. J Consult Clin Psychol 1984; 52: 888-891. 26. Munley PH, Bains DS, Bloem WD, Busby RM. Post-traumatic stress disorder and the MMPI-2. J Trauma Stress 1995; 8: 171-178. 27. Litz BT, Penk WE, Walsh S, et al. Similarities and differences between MMPI and MMPI-2 applications to the assessment of posttraumatic stress disorder. J Pers Assess 1991; 57, 238-253. 28. Lees-Haley PR. Efficacy of MMPI-2 validity scales and MCMI-II modifier scales for detecting spurious PTSD claims: F, F-K, Fake Bad Scale, Ego Strength, Subtle-Obvious Subscales, DIS, and DEB. J Clin Psychol 1992; 48, 681- 688. 29. Greenblatt RL, Davis WE. Differential diagnosis of PTSD, schizophrenia, and depression with the MMPI-2. J Clin Psychol 1999; 55:217-223. 30. Erika JW, Mark WM, Robert JO, Mariann RW, Diane TC, Jaime M, Danny GK, Terence MK. The MMPI-2 Restructured Clinical Scales in the Assessment of Post-traumatic Stress Disorder and Co-morbid Disorders. Psycho Assess 2008; 20: 327-340.

31. Frank WW, Brett TL, Debra SH, Jennifer AH, Terence MK. The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. Paper presented at the Annual meeting of international society for traumatic stress studies, San Antonio, TX, October, 1993. 32. Hepp U, Gamma A, Milos G, et al. Prevalence of exposure to potentially traumatic events and PTSD. The Zurich Cohort Study. Eur Arch Psychiatry Clin Neurosci 2006; 256: 151-158.

106

O R I G I N A L PA P E R

Child and Adolescent Mental Health Services in Laois/Offaly: A One Year Perspective of Services (July 1, 2008 to June 30, 2009) Heather Church Ir J Psych Med 2012; 29 (2): 107-112

Abstract

Annual Report on Child & Adolescent Mental Health Services, Client Satisfaction Questionnaire (CSQ-8).

Objectives: To examine the Laois/Offaly Child and Adolescent Mental Health Services (CAMHS), focusing on new referrals and trends in the service.

Introduction The first annual report on Child and Adolescent Mental Health Services (CAMHS) in Ireland was completed in 2008. It was an audit on current CAMHS services and it took into consideration recommendations from A Vision for Change (2006). The report identified many different parameters such as the total number of CAMHS teams, inpatient beds, caseload and total clinical workforce by profession. We looked at the Laois/Offaly CAMHS over a one-year period (July 1, 2008 to June 30, 2009) to evaluate the services with regard to recommendations in A Vision for Change and the first annual CAMHS report.

Methods: Data was collected over a one-year period from July 1, 2008 to June 30, 2009 using the computer system MAISY (Medical Audit Information System) and through chart reviews. A Client Satisfaction Survey was administered to both parents and children. Results: The Laois/Offaly CAMHS team provides service to a total population of around 140,000, of which around 32,000 are less than 16 years old. In this one-year period, 303 referrals were received with 167 offered an assessment, of which 150 availed of an appointment. Forty-six percent were offered appointments within one week of receiving the referral with 87% being assessed within one month. A further 41 were assessed from a previous waiting list, compiled prior to the actual study period, thus resulting in a total of 191 assessments.

The Laois/Offaly CAMHS team provides services to the two counties of Laois and Offaly, which consist of a total population of about 140,000 people. According to the 2006 Census from the Central Statistics Office Ireland (2006), the population of Laois was 69,012, while Offalyâ&#x20AC;&#x2122;s population was 70,868. Of the total 139,880 population, close to 41,000 were under the age of 20, with approximately 10,000 distributed among five year intervals. Estimating from these statistics, about 32,000 are under the age of 16. Approximately one in ten children and adolescents suffer from a mental health disorder that is severe enough to cause some level of impairment (Green, McGinnity, Meltzer et al. 2005); consequently, about 3,200 children and adolescents in Laois and Offaly will suffer from a mental health disorder by the time they are 16. In A Vision for Change, it is recommended that one team should service a population of 50,000. The Laois/Offaly CAMHS team provides services to nearly three times more than this recommendation. It has also been recommended that a day hospital be available to the catchment area; currently, such a hospital does not exist.

Thirty referrals required assessment only. Behavioural/Emotional difficulties and Attention Deficit Hyperactivity Disorder (ADHD) were the most common reason for referral. During this time the ADHD waiting list was suspended due to staff constraints. Seventy-six percent were diagnosed with an Axis I disorder with 34% given medication treatment. Of the return appointments over the year, eight percent of patients did not attend (DNA). Both parents and children reported being satisfied with the service, according to the Client Satisfaction Survey. Conclusions: The Laois/Offaly team services a catchment area of approximately three times the number recommended by A Vision for Change, with a staff equivalent less than the number recommended for one whole team. The team was able to provide a rapid service for assessment of new referrals, with the ADHD waiting list suspended. Axis I pathology was often diagnosed among those assessed (around 75%), with about one-third being treated with medication. Follow-up appointments achieved a high attrition rate, with only around eight percent not attending. Patient satisfaction with the service rated high by both parents and children.

The Laois/Offaly CAMHS team was officially set up in 1995 and has been led by a Consultant Psychiatrist. The clinical workforce has changed throughout the years. During this one-year study period, the average staff whole time equivalent (WTE) was 12.3 staff members (10.1 clinical and 2.2 administrative) with psychiatrists dominating the percentage (4.5 WTE = 36.6%). There was no social worker or occupational therapist on the team during this year, with other disciplines such as psychology, speech and language therapy, nursing and administrative staff forming the remainder of the team. The recommendation in A Vision for

Key words: Child and Adolescent Mental Health Services (CAMHS) Referrals, CAMHS Diagnosis, A Vision for Change,

*Heather Church, Senior Registrar in Child and Adolescent Psychiatry, Lucena Clinic Child and Adolescent Mental Health Services, 59 Orwell Road, Rathgar, Dublin 6, Ireland Email heather.church@sjog.ie *correspondence

Submitted 13th May 2011 Accepted 27th May 2011

107

Change calls for each CAMHS team to have 11 WTE clinical staff and two WTE administrative staff per population of 50,000. The Laois/Offaly team had 10.1 WTE clinical staff and 2.2 WTE administrative staff for a population of 140,000, which is nearly three times less than the recommendation in A Vision for Change.

suicidal ideation (SI), deliberate self-harm (DSH), symptoms suggestive of an Axis I disorder and school refusal with associated psychiatric difficulties. In April 2008 there were approximately 140 people on a waiting list for assessment of Attention Deficit Hyperactivity Disorder (ADHD), with an estimated waiting time of up to four years, due to staffing constraints. As a result, the list was therefore closed and general practitioners along with community psychology personnel providing primary care were often involved in these cases. Throughout this one-year audit period, the waiting list did not reopen and referrals were not accepted for assessment of ADHD. However, previous existing ADHD cases continued to be followed up in the clinic.

The CAMHS team serving Laois and Offaly is located on the grounds of the Midland Regional Hospital in Portlaiose. It provides services for these counties for children and adolescents under the age of 16, both for initial assessments and subsequent treatment. The child/adolescent may be followed up by the service until the age of 18 if clinically indicated. In addition, the team provides a liaison service to the Paediatric Ward in Portlaiose Midland Regional Hospital and to the Accident and Emergency Departments in Portlaoise and Tullamore Hospitals. Referrals are accepted from general practitioners (GPs) and paediatricians.

In this one-year period, there were a total of 303 referrals. Of those, 167 (55%) were accepted and 150 availed of an appointment. However, 43 more assessments were carried out from referrals received prior to July 1, 2008; therefore, a total of 193 assessments were completed. Thirty appointments were for assessment only and did not require follow up by child psychiatry personnel. (See Table 1 below)

Initial assessments are carried out on a designated day with urgent referrals given appointments as needed throughout the week. Two team members take part in the assessment. The assessment is divided into an interview with the parents/young person, followed by a discussion among the interviewers with the consultant. Feedback and recommendations are then provided to the family. The assessment takes approximately two hours to complete. A report is written and sent to the GP and other relevant agencies. Follow-up appointments are given if clinically indicated, with transparent treatment plans. There are treatment packets in the department for the various presentations. There is a review of the case at three months at the team meeting or earlier if there are concerns. The aim is for each young person to be receiving active treatment with transparent plans.

Reason for Referral

Aims The aim of this audit was to evaluate the Laois/Offaly CAMHS service over a one-year period from July 1, 2008 to June 30, 2009, focusing on new referrals and trends in the service. A Client Satisfaction Survey was conducted during this time, in order to assess global satisfaction of parents and children with the service.

Table 1 In each case, the main reason for referral was extrapolated from the letters sent in by the general practitioners/paediatricians. The main reasons for referrals were behavioural difficulties, ADHD, SI, DSH and affective symptoms. Other Axis I disorders were represented in smaller numbers. For the purpose of the audit, only one disorder was entered for each case. (See Table 2)

Methods The data was collected by using the computer system MAISY (Medical Audit Information System) and through chart reviews. The data was analyzed using Microsoft Office software. A one-year review of new and existing patient information, clinical workforce and trends in the service was collected. The Client Satisfaction Questionnaire (CSQ-8) was administered, which is a measurement of general satisfaction with services developed for use in a wide variety of service settings.

Results Referrals Referrals Received During this time, the criteria for acceptance of referrals were as follows: the young person must be under the age of 16 and must live in Laois or Offaly County, with the exception of the liaison service provided to the hospital paediatric ward where the young person would be seen regardless of their home address. The clinical criteria for acceptance consisted of a suicide attempt or

Table 2 Interval between referral received and first appointment Of 150 appointments attended, 69 (46%) were offered an assessment within one week and 130 (87%) were offered an appointment within one month from receiving a referral. The rest were all seen within six months, except for one referral. (See Table 3) 108

Table 3

Table 6

Monthly Distribution of Referrals. It appeared that there were peaks in the number of referrals in November, March and May. The months of June, July and August accrued the least amount of referrals. (See Table 4 below)

Age Distribution The age distribution was divided according to five-year intervals: Under 5, 5-10 years old, 10-15 years old and then over 15 years old, which was then subdivided into under 16 and over 16. The age group 10-15 years old dominated most of the referrals received (149 = 49.2%). However, the age group of 15 years old only accounts for a one-year period of time, as opposed to the other age groups; yet it yielded 50 referrals (16.5%). Those over the age of 10 were more likely to be accepted for assessment. (See Table 7)

Table 4 Geographical Distribution of Referrals There was a Laois predominance of 59% compared to Offalyâ&#x20AC;&#x2122;s 41% for new referrals. However, it should be noted that any liaison work in Portlaoise Hospital, if originated in other counties (aside from Offaly), would have been recorded under Laois. In cases that were already open, there were a total of 1,921 appointments scheduled over the year, of which 1,125 were from Laois and 796 were from Offaly, which equates to the same figures as above, in which 59% of return appointments came from Laois and 41% came from Offaly. (See Table 5)

Table 7 Gender Distribution Overall, there were 126 females and 177 males referred. Of the females, 83 referrals were accepted (66%). Of the males, 84 referrals were accepted (47.5%). (See Table 8)

Table 8 Clinical Assessment The Portlaiose Child Psychiatry Service uses the ICD-10 multi-axial classification for diagnosis. Preliminary diagnosis is made after each new assessment. Of the 150 assessed, 114 (76%) met the criteria for an Axis I diagnosis after the initial assessment. Thirty-three (22%) did not meet the criteria for an Axis I diagnosis, with the remaining three requiring ongoing assessment for establishing a diagnosis. (See Table 9)

Table 5 Referrals not Accepted There were 136 referrals not accepted. Sixty-nine did not meet the acceptance criteria. Fifty were due to the waiting list for ADHD being suspended. Seven were outside the catchment area and ten were over the age of 16. The main reason for these referrals not being accepted was due to behavioural difficulties, with no indication of a psychiatric co-morbidity. (See Table 6)

109

cases were closed due to not attending. We used the computerised system for this information, which accounts for the category, ‘data not recorded’. (See Table 12)

Table 9

Axis I distribution Of the 150 assessed, Adjustment Disorder and Emotional/Behavioural Difficulties formed the majority of Axis I diagnoses. Conduct disorder was the most common emotional/behavioural difficulty. Although child psychiatry does not provide a service specifically to those with pervasive developmental disorders (PDD), it was diagnosed in 10 cases. (See Table 10)

Table 12 Client Satisfaction Questionnaire In 2009, a Client Satisfaction Questionnaire (CSQ-8) was administered and 100 people participated. Parents completed 65 surveys and the children completed 35. The mean age of the responding children was 14.7 (range 12-18). It utilised a four point Likert scale containing eight questions, with an opportunity for the respondent to volunteer comments. An Answer of 1 indicated low satisfaction, with high satisfaction indicated by an answer of 4. Examples include, ‘How satisfied are you with the amount of help you have received?’ and ‘If you were to seek help again, would you come back to our service?’ Overall satisfaction reported by parents was 3.6/4 (range 1.9-4) and children 3.2/4 (range 1.1-4). Question 4 yielded the highest score in both parents (3.8/4) and children (3.4/4). This question asked: ‘If a friend were in need of similar help, would you recommend our service to him or her?’ Children reported the lowest score (3.1/4) in the question: ‘Did you get the kind of service you wanted?’ Parents reported the lowest score (3.4/4) in the question: ‘To what extent has our service met your needs?’

Table 10 Interventions Of the 150 assessed, 91 had a combination of treatments with the remainder having one treatment modality. In total, 34 received medication treatment (37%).

There were a wide variety of comments by both parents and children. Some positive comments made by parents regarding what they found helpful were as follows: “Contact, continuity, availability.”, “The time I was given as a parent and the support.”, “When I phoned there was always somebody to talk to and listen and help if at all possible.”, “We were told what was going on and we could understand our child’s problems more clearly.”, “Support, talking, and books.”, “It was a friendly atmosphere, made me feel welcome.”, “We got in straight away within one week…was very happy with the services.”, “Attention from the staff, information received regarding problem, follow-up appointments including parents very helpful.”, “That when one thing did not work, there was always another option for us to try, no one gave up.”, “Kind and respectful manner in which my family was dealt with.”, Some of the comments parents made as suggestions for improvement were as follows: “Inpatient unit.”, “A support group for parents.”, “More feedback after child’s one-to-one sessions.”, “More childcentered therapy.”, “More discussion with the parents about home-life.”, “Same doctors each visit.”, “Better communication between the schools and the service.”, “Getting an answer about what is wrong earlier.”, “A more intense psychological examination.”, “Tea and coffee available to help people relax.”, “Not challenging the parent in front of the child during disagreements.”, “More regular sessions.”, “More follow-up appointments.”, “More rooms in Tullamore.”

Open Cases Return Appointments In total, 1,921 return appointments were offered. Of those, 1,423 were attended. In 280 (about 15%) of the cases, the patient cancelled. In 155 (about eight percent) of the cases, the patient did not attend (DNA). In 54 cases, the clinic rescheduled. (See Table 11)

Table 11

Cases Closed In total, 176 cases were closed. The main reason for closing a case was due to a mutual agreement between the clinician and young person/guardian that the treatment was complete. Twenty-one 110

Children’s comments regarding what they found helpful were: “The advice and art therapy.”, “The staff is very kind.”, “The Psychiatry was extremely helpful in dealing with my difficulties.” Children’s comments regarding suggestions for improvement were as follows: “Spend more time in sessions.”, “Have the doctors listen to the child more.”, “Decrease time between appointments.”, “Sky Sports in the waiting room.”, “Hot chocolate in the waiting room.”

reasons to provide psychiatric input. It was more common to have multiple interventions. Medication treatment was used in only 37% of cases, despite 76% of cases receiving Axis I diagnoses. Among open cases in the clinic, 1,921 return appointments were offered during the year. In 15% of the cases the patient cancelled their appointment. Approximately eight percent of patients did not attend. This is lower than the national average during this time of about a 15.9% DNA rate.

Discussion In total, 176 cases were closed in this one-year period. One hundred and ninety-one were assessed with 30 requiring assessment only, therefore 161 were followed up for treatment. This figure represents a service maintaining equilibrium. Active treatment is the aim for all the young people, with ongoing team discussions and reviews of cases.

Over this one-year period, 193 assessments were completed. Forty-three were from the overflow of a waiting list that had closed in April 2008. This averages to about 3.7 assessments per week. Two team members participate in each assessment with the consultant overseeing all assessments. This equates to around seven to eight team members participating in assessments per week on a team with an average WTE of 10.1, including consultants who are often not part of the assessment.

Peak referral periods were identified in November and February. This was associated with school-related difficulties that exacerbated symptoms. More males than females were referred for assessment (177 vs. 126). A higher percentage of females were accepted for assessment (66% vs. 47.5%). Males were more likely to have been referred for behavioural difficulties and ADHD with no co-morbid psychiatric problem, rather than females, which accounts for the discrepancy in the acceptance rate. Referrals received for children under 10 were less likely to be accepted for assessment. Many of these referrals were for ADHD and behavioural difficulties with no co-morbid psychiatric difficulties, which would not have been accepted for assessment. Referrals for children over 10 were more likely to have SI, DSH and more identifiable psychiatric pathology. Therefore, these would have been accepted for assessment.

Overall, 136 referrals were not accepted. During this time, the ADHD waiting list was closed and 50 of those referrals were for assessment of ADHD. Sixty-nine referrals did not meet the criteria for acceptance. Most of these referrals were for behavioural difficulties with no co-morbid psychiatric difficulties. The remaining referrals not accepted were either outside the catchment area or for assessment of a young person over the age of 16. During this one-year period, 303 referrals were received and 167 were offered an assessment, with 150 appointments attended. Approximately 90% of those offered an initial assessment availed of an appointment. The remainder either did not attend or felt symptoms had improved enough that an assessment at that time was not warranted. Sixty-nine (46%) were offered an assessment within one week and 130 (87%) were offered an appointment within one month from receiving a referral. The rest were all seen within six months, except for one referral. The reason for any delay in seeing referrals was primarily due to the case requiring further information prior to assessment. This is in contrast to the national average, according to the first annual report on child and adolescent mental health services, 45.6% of new referrals were seen within one month after receiving a referral. During this time, the ADHD waiting list had been closed, which afforded more time to the team for assessments of other psychiatric problems. Therefore, a time-efficient service was provided for those with a psychiatric disorder other than ADHD.

The results of the Client Satisfaction Survey indicated that both children and parents were satisfied with the services, with parents being more satisfied (children = 3.2/4 vs. parents 3.6/4). We would see children often less inclined to attend psychiatric service in general than the parents. Since the time period of this audit, a second annual report has been published on child and adolescent mental health services (2009-2010). The structure of the Laois/Offaly team is changing, with the addition of a full-time consultant now providing one consultant per county in December 2010. There is a plan to commence assessing ADHD referrals and to offer appointments to those who had been referred during the period of the waiting list suspension. With a change in team structure and the addition of opening the ADHD waiting list, it would be interesting to re-audit the Laois/Offaly team structure to identify changes.

The main reason for referral was for behavioural difficulties (22.8%) and ADHD (19.1%). This coincides with the First Annual Report in which the two most frequent primary presentations were hyperkinetic category (29.1%) and emotional/behavioural disorders (26.3%). This was followed by symptoms of SI, DSH and affective symptoms. Other Axis I disorders were represented, but in lesser amounts. The suspected reasons for less ADHD referrals than the national average is that there is a community psychology service and that it was made aware to the referrers that the ADHD waitlist was closed.

We did not look at re-referral rates and the average length of cases remaining open. This would be important as the Laois/Offaly service operates using active treatment and sets treatment goals with estimated discharge dates. Keeping cases open for extended periods of time for general reviews after the presenting problem has settled is not common. An examination of our turnover and re-referral rate would provide an idea of whether or not this ethos is effective.

Of those assessed, around 76% were diagnosed with an Axis I disorder. The remainder of cases often had elements of DSH/SI in the absence of an Axis I disorder, all of which are appropriate 111

Conclusion The Laois/Offaly service, during the period of July 1, 2008 to June 2009, was working with a team that had a WTE staff of less than had been recommended for one team, yet it was providing a service to a population nearly three times of that recommended by A Vision for Change. Under these circumstances, the ADHD waiting list was suspended to provide adequate service for core psychiatric problems; consequently, this provided a minimal waiting time for assessments (87% seen within one month). Of those seen, three-quarters fulfilled Axis I disorder criteria, with the remaining one-quarter exhibiting problems that were appropriate for assessment by a psychiatric service. The number of cases closed was nearly equivalent to the number of cases that were assessed and followed up for treatment, which points to a service working at equilibrium. Patients were in active treatment with appropriate transparent plans working towards a discharge date, which promotes high turnover and the ability to take on new cases. Of the returning cases, DNA rates were remarkably low at about eight percent, indicating the value of the service to the Laois/Offaly community. Patient satisfaction rated high among both the parents and children attending the service.

Conflict of interest None.

References Central Statistics Office Ireland. 2006 Census Results. http://www.cso.ie/census/ Child & Adolsecent Mental Health Services. First Annual Report. Health Service Executive, 2008. Expert Group on Mental Health Policy. A Vision for Change. Department of Health and Children, 2006. Green H, McGinnity A, Meltzer H, Ford T, Goodman R. Mental Health of children and Young People in Great Britain. Department of Health and the Scottish Executive, 2008. Larsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning 1979; 2: 197-207.

112

BRIEF REPORT

The Vron – An Early Intervention In-patient Recovery Unit Rob Macpherson, Pradeep Peddu, Chris David Ir J Psych Med 2012; 29 (2): 113-116

Abstract

treatment resistant, severe mental illness, maximising medication responses and using a range of psychosocial interventions to improve social and vocational functioning. Mostly referrals to the Vron are triggered by staff in-inpatient services where a patient has such complex, ongoing needs for support and treatment, that discharge to the community is not possible.

Background and aims: This paper describes the context in which the Vron, a six-bedded 24-hour nursed care unit, has developed its role from a fast track rehabilitation unit, to work explicitly within an early intervention service. The study aimed to evaluate the work of the Vron by examining the change in CANSAS, HoNOS and EM scores between admission to and discharge from the unit.

The rehabilitation services in Gloucestershire have undergone major change over the past decade. Between 1997 and 2007 there was a reduction in the county from seven to three 24-hour nursed care units, with a loss of 22 24-hour nursed care beds. Reorganisation of in-patient services led to the loss of two rehabilitation hospital wards. Community rehabilitation teams were developed into assertive outreach teams, of which there are now three in the county. Traditional, generic locality-based community mental health teams were re-designed to become functional teams focusing on early intervention (targeting individuals up to 35 years with first onset psychosis), crisis/home treatment (which aims to prevent psychiatric admission), primary care assessment and treatment (focusing on common mental disorders and assessment of cases in primary care), recovery (the longer-term care of individuals with severe mental illness) and assertive outreach (targeting people with severe mental illness who are difficult to engage). The reduction of 24-hour nursed care beds was associated with an increase in individual ‘care packages’, which are mostly individual tenancies in flats or bungalows, with domicillary care (up to 24 hours per day in some cases), provided largely by three local social/health care organisations.

Results: Approximately half of the admissions to Vron were from acute psychiatric wards. Most patients were discharged to their own tenancy or supported accommodation. There was a significant reduction in mean HoNOS score and increase in mean EM score during admission. Mean staff and patient-rated unmet needs reduced in the course of admission. In the course of admission, approximately half of the patients developed occupational roles. Discussion and conclusions: The findings of this service evaluation must be interpreted with caution in view of the methodological limitations, in particular the lack of a comparator service intervention. However, it is suggested that units of this type may have a useful role in the rehabilitation of patients with complex severe mental illness, particularly if deployed at an early stage in an individual’s illness, to prevent development of disability. The Vron focuses on a number of specific clinical and social areas which align with typical strategies in early intervention. Key words: outcome, rehabilitation, early intervention.

In this context, it was proposed that within the new, functionally defined mental health services commissioned by the PCT, there should be two longer-term rehabilitation/ recovery 24 hour nursed care units, which focus on the active rehabilitation, ideally up to two years, of patients who have enduring symptoms and disability, and as a result cannot be discharged from hospital. The redeployment of the Vron as a part of early intervention services seemed appropriate as the unit’s role recently had increasingly adapted to promote engagement with service patients at an early stage, in a positive and recovery orientated manner.

Introduction This paper describes the Vron, a 24-hour nursed-care unit, which has developed its role in recent years to focus increasingly on early intervention with a younger group of patients, at an early stage of their illness history. The work of this unit was described previously as a “fast track” rehabilitation facility, which aimed to “prevent new long stay patients and block revolving door admissions”.1 In the 1990s, the unit mainly worked with patients who were admitted from acute wards, and the average age was 35 years. Rehabilitation in the Vron was associated with significant reduction in hospitalisation over the following two years.1 The unit is staffed by psychiatric nurses and the approach is to work, generally over a period of months, with patients suffering from complex, *Rob Macpherson, Consultant Psychiatrist, Wotton Lawn, Horton Road, Gloucester, GL1 3WL, England Email rob.macpherson@glos.nhs.uk

Method As part of its changing role, it was decided in 2003 to incorporate routine outcome measurements as a standard part of the treatment of all cases in the Vron. The Camberwell Assessment of

Chris David, Manager The Vron, 25 Estcourt Road, Gloucester, England Work carried out in: 2Gether NHS Foundation Trust, Gloucestershire, England

Pradeep Peddu, Specialist Registrar, 2gether NHS Foundation Trust, Wotton Lawn, Horton Road, Gloucester, GL1 3WL, England *correspondence

113

Submitted 16th October 2009 Accepted 28th January 2012

the research governance committee in Gloucestershire Partnership NHS Trust in 2007. Formal ethical committee submission was not required.

Need Short Appraisal version (CANSAS) 2, the Engagement Measure (EM) 3 and the Health of the Nation Outcome Scores (HoNOS) 4 were rated at the time of admission to the Vron and then at points of significant review throughout admission, and again at the end of the admission, in the lead up to discharge.

Results

The CANSAS assesses patient, staff and potentially carer perception of need across 22 health/social care domains. Ratings are 0 (no need), 1 (no/moderate problem due to help given, indicating met need) or 2 (unmet need). All staff had training in the use of CANSAS and were asked to support patients if they needed help to complete forms, but not to influence them, so that patient ratings would be genuinely independent from the staff ratings. HoNOS is a 12-item observer-rated measure of social disability, with a 5-point scale with anchor points provided for each 10-point interval. The EM is an 11-item observer rated scale which scores on a 5-point Likert scale 6 dimensions of engagement: appointment keeping, client-therapist interaction, communication, perceived acceptance of treatment, collaboration and compliance with medication. Aggregated scores range 11 to 55, 33 being proposed as a cut off for good/poor engagement.

Between 2003 and 2007 there were 35 referrals to the Vron. Results were only considered for the 24 patients who were treated for a minimum of two months in the Vron, to allow for a realistic period of intervention. Demographic and illness related data for these patients are presented in Table 1. It can be seen that there was a substantial increase in the number of patients having their own tenancy at the point of discharge from the Vron, and an increase in various forms of occupation. Tables 2 and 3 show the HoNOS, EM and CANSAS scores at admission and discharge from the Vron. As noted in the tables, some data were missing. It can be seen that there were relatively few unmet needs remaining after treatment in the Vron, but there was no over representation of unmet need in particular CANSAS domains at this time. In general, there seemed to be good concordance between rating of needs by staff and patients, although this was not formally assessed within the present study.

It was intended to use rating scales within the unit to assist care planning and clinical management and to provide feedback to patients, regarding progress. When it was subsequently proposed to use these in a retrospective way to evaluate the service, it was agreed that ratings made on admission and prior to discharge from the Vron would be considered. In a small number of cases, carer ratings had also been completed but it was recognised that these were insufficient to be representative. They have not, as a result, been included in this paper.

Discussion The main findings of this service evaluation were that in the course of treatment in the Vron early intervention recovery unit, there was a significant reduction in total HoNOS scores and increase in total EM scores, between admission and discharge to the unit. Staff and patient-rated met needs increase significantly between admission and discharge, while staff and patient rated mean unmet needs reduced significantly. Patients were admitted from a variety of placements, roughly half from psychiatric wards. They were discharged predominately to their own tenancy or supported

This study was carried out as a service evaluation, the protocol for which was developed with support from the Gloucestershire research and development support unit and formally agreed by

Table 1 Demographic and illness related data Sex Marital Status Age on admission Duration of admission Admitted from:

Male: 21, Female: 3 Single: 24 Range 16-42, mean 24.6 years (SD 7.5) years Mean 9.9 months, range 3-26, SD 7.5 6 10 3 3 2 1.25 (range 1 â&#x20AC;&#x201C; 2) 23 1 3 0 13 6 2 12 1 4 3 4

Family home Acute psychiatric ward Own tenancy Supported accommodation Low security unit Mean total number previous psychiatric admissions Occupation on admission: Unemployed Voluntary work Discharged to: Family home Acute psychiatric ward Own tenancy Supported accommodation Group training home Occupation on discharge: Unemployed (full/part time) Voluntary work Student Employed Sheltered employment

114

Table 2. Mean HoNOS and EM scores at admission and discharge Mean total HoNOS score (total 17 pairs data)

28.3 (range 19-40, SD 5.6)

15.1 (range 7-23, SD 5.4)

Mean total EM score (total 22 pairs data)

28.1 (range 11-38, SD 6.6)

46.0 (range 21-55, SD 7.4)

*Note: Limited number of full paired data sets due to missing data. In both cases, p<0.001

Table 3. Mean CANSAS met and unmet need scores at admission and discharge

Staff-rated mean met needs Staff-rated mean unmet needs Patient self-rated mean met needs Patient self-rated mean unmet needs

Admission scores

Discharge scores

7.8 (range 2-12, SD 3.9) 11.8 (range 7-16, SD 3.5) 8.7 (range 2-12, SD 3.5) 11.5 (range 7-19, SD 4.0)

16.3 (range 11-21, SD 3.3) 3.6 (range 1-8, SD 2.9) 17.0 (range 14-21, SD 2.7) 3.5 (range 1-8, SD 2.9)

p value (Wilcoxon matched pairs signed ranks tests) 0.008 0.005 0.005 0.005

*Note: Total number of paired scores was 10, due to missing data.

accommodation. Most were unemployed on admission, while half were carrying out some form of employment at the point of discharge.

levels of social networks and reduced negative symptoms. These findings were echoed in the present study.

The results of this service evaluation need to be treated with some caution. The results related to a heterogeneous sample in one unit, which makes it difficult to generalise results. There were no inclusion/exclusion criteria, referrals to the Vron being assessed clinically regarding the likelihood of effective engagement and perceived benefits for the patient at that time. The study was retrospective and may have been subject to rating bias, although to try to avoid this simple, easy-to-rate instruments, which have obvious face validity, were used. This was not a randomised, controlled trial and the lack of a comparator means that it is not possible to know how the patients would have progressed in standard community treatment or within a different form of supported accommodation. The lack of data regarding progress after discharge means that it is not possible to judge how patients managed in the community, arguably the real challenge to most patients, although follow-up data referred to in an earlier study1 were positive. There was a marked gender imbalance (21 of 24 patients being male) and this may be important as men with severe mental illness are known to have poorer outcomes.

The Vron operates alongside a range of private and charitable services which provide longer-term supported accommodation. While in theory services like the Vron may have a place in helping individuals to live more normal and independent lives, in order to understand the need for different forms of supported accommodation in a locality, a ‘total system approach’ is needed, taking account of all services including charitable and private provision.6 In England and Wales the ‘Supporting People’ policy initiative7 was intended to facilitate this but it is not clear whether, in the complex mixed economy of modern residential case, this aim has been achieved. Our results suggest that some of the important components for a unit of this type to be successful include: attention to occupation and activity, focus on identifying appropriate accommodation, and an attempt to maximise the benefits from psychiatric treatment and engagement in individual and family-based psychosocial interventions. Hopefully, as the unit strengthens its links with the early intervention community mental health team across the County it will be possible to use beds flexibly for functions including crisis/respite, assessment and treatment initiation of specific forms of treatment. It appears that many patients could benefit from treatment in a unit of this type, and this finding could be used to argue for the development of this form of service in other areas.

However, the results of this study add to the data previously cited in this paper from the unit,1 which indicate that for many service patients there appears to have been a significant positive change in the course of admission to the Vron. We felt there were likely to be multiple reasons for the good outcomes found: the unit focuses on helping people with diagnosis schizophrenia and other severe mental illnesses and there is a strong focus on employing effective treatment, for example early use of Clozapine and as an in-patient service, ensuring compliance. The unit is ‘dry’ and harmful effects of substance abuse were reduced by staff efforts to maintain this policy (not, of course, always successfully). We are not aware of any previous studies which have evaluated 24-hour-nursed care by use of routine outcome measurement. A previous review5 found that this form of service was generally effective in supporting most patients referred, with improvements in social functioning, higher

It is hoped that the future role of the Vron will continue to evolve. Its place within the early intervention services seems appropriate and fits with the observation that over the course of the last 10 years the average age of residents has dropped to 25 years. In recent years, in addition to its traditional rehabilitative focus, the Vron has progressively developed to carry out work on substance abuse, formal psychosocial intervention work, social and vocational roles development and a significant role in assessing social skills/circumstances, which can be used to identify

115

appropriate longer-term needs for support and appropriate accommodation. It is hoped that it will continue its role as an effective alternative to hospital admission, as well developing other, broader roles, serving the early intervention population.

References 1. Macpherson, R, Butler, J. Effect of treatment in an active rehabilitation hostel on the need for hospital treatment. Psychiatric Bulletin; 1999, 23, 594-597. 2. Slade, M, Bick, A., Bindman, J. Routine outcome measurement for those with severe mental illness: CANSAS and HONOS. The British Journal of Psychiatry; 1999, 174, 404-408. 3. Hall, M, Meadon, A, Smith, J. Brief Report: The development and psychometric properties of an observer rated measure of engagement with mental health services. The Journal of Mental Health, 2001, 10, 457-465. 4. Wing, J.K., Reevor, A.S., Curtis, R. Health of the Nation Outcome Scales (HoNOS) Research and development. The British Journal of Psychiatry; 1998, 172, 11-18 5. Macpherson, R, Shepherd, G, Edwards T. Supported accommodation for people with SMI: a review. Advances in Psychiatric Treatment, 2004, 10, 180-188. 6. Shepherd, G.. System failure? The problem of reductions of long stay beds in the UK. Epidemiology and Social Psychiatry; 1998, 7, 127-134. 7. Department of the Environment, Transport and the Regions. Supporting People â&#x20AC;&#x201C; policy into practice. 2001; London: DETR.

We would be interested to hear from colleagues working in other localities, regarding the experience of working in similar units.

Acknowledgements The authors would like to acknowledge the support of Julie Bundy in preparing this manuscript for submission and thank Genevieve Riley for support with managing the data. We would also like to acknowledge Chris Foy, Medical Statistician at the Gloucestershire R&D Support Unit for advice and guidance on statistical analysis. We also thank colleagues and patients in the Vron for their contribution.

Conflict of interest None.

116

BRIEF REPORT

Knowledge and Attitude of Basic Psychiatric Trainees in Ireland to the Clinical Indemnity Scheme Nnamdi Nkire, Oluwatosin Akinsola, Annette Kavanagh Ir J Psych Med 2012; 29 (2): 117-121

Abstract

to examine factors that influence trainees in obtaining/not obtaining additional cover.

Objectives: To assess the knowledge of basic psychiatric trainees in Ireland of the Clinical Indemnity Scheme (CIS) and to ascertain how many basic specialist trainees in psychiatry had obtained additional medical indemnity cover and reasons for obtaining additional cover.

Introduction Systems for managing health care accidents are designed to deliver two primary outcomes: accident prevention and, if accidents occur, compensation to victims.1 The Clinical Indemnity Scheme2 (CIS) was established in 2002 and it is managed by the State Claims Agency3 (SCA). It was established to address the fragmented nature of medical insurance and indemnity in Ireland. This fragmentation had resulted in duplication of effort, longer times for claim processing and inflated costs. The CIS is based on the concept of enterprise liability,4 whereby responsibility for defending malpractice claims rests with institutions or organisations instead of individual practitioners and their indemnity bodies. This concept has also been applied in the United Kingdom, Australia, New Zealand and the United States.5, 6

Method: A structured questionnaire was distributed by post to 300 basic specialist trainees in psychiatric training schemes in Ireland. The questionnaire enquired about demographic details and examined the level of trainees’ knowledge of the clinical indemnity scheme. Results were compiled and analysed using descriptive statistics and SPSS version 14. Results: The response rate was 49%. The bulk of respondents were male (65.5%), aged between 30-35 years of age (44.6%). The majority of the respondents were aware of the CIS, with approximately half of the respondents having acquired additional medical indemnity cover. The level of awareness of the CIS was proportionately more amongst male respondents (69.1%), compared with females (58.5%). However, more females (61.5%) had additional medical indemnity cover compared with males (45.5%). Irish national trainees were more aware (72.9%) and had additional medical indemnity (80%), compared with non-Irish national trainees of whom approximately 61% were aware of the CIS and only 40% had an additional cover. The level of knowledge regarding details of what the CIS provided coverage for was quite poor. Respondents who had obtained additional indemnity were unsure what cover their additional indemnity provided. Only 10 respondents had been involved in medico-legal cases and of these, five had medical indemnity at the time of the case, stating that the legal advice and support was helpful.

In establishing the CIS,2 the state assumed full responsibility for the indemnification and management of all clinical negligence claims through the SCA. The CIS is funded by the Department of Health and Children on a ‘pay as you go basis’, with the department reimbursing costs made for payments in respect of legal costs.7 The scheme covers all Health Service Executive (HSE) facilities, public hospitals and other agencies providing clinical services.3 It also covers consultants, non-consultant hospital doctors, nurses and other clinical staff employed by health agencies whether permanent, locum or temporary; clinical support staff in pathology and radiology services; clinical activities of public health doctors, nurses and other community-based clinical staff and dentists providing public practice.3 All clinical claims arising from the diagnosis, treatment and care of patients are covered. Furthermore, the scheme provides representation at coroners’ inquests, covers personal injury claims against staff who provide emergency treatment on the island of Ireland, and covers claims from patients whose treatment was part of a clinical trial or other approved research project.

Conclusion: Our survey has highlighted that a considerable number of basic specialist trainees in psychiatry in Ireland had no detailed knowledge of what the CIS indemnifies them for and what situations were not covered by the scheme. Additionally, it revealed a clear split in favour of Irish national trainees in comparison to non-Irish national trainees in terms of awareness of the CIS and the procurement of additional medical indemnity. There needs to be an educational drive to provide more information to psychiatric trainees regarding the CIS and other medical insurance schemes. Furthermore, it would be important

*Nnamdi Nkire, Senior Registrar, Dept. of Psychiatry, Our Lady's hospital Navan and MD Fellow, Dept. of Molecular and Cellular Therapeutics, RCSI, Dublin, Ireland Email nnkire@yahoo.com

The CIS does not provide representation at disciplinary proceedings or before professional regulatory bodies. Cover is not provided for Good Samaritan acts outside of Ireland. In general, it does not provide cover for work carried out in private hospitals. Additionally, it does not cover employer's liability or public liability claims against

Annette Kavanagh, Consultant Psychiatrist, Wexford Mental Health Service, St. Senan's Hospital, Enniscorthy, Co. Wexford,

Oluwatosin Akinsola, Consultant Psychiatrist, Cape Breton District Health Authority Nova Scotia, Canada *correspondence

117

Submitted 9th January 2011 Accepted 30th June 2011

respondents were males and approximately 45% of our respondents were aged between 30-35 years of age. A third of respondents were of Irish nationality and half of respondents were of African descent. These proportions were mirrored in the country where the primary medical degree was obtained. Approximately 66% of respondents were married. Postgraduate psychiatric training scheme representation of respondents is shown in Table 2. Only 20% of respondents had obtained MRCPsych. The groups were evenly divided in terms of years of psychiatric experience.

health agencies which are already covered under policies of insurance with commercial insurers. Due to those areas of practice not covered by the CIS, medical staff tended to obtain additional cover from private insurers. The Irish Medical Organisation (IMO) National Benchmark Study8 revealed that 78% of non-consultant hospital doctors in Ireland stated that legal issues were one of their greatest concerns. The aims of this study were to assess the level of knowledge of the CIS amongst basic specialist trainees in psychiatry in Ireland, and to ascertain how many of these trainees had obtained additional medical indemnity cover and reasons for obtaining additional medical indemnity cover.

Overall, 62.2% of trainees surveyed reported that they were aware of the existence of the CIS. Approximately 73% of Irish national trainees were aware of the CIS versus 61% of non- Irish national trainees.

Methodology

Trainees’ knowledge of the activities covered by the CIS is shown in Table 3. Of trainees surveyed, 70.9% correctly answered that the CIS covered clinical work in public hospitals. Approximately a quarter knew that the CIS covered locum work in public hospitals, with less than a fifth correctly identifying that the CIS does not cover clinical work in private hospitals.

A structured questionnaire (available on request) which was designed by the researchers collected data on demographic characteristics of trainees, postgraduate training scheme, length of psychiatric training, Royal College of Psychiatrists membership status (MRCPsych), knowledge of the CIS, whether additional medical indemnity cover was obtained, reasons for and benefits provided by additional cover. Three hundred basic specialist trainees in psychiatry in Ireland were identified and their contact details obtained from the Irish Psychiatric Training Committee. A copy of the questionnaire was circulated by post to each basic psychiatric trainee in Ireland accompanied by a letter explaining the aims of the study, proposed deadline date of return of questionnaires and a self-addressed envelope for returning completed questionnaires to researchers. The results were analysed using descriptive statistics and SPSS version 14.

Less than nine percent (8.8%) of trainees correctly identified that the CIS covers Good Samaritan acts in Ireland while 22.9% correctly identified that it does not cover Good Samaritan acts outside of Ireland. Only 13.5% correctly identified that the CIS does not cover disciplinary hearings or Medical Council Fitness to Practice inquiries. The average rate of incorrect and ‘don’t know’ answers was 42.6%. Approximately 50% of respondents reported that they had purchased additional medical indemnity cover (Table 4), with the Medical Protection Society (MPS) having more subscribers (70.7%). Some respondents cited cost as a reason for choosing one private provider over the other. Eighty percent of Irish-national trainees obtained additional medical indemnity cover whereas only 40% of other nationalities did so. Of those who obtained additional cover, advice from colleagues was the main reason reported for obtaining additional cover (60%).

Results One hundred and forty eight completed questionnaires of the 300 distributed were returned giving a response rate of 49%. Demographic details are shown in Table 1. Two thirds of

Table 1 Demographic data Age range 20-25 26-30 30-35 36-40 41-45 46-50 Nationality Irish European African Asian/Middle East South American Australian/NZ Marital Status Single Married Divorced/separated

Male 97 (65.5%)

Female 51 (34.5%)

Total 148

2 (2%) 15 (15.5%) 40 (41.2% 33 (34%) 3 (3%) 4 (4.1%)

3 (5.9%) 12 (23.5%) 26 (51%) 9 (17.6%) 1 (2%) 0

5 (3.4%) 27 (18.2%) 66 (44.6%) 42 (28.4%) 4 (2.7%) 4 (2.7%)

22 (22.7%) 3 (3.1%) 60 (61.9%) 10 (10.3%) 1 (1%) 1 (1%)

22 (43.1%) 6 (11.8%) 15 (29.4%) 7 (13.7%) 1 (2%) 0

44 (29.7%) 9 (2%) 75 (50.7%) 17 (11.5%) 2 (1.4%) 1 (0.7%)

31 (31.9%) 65 (67%) 1 (1.1%)

18 (35.3%) 32 (62.7%) 1 (2%)

49 (33.1%) 97 (65.5%) 2 (1.3%)

118

Table 2 Psychiatry training and experience

Male 97 (65.5%)

Female 51 (34.5%)

Total 148

Basic specialist training scheme Cavan/Monaghan Donegal Mater/UCD Longford/Westmeath/Laois/Offaly Clare/Limerick/North Tipperary Sligo South Eastern region Cork/Kerry Galway/Mayo/Roscommon RCSI St. John of God Dublin University Psychiatric Rotational Training Programme

3 (3%) 3 (3%) 14 (14.4%) 5 (5.2%) 3 (3%) 3 (3%) 5 (5.2%) 7 (7.2%) 8 (8.2%) 13 (13.4%) 13 (13.4%) 20 (20.6%)

0 (0%) 1 (2%) 6 (11.8%) 1 (2%) 2 (3.9%) 2 (3.9%) 4 (7.8%) 3 (5.9%) 5 (9.8%) 10 (19.6%) 5 (9.8%) 11 (21.6%)

3 (2%) 4 (2.7%) 20 (13.5%) 6 (4%) 5 (3.4%) 5 (3.4%) 9 (6%) 10 (6.8%) 13 (8.8%) 23 (15.5%) 18 (12.2%) 31 (20.9%)

General Practice trainee

0 (0%)

1 (2%)

Years of psychiatric experience 0-1 1-2 2-3 3-4 >4

16 (16.5%) 23 (23.7%) 18 (18.6%) 18 (18.6%) 22 (22.7%)

12 (23.5%) 13 (25.5%) 10 (19.6%) 6 (11.8%) 10 (19.6%)

28 (18.9%) 36 (24.3%) 28 (18.9%) 24 (16.2%) 32 (21.6%)

1 (0.7%)

Table 3 The Clinical Indemnity Scheme covers me for: N=148 (*Correct answer is highlighted)

Yes

Don’t Know

Unanswered

Clinical work in public hospital Locum work in public hospitals Clinical work in private hospitals Good Samaritan acts in Ireland Good Samaritan acts outside of Ireland Coroner inquests Clinical drugs trials/research Disciplinary hearings Medical Council Fitness to Practice inquiries

*105 (70.9%) *40 (27%) 20 (13.5%) *13(8.8%) 1 (0.7%) *18 (12.2%) *8 (5.4%) 25 (16.9%) 24 (16.2%)

0 (0%) 14 (9.5%) *28 (18.9%) 25 (16.9%) *34 (22.9%) 11 (7.4%) 27 (18.2%) *20 (13.5%) *20 (13.5%)

13 (8.8%) 38 (25.7%) 44 (29.7%) 54 (36.5%) 57 (38.5%) 63 (42.6%) 57 (38.5%) 47 (31.8%) 48 (32.45%)

30 (20.3%) 56 (37.8%) 96 (64.95%) 56 (37.8%) 56 (37.8%) 56 (37.8%) 56 (37.8%) 56 (37.8%) 56 (37.8%)

Discussion

such legal settlements rather than due to an increase in clinical negligence.10 There has been considerable debate about whether there has been a parallel increase in medical errors but all are agreed that the number of claims currently litigated represents only a small proportion of medical error cases.9 This is further highlighted by the fact that autopsy studies have revealed that doctors misdiagnose one in five fatal illnesses9. The Department of Health in its report entitled ‘Building a Culture of Patient Safety’, published in 2008 stated in relation to medical errors that “although there are no available statistics for Ireland in this context, it must be assumed that the rate of preventable error in Ireland matched those described (internationally)”. With the widespread introduction of the European Working Time Directive in Ireland, shorter shifts worked and more frequent handovers may also lead to an increased risk of medical error.11

When a healthcare accident occurs as a result of a medical error, it may result in an inquiry by the Fitness to Practice Committee of the Medical Council, review by the SCA and/or a court action. Inquiries by the Fitness to Practice Committee are primarily held to determine if a doctor acted in such a way as to have breached the code of practice of his profession. The SCA and the courts primarily determine culpability on the balance of probabilities and they award appropriate compensation for damages caused and costs incurred. Since the middle of the twentieth century medical liability litigation has increased in severity and frequency.9 In the UK, this increase has been attributed to the increasing tendency of patients to seek legal redress and to the rising amount of damages awarded for

119

Table 4 Additional medical indemnity cover Additional Medical Indemnity Cover Obtained additional medical indemnity cover Yes No

Total N=148

Medical Indemnity Company Medical Defence Union (MDU) Medical Protection Society (MPS)

N=75 22 (29.3%) 53(70.7%)

Duration of additional medical indemnity cover (yrs) 0–1 1–2 2–3 3–4 >4

N=75 13 (17.3%) 18 (24%) 19 (25.3%) 9 (12%) 16 (21.3%)

Reason for obtaining additional medical indemnity cover (allowed more than one choice) Involvement in medico-legal case Mandatory at place of work Advice from colleagues

N=75 10 (13.3%) 20 (26.7%) 45 (60%)

75 (50.7%) 73 (48.6%)

The SCA which oversees the CIS may expect that their payouts for medical negligence claims will increase in the coming years. This is not only due to the number of claims which are expected to mature in time, but also to a forecasted increase in the number of claims in line with ‘higher compensation awards and the chance for successful claimants to win back their legal costs’.12

doctors (NCHDs)/‘junior’ doctors in Ireland remains limited. Oglesby in her analysis of data from the SCA and CIS in relation to emergency medicine incidents and claims in Ireland found that senior house officer grade and registrar grade doctors were more likely to be involved in claims (74% and 14% respectively) than consultant grade doctors (14%). Additionally, an analysis of claims by specialties documented by the SCA from the inception of the STARSWeb reporting system to 2008 revealed that mental health-related claims ranked fifth behind medicine, surgery, obstetrics and gynaecology18 in that order.

Indeed, with the rising medical litigation rate and the cost of these cases, organisations like the British Medical Association (BMA)13 and the General Medical Council (GMC) have advised that all medical practitioners must obtain adequate indemnity for any part of their practice not covered by the employers’ indemnity scheme, for the patients’ best interests as well as that of the medical practitioner.14 This guidance presupposes that the medical practitioner has or should have a detailed knowledge of what employers’ indemnity scheme is and what it covers. In order to heed this advice trainees need to acquaint themselves with the CIS viz-a-viz their practice.

Our study has shown that Irish national psychiatric trainees had a better awareness of the existence of the CIS than non-Irish national trainees. They were also more likely to have obtained additional medical indemnity cover. As these trainees obtained their medical training in Ireland with clinical postings in hospitals in Ireland, we believe that they received greater exposure to the CIS via conversations with senior colleagues and also via the mass media. Overseas-trained trainees may lack awareness of the medical indemnity issues that pertain to practice in Ireland as these may be quite different to their previous jurisdiction of basic medical training and practice.

The Medical Council advise that if it receives a complaint concerning a doctor, that doctor should refer to their Medical Defence Organisation for ‘advice and guidance’ in providing a response to the complaint.15 The Medical Council makes it clear that the CIS does not cover such complaints to the Medical Council or representation at Fitness to Practice Inquiries. Medical defence organisations like the MDU and the MPS provide advice on medico-legal and ethical aspects of clinical practice. They also provide professional support, legal representation, assistance with media relations and offer useful tips on inquiries into professional competence.16, 17 They may also help to advice on potential grey areas in a clinical incident report.

This study has revealed considerable gaps in the knowledge of trainees regarding the coverage of the CIS. These gaps may not only lead to a risk of exposure of personal financial assets to court awards but may also result in overspending on additional indemnity. Furthermore, it may lead to an unduly restrictive choice of career path or impede practitioners in their work. This is an area which merits further exploration in future studies. We have also demonstrated that while the majority of basic psychiatric trainees are aware of the existence of the CIS, their level of knowledge about the coverage it offers them is limited. Because certain aspects of practice are not covered by the CIS, trainees in our survey invested in additional cover mainly on the advice of

However, despite the expected rise in cases of medical litigation and the advices offered by the Medical Council, research on cases of medical claims/complaints involving non-consultant hospital 120

colleagues. However, it is worth noting that approximately 16% of trainees regard it as the duty of the State to indemnify them against personal fitness to practice costs (Table 3). This finding draws attention to a flaw in the current system of publicising the CIS. Indeed, although we did not explore the information given to trainees in induction programmes into psychiatry, anecdotal evidence and our personal experiences would suggest that this is an area that receives only a fleeting mention in the majority of these programmes. As such, consideration should be given to including standardised information on medical indemnity in induction programmes for trainees with refresher sessions every six months during rotational placements. This is currently the case for trainees who rotate through the Central Mental Hospital Dundrum where an additional medical indemnity cover is a mandatory prerequisite for commencing postings and is included in the trainee induction programme. However, all trainees have a responsibility to educate themselves on the CIS and other medical insurance schemes available in Ireland, and on what their additional medical indemnity cover provides.

Conclusion There is scant research on issues relating to clinical indemnity amongst NCHDs in Ireland in general and more specifically, amongst psychiatric trainees. This study has shown considerable deficiencies in basic specialist traineesâ&#x20AC;&#x2122; knowledge of the CIS. In particular, the poorer knowledge of non-Irish national trainees is of concern. As a result individual trainees may be at risk of adverse professional and financial consequences. In order to improve knowledge of the CIS, stakeholders (including hospital management, consultants and supervisors) must play an active part in providing more information at regular intervals to trainees. Additionally, more research is required to determine trends of medical litigation; Fitness to Practice cases involving trainee doctors in general, and psychiatric trainees specifically. Future studies may also examine the impact of the current economic recession on such cases and on the uptake of additional medical indemnity cover by trainees. The limitations of this study included the lack of enquiry from respondents about whether medical indemnity was covered in their induction programmes. Additionally, while trainees were asked about their involvement in a medico-legal case as a reason for obtaining additional cover, no distinction was drawn between Fitness to Practice inquiries and court actions for medical errors.

Conflict of interest None.

121

BRIEF REPORT

Experience of an Inter-regional Research Symposium for Higher Psychiatric Trainees in Scotland Ashleigh C Duthie, Allen J Shand, Seonaid M Anderson, Ross J Hamilton Ir J Psych Med 2012; 29 (2): 122-124

Abstract

Concerns have been raised regarding a perceived lack of productivity from protected research sessions with trainees failing to achieve publication.4 However, very little is known about rates of publication among psychiatric trainees. A UK study found that the majority of training programme directors and specialist registrars (SpRs) felt that protected time was not used adequately.1 A survey of trainees in Scotland found over half would rather use the time for alternative objectives.5 Such objectives could include special interest, achieving a higher degree or meeting other training competencies. The evidence base regarding interest in research among psychiatry trainees is scarce, however, a review of papers published between 1987 and 2004 has indicated high levels of interest in research participation.6 Fogel6 reviews potential barriers to trainee research which included identification of a manageable research topic, lack of structured research training, lack of time, and lack of a mentor. A recent review of the current state of psychiatric research training in Ireland offers suggestions to encourage research, including monthly meetings with a mentor, clear research objectives set out at the beginning of placements and local opportunities to share research projects such as newsletters.7

Objectives: We present our experience of an annual research symposium for psychiatric trainees in Scotland. This paper aimed to consider trainees’ involvement in research by examining firstly rates of publication and secondly the views of trainees. Methods: A list of all presentations to the Senior Trainees’ Annual Research Symposium (STARS) meetings 2007-2009 was compiled and a detailed search made of major research databases. A questionnaire survey examined the views of attendees at the 2009 meeting. Results: Fifty percent of presented work achieved publication. Feedback from symposia attendees was almost universally positive. Conclusions: At a time of debate on the value of research sessions as part of higher training and a recent reduction in time allocated to research in the UK, we report on a thriving annual meeting. Research symposia for higher trainees were valued by participants and may be one useful means of encouraging trainee research. Key words: higher training, research training, publication rates.

In this paper we firstly present our experience of organising an annual inter-regional research symposium for psychiatric higher trainees in Scotland including trainee feedback, and secondly we describe rates of publication following the meeting.

Background In the climate of financial pressures on the health service, questions have been raised regarding the place of protected research time in psychiatric training.1 Significant reform to psychiatric training occurred in the UK in 2007 which included reduction of the traditional allocation of protected research time for higher trainees from two sessions weekly to one.

The Senior Trainees’ Annual Research Symposium (STAR Symposium) is an annual full-day meeting which has been running in the North-East of Scotland since 2007. It is run for, and organised by, higher psychiatric trainees (SpRs and ST4-6s). Submissions are encouraged from the Grampian, Tayside and Highland training schemes, which in 2009 employed 29 higher trainees. Trainees are widely dispersed across a geographical area of more than 15,000 miles2, representing over half the Scottish mainland. The aim of the meeting is to provide local trainees with an opportunity to showcase the research they have undertaken during their allocated research sessions, as well as to allow others insight into the research pursuits of their peers, and to promote inter-regional collaboration.

However, participation in research is still deemed an important component of psychiatric training, and this is reflected by the inclusion of research outcomes in the most recent competency framework for progression.2 In Ireland, the time designated for research in higher training remains two sessions weekly.3 Participation in research is encouraged earlier in training, with research accomplishments forming part of the criteria for appointment to higher training posts.

*Ashleigh C. Duthie, ST6 Old Age Psychiatry, Royal Cornhill Hospital, Cornhill Road, Aberdeen, AB25 2ZH, Scotland Email: ashleighduthie@nhs.net Allen J Shand, Consultant in General Adult Psychiatry, Royal Cornhill Hospital, Aberdeen, Scotland

*correspondence

Each year the meeting is held at an equidistant location from the two major centres of Aberdeen and Dundee. A judging panel of

Seonaid M Anderson, Consultant in Addictions Psychiatry, Royal Cornhill Hospital, Aberdeen, Scotland Ross J Hamilton, Consultant in General Adult Psychiatry, Royal Cornhill Hospital, Aberdeen, Scotland

122

Submitted 22nd March 2011 Accepted 20th June 2012

experts is invited from across the three regions, who offer constructive feedback following each 30 minute presentation. The panel awards a glass trophy for the presentation deemed to be the best, in terms of scientific rigour, quality of presentation and response to questions.

Eleven presentations were topics relating to general adult psychiatry, three old age, one forensic, two learning disability, one psychotherapy and two child and adolescent psychiatry. This distribution may simply reflect the number of trainees in each sub-specialty.

Method

Regarding feedback from attendees at the 2009 meeting 22 from 24 questionnaire forms were returned (response rate 92%) and results collated. All respondents either agreed or strongly agreed with the statement ‘The STAR Symposium was useful’. Seventeen (77%) strongly agreed that they would attend another STAR symposium and all agreed or strongly agreed that they would recommend the symposium to a colleague. Sixteen (73%) agreed or strongly agreed that protected research sessions were vital to psychiatric training, with three (14%) neutral and three (14%) in disagreement.

At the end of the 2009 meeting all attendees were given the opportunity to complete an anonymous evaluation form. For each question responses were requested on a five-point Likert rating scale from ‘completely agree’ to ‘completely disagree’. There was also space for free text comment. A list of all presentations to the STARS meetings between 2007 and 2009 was compiled, and study design, title, date of presentation and name of presenter were noted. A search of Medline, PsycINFO, Pubmed and Science Direct databases for author was carried out in November 2011. If no match was found for author name, keywords from the title were employed. If still no match was found, an email was sent to the presenter to confirm that the article had not been accepted for publication (November 2011). A match was accepted where there was similarity between title of presentation and paper, and where the presenter featured as an author. Journal of publication and date of publication were noted. The journal impact factor was retrieved from ISI Citation Index (http://www.isiwebofknowledge.com) from the publisher’s website.

Ten from 20 (50%) of the projects presented have been published or accepted for publication as a paper in a peer-reviewed journal. Four of these were first-author publications. Two individuals published two papers each from the project presented. The titles of journals and impact factor where available are shown in Table 2. For one case the paper had been published at the time of presentation, for all others the mean time to publication (calculated to nearest full month) was 20.2 months (5 to 41). Of those unpublished, email responses stated the following reasons for non-publication: project failing to progress to submission, project abandoned and another pursued, paper not resubmitted after rejection, and no time available to complete research in Consultant post. No papers were still awaiting decisions following submission.

Results There were 20 presentations over the three years, presented by 19 individuals. All except one were clinical rather than scientific studies. No projects were randomized controlled trials. The titles and study design of all the presentations are shown in Table 1.

Table 1 Presentations by design and title Type of study Cohort/Cross sectional

Case Control Survey

Audit

Pilot

Abbreviated article title “Anxiety and depression, I.Q. and early life privations in 64 year olds” “Validity of the PHQ-9, HADS and BDI-II to assess severity of depression in primary care” “Antipsychotic use in hospital and nursing home settings” “Neuropsychological function in childhood and early adolescence in boys with ADHD and controls” “Suicide in Grampian 2000-2005: Comparison with previous studies” “Psychometric properties of the PHQ9 in a UK general population sample” “The seasonality of bipolar affective disorder and comparison with a primary care sample” “Attitudes and practice of GPs regarding Adults with Incapacity (Scotland) Act 2000 (Part 5)” “Fairness of interview: a Scottish perspective” “Staff attitudes to an integrated care pathway in a low security forensic unit” “Assessing fitness to plead in Scotland’s Learning Disabled” “Views and prescribing patterns of cholinesterase inhibitors in Scotland” “Eating attitudes in college students in Mumbai, India” “Patient information leaflets on psychotropic drugs: opinions and use by clinicians” “Use of a proforma for emergency assessments in General Adult Psychiatry” “Evaluating the clinical efficacy of a Therapeutic Community” “GP referrals for depression: Comparison against NICE guidelines” ‘‘Cardiac monitoring for Cholinesterase Inhibitors” “The functional pharmacogenetics of the carboxylesterase CES1 enzyme in ADHD” “The Niacin skin patch test in Schizophrenia”

123

Table 2 Projects achieving publication

Type Of Study Cohort/cross sectional

No. Presented 6

No. Published Or Accepted 3

Case control

Survey

Audit Pilot Total

4 2 20

1 0 10

Publication Name Of Journal Impact Factor Primary Care and Community Psychiatry * British Journal of General Practice 2.07 International Journal of Geriatric Psychiatry 2.029 Journal of Affective Disorders 3.740 Journal of Affective Disorders 3.740 Journal of Child and Adolescent Mental Health N/A Journal of Forensic Psychiatry and Psychology 0.615 Psychiatric Bulletin N/A Geropsych N/A International Psychogeriatrics 2.478

*Discontinued 2009. 2010 impact factor copyright Thomson Reuters Journal Citation reports 2011

Discussion

Acknowledgements

The publication rate of 50% described in this paper is greater than rates described previously for larger UK national meetings ranging from 24% (British Association of Maxillofacial Surgeons)8 to 47% (Welsh Surgical Society).9 A questionnaire survey of Scottish higher psychiatric trainees found that 66% had published work carried out in higher training.5 The same proportion of respondents reported regular access to protected time for research. The most frequently reported barriers to research were lack of research skills, difficulties in generating ideas, access to technical support and lack of supervision.

We would like to thank all panel members over the three years including Mr. Simon Naji, Dr. David Christmas, Professor Keith Matthews, Professor John Eagles and Dr. Harry Millar. We would also like to thank all the trainees who have attended and presented as well as pharmaceutical companies Wyeth and AstraZeneca for sponsoring the symposia.

It is our view that the publication rate described here is an indicator of reasonable productivity in research. We recognise that caveats exist regarding the use of publication rates as a measure of productivity. Publication is not the only measure of a meaningful research project, and even failed projects can offer a useful learning experience.10 Furthermore, research training should encourage meaningful contribution to the knowledge base rather than quantity of papers.

References 1. Vassilas C, Tadros G, Day E. The research day: a suitable case for treatment? Psychiatric Bulletin 2002; 26: 313-314 2. Royal College of Psychiatrists. OP 69: Specialist Training in Psychiatry. London: Royal College of Psychiatrists; Jan 2010. 3. The Royal College of Psychiatry of Ireland. Postgraduate training in psychiatry and Ireland Blueprint; November 2011 p36. www.irishpsychiatry.ie/Postgrad_Training/Handbooks_Useful_Documents.aspx 4. Ramchandani P, Corby C, Guest L, Cole-King A. The Place and Purpose of Research Training for Specialist Registrars: A View from the Collegiate Trainees' Committee (CTC) of the Royal College of Psychiatrists. Irish Journal Psychological Medicine 2001;18(1):2931. 5. Petrie R, Anderson K, Hare E, Mayfield N, Tipper R. Research activity of specialist registrars. Psychiatric Bulletin 2004; May 1;28(5):180-2. 6. Fogel J. Research as part of the career of a psychiatrist entering clinical practice. Psychiatric Bulletin 2009; 33:269-272 7. Nkire N, Edokpolo O. Psychiatric training and research in Ireland, the traineeâ&#x20AC;&#x2122;s perspective. Irish Journal of Psychological Medicine 2011; 28 (1): 3-5. 8. Collier JM, Vig N, Hammond D. Publish or perish? A survey of abstracts accepted for meetings of the British Association of Oral and Maxillofacial Surgeons, and subsequently published. British Journal of Oral and Maxillofacial Surgery 2010; 10;48(7):540-3. 9. Bowrey DJ, Morris-Stiff GJ, Clark GWB, Carey PD, Mansel RE. Peer-reviewed publication following presentation at a regional surgical meeting. Medical Education 1999; 33(3): 212-4. 10. Vaidya G. Lessons learned from a failed research project. Psychiatric Bulletin 2004; August 1;28(8):301-3.

Conflict of interest None.

In the Grampian scheme, trainees are supported by a research mentor, with academic links through the University department of mental health. A Higher Trainee Research Peer group meets monthly. These supports for research activity, specifically recommended by the Royal College of Psychiatrists, may well contribute to the productivity documented here.2 Our experience indicates that the organisation of an annual research symposium is a further way to create structure, improve motivation and instill interest in undertaking research projects. Our data suggest that where these factors are present, a substantial proportion of (though not all) higher trainees will achieve publication. At a time of decreased commitment to protected research time in the UK, we are pleased to report on an annual research meeting which trainees appear to value. The publication rate of presented papers infers productive use of protected research time. Consequently, we take the view that, despite ongoing service pressures, efforts should be made to maintain traineesâ&#x20AC;&#x2122; access to protected time for research.

124

CASE REPORT

Delayed Onset of Neuropsychiatric Effects Associated with Montelukast Fintan Byrne, Bolarinwa Oluwole, Vanessa Whyte, Sabina Fahy, Delia McGuinness Ir J Psych Med 2012; 29 (2): 125-127

Abstract

LTRAs have been prescribed with increasing frequency in the past decade. In the UK from the year 2000 to 2006, the number of prescriptions for LTRA preparations increased from 42,000 to 197,000 prescriptions.4

Montelukast (a leukotriene receptor antagonist) is a commonly prescribed medication used in the management of asthma in both children and adults. It has been associated with a possible increased risk of various neuropsychiatric events in post-marketing analyses of clinical trial data and surveillance studies. When establishing a link between a medication and side effects, it is usual to establish and enquire whether there is a chronological relationship between the commencement of the medication and the onset of the symptoms.

Case Master C is a nine year old boy who was referred to CAMHS (Child and Adolescent Mental Health Service) by his GP for difficulty sleeping, somnambulism and associated anxiety. He is of Caucasian ethnicity, and born and raised in Ireland to an Irish mother and a French father. His mother remembered the date of onset of symptoms being 25th June 2009 because Michael Jackson had died that day. Since then the boy had been wakening around midnight and knocking on his parents’ door. His mother started to sleep with him for reassurance. She reported that he had been sleepwalking every night at 10.30pm if she didn’t go to bed with him. She also reported that the boy had bruxism while sleeping.

We report a case where a number of unusual neuropsychiatric events were reported several years after commencement of montelukast in a young boy who may have a genetic predisposition and a likely psychological trigger. There was complete resolution of these symptoms upon the withdrawal of montelukast. Key words: Asthma, montelukast, leukotriene receptor antagonist, delayed onset adverse effects, neuropsychiatric adverse effects.

He reported feeling ‘funny in his tummy’ towards bedtime with anticipatory anxiety regarding whether he would sleep or not later that night. He had reported a good night’s sleep on occasion only to be told the next morning that he had been sleep walking. These reports devastated him.

Introduction Leukotriene receptor antagonists (LTRAs) are recommended as a second step in the treatment of asthma in children over five years. They are most effective for patients with mild persistent asthma. They provide additive benefit when added to inhaled corticosteroids although not as effective as inhaled long-acting beta 2-agonists.1 Available LTRA preparations in Ireland are montelukast and zafirlukast.

Prior to being seen in CAHMS, his parents had tried a number of measures to combat the boys sleeping difficulty including music, reading stories, playing Nintendo games, a reward system, calamine lotion, hot tea, lavender on his pillow, night lights, herbal tea, magnesium and calcium supplements and even a Tic Tac as a placebo ‘sleeping tablet’. His parents were understandably anxious and frustrated about the lack of progress and his mother still needed to sleep with him every night, straining the parental relationship for approximately six months prior to presentation.

Montelukast is indicated for the prophylaxis and chronic treatment of asthma in adults and paediatric patients 12 months of age and older, acute prevention of exercise-induced bronchoconstriction in patients 15 years of age and older, and relief of symptoms of allergic rhinitis: seasonal allergic rhinitis in patients two years of age and older, and perennial allergic rhinitis in patients six months of age and older.2

He had a background history of asthma which was well controlled on beclomethasone inhaler 50mcg one puff twice daily and montelukast 5mg once daily. He had been on this medication for 2½ years with no adverse effects noted. There were no recent changes or additions to his medication, either prescribed or over the counter. It was therefore felt that the association between his presenting symptoms and montelukast was unlikely. His father had suffered from anxiety and somnambulism years earlier.

It is usually administered orally. Montelukast blocks the action of leukotriene D4 on the cysteinyl leukotriene receptor CysLT1 in the lungs and bronchial tubes by binding to it. This reduces the bronchoconstriction otherwise caused by the leukotriene, and results in less inflammation.3 *Fintan Byrne, Clinical Lecturer Psychiatry, University Hospital Galway and National University of Ireland Galway, Ireland Email: fintanbyrne@gmail.com Bolarinwa Oluwole, Staff Psychiatrist, London Health Sciences Centre, London, Ontario, Canada *correspondence

Vanessa Whyte, General Practitioner, Castle St Surgery, Roscommon Town, Co. Roscommon, Ireland

Delia McGuinness, Child and Adolescent Consultant Psychiatrist, CAMHS, Ballard House, Galway, Ireland

Sabina Fahy, Consultant Psychiatrist/Clinical Tutor, St. Brigids Hospital, Ballinasloe, Co. Galway, Ireland

Submitted 12th October 2010 Accepted 6th February 2012

125

It was felt that his current symptoms were triggered by the extensive news coverage of Michael Jackson’s death and propagated by parental anxiety. Although the boy was not a big fan of Michael Jackson, he had followed the news coverage and had asked his parents questions about the event.

In light of concern over the potential for neuropsychiatric events associated with montelukast, and at the behest of the FDA, the pharmaceutical company Merck commissioned retrospective analyses of its clinical trial data for Singulair to determine frequency. Two studies by Philip et al were published in the Journal of Clinical Immunology in October 2009. The first reviewed reporting of suicidality in clinical trials of montelukast. In a descriptive review of 116 double-blind open label trials in which over 20,000 adults and children received montelukast, the authors found that adverse events possibly related to suicidality were rare, and similar between montelukast and placebo or active control groups. In an adjudicated review of over 22,000 patients, there was one possible suicidality-related adverse event (suicidal ideation) in the montelukast group, and none in the placebo and active control groups.7 The second review by Philip et al looked at behaviour-related adverse experiences (BRAEs). Retrospective analysis of 35 adult and 11 paediatric placebo-controlled trials showed patients experienced one or more BRAEs with a frequency of 2.73% in the montelukast group and 2.27% in the placebo group. The frequency of patients experiencing BRAEs leading to study discontinuation was 0.07% and 0.11% in the two groups respectively.8 Both articles comment that the studies were not originally designed to assess suicidality or behaviour-related adverse events, which is a shortcoming. The authors also highlighted that individuals with more severe asthma are at increased risk for depression and behaviour related problems.9,10,11

After the first assessment, his mother was asked to take on the disciplinary role and his father was asked to participate in enjoyable activities with his son and to step back from his usual disciplinary role. Both parents were quite willing to try this approach. The young boy was happy to go to bed alone over the next two weeks. He and his parents were asked to return for review after this period. On review, both parents reported an improvement. There was less anxiety with regard to his bedtime. He had managed to sleep in his own bed for approximately six nights out of fourteen. The presenting complaints were still present but to a lesser extent according to his parents. They were asked to continue the same plan and they would be reviewed in a month. They were asked to contact us with any problems or changes in the interim. Approximately one week later his mother telephoned to thank the team for our help but she had read the product literature of montelukast and had decided to stop it in conjunction with her GP. She reported that there had been complete resolution of all symptoms almost immediately. She was overjoyed to ‘have her son back’. I contacted his mother by telephone approximately nine months later and there had been no return of any symptoms.

Quite recently, in May 2011, a further case series entitled ‘montelukast-induced anxiety in two paediatric patients’ was published.12 The first case was of a four year old boy who experienced anxiety and sleep disturbance within five months of starting montelukast, which subsequently resolved two weeks after discontinuation. The second child was a six year old girl who developed anxiety symptoms three weeks after her montelukast dose was increased from 4mg to 5mg. Her symptoms resolved without recurrence within four weeks, after the dose was reduced to the previously tolerated lower dose.

Background In a recent publication evaluating psychiatric adverse drug reactions (ADR) during treatment with montelukast, it was suspected to have caused ADRs in 103 reports concerning children in the Swedish ADR database SWEDIS (1998-2007). A total of 48 ADR reports were registered concerning psychiatric disorders in children. The specific ADRs reported were nightmares (n=15), unspecified anxiety (11), aggression (11), sleep disorders (10), insomnia (3), irritability (3), hallucination (3), hyperactivity (3) and personality disorder (2). In 48% (23 cases), the child concerned was ≤ three years old. The time from exposure to ADR was less than one week in 80% of cases.5 The longest times from exposure to ADR were two years, reporting depressed mood, and eight months, reporting aggressiveness and agitation.5

The authors of this case series used the Naranjo adverse drug reaction probability scale to calculate the likelihood that montelukast was the cause of the anxiety symptoms experienced by the children. The Naranjo scale indicated a possible (score of 3 in the first patient), and probable (score of 8 in the second child) relationship between the development of symptoms and montelukast therapy.12 If we apply the Naranjo scale13 to our patient, Master C, it indicates a possible (score of 3) relationship between the development of his symptoms and montelukast therapy.

Following post-market reports of neuropsychiatric events, on 28th August 2009 the US Food and Drug Administration (FDA) published updated information on leukotriene inhibitors. The FDA recommended that patients should be informed of the potential for these events, and that healthcare providers should consider discontinuing these medications if patients developed neuropsychiatric symptoms.6 The following symptoms were subsequently included in the precaution section of the updated prescribing information for Singulair (montelukast): agitation, aggression, anxiousness, depression, disorientation, dream abnormalities, hallucinations, insomnia, irritability, restlessness, somnambulism, suicidal thinking and behaviour (including suicide), and tremor.2

Discussion Initially the team had felt that in Master C’s case, an association between a medication and the onset of symptoms was unlikely because it had been started two and a half years prior to the onset of symptoms. These symptoms were ongoing for nearly seven months before resolution. The parents had tried numerous interventions themselves with no effect. The intervention of the CAMHS team may have had considerable anxiety-relieving effects for both the parents and the child. However, it was not until the child’s mother read the updated product information for

126

montelukast, associated the medication with his symptoms, and stopped it, that was there complete and permanent resolution of all symptoms.

Conflict of interest

It is noteworthy in this case that there is a family history of anxiety and somnambulism. This case might not be so surprising considering a possible genetic predisposition, asthma and atopy, a psychological trigger and a medication that has been possibly associated with neuropsychiatric events. These four factors together may have been required in order for this young boy to eventually become symptomatic. As such, it is impossible to say that montelukast alone definitely caused this boyâ&#x20AC;&#x2122;s symptoms. But it was at least a possible contributing factor.

Acknowledgements

None.

The authors would like to thank the family of this patient for their consent for the publication of this report.

References 1. Global Strategy for Asthma Management and Prevention 2009 (Update) 2. Full Drug Prescribing information, MERCK & CO., INC. available at www.singulair.com/montelukast_sodium/hcp/asthma/prescribing-information.jsp accessed 17/09/10 3. Canadian Drug Bank available at http://www.drugbank.ca/drugs/DB00471 accessed 17/09/10 4. Cohen S, Taitz J, and JaffĂŠ A. Paediatric prescribing of asthma drugs in the UK: are we sticking to the guideline? Arch Dis Child 2007; 92:847â&#x20AC;&#x201C;849. 5. Wallerstedt SM et al. Montelukast and psychiatric disorders in children. Pharmacoepidemiol Drug Saf. 2009 Sept;18(9):858-64 6. Leukotriene inhibitors: montelukast (marketed as Singulair), zafirlukast (marketed as Accolate), and zileuton (marketed as Zyflo and Zyflo CR). Healthcare Professional Sheet, Washington (DC): US Food and Drug Administration; 2009. 7. Philip G, Hustad C, Noonan G, Malice M-P, Ezekowitz A, Reiss TF, et al. Reports of suicidality in clinical trials of montelukast. J Allergy Clin Immunol 2009;124:691-6 8. Philip G, Hustad CM, Malice M-P, Noonan G, Ezekowitz A, Reiss TF, et al. Analysis of behaviour-related adverse experiences in clinical trials of montelukast. J Allergy Clin Immunol 2009;124:699-706 9. Kelsay K. Assessing risk: Data from montelukast clinical trials. J Allergy Clin Immunol 2009;124:697-8 10. Goodwin R, Eaton W. Asthma, suicidal ideation, and suicide attempts: findings from the Baltimore epidemiological catchment area follow-up. Am J Public Health 2005; 95:717-22. 11. McQuaid E, Kopel S, Nassau J. Behavioral adjustment in children with asthma. J Dev Behav Pediatr 2001; 22:430-9. 12. Skillman K, Stumpf J. Montelukast-induced anxiety in two pediatric patients. Pharmacotherapy 2011; 31:524. 13. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239-245.

Data from adverse drug reaction surveillance studies and case reports suggest a possible link between LTRAs and neuropsychiatric symptoms. The large retrospective studies undertaken by Philip et al that were initiated after post-marketing reports of adverse events do not show convincing evidence of a link overall. Furthermore the authors comment that given the higher rate of psychiatric comorbidity in patients with asthma and atopy, the reporting of adverse events related to psychiatric illness is not surprising. However, they do acknowledge that the studies were not originally designed to assess suicidalilty or behaviour related adverse events. This may impact on the validity of findings, regardless of the fact that the post-marketing analyses were requested by, and in part specified by, the FDA. In an editorial in the same edition, Kimberly Kelsey points out that although the overall results show similar low rates of neuropsychitric symptoms in montelukast and placebo groups, analyses within the age groups of 12-17 years, and subjects older than 65 did show that patients in these groups who received montelukast were at higher risk than those who received placebo.9 In summary, it is not clear at present to what extent and with what frequency LTRAs may cause or contribute to the develpopment of neuropsychiatric adverse events. Patients with asthma and atopy are likely a more vulnerable cohort in general, but are there other factors which may make an individual more susceptible? Further prospective trials on this class of drugs are necessary. Given the adverse event reports to date, it would seem prudent that neuropsychiatric profiling become part of drug development, and efficacy and tolerability studies in the future. As clinicians we must be constantly aware of the potential of any drug to cause adverse reactions. We should also be aware that although onset of symptoms usually correlates with introduction of a new medication, this is not always the case. In the case of children treated with medication with the potential for neuropsychiatric side effects, we must be alert to the possibility, and ensure that there is early involvement of specialist psychiatric services. In all patients with asthma and atopy, clinicians should be alert to the increased risk of mental health issues, and screen patients accordingly. When commencing any patient on LTRA medication, it should not be assumed that any behavioural risk outweighs the potential benefits, as for a considerable number of patients this class of medication has the potential to improve symptoms considerably and hence their quality of physical and mental health.

127

CLINICAL AUDIT

Benzodiazepine and Z-drug Prescribing for Elderly People in a General Hospital: A Complete Audit Cycle Catherine Dolan, Sami Omer, Deirdre Glynn, Michelle Corcoran, Geraldine McCarthy Ir J Psych Med 2012; 29 (2): 128-131

Abstract

Introduction

Background: Use of benzodiazepines and Z-drugs in the elderly is associated with adverse outcomes such as increased risk of falls and fractures and cognitive impairment. We aimed to assess the prescribing practice of benzodiazepine and Z-drugs in those aged over 65 years in a general hospital against evidence based standards and to examine the effects of multidisciplinary feedback, as well as determine the prevalence of usage.

Benzodiazepines are among the most widely prescribed drugs for older persons and used for a multitude of conditions, most commonly insomnia, anxiety, and other psychiatric disorders.1-4 Newer hypnotic drugs named Z-drugs are drugs which are also widely prescribed in the elderly population. Z-drugs are medications which have similar pharmacological action as benzodiazepines including side effects, benefits and risks but are structurally distant and unrelated to benzodiazepines on a chemical level. There are currently three major chemical classes of these drugs: 1) imidazopyridines, 2) pyrazolopyrimidines and 3) cyclopyrrolones. Z-drugs are so called because their names largely begin with the letter â&#x20AC;&#x2DC;Zâ&#x20AC;&#x2122; e.g. zaleplon, zolpidem and zopiclone.

Methods: All case-notes and medication charts of patients over the age of sixty five on surgical and medical wards in Sligo General Hospital (SGH) were retrieved and analysed over a two-day period in 2008. Data was collected in relation to benzodiazepine and Zdrug prescribing. We followed up on this initial data collection by screening discharge summaries at six weeks to assess benzodiazepine and Z-drug prescribing on discharge. Audit results were disseminated together with consensus guidelines on the prescribing of these medications in older adult population to all general practitioners in County Sligo. Educational sessions were held for both doctors and nurses in SGH. The audit cycle was completed by a re-audit of benzodiazepine and Z-drug prescribing six months from original study using identical methods.

A large population-based study in Dublin found 17% of older people to be using Benzodiazepines5 and a multicentre hospitalbased study from Australia found 36% of the study population to be prescribed a benzodiazepine.6 Due to altered pharmacokinetics and pharmacodynamics with increasing age, elderly people are at increased risk of adverse events of benzodiazepines. These include falls, fractures, and cognitive impairment.7-9 In a meta-analysis of benefits and risks of use of sedative hypnotics in older persons, the authors concluded that the risks of adverse events outweighed the benefits of improvement in sleep when sedative hypnotics were used.9

Results: We found a high prevalence of benzodiazepine and Z-drug use in original audit, 54% (38/70) of the group audited. The prevalence fell to 46% (32/70) at the re-audit post intervention. This result was not statistically significant. The percentage of patients commenced on benzodiazepine and Zdrugs prior to admission fell from 36% (25/70) at the initial audit to 23% (16/70) at the re-audit.

Numerous guidelines regarding benzodiazepine prescribing have been issued by major medical bodies from which we have formed our gold standard, including the Royal College of Psychiatrists,10 National Institute for Clinical Excellence (NICE),11 as well as the report of the benzodiazepine committee 2002, established by the department of health in Ireland.12 These professional guidelines are based, in the main, on consensus views and advise that benzodiazepines and Z-drugs are only indicated for severe symptoms and, if prescribed, should be at the lowest effective dose and as a short-term therapy not exceeding four weeks.

Conclusion: Prescribing practices were not in keeping with consensus guidelines as highlighted by this relatively basic audit cycle. Multidisciplinary feedback and letters to GPs resulted in some reduction in the number of patients prescribed benzodiazepines and Z-drugs. Ongoing educational strategies aimed at relevant health care workers with regular audit of medication use within the general hospital setting is pertinent to further improve prescribing practice.

*Catherine Dolan, Surgical Intern, Sligo General Hospital. The Mall, Sligo, Ireland. Email catherine.dolan1@hotmail.com Sami Omer, Senior Registrar, Department of Old Age Psychiatry, Liscarney House, Pearse Road, Sligo, Ireland *correspondence

Audit of all aspects of medication use is a recognised means of monitoring and improving the quality and safe use of medication.13 Behaviour is unlikely to be altered via audit by itself, but information provided by audit will help guide educational

Deirdre Glynn, Surgical Intern, Sligo General Hospital. The Mall, Sligo, Ireland. Michelle Corcoran, Pharmacist, Sligo General Hospital. The Mall, Sligo, Ireland.

128

Geraldine McCarthy, Consultant Psychiatrist, Department of Old Age Psychiatry, Liscarney House, Pearse Road, Sligo, Ireland. Submitted 21st January 2011 Accepted 13th February 2012

Table 1 Characteristics of study participants Characteristic Number of patients % Female Mean age

Baseline Audit 70 50 % 77 (range 66-98 years).

Re-Audit 70 69 % 79 (range 65-92 years)

Reason for admission Falls and confusion Fracture Cardio-respiratory Gastrointestinal Other

Number (%) 11 (16) 10 (14) 10 (14) 9 (13) 30 (43)

Number (%) 13 (18) 0 (0) 7 (10) 18 (26) 32 (46)

strategies to correct identified deficiencies in prescribing practice. The specific objectives of this audit were: (1) to compare benzodiazepine and z-drug prescribing practice against a gold standard and determine the prevalence of usage among elderly inpatients in a general hospital and (2) to examine the effect of multidisciplinary feedback and education on prescribing practices. We hypothesized that a reduction in the prevalence and practise of benzodiazepine and Z-drug prescribing would result from the feedback and educational intervention.

Six months following the baseline audit, a point-prevalence study of Benzodiazepine and Z-drugs use in patients aged 65 and above was conducted in the same hospital with the identical methods as outlined above. Data collected was analysed using SPSS 16.

Results Over the two-day period of the initial audit a total of 70 patient records were reviewed. Of this group 50% (35/70) were female. The mean age of this group was 77 years with a range of 66-98 years old.

Methods The study was approved by the hospitalâ&#x20AC;&#x2122;s audit committee. Over a two-day period in October 2008, all adult inpatients aged over 65 on medical and surgical wards in a general hospital setting were identified. Data collections were carried out using case-notes and medication charts. Information on use of and prescribing practice of sedatives and hypnotics were retrieved by two authors (CD&DG) using a pre-set questionnaire compiled using standards set from professional medical body guidelines as mentioned in the introduction.

There were 16% (n=11) of inpatients admitted for treatment of falls and confusion with 14% (n=10) admitted for treatment of fractures and 14% (n=10) for cardio respiratory problems, 13% (n=9) were admitted for gastrointestinal problems and 43% (n=30) were admitted for treatment of other medical issues. At the time of re-audit (post intervention), once again 70 patient records were reviewed. On this occasion 69% (48/70) of the group were female.

Information gathered included, total number of patients prescribed a benzodiazepine or a Z-drug and type and number of such drugs prescribed for the patient, whether it was prescribed since the admission or prior to admission, was an indication for prescribing documented, was a review date documented and was there a drug utilisation review by a pharmacy staff member.

The main reason for admission in 18% (n=13) of these inpatients was for treatment of falls and confusion, 10% (n=7) admitted with cardio respiratory problems, 26% (n=18) admitted with gastrointestinal problems and 46% (n=32) were admitted for treatment of other medical issues.

Confidentiality was maintained of patients and prescribers with removal of identification by the auditors before data entry. Discharge summaries of these patients were assessed, where available, at six weeks from the initial date of the study to audit discharge benzodiazepine and Z-drug prescribing. Discharge information gathered included whether patient was prescribed benzodiazepine or a Z-drug on discharge and whether their GP was informed of the indication for prescription.

At the initial audit, 54% (38/70) of the total study sample were prescribed a benzodiazepine or a Z-drug. In total 61% (23/38) of this group were females and 39% (15/38) were male. Within this group 34% (13/38) were initiated on this medication while an inpatient in Sligo General Hospital and the remaining 66% (25/38) were initiated on same prior to admission. In this group prescribed benzodiazepine or Z-drug medication 15% (5/38) were prescribed more than one such medication.

The intervention consisted of sending feedback letters of the audit results together with consensus guidelines on benzodiazepine and Z-drug prescribing to all general practitioners in County Sligo. Moreover, two educational sessions, one for doctors and one for nurses, were held for general hospital staff.

An indication for prescribing benzodiazepines or Z-drugs was documented in only five percent (2/38) and a drug utilisation review by pharmacy department (as confirmed by pharmacy staff filling in allocated section of drug charts) was completed in only 55% (21/38) of cases.

129

Table 2 Differences in prescribing practices between baseline and re-audit Item

Baseline Audit

Re-Audit

Total number of patients on benzodiazepine and Z-drugs % Female % Male Benzodiazepine and Z-drugs commenced during admission Benzodiazepine and Z-drugs commenced prior to admission Number of patients prescribed more than one benzodiazepine and Z-drug Indication for prescribing documented Drug utilisation review by pharmacist

38/70 (54%) 23/38 (61%) 15/38 (39%) 13/38 (34%) 25/38 (66%) 5/38 (15%) 2/38 (5%) 21/38 (55%)

32/70 (46%) 25/32 (78%) 7/32 (22%) 16/32 (50%) 16/32 (50%) 6/32(19%) 4/32 (12.5%) 8/32 (25%)

Medication

Baseline No (%)

Re-Audit No (%)

Lorazepam Diazepam Temazepam Zopiclone Midazolam Zolpidem Alprazolam Other

2 (4) 3 (7) 11 (25) 16 (36) 3 (7) 2 (5) 4 (9) 3 (7)

4 (11) 2 (5) 6 (16) 12 (32) 1 (3) 2 (5) 6 (16) 4 (12)

Table 3 Type of medication prescribed

During the two day re-audit period the percentage of the study sample being prescribed a benzodiazepine or a Z-drug fell to 46% (32/70). This difference was not statistically significant. In total 78% (25/32) of this group were female and 22% (7/32) were male. In this group 50% (16/32) were initiated on this medication during their inpatient admission and the remaining 50% (16/32) were initiated on same prior to admission. Within the group prescribed benzodiazepine or Z-drug medication, 19% (6/32) were prescribed more than one such medication.

In the absence of documentation of the indication for usage, it is difficult to comment on the appropriateness of prescribing in our study sample. The low rate of documentation of â&#x20AC;&#x2DC;Indication for Prescribingâ&#x20AC;&#x2122; is striking at only 2/38 (5%) before and 4/32 (12.5%) after intervention. This emphasises the particular importance of record-keeping and communication with regard to benzodiazepine and Z-drug prescribing. Improvement of prescribing practices in medical practice is a challenging undertaking as demonstrated by our findings suggesting that in-hospital prescribing practices were unaltered by our educational intervention.

An indication for prescribing benzodiazepine or Z-drugs was documented in only 12.5% (4/32) and a drug utilisation review by pharmacy department was completed in only 25% (8/32) of cases.

This is in keeping with results from a large randomised controlled trial involving primary care physicians in Canada where a single educational intervention failed to make significant changes to benzodiazepine prescribing practices.14 Jamtvedt et al in an extensive review also had similar conclusions that audit and feedback may be effective in improving professional medical practice, although effects are generally moderate.15 This may indicate that more complex interventions involving different stakeholders are necessary to effect change in medication prescribing practices.

Zopiclone, a Z-drug, was overall the most commonly prescribed hypnotic medication whilst Temazepam was the most common benzodiazepine prescribed. Table 3 shows breakdown of the types of medications prescribed. In the initial audit, 47% (18/38) of the study participants who were prescribed a benzodiazepine or Z-drug were discharged on those medications. This compares to 63% (20/32) at the time of re-audit.

With regard to primary care physicians, local general practitioners were provided with feedback on initial audit results and given a copy of consensus guidelines via letter. As our figures show from the re-audit of prescribing practice, six months following the original study, with intervention as described above in the interim, 50% (16/32) of patients were prescribed these medications prior to admission, presumably in the primary care setting, compared to 66% (25/38) at baseline. This therefore shows a notable improvement in prescribing practice in the primary care setting following intervention. While these results were not statistically

Discussion This study describes the completion of an audit cycle regarding benzodiazepine and Z-drug prescribing among elderly patients in a general hospital. Our study reported a high prevalence of benzodiazepine and Z-drug usage among the elderly inpatients both at baseline and at the re-audit. Our figures are twice those found by Kirby et al5 and higher than those by Elliot et al from Australia.6

130

References 1. Hollister LE, Müller-Oerlinghausen B, Rickels K, Shader RI. Clinical uses of benzodiazepines. J Clin Psychopharmacol. 1993 Dec;13(6 Suppl 1):1S-169S. 2. Longo LP, Johnson B. Addiction: Part 1. Benzodiazepines - side effects, abuse risk and alternatives. Am Fam Physician. 2000 Apr 1;61(7):2121-8. 3. Nolan L, O’Malley K. Patients, prescribing, and benzodiazepines. Eur J Clin Pharmacol. 1988;35(3):225-9. 4. Petrovic M, Mariman A, Warie H, Afschrift M, Pevernagie D. Is there a rationale for prescription of benzodiazepines in the elderly? Review of the literature. Acta Clin Belg. 2003 Jan-Feb;58(1):27-36. 5. Kirby M, Denihan A, Bruce I, Radic A, Coakley D, Lawlor BA. Benzodiazepine use among the elderly in the community. Int J Geriatr Psychiatry. 1999 Apr;14(4):280-4. 6. Elliott RA, Woodward MC, Oborne CA. Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback. Intern Med J. 2001 Dec;31(9):529-35 7. Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sc. 2007 Oct;62(10):1172-81. 8. Paterniti S, Dufouil C, Alperovitch A. Long-term benzodiazepine use and cognitive decline in the elderly: the Epidemiology of Vascular Aging Study. J Clin Psychopharmacol. 2002 Jun;22(3):285-93. 9. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005 Nov 19;331(7526):1169. Epub 2005 Nov 11. 10. Royal College of Psychiatrists. Benzodiazepines: Risks, benefits or dependence: a reevaluation. Royal College of Psychiatrists Council Report CR59, London. Jan 1997. 11. National Institute for Health and Clinical Excellence. Anxiety: management of anxiety (panic disorder, with or without agoraphobia and generalised anxiety disorder) in adults in primary, secondary and community care. CG22. London: National Institute for Health and Clinical Excellence. December 2004. Available at: http://guidance.nice.org.uk/CG22. Accessed Nov 2010. 12. Department of Health and Children. Report of the Benzodiazepine Committee. The Stationary Office, Dublin, 2002. 13. Department of Health and Personal Social Services. Medicines Management Standard (Safe and Secure Handling of Medicines), Northern Ireland. 2006. Available at: www.dhsspsni.gov.uk/medicines_management_06.doc. Accessed Nov 2010. 14. Pimlott NJ, Hux JE, Wilson LM, Kahan M, Li C, Rosser WW. Educating physicians to reduce benzodiazepine use by elderly patients: a randomized controlled trial. CMAJ. 2003; 168(7):835-9. 15. Jamtvedt G, Young JM, Kristoffersen DT, Thomson O’Brien MA, Oxman AD: Audit and feedback: effects on professional practice and health care outcomes. Cohrane Database Syst Rev 2003:CD000259.

significant, it is likely dissemination of results of the initial audit plus educational material supplied on consensus guidelines is likely to have improved primary care prescribing practices. The importance of continuing audit of the practice of benzodiazepine and Z-drug prescribing in the inpatient setting is also emphasised as a result of this study. Of patients prescribed a sedative or hypnotic 34% (13/38) were commenced on this medication during the course of the admission in the baseline audit compared to 50% (16/32) commenced on these medications during admission at re-audit. Also the increase in frequency of prescribing of sedative or hypnotic medication on discharge at time of re-audit being 63% (20/32) versus 47% (18/38) at baseline, highlights the need for development and implementation of local guidelines as well as regular education and training of healthcare professional. This is necessary as there is a particularly high staff turn-over of health care workers, particularly of NCHDs who are usually the most frequent sedative and hypnotic prescribers in the general hospital setting. Therefore those who may have been educated as part of our intervention may have not been the prescribing doctors whose practice we re-audited six months from baseline. Nursing staff on this occasion were also educated on correct prescribing practices in the hope of bringing to the attention of the prescribing doctor any deficiencies in prescribing practice. Further improvements might be achieved by establishing rolling programmes of education for relevant healthcare workers. The fact that a large percentage of patients were commenced on sedative or hypnotic medication in the inpatient setting may reflect the clinical difficulties of sleep disturbance associated with admission to hospital of the elderly population. Education on avoidance of ‘knee-jerk prescribing’ and non-pharmacological interventions would also be appropriate to possibly improve upon the findings of this audit. This completed audit cycle has emphasised the importance of repeat audits, publication of results and regular feedback to relevant healthcare workers. This is essential to continue to monitor response to educational strategies, identify any deficiencies in prescribing practice and facilitate progressive modification of interventions designed to improve the quality of prescribing. We plan to introduce a brief educational component as part of non-consultant hospital doctor (NCHD) induction on a rolling basis to see if this influences prescribing practices. This audit cycle has also had a major influence on clinical practice within the Psychiatry of Old Age service. It has led to the modification of our Consultation Liaison assessment, to include a section on advice re benzodiazepine, hypnotic and psychotropic prescribing. It has also led to more active input to facilitate reduction and withdrawal from benzodiazepines whenever possible. There have been a number of very successful individual clinical outcomes, again highlighting the importance of audit.

Conflict of interest None.

131

OPINION

Threshold Concepts and Teaching Psychiatry: Key to the Kingdom or Emperor’s New Clothes? Seamus Mac Suibhne Ir J Psych Med 2012; 29 (2): 132-134

Abstract

seen as crucial in ensuring successful completion of a course of learning.4 Psychiatry is generally taught later in undergraduate medical education, by which time the acculturation process into medical school is well advanced; as a discipline, it has its own particular issues regarding engagement, with studies reporting a perception among medical students see that it is a a less dynamic and ‘unscientific’ field compared with other specialties.5

Psychiatry, more than most medical specialties, must engage with undergraduate medical education to prevent the further marginalisation of mental health within medicine. There is an urgency to the need for psychiatrists and educationalists to communicate, and for psychiatrists to be aware of developments in educational theory. The idea of ‘threshold concepts’ is currently widely discussed by educationalists. Threshold concepts are described as areas of knowledge without which the learner cannot progress, and which, when grasped, lead to a transformation in the learner’s perspective and understanding. Threshold concepts have been criticised on conceptual grounds, and there is a lack of clarity as to how to identify them empirically. While they may represent a fruitful approach to the task of engaging medical students in psychiatry teaching, it is suggested that further development of the idea is required before it could be usefully applied. However empirical studies in other disciplines suggest that there may be associated benefits to the teaching of the discipline from trying to identify threshold knowledge.

It follows from the above that psychiatry as a specialty must have a particular interest in medical education. To avoid the fate of being a ‘Cinderella’ in the medical school, psychiatry must take a lead in critically engaging with new concepts and theoretical approaches in education.6 Optimising the student experience of psychiatric teaching and ensuring that the acculturation of medical students does not lead to the further marginalisation of mental health issues are vital tasks for the specialty. This paper is intended to bring awareness of a recently emergent theory of education – that of threshold concepts – to a readership of psychiatrists. It does not suggest that this is a magic solution to the problems of psychiatric education; it is intended as a small element in a bridge between psychiatric and educational practices .

Key words: Threshold concepts, teaching psychiatry, troublesome knowledge, student engagement, medical education, psychiatry teaching, recruitment of psychiatrists.

Threshold concepts Introduction The threshold concept is a currently influential idea in higher education. It can be understood “as akin to a portal, opening up a new and previously inaccessible way of thinking about something. It represents a transformed way of understanding, or interpreting, or viewing something without which the learner cannot progress.”7 There are two components to this threshold concept – it is a sine qua non for further learning, and comprehension leads to an internal transformation that enables this further learning.

Eagles et al identified the experience of undergraduate psychiatry teaching as one of the two key factors in determining interest or otherwise among medical graduates in psychiatry as a career (the other is the negative or otherwise view of psychiatry amongst other medical practitioners).1 Much research has identified negative attitudes amongst medical students to mental illness in general and to psychiatry as a career option.2 Both from the point of view of recruiting and retaining medical graduates into psychiatry, and of ensuring that all medical graduates are adequately grounded in the speciality, engaging medical students in undergraduate psychiatry teaching is a crucial task for psychiatry.

While there seems to be common ground with Mezirow’s ‘transformational learning’ concept, defined by Mezirow as a process of “becoming critically aware of one’s own tacit assumptions and expectations and those of others and assessing their relevance for making an interpretation”8, the focus is less on overcoming personal assumptions and the influence of others, but on the approach to a body of knowledge itself.

Indeed, engaging students in higher education is a topic of consuming interest for educationalists across all disciplines. Post-secondary education has, in developed countries, become the norm rather than the exception. Student drop-out rates are a major concern given both the fiscal cost of higher education and the fact that dropping out acts as a risk marker for various adverse outcomes.3 The student body is increasingly diverse not only demographically but in terms of previous educational experiences. The introduction to a particular discipline, and in particular the ‘acculturation’ into disciplinary discourse and ways of thinking, is

Meyer and Land relate threshold knowledge to troublesome knowledge, i.e. knowledge which does not seem to cohere with the learner’s existing understanding. This is knowledge “that is ‘alien’, or counter-intuitive or even intellectually absurd at face value – or, alternatively, may lead to an awareness of troublesome

*Seamus Mac Suibhne, Honorary Fellow, School of Medicine, University College Cork, Co. Cork, Ireland Email Seamus.MacSuibhne@ucd.ie *correspondence

Submitted 9th June 2010 Accepted 27th January 2012

132

knowledge.” They conclude that “a threshold concept can of itself inherently represent troublesome knowledge”9 although not all threshold knowledge is troublesome and not all troublesome knowledge is threshold.

troubling thoughts, feelings and adjustments of roles. Rather than an approach based on threshold concepts, reflective practice may be more suited for the exploration and resolution of these conflicts associated with role transitions.13

Threshold concepts have become influential among educationalists across many disciplines. For Clouder, the threshold concept in health care education is the transformation from student to carer.10 On meeting patients in practice, learners can experience conflicts between their previous role as ‘academic’ learners (which usually persists in parallel to clinical teaching), their own everyday understanding of ‘caring’, biomedical models of health, illness and therapy, and moral and ethical dilemmas. These conflicts can constitute troublesome knowledge, and in Clouder’s view also create threshold knowledge.

Threshold concepts and psychiatry With these caveats about threshold knowledge and concepts in mind, it does seem a potentially fruitful approach to considering how to engage medical students in psychiatric teaching. That psychiatry is replete with ‘troublesome knowledge’ seems clear. It would appear to be intuitive that an undergraduate medical student who has had teaching in pharmacology, pathology and some clinical medicine will find the concepts of psychopharmacological treatment of mental illness less challenging than the concepts of psychotherapeutic approaches. Similarly, the definition of mental illness is a more challenging concept than that of physical illnesses, one which continues to be the subject of debate. An emphasis on collaborative management of lifelong mental health may seem foreign to students used to the prescriptive, curative approach of most medical practice. Other examples of how psychiatry may be seen as radically different from the rest of medicine by medical students will no doubt spring to mind.

Critiques of threshold concepts Campbell and Johnson describe (and decry) the popularity of educational fashions, and their effect on medical education.11 They argue that a lack of conceptual clarity bedevils the application of educational theories in medical education, and that medical teachers should be more aware of this tendency, and therefore more critical of these theories. This acts as a salutary warning against the blind, uncritical adoption of whatever the latest educational notion may be.

Of course, this is speculative, and empirical research into what medical students find difficult and possibly may experience as ‘threshold’ knowledge about psychiatry may turn up surprising results. Furthermore, as Rowbottom reminds us, the definition of threshold concept can be left so vague that identifying them is impossible.

Rowbottom offers a deep critique of threshold concepts on philosophical grounds.12 He notes that Mayer and Land's definition of threshold concepts does not allow, even in principle, for them to be empirically identified. This is because there are three major philosophical approaches to the term ‘concept’, the first – dominant in philosophy of mind – posits concepts as mental representations. Another reduces concepts to a series of intellectual abilities. A third sees concepts as objects of thought associated with names, neither mental nor spatiotemporal. Given these contending understandings of a ‘concept’, it is difficult to see how to arrive at a consistent, reliable way of defining a ‘threshold concept.’

Meyer and Land write that ‘threshold concepts would seem to be more readily identified within disciplinary contexts where there is a relatively greater degree of consensus on what constitutes a body of knowledge’ (for example, Mathematics, Physics, Medicine, Pace Meyer and Land); there is perhaps less of a consensus on ‘what constitutes a body of knowledge’ within medicine in general and psychiatry in particular than it may appear from outside these disciplines.

Indeed, Rowbottom goes on to argue that as ‘threshold’ is an extrinsic property, what is threshold for one learner will not be so for another. Mayer and Land give as an example of a threshold concept contrasted with a non-threshold concept in physics is gravity (threshold) vs centre of gravity (non-threshold). For Rowbottom, this distinction is spurious – why is centre of gravity less ‘threshold’ than ‘gravity’?

Meyer and Land, in their discussion of threshold concepts, do not specify just how they are to be identified. Teachers in a range of disciplines are cited as giving examples of counter-intuitive knowledge in their disciplines – for instance, opportunity cost in economics, or the total abolition of the high culture/low culture distinction in cultural studies – but they do not suggest a methodology for arriving at threshold knowledge.

Of course, the same point could be made about contending definitions of terms like ‘foundation knowledge’, ‘core competencies’, ‘professional attitudes’, ‘reflective practice’ and other terms used in educational discourse. This does not prevent teaching and learning from happening. Even if there are grounds for philosophical debate on the precise meaning of a particular term, it may still have a useful role in curricular design and implementation.

Potential practical approaches are suggested by Irvine and Carmichael.14 They describe how, over eight disciplines, teaching staff in higher education were introduced to the idea of threshold concepts. They were then invited to identify potential threshold concepts in their own disciplines via smallscale research projects. Some participants worked with students near the end of their studies, or with recent graduates, to identify threshold concepts; others worked with students from throughout their teaching spectrum.

Role transitions such those described by Clouder can be seen as more affective and attitudinal than conceptual, and what is being described as ‘troublesome knowledge’ is really a collection of

Irvine and Carmichael focus on three disciplines – sports science, English, and engineering, and describe the process of identifying

133

References 1. Eagles J M, Wilson, S, Murdoch, JM. Brown T. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatric Bulletin, 31: 70-72, 2007 2. Scott I.M. (2009) Whether or wither some specialties: a survey of Canadian medical student career interest. BMC Medical Education, 9:57 3. Tinto, V. Leaving College: Rethinking the Causes and Cures of Student Attrition. Chicago: The University of Chicago Press. 1987. 4. Braxton, J.M. (2000) Reworking the student departure puzzle. Vanderbilt University Press, Nashville. 5. Feifel D, et al. Attitudes Toward Psychiatry as a Prospective Career Among Students Entering Medical School. American Journal of Psychiatry 1999; 156:1397–402 6. Guerandel, A., Mac Suibhne S, Malone K. Best evidence medical education and psychiatry in Ireland: a three step framework for change. Irish Journal of Psychological Medicine 25(4): 120-122 7. Meyer J H F Land R (2003) "Threshold Concepts and Troublesome Knowledge – Linkages to Ways of Thinking and Practising" in Improving Student Learning – Ten Years On. C.Rust (Ed), OCSLD, Oxford. 8. Mezirow, J. (2000). Learning as Transformation: Critical Perspectives on a Theory in Progress. Jossey Bass, San Francisco 9. Perkins, D.. (1999) The many faces of constructivism. Educational Leadership, 57 (3), 1999. 10. Clouder L (2005). Caring as a 'threshold concept': Transforming students in higher education into health (care) professionals. Teaching in Higher Education,10(4), 505517, 2005 11. Campbell, J.K, Johnson, C. (1999) Trend spotting: fashions in medical education. British Medical Journal, 318: 1272-1275. 12. Rowbottom DP . (2007) “Demystifying threshold concepts.” Journal of Philosophy of Education, 41(2), 263-270 13. Raw, J. Brigden D. Gupta R. Reflective diaries in medical practice Reflective Practice, Vol 6. No. 1, pp 165-9, 2005 14. Irvine N, Carmichael, P. Threshold Concepts: A point of focus for practitioner research., Active Learning in Higher Education, Vol. 10, No. 2, 103-119, 2009 15. Ibid. 16. Chen FM, Burstin, H. and Huntington, J. (2005), The importance of clinical outcomes in medical education research. Medical Education, 39(4), 350-1

threshold knowledge, and the participants’ reflective comments on this, in detail. They describe differing conceptualisations of threshold knowledge across the disciplines, “with varying stress laid on their transformative, integrative, troublesome, irreversible or bounded aspects.” Therefore there was considerable variety and a lack of strict conceptual consistency about threshold concepts from these practitioners. Despite this, participants did not question the utility of the threshold knowledge concept, and the authors also reported that the experience was fruitful in engaging the participants in thinking about their teaching and what makes their discipline distinctive.15 The conceptual difficulties pointed out by Rowbottom are far from satisfactorily resolved. Assuming that all students will find the same ideas either threshold concepts or troublesome knowledge is misleading. However, notwithstanding these objections, the threshold knowledge concept may offer promise for conceptualising approaches to teaching in psychiatry for both undergraduates and postgraduates. Just as teachers need to allow for the wide range of learning styles that exist in any group, accepting that a range of concepts could be considered threshold amongst a group of learners is important. The distinction between core and threshold knowledge is a difficult one to make. It may simply be a question of contending metaphors of learning. ‘Core’ or ‘foundation’ knowledge implies a metaphor of learning as the construction of a solid structure or object. ‘Threshold’ knowledge implies a journey, a process of discovery with new vistas opening up along the way. Empirical research on this topic, and judicious application of the fruits of this research, may help medical students manage threshold and troublesome knowledge within psychiatry and become more fully engaged in the subject. Bridging the gap between educational theory and the reality of medical practice is no small task. It is recognised that medical educationalists must begin to define clinical outcomes for their innovations in teaching and curricular design.16 As well as a need for educationalists to engage with clinical reality, clinicians need to engage with the educational process. This includes a critical awareness of trends and developments in educational theory and practice. Among the benefits that Irvine and Carmichael report from the process of identifying threshold knowledge is a greater conceptual clarity about the nature of the discipline. Thinking about what distinguishes a particular subject from others can be concentrated by trying to identify what is threshold knowledge for that subject. The process of trying to attempt to identify threshold knowledge may be of benefit to psychiatry as a discipline in ways beyond teaching of medical students.

Conflict of interest None.

134

BOOK REVIEW

A Practical Guide to Cluster Randomised Trials in Health Services Research Sandra Eldridge and Sally Kerry John Wiley & Sons, Ltd. 2012 (298pp), ISBN: 978-0-470-51047-6 Ir J Psych Med 2012; 29 (2): 135 In this book, Sandra Eldridge and Sally Kerry have provided an informative and readable resource for conducting cluster randomised trials. Clustered trials first occurred in schools in the 1940s and by the 1970s they were used for medical research; however it was not until the 1990s that a text book was first written on the subject. Due to the relative newness of this medical research tool, many methodological developments have occurred in the last 10 years. This practical guide provides well-referenced information on many of the recent developments in this area, as well as a comprehensive general overview.

chapter nine. These three chapters cover analysis, sample size calculation and inter-cluster correlation coefficient, and are well laid out and very approachable, however they are unavoidably mathematically dense. The chapter dealing with analysis is comprehensive and provides illustrations for different types of outcome and design: while the 37 pages dedicated to this require full concentration they are surprisingly manageable. This chapter discusses, amongst other things, the important influence of cluster size, number and variability. Chaper seven covers sample size calculation. This chapter does a good job of alleviating much of the fear and paralysis which is often often associated with power calculations. This chapter is as compelling a read as the title; Sample size calculation would lead you to believe. It does, however, carefully talk through some important considerations and address many of the questions concerning power calculation in a straight-forward manner. Chapter eight, on calculation of intra-cluster correlation coefficient, gives information on an area which researchers unfamiliar with cluster based trials will find essential.

Cluster-based trials have specific strengths that are useful in modern healthcare. There is an increasing emphasis on prevention in medicine, and psychiatry is no exception. In recent years, there has been a significant financial investment in educational and population-based interventions aimed at prevention. This is seen in campaigns such as ‘drink responsibly’ and ‘see change’. In addition to this, there is growing pressure to improve the provision of services and to restructure organisations more efficiently. Interventions in these two areas, prevention and organisational management, have two elements in common that make cluster based trials an efficient tool for evaluating change. Firstly, these interventions do not occur at an individual level and secondly, such interventions are often complex in nature. One of the strengths of cluster-based trials is that they are able to investigate interventions on these levels. These trials can help answer questions such as: Are the leaflets and information posters we see in GPs, pharmacies and hospitals an effective use of resources, and do administrative changes improve the attendance at a clinic?

The final two chapters cover topics including systematic reviews, cost-effective analysis, process evaluation and trial reporting. The information on trial reporting discusses the CONSORT statement section by section and gives information on improving trial reporting. One of the main strengths of this book is the breadth of topics considered. This book, also, walks the fine line between providing too much basic epidemiological information and not providing enough. From the start this book gives lots of examples of cluster trials to flesh out theoretical points, which helps hold the readers interest and promotes thinking about practical issues. Each chapter is well referenced allowing a reader to easily gain a deeper understanding of the topic should they so wish. This is essential reading for anyone considering conducting a cluster based intervention and a useful reference book for people evaluating the results of such trials.

As we can see from the above, cluster randomised trials are important and this book serves as an excellent introduction to conducting them. This book covers every aspect of embarking on trials of this nature: from initial planning, through ethics, design and analysis, to reporting. The first five chapters begin by looking at the basic principals of cluster based trials. The introduction is very informative and gives some useful background. Recruitment and ethics are discussed next which give guidance in the complex area of consent in cluster trials. The third chapter, on design of intervention, is very helpful in providing an approach to creating an intervention and may be the most useful section in the book. Study design including pilot and feasibility studies are discussed in these early chapters. These chapters also cover such questions as: Who consents in a cluster, is information gathered on all members of a cluster, does not doing this introduce bias, and how is a complex intervention developed?

Richard Duffy, UCD Special Lecturer in Psychiatry, Department of Adult Psychiatry, 63 Eccles St, Mater Misericodiae University Hospital, Dublin 7, Ireland Email: duffyrm@gmail.com

While this is not a book that will be enjoyed by the arithmophobic, should they survive the first five chapters they may well want to take a well-deserved break of a few chapters, and skim through to

135

BOOK REVIEW

Trinity’s Psychiatrists: From Serenity of the Soul to Neuroscience Marcus Webb Trinity College Dublin. 2011 (141pp), ISBN: 9781871408614 Ir J Psych Med 2012; 29 (2): 136 Social historians castigate doctors for writing about their historical peers without taking the social and political contexts in which they practiced into account. This book, published as part of the tercentenary celebrations of the TCD School of Medicine, may escape some of these criticisms. It has been authored by Marcus Webb, retired Professor of Psychiatry at that College and ranges over the history of mental disorder and the responses to it (medical and social) from the 17th century onwards and the TCD medical graduates who played a part in this, as well as some who graduated elsewhere.

to the Adelaide, he was President of the Royal College of Physicians, and on resigning from that hospital to devote himself full time to Farnham, became president of the Medico-Psychological Association (MPA) in 1875. That Trinity psychiatrists contributed to the public asylum service is evident by the roles of Connolly Norman in Grangegorman, Drapes in Enniscorthy and Woods in Cork. All three had served as presidents of the MPA and the first two in particular had made substantial contributions to the science of their speciality. Drapes has always struck me as not quite receiving due credit for his scholarship and the work he did in interpreting research work in France and Germany in his reviews as Editor in Chief of the Association’s Journal. Despite their extensive enquiries they and other contemporaries portrayed frustration in their searches for understanding the origins of mental disorder. W R Dawson, another TCD graduate and lunacy inspector, who had worked at the aforementioned Farnham House, was also a keen researcher with interests in the epidemiological field who, following 1922, became Chief Medical Officer in Northern Ireland. And then there was the energetic (he played rugby for Ireland) Daniel Rambaut organising concerts, drama and cricket at fin de siècle Grangegorman before departing for St Andrew’s, Northampton, and presidency of the MPA in 1934. In contrast to the 19th century, of the 95 medical officers employed in district mental hospitals in 1963 only one was a Trinity graduate

Inevitably we re-encounter the ubiquitous Swift and notice how churchmen contributed in siring sons who, instead of following their father’s footsteps in making souls serene, pursued the closely allied art (or was it science?) of succouring the mind disabled. These included Connolly Norman, Drapes, Rambaut and Moore, all sons of the manse, and some such as Bennet and McCracken dually anointed clergymen and psychiatrists. Religion came to the fore again in the founding by the Quakers of Bloomfield in 1812 where the influence of moral treatment as practised at the York Retreat was adopted. And it was at Bloomfield that the Eustace dynasty was established when John Eustace was appointed superintendent in 1813. Leaving Bloomfield in 1825 he and two others opened Hampstead in Glasnevin as a private enterprise and the rest is history. While many of those prominent in this book were not Trinity graduates neither were some of them psychiatrists. Cheyne, of Cheyne-Stokes, for instance, was neither Irish, TCD graduate nor psychiatrist but nevertheless was much pre-occupied by mental disorder as quotations from his reflections on the topic testify, particularly his prescient recognition of what we now call bipolar disorder.

Having qualified at RCSI, Richard Leeper came to the rescue of St Patrick’s in 1899 bringing it back to respectability from the chaos into which it had descended in the later years of the previous century. He, too, became yet another Irishman to preside the MPA in 1931/32. More within recent memory is the role of Norman Moore in extending and further modernising that hospital and establishing a link with the St James Psychiatric Unit of which the author was clinical director until his retirement. Although the first professorship of psychiatry had been established by UCD in 1950 the TCD equivalent did not follow until Peter Beckett was appointed in 1969. Fresh from the US he brought enthusiasm and openness to a scene that had become inward looking and became Dean of TCD Medical School but died very soon afterwards. Following a brief interregnum he was followed in the Professorship by our author

Those post-graduates hoping to pursue a career in psychiatry in the 1950s had the choice of Diplomas of Psychological Medicine awarded by each of the three Dublin medical schools with Trinity being in the van having introduced this qualification as early as 1926. Nonetheless there was no formal lecture or instruction course in those days and aspirants were left to muddle on as best they could with Henderson and Gillespie’s textbook as their bible. Not surprisingly neither US nor British reviewers of the Irish medical educational scene of the 1950s were impressed by what they saw on visits here. It is surprising therefore to learn that, in contradistinction to the postgraduate scene, TCD had initiated undergraduate study of mental disease as far back as 1893 which the General Medical Council was later to make compulsory for Irish medical schools. These were initiated by Dr John Molony, Superintendent of St Patrick’s, later deposed when he married one of his former patients. A shadowy figure of whom I had heard little until I read this book was James Duncan who followed his father as chatelain of the private Farnham House in Finglas. A physician

In subsequent chapters this book outlines the development of the TCD Department of Psychiatry. There follows a dramatis personae of those involved. Irish psychiatrists may boast of, or wonder at, the plurality of academic posts in Irish psychiatry per head of population in no less than six medical schools (surely something of a world record, including an ex-officio professorship with Medical Directorship of St Patrick’s). And Trinity psychiatrists abroad are not forgotten. contd. over >

136

BOOK REVIEW

The Language of Mental Health: A Glossary of Psychiatric Terms Narriman C. Shahrokh , Robert E. Hales, Katharine A. Phillips, Stuart C. Yudofsky American Psychiatric Publishing. (346pp), ISBN: 978-1-58562-345-7 Ir J Psych Med 2012; 29 (2): 137 This book is a recent publication from American Psychiatric Publishing. In the preface, the authors hope that this glossary will be ‘a resource for anyone who needs concise but thorough explanations of terms that have pertinence to the practise and study of mental health’. Not only is it aiming to be used by and useful to mental health professionals but also to patients and their families, mental health advocacy organisations and attorneys amongst others. On reading this the target audience may appear broad yet all of the glossary’s entries, while some aimed at one mental health group more than another, merited inclusion. So here you will find specialised terms sitting alongside more general ones. For example, sympathomimetic and sympathy. In all cases, the authors focus on a term’s essential salient points to convey the meaning to as wide an audience as possible. However there is never a sense that explanations or descriptions are being dumbed down in the mass appeal. The entries are extensively cross-referenced and lead the reader on to other related terms which helps add to the user’s knowledge.

also have the annoying habit of appearing in exams. But omissions were the exception rather than the rule. Another bug bear of mine with this book was that on some occasions when describing a particular neurological sign, e.g. abulia, it did not contain the relevant location of the insult, whereas for other terms such as prosopagnosia, it did. Consistency here would be desirable. Descriptions of major mental disorders are explained succinctly and focus on the core features of the illness. While the DSM-IV is referenced, the explanations do not become overly engrossed in the complete diagnostic criteria. Again this reflects the author’s wish to allow readers to ‘grasp the meanings more easily’ and it works. Following the glossary, there is a section listing abbreviations used in psychiatry. Next, a section on medications used in Psychiatry which classifies medication on the basis of its therapeutic effect. The pharmacology of each medication has already been described in the glossary itself which nicely compiles relevant tests under different psychiatric diagnoses headings for your consideration following the assessment of a patient. Next there is a section on legal terms which would be useful in the preparation of court reports or in giving evidence. Finally there is a section listing support organisations and websites, all of which are based in the United States and perhaps not as relevant to clinicians or service users in Ireland.

As a glossary its scope is wide. It includes terms that provide insight into the historical, biological, pharmacological, psychological and medico-legal aspects of psychiatry amongst many others. What I really liked was its well stocked bank of transcultural psychiatry terms, many of which I had not heard of before (Grisi siknis, anyone?). It uses an alphabetical system to move through terms, so each subsequent entry in its description may be unrelated to what came previously, from alien hand syndrome to alienist unless they have a common root.

In summary, this book would be a welcome addition to any library or your own bookshelf. It comprehensively deals with a wide variety of psychiatric terms and explains them clearly and simply. Apart from its use as a reference text, it is a useful book to dip into and discover different psychiatric terms that you may need to brush up on. I would certainly recommend this book to others working in mental health especially trainees new to the grade.

I approached the book as a 3rd year BST trainee in the final throes prior to the MRCPsych CASC exam. As a trainee, there are certain terms that can create confusion particularly early in training e.g. circumstantiality/tangentiality, catalepsy/cataplexy. This book deals with examples such as these well and references other relevant terms, clarifying the distinguishing characteristics. It may seem pedantic to talk about what has been left out when so much has been put it but there were some terms such as reflex hallucination/ synthesthesia, delusional mood and delusional perception, of which I would have welcomed a clear explanation. These terms

Eric Kelleher, Clinical Research Fellow, Department of Psychiatry and Neuropsychiatric Genetics Research, Trinity Centre for Health Sciences, Dublin 8, Ireland Email: eric.kelleher@tcd.ie

contd. > Dermot Walsh, Consultant Psychiatrist Emeritus, Health Research Board, Knockmaun House, Lower Mount Street, Dublin 2, Ireland

This is a potpourri of a book which would have benefitted from a modicum of structural control and the shedding of some of the oft-repeated general historical background. Nonetheless it contains a quantum of information not available elsewhere and for that alone, coupled with the author’s diligence in mining sources, it has been a worthwhile exercise. Finally, unlike many publications of its type, it provides an index and short glossary of technical terms.

137

BOOK REVIEW

Health Equity, Social Justice and Human Rights Ann Taket Routledge/Taylor and Francis Group, London and New York, 2012 (224pp), ISBN: 978-0-415-61375-0 Ir J Psych Med 2012; 29 (2): 138 This is a good book about an important topic: health equity. Inequities which are unfair and unjust are evident in societies and health systems all around the globe. Differences in life-expectancy, maternal mortality, patterns of preventable disease, and distribution of health-care resources are all around us. This list is endless, and this book attempts to chart an approach to this situation based on the twin concepts of social justice and human rights.

practice, policy advocacy, programme design, health planning and empowerment education. Particular emphasis is placed on evaluating the human rights effects of health and social policy in Chapter 6, which also presents an interesting seven-stage method of human rights analysis in this field. This is an extremely involving passage in the book, which merits reading in full, if only because it addresses one of the recurring and most troubling questions in this field: while the theory of human rights is undoubtedly highly relevant in field of health-care, how precisely can we evaluate and re-design programmes in order to improve their human rights implications? In other words, how can health-care providers and planners operationalise the noble ideals underpinning concepts of human rights? The seven-stage method outlined in this book is very useful in this regard, not least because it combines high ideals with pragmatism in a field which is often filled with admirable rhetoric rather than practical suggestions.

Seven of the 12 chapters in this fascinating book are written by Ann Taket, Professor of Health and Social Exclusion, and Director of the Centre for Health through Action on Social Exclusion (CHASE) at the School of Health and Social Development in Deakin University, Australia. Professor Taket sets the scene at the outset by providing a concise overview of the field of health equity and places particular emphasis on human rights and the possibilities offered by a rights-based approach to health equity. The global human rights system is examined in greater depth in Chapter 2, which commences with a quote from former UN Secretary-General Boutros Boutros Ghali, emphasizing the centrality of human dignity in considerations of social justice and human rights:

The next four chapters, written by various different experts, assume a similarly pragmatic approach to examine specific human rights and health issues in various settings, including the sexual and reproductive health needs of adolescents in South Africa (written by Melika Chiswell), a ‘mid-day meal scheme in Madhya Pradesh’ in India (Arjun Singh) and a ‘tobacco prevention strategy in Styria, Austria’ (Michaela Adamowitsch). From the perspective of mental health, the most interesting contribution is the ‘retrospective human rights analysis’ of the National MindMatters Project in Australia, a programme to promote mental health and wellbeing in secondary school students. Those designing similar programmes in other countries might find this interesting reading.

“Our contemporary human rights system is heir to demands for human dignity throughout history and across cultures. It expresses the enduring elements of the world’s great philosophies, religions and cultures.” The theme of human dignity duly recurs repeatedly throughout this book. The general consideration of human rights is especially good here in this early section of the book, acknowledging, for example, the idea of ‘valid’ limitations on human rights in situations of ‘significant risk.’ These are difficult concepts which are well-articulated and explored in this chapter. With pleasing logic, Chapter 3 moves on to look at ‘regional human rights systems’ in Africa, the Americas, Europe and the Middle East, amongst other areas, while Chapter 4 examines ‘national and subnational human rights systems.’

This extremely useful volume concludes with a thoughtful consideration of the ‘instrumental value of human rights in health’ by Brad Crammond and a concluding chapter by Ann Taket, entitled ‘Success or failure: How useful are rights-based approaches in public health?’ Overall, this book is a sturdy addition to the literature on human rights and health: it combines high ideas with pragmatism, and charts a reasonable course forward for practitioners concerned with the human rights implications of health policies and programmes.

The issue of health equity moves to centre stage in Chapter 5, which articulates three components of the relationship between health and human rights: • Violations of human rights can affect health negatively (e.g. slavery, torture); • Promotion of human rights can affect health positively (e.g. through enhancing social determinants of health); • Health development can affect observance of rights (e.g. reducing discrimination).

Brendan D. Kelly, Consultant Psychiatrist and Senior Lecturer in Psychiatry Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Dublin 7, Ireland. E-mail: brendankelly35@gmail.com

Chapter 5 goes on to outline various rights-based approaches to different aspects of health-care processes, including clinical

138

LETTERS

TO THE

EDITOR

Ir J Psych Med 2012; 29 (2): 139

Exploring Health in Census 2011 Frank Houghton, Sharon Houghton Dear Editor, From a health perspective the Irish 2011 Census represents something of a mixed blessing. Its obvious limitations include the continuing absence of questions exploring both smoking1 and income,2 as well as the disappearance of the Census 2006 voluntary activity question. These questions could have helped direct health promotion efforts, measure and explore the health impacts of income inequality, and examine links between health and social capital/ social cohesion.3 Although some of this information has been captured via the Survey on Lifestyles, Attitudes & Nutrition (SLAN4), the Census facilitates the collection of such data on an almost universal level and includes valuable information at a local level. Inclusion of such personal questions may raise ethical issues in some quarters. However, it must be acknowledged that there appears to be little formal opposition to the Census in Ireland. There are also a number of positive developments in relation to health in the 2011 Census that must be acknowledged. One such development has been the insertion of the age filter at a later point in the census form, so that it now appears after the question relating to Carers. In the last Census valuable data on the extent and burden of carers, and the relationship between these factors and the health of carers was collated.5 However, in 2006 due to the insertion of the age filter at an earlier stage on the Census form, data relating to Child Carers was missed. The UK Census of the same year however highlighted a significant number of children who performed the role of Carer.5 The alterations to the Irish census form should allow for the collection and collation of this data, which should in turn help to provide a better picture of the situation in relation to Irish Children who find themselves in the role of Carer. As health researchers have come to expect, the Census will continue to ask questions about both long-term, restrictive conditions and their impact on activities of daily living. Perhaps the most interesting new healthrelated development in the Census is the inclusion of a single-item global health

measure. Many researchers will be familiar with items such as these via routine measures like the MOS SF-36, which includes a global measure in both versions (‘In general, would you say your health is: Excellent; Very good; Good; Fair; Poor’).6 Although such items may be contested, they can still provide a valuable, cost-effective, and virtually instantaneous insight into general wellbeing, and have been shown to be a robust predictor of mortality in longitudinal studies.7 The actual question (listed below) is a standard Organisation for Economic Cooperation and Development (OECD) measure that will facilitate international comparisons8 and includes a more balanced range of answers than the standard SF-36 measure given above: How is your health in general? • Very good • Good • Fair • Bad • Very bad Although this question asks generically about health, it is clear that this type of question will undoubtedly be very useful in evaluating mental as well as physical health. A wide-ranging review conducted by Ware et al. for the Rand Corporation noted the significant relationship between such global measures and mental health constructs such as Happiness, Anomie, Life Satisfaction, and Self-Satisfaction9. More recent research has clearly confirmed this finding at local, national and international scales.10-11 Although other easy-to-complete measures which discriminate between mental and physical health exist, these are unlikely to be available at population level for Ireland in the near future. However, age, gender, and social class/educational level norms for the OECD general health question will be available shortly for Ireland. Therefore clinicians and researchers conducting research and evaluations into the future should seriously consider appending this single-item measure into their research to explore how this single-item measure maps across onto other conditions and domains.

139

Frank Houghton* Public Health Geographer & Lecturer, Dept. of Humanities, Limerick Institute of Technology, Moylish, Limerick, Ireland. E-mail: Frank.Houghton@LIT.ie Sharon Houghton, Dept. of Education & Professional Studies, University of Limerick, Limerick, Ireland * Correspondence References 1. Houghton F. Smoking & the Census – Need for an International Consensus. Aust N Z J Public Health 2001; 25(5): 478. 2. Houghton F. Census 2001 – Steps in the right direction, but still room for improvement. Ir Med J 2001; 94(6): 185. 3. Harper R. The Measurement of Social Capital in the United Kingdom. London, Office for National Statistics; 2002. 4. Morgan K, McGee H, Watson D, Perry I, Barry M, Shelley E, Harrington J, Molcho M, Layte R, Tully N, van Lente E, Ward M, Lutomski J , Conroy R, Brugha R. SLÁN 2007: Survey of Lifestyle, Attitudes & Nutrition in Ireland. Main Report. Dublin: Department of Health and Children, 2008. 5. Houghton F. The CSO, the Census and the needs of Carers. Irish Geography 2009; 42(3): 353-355. 6. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and Interpretation Guide. Boston, MA: New England Medical Center, The Health Institute, 1993. 7. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J. Health Soc Behav 1997; 38(1): 21-37. 8. OECD. Health at a Glance Europe: 2010. OECD Publishing; 2010. Accessed on September 30th 2011 at http://dx.doi.org/10.1787/health_glance-2010-en. 9. Ware JE, Davies-Avery A, Donald CA. Conceptualization and Measurement of Health for Adults in the Health Insurance Study: Vol. V, General Perceptions. Santa Monica, CA: Rand; 1978. 10. Marmot M, Wilkinson RG Social Determinants of Health. Oxford: Oxford University Press 2006 11. Berkman LF, Kawachi, I. Social Epidemiology. Oxford: Oxford University Press, 2000.

LETTERS

TO THE

EDITOR Ir J Psych Med 2012; 29 (2): 140-141

The Dissociative Experiences Scale: A Welsh Translation Christopher Alan Lewis, Martin J. Dorahy, Julie Brake, Mary Jane Lewis Dear Editor, For both researchers and clinicians there exists a wide range of self-report instruments to measure frequency and types of dissociative experience. Examples include the Perceptual Alterations Scale,1 the Questionnaire of Experiences of Dissociation,2 the Dissociation Questionnaire,3 the Dissociative Processes Scale,4 the Multiscale Dissociation Inventory,5 and the Child Dissociative Checklist.6 The Dissociative Experiences Scale (DES),7 a 28item instrument that measures a wide variety of dissociative phenomena (e.g., absorption, imaginative involvement, depersonalisation, derealisation, amnesia), is the most frequently used.8 In addition to the original DES, there now exists a wide range of adaptations of the measure for use among specific samples, including adolescents,9 the visually impaired,10 and the profoundly deaf.11 Moreover, there are a large number of foreign language translations of the DES.12 Examples include translations into Dutch,13 Turkish,14 Japanese,15 German,16 French,17 Hebrew,18 Finnish,19 and Portuguese.20 The present aim was to provide a Welsh translation of the DES for use among Welsh speakers. The utility of such a tool is that it should help facilitate the work of clinicians and researchers in Wales. For clinicians, the availability of such a tool would allow assessment of dissociative experiences and symptoms among service users who prefer to be assessed in Welsh. At present, outside of the GP practice most “health-related business” is conducted in English.21,22,23,24,25 For researchers, the availability of the tool would mean that dissociation, and potentially its antecedents and correlates, could be examined using language sensitive measures, thus heightening the ecological validity of work in this area The DES was translated and back translated by two experienced translators familiar with health-related research. No relevant cultural differences were found for any item. This is not surprising given that the events and activities which evoke, anchor to, or are associated with dissociation in the North American context from which items were written do not differ from those of Welsh speakers in Wales. Linguistically, only item 8 proved a little problematic in translation. This is because the

impersonal “some people are told” in Welsh is quite formal (linguistic registers in Welsh are more obvious than in English) and there is a tendency to use active rather than passive constructs. “Some people find” also could not be translated directly as this idiom is not used in Welsh. Appendix 1 contains the 28 items of the Welsh translation of the DES. Further work is now required to examine the reliability and validity of the Welsh translation of the DES. Initial research should focus on establishing the psychometric properties of the scale, including examining the internal reliability, temporal stability, convergent validity, and construct validity. Providing the scale was found to be reliable and valid, subsequent research may wish to establish the correlates and antecedents of dissociation within the Welsh context. It is hoped that the present contribution helps stimulate research on dissociation within Wales among Welsh speakers. More broadly, at present there is a dearth of Welsh translated tests in both clinical and health psychology,26,27,28 or indeed more widely within psychology.29,30,31 Further research may wish to provide a systematic review of available tests in psychology in the Welsh language, as well as providing translations of the more widely used psychometric tests. *Christopher Alan Lewis, Professor of Psychology, Division of Psychology, Institute for Health, Medical Sciences and Society, Glyndŵr University, Plas Coch Campus, Mold Road, Wrexham, LL11 2AW, Wales, UK. Email: ca.lewis@glyndwr.ac.uk Martin J. Dorahy, Associate Professor of Psychology, Department of Psychology, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand. Julie Brake, Senior Lecturer in Welsh, Division of Education, Institute for Health, Medical Sciences and Society, Glyndŵr University, Plas Coch Campus, Mold Road, Wrexham, LL11 2AW, Wales, UK. Mary Jane Lewis, Research Assistant, Division of Psychology, Institute for Health, Medical Sciences and Society, Glyndŵr University, Plas Coch Campus, Mold Road, Wrexham, LL11 2AW, Wales, UK.

140

References 1. Sanders S. The Perceptual Alteration Scale: A scale measuring dissociation. American Journal of Clinical Hypnosis 1986; 29: 95-102. 2. Riley KC. Measurement of dissociation. Journal of Nervous & Mental Disease 1988; 176: 449-450. 3. Vanderlinden J, Van Dyck R, Vandereycken W, & Vertomen H. Dissociative experiences in the Netherlands and Belgium: A study with the Dissociative Questionnaire (DIS-Q). Dissociation 1993; 4: 180-184. 4. Harrison JA, Watson D. The Dissociative Processes Scale. Unpublished manuscript, Department of Psychology, University of Iowa, Iowa City, 1992. 5. Briere J. Multiscale Dissociation Inventory. Odessa, FL: Psychological Assessment Resources, 2002. 6. Putnam FW, Helmers K, Trickett PK. Development, reliability, and validity of a child dissociation scale. Child Abuse & Neglect 1993; 17: 731-741. 7. Bernstein EM, Putnam FW. Development, reliability, and validity of a dissociation scale. Journal of Nervous & Mental Disease 1986; 174: 727-735. 8. Carlson EB. Trauma assessment: A clinician’s guide. New York: Guilford Press, 1997. 9. Armstrong JG, Putnam FW, Carlson EB, Libero DZ, Smith SR. Development and validation of a measure of adolescent dissociation: The Adolescent Dissociative Experiences Scale. Journal of Nervous & Mental Disease 1997; 185: 491-497. 10. Lewis CA, Dorahy MJ, O’Rawe B, O’Rawe A. The Dissociative Experiences Scale: Replacement items for use with the visually impaired. Irish Journal of Psychological Medicine 2006; 23: 121-122 (Letter). 11. Lewis CA, Dorahy MJ, Lewis MJ, Baker SA. The Dissociative Experiences Scale: Replacement items for use with the profoundly deaf. Irish Journal of Psychological Medicine 2010; 27: 102 (Letter). 12. Carlson EB. Studying the interaction between physical and psychological states with the Dissociative Experiences Scale. In D. Spiegel (Ed.), Dissociation: Culture, mind, and body (pp. 41-58). Washington, DC: American Psychiatric Press, 1994. 13. Ensink BJ, Van Otterloo D. A validation study of the DES in the Netherlands. Dissociation 1989; 2: 221–223. 14. Yargic LI, Tutkun H, Sar V. Reliability and validity of the Turkish version of the Dissociative Experiences Scale. Dissociation 1995; 8: 10-13. 15. Umesue M, Matsuo T, Iwata N, Tashiro N. Dissociative disorders in Japan: A pilot study with the Dissociative Experiences Scale and a semi-structured interview. Dissociation 1996; 9: 182-189. 16. Spitzer C, Freyberger HJ, Stieglitz RD, Carlson EB, Kuhn G, Magdeburg N, Kessler C. Adaptation and psychometric properties of the German version of the Dissociative Experiences Scale. Journal of Traumatic Stress 1998; 11: 799-809. 17. Darves-Bornoz JM, Degiovanni A, Gaillard P. Validation of a French version of the Dissociative Experiences Scale in a rape victim population. Canadian Journal of Psychiatry 1999; 44: 271-275. 18. Somer E, Dolgin M, Saadon M. Validation of the Hebrew Version of the Dissociative Experiences Scale (H-DES) in Israel. Journal of Trauma & Dissociation 2001; 2: 53-65. 19. Lipsanen T, Saarijärvi S, Lauerma H. The Finnish version of the Dissociative Experiences Scale-II (DES-II) and psychiatric distress. Nordic Journal of Psychiatry 2003; 57: 17-22. 20. Espírito Santo H, Abreu JLP. Portuguese validation of the Dissociative Experiences Scale (DES). Journal of Trauma & Dissociation 2009; 10: 169-182. 21. Dobson R. Doctors in Wales should learn Welsh. British Medical Journal 1996; 313: 444. 22. Hughes L, Brookes C, Cocker C, John DN, Jones AT,

Table 1 The 28 items of the Welsh translation of the DES G P D Mae’r cwestiynau hyn yn disgrifio profiadau y mae’n bosib ichi eu cael yn eich bywyd bob dydd. Dylai eich ateb ddangos pa mor aml y mae’r profiadau’n digwydd ichi pan NA FYDDWCH dan ddylanwad alcohol neu gyffuriau. RHOWCH GYLCH O GWMPAS rhif rhwng 0% i 100% i nodi’r ganran o’r amser y mae hyn yn digwydd ichi. Os yw’n digwydd 45% o’r amser, rhowch gylch o gwmpas 40% a 50%. Dyddiad_______________

Oedran__________

Rhyw: G

1. Mae rhai pobl yn cael y profiad o yrru neu o deithio mewn car neu ar fws neu drên tanddaearol ac yn sylweddoli yn sydyn nad ydynt yn cofio’r hyn sydd wedi digwydd yn ystod yr holl daith neu am ran o’r daith. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 2. Mae rhai pobl yn gwrando ar rywun yn siarad ac yn sylweddoli’n sydyn na chlywsant ran neu’r cwbl o’r hyn a gafodd ei ddweud. 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 3. Mae rhai pobl yn mynd i le heb fod ganddynt syniad yn y byd o sut y cyraeddasant. 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 4. Mae rhai pobl yn cael y profiad o sylweddoli eu bod wedi eu gwisgo mewn dillad nad ydynt yn cofio eu gwisgo. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 5. Mae rhai pobl yn cael y profiad o gael hyd i bethau newydd ymhlith eu heiddo nad ydynt yn cofio eu prynu. 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 6. Mae rhai pobl weithiau’n cael pobl yn dod atynt nad ydynt yn eu hadnabod sy’n galw enw arall arnynt neu’n mynnu eu bod wedi cyfarfod â nhw o’r blaen. 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 7. Mae rhai pobl weithiau’n cael y profiad o deimlo eu bod yn sefyll yn eu hymyl eu hunain neu’n eu gwylio eu hunain yn gwneud rhywbeth a byddant yn eu gweld eu hunain fel petaent yn edrych ar rywun arall. 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 8. Dywedir wrth rai pobl weithiau nad ydynt yn adnabod ffrindiau neu aelodau o’r teulu. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 9. Mae rhai pobl yn methu â chofio rhai digwyddiadau pwysig yn eu bywydau (er enghraifft, priodas neu seremoni graddio). 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 10. Mae rhai pobl yn cael eu cyhuddo o ddweud celwydd pan nad ydynt yn meddwl eu bod wedi dweud celwydd. 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 11. Mae rhai pobl yn cael y profiad o edrych mewn drych a pheidio â’u hadnabod eu hunain. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 12. Mae rhai pobl yn cael y profiad o deimlo nad yw pobl a gwrthrychau eraill a’r byd o’u cwmpas yn real. 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 13. Mae rhai pobl yn cael y profiad o deimlo nad yw eu cyrff yn rhan ohonynt. 10 20 30 40 50 60 70 80 90 100 (BOB TRO) (BYTH) 0% 14. Mae rhai pobl yn cael y profiad weithiau o gofio digwyddiad a ddigwyddodd yn y gorffennol mor fyw maent yn teimlo fel petaent yn ail-fyw’r digwyddiad. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 15. Mae rhai pobl yn cael y profiad o beidio â bod yn sicr a yw’r pethau y maent yn eu cofio’n digwydd iddynt yn ddigwyddiadau go iawn neu a oeddynt wedi breuddwydio amdanynt. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 16. Mae rhai pobl yn cael y profiad o fod mewn lle cyfarwydd sydd i’w weld yn ddieithr ac yn anghyfarwydd. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 17. Pan fydd rhai pobl yn gwylio rhaglen deledu neu ffilm maent yn ymgolli gymaint yn y stori nid ydynt yn gwybod beth arall sy’n digwydd o’u cwmpas. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 18. Mae rhai pobl yn ymgolli gymaint mewn ffantasi neu freuddwyd liw dydd mae fel petai’n digwydd iddynt yn go-iawn. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 19. Mae rhai pobl weithiau’n gallu anwybyddu poen. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 20. Mae rhai pobl weithiau’n gallu syllu i ganol unlle, yn meddwl am ddim, heb sylwi fod amser yn mynd heibio. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 21. Mae rhai pobl weithiau’n siarad â’u hunain yn uchel pan fyddant ar eu pennau eu hunain. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 22. Mae rhai pobl yn ymddwyn mor wahanol mewn un sefyllfa o’i chymharu â sefyllfa arall maent yn teimlo bron petaent yn ddau berson gwahanol. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 23. Mae rhai pobl weithiau’n gallu gwneud pethau yn hynod o rwydd a digymell mewn rhai sefyllfaoedd y byddai fel arfer yn anodd iddynt eu gwneud (er enghraifft, chwaraeon, gwaith, sefyllfaoedd cymdeithasol, etc.). (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 24. Mae rhai pobl yn sylwi nad ydynt yn gallu cofio a ydynt wedi gwneud rhywbeth neu dim ond wedi meddwl am ei wneud (er enghraifft, peidio â gwybod a ydynt newydd bostio llythyr neu dim ond wedi meddwl am ei bostio). (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 25. Mae rhai pobl yn cael hyd i dystiolaeth eu bod wedi gwneud pethau nad ydynt yn cofio eu gwneud. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 26. Mae rhai pobl weithiau’n cael hyd i waith ysgrifenedig, lluniau, neu nodiadau ymhlith eu heiddo y mae'n rhaid mai nhw sydd wedi eu gwneud ond eu bod yn methu â chofio eu gwneud. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 27. Mae rhai pobl weithiau’n clywed lleisiau yn eu pen sy’n dweud wrthyn nhw am wneud pethau neu’n gwneud sylwadau ar bethau y maen nhw’n eu gwneud. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) 28. Mae rhai pobl weithiau’n teimlo eu bod yn edrych ar y byd drwy niwl fel bod pobl a gwrthrychau’n ymddangos yn bell i ffwrdd neu’n aneglur. (BYTH) 0% 10 20 30 40 50 60 70 80 90 100 (BOB TRO) Longley M. The role of the Welsh language in community pharmacy service provision in Wales. London: The Pharmacy Practice Research Trust, 2008. 23. Madoc-Jones I. Linguistic sensitivity, indigenous peoples and the mental health system in Wales. International Journal of Mental Health Nursing 2004; 13: 216-224. 24. Misell A. Welsh in the Health Service: The scope, nature and adequacy of Welsh language provision in the National Health Service in Wales. Cardiff: Welsh Language Board, 2000. 25. Roberts G, Irvine F, Jones P, Spencer L, Baker C, Williams C. Report of a study of Welsh language awareness in

healthcare provision in Wales. Cardiff: Welsh Assembly Government, 2005. 26. Francis LJ, Thomas EM. Welsh language adaptation of the short-form Junior Eysenck Personality Questionnaire Revised (JEPQR-S). Psychologist in Wales 2008; 21: 25-32. 27. Hills PR, Francis LJ, Thomas E. The psychometric properties and factor structure of a Welsh translation of the School Short Form of the Coopersmith Self-Esteem Inventory. Research in Education 2007; 78: 103-109. 28. Muntz R, Edwards RT, Tunnage B, Prys C, Roberts GW. Development of a Welsh language version of the EQ-5D Health-Related Quality of Life Measure. Stage one:

141

Translation. The Psychologist in Wales 2005; 18: 21-25. 29. Evans TE, Francis LJ. Measuring attitude toward Christianity through the medium of Welsh. In LJ Francis, WK Kay WS Campbell (Eds.), Research in religious education (pp. 279294). Leominster: Fowler Wright Books, 1996. 30. Lewis CA, Francis LJ. Reliability and validity of a Welsh translation of a short scale of attitude toward Christianity among 9-15 year olds. Irish Journal of Psychology 2002; 23: 101-108. 31. Wiliam U, Roberts G. The Welsh Children’s Intelligence Scale. Windsor: NFER, 1972.

Irish Journal of Psychological Medicine Guidelines for Authors Aim and Scope of the Journal The aim of the Irish Journal of Psychological Medicine is to publish original scientific contributions in psychiatry, psychological medicine (including surgery and obstetrics), and related basic sciences (neurosciences, biological, psychological, and social sciences). The scope of the Journal includes any subspecialties of the above, including, but not limited to, behavioural pharmacology, biological psychiatry, child and adolescent psychiatry, intellectual disability, forensic psychiatry, psychotherapies, psychiatry of old age, epidemiology, rehabilitation, psychometrics, substance misuse, sexual studies, linguistics, and the history, philosophy and economics of psychiatry. The Journal is dedicated to providing reliable, valid clinical and scientific information to inform mental health care decisions and improve the quality of mental health care.

Editorial Standards The Irish Journal of Psychological Medicine complies with the “Code of Conduct and Best Practice Guidelines for Journal Editors” of the Committee on Publication Ethics (2011) and the “Editorial Policy Statements” of the Council of Science Editors (2009). • http://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf • http://www.councilscienceeditors.org/i4a/pages/index.cfm?pageid=3286

Submission Guidelines

• • • • •

The Journal will accept for consideration original papers, brief research reports, audits, clinical case reports, review articles, historical papers, perspective articles, editorials, letters to the editor and book reviews. Original data papers receive top priority for speedy publication.

Means should be accompanied by standard deviations. Exact p values should be provided, unless p<0.0001. Recommended non-proprietary drug names should be used. Writing should be clear, simple and direct. Short sentences are preferred.

Abstract and Key Words The page following the title page should carry an abstract followed by a list of three to ten key words drawn, if possible, from the medical subject headings (MeSH) list of the United States National Library of Medicine and National Institutes of Health (www.ncbi.nlm.nih.gov/mesh). The title and key-words should be chosen to help future literature searchers.

Manuscripts should be prepared in accordance with the “Uniform Requirements for Manuscripts (URM) Submitted to Biomedical Journals” of the International Committee of Medical Journal Editors (2010). www.icmje.org

Title Page

The abstract, up to 150 words for an unstructured or 250 words for a structured abstract (Haynes et al, 1991), should state specifically the main purposes, procedures, findings and conclusions of the study, emphasising what is new or important. For original papers, brief research reports, audits and review articles, a structured abstract is required, using the headings: Objectives, Methods, Results and Conclusions.

The title page should include the paper title, author name(s), author qualifications, author job title(s), author affiliation(s) and full address (es). The name, address, email address and telephone number of the corresponding author should be clearly and separately indicated.

Text

Under the Abstract heading of Method, include, wherever applicable the study design, setting, patients/participants (selection criteria, description), interventions, observational and analytical methods and main outcome measures. (For review articles specify the methods of literature search and selection). Under the Abstract heading of Results, give the most important specific data together with their statistical significance.

• The manuscript should be typed, double-spaced, in 12-point Times New Roman font. • Pages should be numbered but do not use any other automated features (such as endnotes, headers or footers), any form of automated referencing software, or any mechanism to track changes to various drafts of a manuscript. • Numbers one to ten should be written as words in the text, unless used as a unit of measurement; all numbers should be written in digits in tables and figures. • All numbers which start sentences should be written in words, not digits. • Bold type-face should be used for headings of sections and subsections within the paper. • Do not use tabs or indents within the text of the paper. • SI units are required for all measurements.

Original Papers Original papers should be divided into sections as follows: Introduction, Methods, Results and Discussion. A Conclusions section is not mandatory but may be included in the original submission if the author wishes, or may be requested at a later stage by peer-reviewers or editors. The Results section should

142

Conflict of Interest

present a summary of main results and should not simply refer to tables. Reports of randomised trials must conform to CONSORT 2010 guidelines. http://www.consort-statement.org/consort-statement/overview0/

In the interest of accountability all financial and material support for the research and the work should be clearly stated (DeAngelis et al, 2001). Authors of original data must take responsibility for the integrity of the data and accuracy of the data analysis. All authors must have full access to all the data in the study (Davidoff et al, 1986). Authors must declare any conflict of interest clearly, in accordance with the guidance of the International Committee of Medical Journal Editors (2006):

Audit Papers It is preferable that audit papers present the full cycle of clinical audit, including audit, intervention and re-audit. In exceptional circumstances, papers presenting one element of the audit cycle may be published, but priority will be given to papers presenting full audit cycles. The format for audit papers may differ from that outlined for original papers, and may include, for example, Introduction, Audit, Intervention, Re-Audit, Discussion and Conclusions.

“Public trust in the peer review process and the credibility of published articles depend in part on how well conflict of interest is handled during writing, peer review, and editorial decision making. Conflict of interest exists when an author (or the author's institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties). These relationships vary from those with negligible potential to those with great potential to influence judgment, and not all relationships represent true conflict of interest. The potential for conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment. Financial relationships (such as employment, consultancies, stock ownership, honoraria, paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion.”

Clinical Case Reports All clinical case reports must have the patient’s written, informed consent before the paper is submitted.

References Timely references should highlight the paper’s relevance to current research or clinical practice. For references to journal articles (International Committee of Medical Journal Editors, 2006; 2010; Haynes et al, 1991; Bailar & Mosteller, 1998) and to books (Daly et al, 1991; Gardner & Altman, 1989; American Psychiatric Association, 1987) use the ‘Vancouver’ style, i.e. number references in the order they appear in the text, do not alphabetise. Journal titles should be abbreviated as outlined on PubMed by the United States National Library of Medicine and National Institutes of Health (www.ncbi.nlm.nih.gov/nlmcatalog/journals). Please see the sample paper on the website of the College of Psychiatry of Ireland for further details : http://www.irishpsychiatry.ie/Members/MembersInformationTools/i rishjournalofpsychologicalmedicine.aspx

Statement of Informed Consent Where relevant, papers must include a statement regarding informed consent, in accordance with the guidance of the International Committee of Medical Journal Editors (2006): “Patients have a right to privacy that should not be infringed without informed consent. Identifying information, including patients' names, initials, or hospital numbers, should not be published in written descriptions, photographs, and pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. Informed consent for this purpose requires that a patient who is identifiable be shown the manuscript to be published. Authors should identify Individuals who provide writing assistance and disclose the funding source for this assistance. Identifying details should be omitted if they are not essential. Complete anonymity is difficult to achieve, however, and informed consent should be obtained if there is any doubt. For example, masking the eye region in photographs of patients is inadequate protection of anonymity. If identifying characteristics are altered to protect anonymity, such as in genetic pedigrees, authors should provide assurance that alterations do not distort scientific meaning and editors should so note. The requirement for informed consent should be included in the journal's instructions for authors. When informed consent has been obtained it should be indicated in the published article.”

Tables and Figures Figures and graphs should be clear and of good quality, and should be accompanied by relevant data to facilitate redrawing where necessary. Clear and informative headings and captions should be provided.

Submission Process Manuscripts may be submitted electronically via email to journal@irishpsychiatry.ie or sfarrell@irishpsychiatry.ie Full postal address, telephone and fax numbers should be included. Where possible, tables, figures and text should be included in the same document. There is no need to also submit by post or fax. All submitted material will become the property of the Journal until, and if, publication is refused. Material so referred should not be sent elsewhere for publication.

143

Statement of Human and Animal Rights

Other Modes of Review

Where relevant, papers must include a statement regarding human and animal rights, in accordance with the guidance of the International Committee of Medical Journal Editors (2006):

Some guidance on statistical matters for authors is provided by International Committee of Medical Journal Editors (2006; 2010) and Bailar & Mosteller (1998). Notwithstanding this guidance, statistical review may be required for certain papers, and this will be arranged by the Journal editors where indicated. Other, more specialist forms of peer-review may also be required on occasion, and these, too, will be arranged by the Journal editors where indicated.

“When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach, and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should be asked to indicate whether the institutional and national guide for the care and use of laboratory animals was followed.”

Fast-Track Publication Papers which the editors feel warrant fast-track publication will be expedited through the publication process. The decision to ‘fasttrack’ papers lies with the editors.

Plagiarism and Duplicate Publication

Acknowledgements Authors should obtain permission to acknowledge individuals named in any Acknowledgments section, since readers may infer endorsement.

Manuscripts are considered with the understanding that they have not been published previously, either in print or electronic format. In the event that plagiarism or duplicate publication is suspected, the author will be invited to comment on the matter and a decision will be taken by the editors.

Suggested Peer-Reviewers

Appeals

Each submission must be accompanied by the names, professional titles, professional addresses and email addresses of three suggested peer-reviewers. Authors should select these suggested peer-reviewers to include individuals, in any part of the world, who are recognised experts in the area to which the submission refers, and whom the authors believe would provide useful, objective peer-reviews of the manuscript. The editors will give consideration to sending the manuscript to some or all of these peer-reviewers, but are not under any obligation to do so.

In the event that an author wishes to appeal an editorial decision, the author can send a letter of appeal to the Editor-In-Chief. The Editor-In-Chief will pass the relevant materials to the Consulting Editor who may seek external opinion. The Consulting Editor will advise the Editor-In-Chief in relation to the appeal but the final decision on the matter rests with the Editor-In-Chief.

References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington DC: American Psychiatric Association, 1987. Bailar JC, Mosteller F. Guidelines for statistical reporting in articles for medical journals. Ann Intern Med 1988; 108: 266-273. Committee on Publication Ethics. Code of Conduct and Best Practice Guidelines for Journal Editors. London: Committee on Publication Ethics, 2011. http://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf Council of Science Editors. Promoting Integrity in Scientific Journal Publications. Wheat Ridge, CO: Council of Science Editors, 2009. http://www.councilscienceeditors.org/i4a/pages/index.cfm?pageid=3286. Daly LE, Bourke GJ, McGilvray J. Interpretation and Uses of Medical Statistics (4th Edition). Oxford: Blackwell Scientific Publications, 1991. DeAngelis CD, Fontanarosa PB, Flanagin A. Reporting financial conflicts of interest and relationships between investigators and research sponsors. JAMA 2001; 286: 89-91. Davidoff F, DeAngelis CD, Drazen JM, Hoey J, Højgaard L, Horton R, Kotzin S, Nicholls MG, Nylenna M, Overbeke AJ, Sox HC, Van Der Weyden MB, Wilkes MS. Sponsorship, authorship, and accountability. JAMA 2001; 286: 1232-1234. Gardner MJ, Altman DG (editors). Statistics with Confidence: Confidence Intervals and Statistical Guidelines. London: British Medical Journal, 1989. Haynes RB, Mulrow CD, Huth EJ, Altman DG, Gardner MJ. More information abstracts revisited. Ann Intern Med 1990; 113: 69-76. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Vancouver: International Committee of Medical Journal Editors, 2006. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Vancouver: International Committee of Medical Journal Editors, 2010. www.icmje.org

Description of the Peer-Review Process All submissions are acknowledged by email. Submissions are initially considered by the Editor-In-Chief or Deputy Editor for suitability for peer-review. Submissions selected for peer-review are sent to three anonymous outside peer-reviewers. Where one or more peer-reviewers recommend acceptance or acceptance after revision, all peer-reviews are sent to the corresponding author, with an invitation to revise the paper. If the author chooses to revise the paper, the revised paper should be accompanied by a detailed cover letter responding to each comment made by each peer-reviewer, indicating precisely how the revision deals with each comment, or why the author disagrees with or cannot incorporate specific comments. Each peer-reviewer will then receive the revised paper, cover letter and comments of the other peer-reviewers. After the peerreviewers’ further comments have been received, a final decision about publication will be made. The editorial process may vary from the above under certain circumstances, at the discretion of the Editor-In-Chief or Deputy Editor.

144