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June 2009 Vol. 18 No. 1 CONTENTS Editorial Schizophrenia: The Changing Focus of Treatment 1-4 Muhammad Najib Mohamad Alwi Original paper School Bullying Amongst Standard Six Students Attending Primary National Schools In The Federal Territory Of Kuala Lumpur: The Prevalence And Associated Socio Demographic Factors 5-12 Wan Salwina WI

Susan MK Tan Nik Ruzyanei NJ Tuti Iryani MD Syamsul S Aniza A Zasmani S

Stigma Arising From Family Members of the Mentally Ill Patients In Hospital Taiping 13-22 Tuti MD Nursyuhaida MN Nik Siti Fatimah M Faridah Hanim Z Nor Akmar S CT Effa FMF Khairunnisa MZ Marhani M Ruzanna Z

Gender Influences on Psychopathology and Functionality in Schizophrenia in University Malaya Medical Centre, Kuala Lumpur, Malaysia 23-26

Zuraida NZ Gill JS Koh OH Kanagasundram S Saniah AR Sapini Y Salina M Zuraida A

Reliability and Validity of the Malay Version of Brief COPE Scale: A Study on Malaysian Women Treated with Adjuvant Chemotherapy for Breast Cancer 27-35

N Yusoff WY Low CH Yip

Service Utilization and Costs Associated With Switching to Risperidone from Previous Treatment with Typical Antipsychotic Agents 36-48

A Hatim J Tan Mas Ayu H Habil

Early Readmission in Patients after Electroconvulsive Therapy In A University Hospital Setting - A Retrospective Study 49-57

Malaysian Journal Of Psychiatry, June 2009, Vol.18 No.1

i

Ng CG Amer Siddiq AN Salina M Koh OH Zuraida NZ

Depression, Anxiety and Stress in Women with Breast Cancer: Effect Of A 4-Week Self Management Intervention 58-66

Loh SY Tan FL Xavier M

Case Report Rechallenging Clozapine after an Episode of Angranulocytosis 67-70

Mohamed S Lockman H

A Case of Suspected Clozapine Related Myocarditis 71-74

Thanasan S Rusdi AR

Education paper Model Answer for Critical Review Paper: Conjoint Examination Master Of Medicine (Psychiatry) And Master Of Psychological Medicine May 2008 75-80

Hatta Sidi Assessing personality: a guide for students 81-85

Saxby Pridmore


ii

EDITORIAL

SCHIZOPHRENIA: THE CHANGING FOCUS OF TREATMENT

Muhammad Najib Mohamad Alwi

Cyberjaya University College of Medical Sciences

The focus of treatment in schizophrenia

has changed tremendously a number of

times since its clinical features were first

described in the „modern‟ literature by

Kraepelin (1) and Bleuler (2) about a

hundred years ago. The discovery of

typical antipsychotics in the 1950s (3)

heralded the change of approach from

predominantly isolating patients in mental

hospitals to effectively moving them back

into the community (4). Nonetheless, in

reality, those drugs were only effective at

treating positive symptoms of

schizophrenia and thus, for many years

psychiatrists had to be contented with such

symptom reductions, while patients had to

endure severe side-effects including extra-

pyramidal side-effects (EPSE).

With the advance of atypical

antipsychotics from the 1980s, the

treatment paradigm of schizophrenia

evolved further to focus on achieving

„remission‟ (5) that is, to effectively treat

negative and mood symptoms, in addition

to positive symptoms. Remission remained

as the aim of schizophrenia treatment until

recently while psychiatrists acknowledged

that many patients remained with residual

symptoms characterised by predominance

of negative and cognitive symptoms and

struggled to cope in the community.

Of late however, there has been a wider

recognition of failure of schizophrenia

patients to attain psychosocial functioning

such as independent living, ability to study

and work, and relate to others in the

community. Consequently, there is now a

shift in treatment focus. Evidence-based

psychosocial rehabilitation programmes

have been developed aiming to improve

functional outcome of schizophrenia (6-

10).

What these programmes have in common

is that they purport an integrated non-

parsimonious approach combining several

evidence-based psychosocial interventions

such as work-skills training,

psychoeducation, family support groups,

and cognitive remediation. This approach

had been shown to be effective in

achieving a more global symptom

reduction and functional improvement in

meta-analyses (11).

Coincidently, this is in line with the recent

interest in defining „recovery‟ for

schizophrenia which inevitably includes

improvement in psychosocial functioning

as a major pre-requisite (12). However,

recovery is not a linear process of gradual

steady improvement, but one that ensues

through a step-wise processes involving

appreciation of success, as well as

experiential learning from mistakes and

hindrances (13). Hence, there is much

more into recovery than just referring

patients to attend rehabilitation

programmes where they were „passive

recipients‟ of rehabilitation. They need to

be given the opportunity to learn or re-

learn „learning skills‟ to enable them to

benefit optimally from the rehabilitation

programmes which are predominantly

„educational‟ in nature.


1

Incidentally, the role of cognitive deficits,

in enabling them to be trained in these

skills, is now better understood. Cognitive

deficits have been shown to have a

mediatory role in affecting improvements

in psychosocial functioning (9, 14, 15).

And, there is now empirical evidence to

conclude that all schizophrenia patients

inevitably present with cognitive deficits

(16). In fact as pointed out by Wilk et al

(17), “it is not possible to be

schizophrenic, and yet

neuropsychologically normal”!

Thus, the focus of treatment in

schizophrenia into this new millennium

has naturally shifted again from resolution

of positive and negative symptoms, to the

more challenging target of treating

cognitive deficits where efficacious

treatments are scarce (18). Even the

atypical antipsychotics have only shown

modest effects on these symptoms (19).

And, new pharmacological strategies are

still being researched to develop are wider

spectrum antipsychotic which would be

efficacious towards all symptom domains

of schizophrenia, including cognitive

deficits (20).

Cognitive remediation therapy (CRT) is an

evidenced-based treatment option to treat

cognitive deficits in schizophrenia (21). It

has shown significant effects at both

ameliorating cognitive deficits and

improving psychosocial outcome, whilst

also showing reasonable effects at

improving psychopathology of

schizophrenia.

The „mechanism of action‟ for these

improvements is still being researched, but

empirical evidence so far has demonstrated

that CRT improves cognition due to

specific effects of the treatment such as,

the strengthening of the requisite

neurocognitive skills through repetitive

practice-drills which generalises to

„unpracticed‟ neuropsychological tests

(22).

Nevertheless, hence far, these promising

outlooks of CRT have only been

demonstrated in the Western setting. The

effectiveness of CRT in the developing

countries where resources were scarce, and

psychiatric rehabilitation services are

limited by lack of trained personnel has

not been tested (23).

A multi-centre randomised-controlled trial

to examine the effectiveness of the

Malaysian CRT programme – acronymed

the Cognitive Remediation Project for

Schizophrenia (CREPS), which is based

on Neuropsychological Educational

Approach to Remediation (NEAR) (24)

originally developed in the United States,

has recently been completed. This project

was the first effort outside the developed

nations, and in Asia to demonstrate the

efficacy of CRT in schizophrenia patients.

Notwithstanding all the difficulties and

limitations faced to develop this new

treatment programme, the CREPS project

has been shown to be efficacious in

treating cognitive deficits in schizophrenia

patients in Malaysia, and similar to the

findings in the Western programmes, it has

also been demonstrated to be helpful in

improving psychopathology and

psychosocial functioning, all with effect

sizes ranging from moderate to large effect

sizes (25).

In conclusion, the treatment focus in

schizophrenia has evolved over the years

due to increasing understanding of the

nature and course of the illness. Effective

and evidence-based treatment options are

continually being researched and the

current body of evidence suggests the use

of integrated treatment approach,

combining the use of atypical

antipsychotics with psychosocial

interventions. In Malaysia, a new addition

to the latter, the CRT, has now been

empirically shown to be effective and

hopefully will soon be made available to


2

psychiatric and mental health facilities

around the country.

References

1. Kraepelin E. Text book of

psychiatry. 7th ed. London: Macmillan;

1907.

2. Bleuler E. Dementia Praecox or the

Group of Schizophrenias. New York:

International University Press; 1911.

3. Lopez-Munoz F, Alamo C, cuenca

E, Shen WW, Clervoy P, Rubio G. History

of the Discovery and Clinical Introduction

of Chlorpromazine. Annals of Clinical

Psychiatry. 2005;17(3):113 - 35.

4. Carlsson L. Schizophrenia

Throughout History. Journal [serial on the

Internet]. 2005 Date: Available from:

www.hubin.org/facts/history/history_schiz

ophrenia_en.html.

5. Andreasen N, C., Carpenter W, T.

Jr., Kane JM, Lasser RA, et al. Remission

in Schizophrenia: Proposed Criteria and

Rationale for Consensus. The American

Journal of Psychiatry. 2005;162(3):441.

6. Bellack AS. Cognitive

rehabilitation for schizophrenia: is it

possible? Is it necessary? Schizophr Bull.

1992;18(1):43-50.

7. Bellack AS, Brown SA.

Psychosocial treatments for schizophrenia.

Current Psychiatry Reports. 2001

Oct;3(5):407-12.

8. Bellack AS, Weinhardt LS, Gold

JM, Gearon JS. Generalization of training

effects in schizophrenia. Schizophr Res.

2001 Mar 30;48(2-3):255-62.

9. Brekke J, Kay DD, Lee KS, Green

MF. Biosocial pathways to functional

outcome in schizophrenia. Schizophrenia

Research. 2005;80(2-3):213-25.

10. Brekke JS, Hoe M, Long J, Green

MF. How Neurocognition and Social

Cognition Influence Functional Change

During Community-Based Psychosocial

Rehabilitation for Individuals with

Schizophrenia. Schizophr Bull. 2007

September 1, 2007;33(5):1247-56.

11. Pfammatter M, Junghan UM,

Brenner HD. Efficacy of Psychological

Therapy in Schizophrenia: Conclusions

From Meta-analyses. Schizophrenia

Bulletin. 2006 October 1,

2006;32(suppl_1):S64-80.

12. Liberman RP, Kopelowicz A.

Recovery From Schizophrenia: A Concept

in Search of Research. Psychiatr Serv.

2005 June 1, 2005;56(6):735-42.

13. Meadows G, Singh B. Mental

Health in Australia: Collaborative

Community Practice. Melbourne: Oxford

University Press; 2001.

14. Addington J, Addington D.

Neurocognitive and social functioning in

schizophrenia: a 2.5 year follow-up study.

Schizophr Res. 2000 Jul 7;44(1):47-56.

15. Brekke JS, Kohrt B, Green MF.

Neuropsychological functioning as a

moderator of the relationship between

psychosocial functioning and the

subjective experience of self and life in

schizophrenia. Schizophr Bull.

2001;27(4):697-708.

16. Palmer BW, Heaton RK, Paulsen

JS, Kuck J, Braff D, Harris MJ, et al. Is it

possible to be schizophrenic yet

neuropsychologically normal?

Neuropsychology. 1997 Jul;11(3):437-46.

17. Wilk CM, Gold JM, McMahon RP,

Humber K, Iannone VN, Buchanan RW.

No, It Is Not Possible to Be Schizophrenic

Yet Neuropsychologically Normal.

Neuropsychology. 2005 Nov;19(6):778-86.


3

18. Marder SR. Neurocognition as a

Treatment Target in Schizophrenia. Focus.

2008 January 1, 2008;6(2):180-3.

19. Woodward ND, Purdon SE,

Meltzer HY, Zald DH. A meta-analysis of

neuropsychological change to clozapine,

olanzapine, quetiapine, and risperidone in

schizophrenia. International Journal of

Neuropsychopharmacology. 2005

Sep;8(3):457-72.

20. Snyder EM, Murphy MR.

Schizophrenia therapy: beyond atypical

antipsychotics. Nat Rev Drug Discov.

2008;7(6):471-2.

21. McGurk SR, Twamley EW, Sitzer

DI, McHugo GJ, Mueser KT. A Meta-

Analysis of Cognitive Remediation in

Schizophrenia. Am J Psychiatry. 2007

December 1, 2007;164(12):1791-802.

22. Kurtz MM, Seltzer JC, Shagan DS,

Thime WR, Wexler BE. Computer-

assisted cognitive remediation in

schizophrenia: What is the active

ingredient? Schizophrenia Research. 2007

Jan;89(1-3):251-60.

23. Alwi MNM. Cognitive

Remediation for Schizophrenia: New

Focus for Malaysian Psychiatry?

Malaysian Journal of Psychiatry.

2006;15(2):11-7.

24. Medalia A, Freilich B. The

Neuropsychological Educational Approach

to Cognitive Remediation (NEAR) Model:

Practice Principles and Outcome Studies.

American Journal of Psychiatric

Rehabilitation. 2008;11(2):123 - 43.

25. Alwi MNM, Harris AWF, Salleh

MR, Boyce P. The Effectiveness of

Cognitive Remediation Therapy (CRT) in

Malaysia. 12th

International Congress on

Schizophrenia Research; 2009; San Diego,

USA. Schizophrenia Bulletin. 2009; 35:

269-70.

Editorial Board Member

Associate Professor Dr Muhammad Najib Mohamad Alwi


4

ORIGINAL PAPER

SCHOOL BULLYING AMONGST STANDARD SIX STUDENTS

ATTENDING PRIMARY NATIONAL SCHOOLS IN THE FEDERAL TERRITORY OF KUALA LUMPUR: THE

PREVALENCE AND ASSOCIATED SOCIO DEMOGRAPHIC FACTORS …

Wan Salwina WI*, Susan MK Tan*, Nik Ruzyanei NJ*,

Tuti Iryani MD*, Syamsul S**, Aniza A**, Zasmani S***

*Department of Psychiatry, Universiti Kebangsaan Malaysia

**Department of Community Medicine, Universiti Kebangsaan Malaysia, ***Gleneagles Hospital, Penang

Abstract

This is a cross-sectional study on school bullying involving 410 standard six students from seven national primary schools in the Federal Territory of Kuala Lumpur. Information on bullying, victimization and bully-victim were gathered using a Malaysian self-rating bullying questionnaire. Socio demographic characteristics of the respondents were also obtained. 41.2% of these children reported having been victims of bullies whilst another 17.6% who had been bullied turned aggressor (bully-victims). Only 2.4% admitted to being the bully. Significant socio demographic characteristics include sex, ethnicity and academic performance were assessed. In the multivariate analysis, the bullies (OR=9.19, CI=1.74-8.45) and the bully-victims (OR=11.43, CI=1.7-73.08) were significantly associated with being male. Similarly, having at least six siblings were significantly associated with bullies (OR=14.33, CI=1.66-123.66), and bully-victims (OR=16.88, CI=1.67-170.60). Victims were significantly associated with Indian ethnicity (OR=6.23, CI=1.14-34.07) and having older fathers (OR=0.87, CI=0.78-0.96). This study suggests that school bullying is common even in the primary schools. The significant socio demographic characteristics identified above help us understand the profiles of children involved in school bullying. Future studies are needed to look into the aetiology and mechanism of such a problem so that steps can be taken to curb the problem before it becomes more severe. Keywords: School bullying: prevalence, socio demographic factor


5

Introduction

School bullying is an increasing

phenomenon in Malaysia. It is defined as

“repeated, ill-negative behaviors by one

or more students directed against a

student who has difficulty defending

himself or herself. Most bullying occurs

without any apparent provocation on the

part of the student who is exposed” (1).

Bullying can be physical (e.g. hitting and

kicking), verbal (e.g. teasing) or non-

physical and non-verbal which can be

done directly (e.g. insulting others) or

non-directly (e.g. spreading rumours).

Although bullies and victims are usually

separate individuals, 20% of victims also

act as bullies (1). They are referred as

bully-victims i.e. victims who turned

bullies after repeatedly being bullied.

Generally, when bullying takes place,

the three main groups involved are

bullies, victims and bully-victims.

Various environmental factors have been

studied in relation to the problem.

Factors in the child such as poor impulse

control (2), low self-control (3), body

size (4) and low academic achievement

(5) have been associated with the

problem. Family factors such as harsh

parenting style, family conflicts and

abuse (6), and low socioeconomic status

(7) have also been proposed.

Interestingly, a recent study provides

evidence of genetic influence on both

bullying and victimization (8).

In Malaysia, studies on school bullying

are scarce despite the increasing

problem. In a local study of 1624

secondary school students, 93.5% of the

students admitted that they had been

indirectly bullied whereas 68.2%

acknowledged being directly bullied at

least once or twice during the previous

four weeks of the study period. There

were significantly larger involvement of

boys compared to girls and the

classroom was the most common place

where bullying occurred (9).

A similar study done amongst the 2528

Malaysian primary school students

reported that 53.2% of the students were

involved in bullying whereas 79.4%

reported having been bullied (10). As

high as 85.8% of the children in the

study acknowledged being

psychologically bullied whereas 85%

acknowledged being physically bullied

at least once or twice during the previous

four weeks. They also found a greater

involvement of standard six children as

compared to children from the junior

classes (10).

Although research in this area is

increasing, most studies are from the

western countries; these findings may

not be generalizable to the Malaysian

population due to the cultural

differences. This study aimed to

determine the prevalence and socio-

demographic features of standard six

students involved in school bullying in

Malaysian primary national schools.

Methods

This was a cross-sectional study of 410

Standard Six students from seven

randomly selected national primary

schools in the Federal Territory of Kuala

Lumpur, conducted in April to June

2006. The study was approved by the

Hospital Universiti Kebangsaan

Malaysia Ethical Board, Ministry of

Education Malaysia (Education

Planning, and Research Development)

and Department of Education of the

Federal Territory of Kuala Lumpur.


6

Consent was obtained from the students

and their parents. Only Standard Six

students with good understanding of

Bahasa Malaysia were included.

Students with mental retardation and

from the special education classes were

excluded. Self-reported questionnaires

were used to obtain information

regarding the bully/victim problem and

the socio demographic characteristics. A

local bullying questionnaire consisting

of 20 questions which measures bullying

behavior, being bullied and bully-victim

were used (10).

Students were asked to rate themselves

with regards to the above problem in the

past one month using a likert scale of 0

(never), 1 (once or twice), 2 (three or

four times) and 3 (more than five times).

Bullying, being victimized and being

bully-victim were defined if the problem

occurred three or more times during the

last four weeks. Demographic data

obtained were sex, ethnicity, academic

performance (rated by teachers), number

of siblings, marital status of parents, age

of parents, parents’ educational level and

amount of time spent with children.

Statistical analysis

Statistical Package for Social Studies

(SPSS) Software version 13.0 was used

for data analysis. Multiple logistic

regressions were used to analyze the

socio-demographic factors in relation to

bullying, victimization and bully-

victims.

Results

Prevalence of bullying, victimization

and bully-victims are presented in Table

1. Most of students reported non-

involvement in the problem (38.8%),

followed by victims (41.2%), bullies

(2.4%) and bully-victims (17.6%).

Table 1. Prevalence of bullies, victims and bully-victims

Bully/victim

problem

Prevalence

(n=410)

Bullies 10 (2.4% )

Victims 169 (41.2%)

Bully-victims 72 (17.6%)

Non-bully-victims 159 (38.8%)

Demographic characteristics are

illustrated in Table 2. Ethnicity, sex and

academic performance were found to be

significantly different between the

bully/victim groups. Table 3, 4 and 5

present the association between socio

demographic factors and bully/victim

groups, using multiple logistic

regression.


7

Consent was obtained from the students

and their parents. Only Standard Six

students with good understanding of

Bahasa Malaysia were included.

Students with mental retardation and

from the special education classes were

excluded. Self-reported questionnaires

were used to obtain information

regarding the bully/victim problem and

the socio demographic characteristics. A

local bullying questionnaire consisting

of 20 questions which measures bullying

behavior, being bullied and bully-victim

were used (10).

Students were asked to rate themselves

with regards to the above problem in the

past one month using a likert scale of 0

(never), 1 (once or twice), 2 (three or

four times) and 3 (more than five times).

Bullying, being victimized and being

bully-victim were defined if the problem

occurred three or more times during the

last four weeks. Demographic data

obtained were sex, ethnicity, academic

performance (rated by teachers), number

of siblings, marital status of parents, age

of parents, parents’ educational level and

amount of time spent with children.

Statistical analysis

Statistical Package for Social Studies

(SPSS) Software version 13.0 was used

for data analysis. Multiple logistic

regressions were used to analyze the

socio-demographic factors in relation to

bullying, victimization and bully-

victims.

Results


and bully-victims are presented in Table

1. Most of students reported non-

involvement in the problem (38.8%),

followed by victims (41.2%), bullies

(2.4%) and bully-victims (17.6%).

Table 1. Prevalence of bullies, victims and bully victims

Bully/victim

problem

Prevalence

(n=410)

Bullies 10 (2.4% )

Victims 169 (41.2%)

Bully-victims 72 (17.6%)

Non-bully-victims 159 (38.8%)

Demographic characteristics are

illustrated in Table 2. Ethnicity, sex and

academic performance were found to be

significantly different between the

bully/victim groups. Table 3, 4 and 5

present the association between socio

demographic factors and bully/victim

groups, using multiple logistic

regression.


8

Table 3. Socio demographic variables in association with bullies, using logistic regression Variables Wald Significance Exp (B) Confidence interval

Sex (boy) 6.835 0.01 9.187 1.742 48.449

Siblings>=6 5.865 0.02 14.334 1.662 123.66

Nagelkerke R Square = 0.592

Table 4. Socio demographic variables in association with victims, using multiple logistic regressions Variables Wald Significance Exp (B) Confidence interval

Ethnicity

(Indian)

4.454 0.04 6.230 1.139 34.066

Father’s age

(older)

7.219 0.01 0.866 0.779 0.962

Nagelkerke R Square =0.475

Table 5. Socio demographic variables in association with bully-victims, using multiple logistic regressions Variables Wald Significance Exp (B) Confidence interval

Sex (boy) 6.623 0.01 11.430 1.788 73.08

Siblings>=6 5.734 0.02 16.88 1.670 170.60

Nagelkerke R Square =0.592

Discussions


and bully-victims vary across the nations

but remain a significant problem

worldwide. This study found a relatively

lower prevalence of bullies (2.4%)

compared to that in previous western

studies which found the prevalence

ranging from 3%-20% (5). The

prevalence rate differed significantly

when compared to the local study that

reported 53.2% of students involved in

bullying whereas 79.4% were bullied

(10). The differences can be explained

by few factors. Firstly, different bullying

questionnaires and different definitions

of bully/victim problem were used.

Secondly, students may be reluctant to

report such behaviour which is culturally

unfavourable. This …may …introduce

biasness since there was no information

obtained from other informants such as

teachers or parents or peer nomination as

used in certain study (7). Thirdly, bullies

tend to be unhappy in schools (11)

leading to truancy and absenteeism

which further reduce the prevalence

since data were gathered during the

school period. It is interesting to note

that the prevalence of victims was the

highest compared to bullies and bully-

victims, and higher when compared to

the previous studies (5, 12).

Various socio demographic features

were studied in relation to bullies,

victims and bully-victims. Ethnicity, sex

and academic performance were found

to be significant factors. Malays were

the highest among bullies (2.9%),


9

Indians were the highest among victims

(51.8%) and other ethnic group was the

highest among bully-victims (54.5%).

These findings need cautious

interpretation considering the limitations

and the lack of local published data for

comparison.

A different racial group from the

majority has been identified as a

vulnerable factor to being bullied (13).

The cultural differences in terms of the

different perception of bully/victim

problem and willingness to report the

problem may also contribute to the

ethnic differences. It is however

important to note that these findings

provide no evidence to suggest specific

involvement of any ethnic groups in the

bullying problem. However, it is

possible that the ethnic majority or

minority have influence on who will

become bullies and victims respectively

(13). In keeping with previous findings

(7, 14), boys were significantly higher

than girls among the bullies and bully-

victims whereas more girls were found

as victims. This may be due to the social

expectation and acceptance that boys

should be more aggressive than girls in

their actions.

Among bullies, more students were rated

by their teachers to have poor academic

performance (2%) compared to good

performance (1.5%). This is supported

by previous study which found

significant association between lower

academic achievement and bullying

behavior (12). Bully-victims were also

rated to have performed poorly. In

contrast, ..more.. victims.. were..found to

have better academic performance

(45.5%) compared to poor performance

(40.2%). Involvement in bullying may

lead to deterioration in academic

performance or preceding poor academic

performance may trigger involvement in

bullying.

When the socio demographic variables

were analyzed with multiple logistic

regression, sex, ethnicity, number of

siblings and father’s age were found to

be significant.

Being a boy was a significant predictor

to bullies (OR=9.19, CI=1.74-48.45) and

bully-victims (OR=11.43, CI=1.79-

73.08). These have been consistent

findings so far. Interestingly, having

more than six siblings was also a

significant risk factor for both bullies

(OR=14.3, CI=1.7-123.7) and bully-

victims (OR=16.9, CI=1.7-170.6). A

possible explanation is that an increased

number of siblings may result in the

students having less attention from

parents and poor parent-child

relationship, leading to behavioral

problem such as bullying.

Indians are more at risk to be victims

(OR=6.230, CI=1.139-34.066). As

discussed earlier, this may be attributed

to the vulnerability of being an ethnic

minority. On the other hand, increasing

father’s age was found a significant

protective factor against victimization

(OR=0.9, CI=0.78-0.96). This is

probably because older fathers who have

more parenting experience are able to

empower their children better in

problem-solving skills at school, thus

helping to protect them from being

bullied.

Limitations

Several limitations of the study should

be considered. Firstly, the study only

involved standard six students from the


10

national schools in the urban area of

Kuala Lumpur. Therefore, findings may

not be generalized to the whole

population of Malaysian school children.

The study population was also

overrepresented by one ethnic group,

making the interpretation of results in

terms of ethnic differences difficult.

Secondly, all the questionnaires were

self-reported which would definitely

introduce to information bias. Although

the bullying questionnaire was in local

language (i.e. Bahasa Malaysia), it was

not validated leading to problems of

validity and reliability.

Clinical implications

School bullying and its related problems

are prevalent among Malaysian standard

six students. Several socio demographic

features have been identified as

significant factors in association with the

bullies, victims and bully-victims. In

comparison to findings from the western

studies, this information is useful in

understanding the problem in the local

context. It has been suggested that

bullying may take a different form in

Asian countries (12) given the cultural

differences. It will also contribute in

developing a local bullying intervention

program that would be more culturally

relevant and acceptable.

Conclusion

In general, this study illustrates the

seriousness of school bullying among

primary school students in Malaysia.

The socio demographic profiles

contribute further in our understanding

of the problem in the local context.

Future studies should embark in

understanding the causal factors of

school bullying, among Malaysian

school children.

Acknowledgement

We would like to acknowledge

Universiti Kebangsaan Malaysia,

Ministry of Education Malaysia,

Department of Education Wilayah

Persekutuan, the participating students,

teachers and parents for their

contributions.

References

1. Olweus D. Aggresion in schools:

Bullies and whipping boys. New York:

Wiley; 1978.

2. Olweus D. Annotation: Bullying

at schools: Basic facts and effects of a

school based intervention program.

Journal of Child Psychology and

Psychiatry. 1994;35:1171-90.

3. Unnever JD, Cornell DG.

Bullying, self-control and ADHD.

Journal of Interpersonal Violence.

2003;18(2):129-47.

4. Olweus D. Bullying at Schools.

What We Know and What We Can Do.

UK: Blackwell: Oxford; 1993.

5. Nansel TR, Overpack M, Pilla

RS, Ruan WJ, Simons-Morton B.

Bullying behaviours among US youth.

Journal of the American Medical

Association. 2001;285(16):1-5.

6. Bidwell NM. The nature and

prevalence of bullying in elementary

school. SSTA Research Centre Report

2007; 1997 [updated 1997; cited];

Available from:

www.saskschoolboards.ca/EducationSer


11

vices/ResearchAndDevelopment/Resear

chReports/SchoolImprovement/97-

06.htm.

7. Kim YS, Koh YJ, Lenventhal

BL. School bullying and suicidal risk in

Korean Middle School Students.

Archives of Pediatrics & Adolescent

Medicine. 2004;158(8):737-41.

8. Ball HA, Arsenault L, Taylor A,

Maughan B, Caspi A. Genetic and

environmental influences on victims,

bullies and bully-victims in childhood.

Journal of Child Psychology and

Psychiatry. 2008;49(1):104-12.

9. Noran FY, Christopher AA,

Mizuar N, Azmi AS, Rosna AH.

Bullying among Malaysian school

children: Some preliminary findings:

Laporan Penyelidikan, Universiti Utara

Malaysia; 2001 Contract No.: Document

Number|.

10. Noran FY, Nagappan R, Jazimin

JA. Bullying among Malaysian

Elementary School Children. 2004

[updated 2004; cited]; Available from:

http://mahdzan.com/papers/bully/bully.a

sp.

11. Forero R, McLellan L, Rissel C,

Bauman A. Bullying behavior and

psychosocial health among school

students in New Youth Wales, Australia.

British Medical Journal. 1999;319:344-

8.

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Shin I-S. Bullying and victimization

behaviours in boys and girls at South

Korean Primary Schools. Journal of

American Academy of Child and

Adolescent Psychiatry. 2006;45(1):69-

77.

13. Moran S, Smith PK, Whitney I.

Ethnic differences in experiences of

bullying: Asian and white children.

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ng%20and%20PTSD%20Review.doc.

Corresponding author: Dr. Wan Salwina Wan Ismail, Department of Psychiatry,

Pusat Perubatan Universiti Kebangsaan Malaysia, Jalan Yaakob Latiff, Bandar Tun

Razak, Cheras, 56000 Kuala Lumpur

Email: [email protected]


12

ORIGINAL PAPER

STIGMA ARISING FROM FAMILY MEMBERS OF THE MENTALLY ILL PATIENTS IN HOSPITAL TAIPING

Tuti MD *, Nursyuhaida MN **, Nik Siti Fatimah M **, Faridah

Hanim Z **, Nor Akmar S **, CT Effa FMF **, Khairunnisa MZ **,

Marhani M*, Ruzanna Z*

*Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Center, **Universiti Kebangsaan Malaysia Medical Center

Abstract

Although public stigma towards the mentally ill is a known challenge, stigma from within the family has not been widely studied. This study aimed to compare the experience of stigma between mentally ill patients and diabetic controls, particularly focusing on stigma arising from family members. This is a cross sectional case control study. The case group consisted of 63 patients who attended the outpatient psychiatric clinic of Hospital Taiping. The control group consisted of 78 diabetic patients attending the outpatient medical clinic, Hospital Taiping and Selama Health Clinic. Patients completed questionnaire assessing stigma experienced by patients. Significantly higher percentage of psychiatric patients (55.6%) experienced stigma compared to diabetic patients (15.4%) (X2 = 25.3, p-value < 0.0001). In addition, significantly higher percentage of patients with psychiatric illness received negative comments during the relapse of illness (57.1% vs 16.7%, chi-square = 5.12, p-value = 0.024) compared to diabetic patients. This study demonstrates that family members themselves could be a source of stigma. The findings support current family psycho-education programs in caring for the mentally ill. Keywords: stigma, family, diabetes, mental illness

Introduction

Stigma is a social-cognitive process that

motivates people to avoid the label of

mental illness (1). Stigma towards

people with mental illness has been

widely studied (2, 3). Regardless of the

sources, stigma towards people with

mental illness is noted to be related to

four cues. These include the psychiatric

symptoms, social-skills deficits, physical

appearance, and labels (1, 4). This

perhaps explains the research findings

that mentally ill people often are

stigmatized more severely than those

with other health conditions (1, 5).

People with mental illness are more

likely to be labeled as dangerous,

incompetent and to be blamed for their


13

illness (1). The impact could be worse if

they experience this from their own

family members (6). The experience of

stigma usually leads to refusal to seek

treatment (7), noncompliance to

medication, unemployment and affected

social acceptability.

While studies on stigma had mainly

focused on stigma arising from the

public stigma (8) arising from family

members has received little attention.

Several studies (9, 10) reported that

stigma arising from family members is

more prevalent. Thus, this study aimed

to compare the experience of stigma

between mentally ill patients and other

common health problems (i.e. diabetes),

particularly focusing on stigma arising

from family members.

Methods This comparative study was carried out

in March 2007. Cases were psychiatric

patients above 18 years old who had

attended the Outpatient Psychiatric

Clinic of Hospital Taiping and were

psychiatrically stable. Controls were

diabetic patients above 18 years old who

had attended Medical Outpatient

Department Hospital Taiping and Larut

Matang and Selama Health Clinic. All

consecutive patients were invited to

participate in the study. Informed

consent was taken from respondents.

Questionnaire A questionnaire assessing the experience

of stigma was designed adapted from a

study by Lee et al (9). A pilot study was

carried out on 10 patients from various

ethnic groups to examine suitability of

the questions. A finalized version of the

questionnaire was produced. Although

the questionnaire was self-report,

responses were obtained through

structured interview for a third of the

patients. The reliability for assessing

stigma by family members was good

(Chronbach-alpha=0.8). Information on

diagnosis and duration of illness were

obtained from case notes.

Sample size

Based on the previous study carried out

by Lee et al (9) on experience of stigma

in patient with Schizophrenia and

patients with Diabetes Mellitus in Hong

Kong, significantly more patient with

Schizophrenia ( > 40%) than diabetes (

average 15%) experienced stigma from

family members, partners, friends and

colleagues. These figures were used to

calculate the sample size for this study.

With a power of 80% and confidence

level of 95%, the sample size calculation

using the Epi Info version 3.2 showed 57

subjects were needed in each group.

Attrition rate of 20 % is expected in this

study thus a target of 70 subjects for

each group is desirable.

Analysis

The questions examining experience of

stigma required dichotomized. Hence,

chi-square test and t-test were used to

examine the associations between stigma

and other independent variables. While

parametric test was used to examine the

association for age (as it was normally

distributed), non-parametric test was

used to examine the association for

duration of illness (as it was not

normally distributed). SPSS version 12.0

was used to carry out the analyses.


14

Results

Eighty-eight psychiatric patients in case

group and 81 diabetic patients in control

group were invited to participate in the

study. Among the cases, 13 did not

consent, another 13 were excluded as

they were mentally unstable and one

questionnaire was incomplete.

Among the control group, 3 did not

consent. The non-participants were

younger and a higher percentage was

from cases rather than controls (Table

1). The demographic characteristics of

participants are shown in Table 2.

Patients with psychiatric illness were

significantly different from patients with

diabetes, as the former were more likely

to be younger, unmarried, unemployed

and Malays.

Table 1. Characteristics of participants vs non-participants (N=171)

Characteristics Participants (N=141)

Non-participants (N=30)

p-value

Age, mean (SD)

49.9 (14.0) 41.9 (13.0) 0.007*

Gender (n, %)

Male

Female

84 (87.5)

57 (77.0)

12 (12.5)

17 (23.0)

0.7**

Ethnicity (n, %)

Malay

Non-Malay

87 (87.0)

53(76.8)

13 (13.0)

16 (23.2)

0.84**

Case vs control (n, %)

Case

Control

63(70.0)

78 (96.3)

27 (30.0)

3 (3.7)

<0.0001**

*Independent t-test

**Pearson chi-square

Stigma

Patients with psychiatric illness (n=35,

55.6%) were more likely to experience

stigma compared to patients with

diabetes (n=12, 15.4%) (X2=25.3,

p<0.0001). Although stigma arising

from family members were higher for all

8 items among patients with psychiatric

illness compared to diabetes, only 1

variable (ie. received negative comments

due to relapse) was found to be

significantly different (Table 3).


15

Table 2. Characteristics of participants

Patients with psychiatric

illness (N=63) %

Patients with diabetes

(N=78) %

p-value

Age, mean (SD)

41.1 (12.4)

56.9 (11.0)

<0.0001*

Gender

Male

Female

36 (57.1)

27 (42.9)

48 (61.5)

30 (38.5)

0.60**

Ethnicity

Malay

Non-Malay

47 (74.6)

16 (25.4)

40 (51.3)

38 (48.7)

0.005**

Marital status

Single

Married

Others

32 (50.8)

21 (33.3)

10 (15.9)

3 (3.8)

58 (74.4)

17 (21.8)

<0.0001**

Employment

Employed

Unemployed

29(46.0)

34(54.0)

49(62.8)

29(37.2)

0.046

Education level

Primary school

Secondary school

Tertiary

21(33.3)

30(47.6)

12(19.0)

30(38.5)

37(47.4)

11(14.1)

0.678

Live with family

members

Yes

No

54 (85.7)

9 (14.3)

71(91.0)

7(9.0)

0.323

Psychiatric illness

Schizophrenia

Depression

Anxiety

Others

35 (55.6)

17 (27.0)

2 (3.2)

9 (14.3)

Duration of illness

56.9 52.2 0.446***

* Independent t-test ** Pearson chi-square

***Mann-Whitney U


16

Table 3. Stigma from family members among patients with psychiatric illness and

diabetes mellitus

Patients with psychiatric

illness (N=35) %

Patients with diabetes

(N=12) %

p-value

Family considered patient highly

violent owing to his or her illness

9(25.7) 0(0.0)

Anticipated that family members

would feel inferior to be with

patient

13 (37.1) 2(16.7) 0.340*

Disliked by family members

because of illness

12(34.3) 0(0.0)

Anticipated that family members

hope that the patient had never been

born

10(28.6) 0(0.0)

Patients had been unfairly treated

by family members owing to their

illness

12(34.3) 1(8.3) 0.174

Family members wanted to conceal

from others that there was

psychiatric patient in the family

16(45.7) 2(16.7) 0.149*

Being avoided by family members

6(17.1) 0(0.0)

Received negative comments from

family members during relapse of

the illness

19(54.3) 2(16.7) 0.024**

*Yates continuity correction

**Pearson chi-square

Discussion

Consistent with previous studies (9, 11),

we found that patients with psychiatric

illness were more likely to report the

experience of stigma compared to

patients with diabetes. This is despite

that both mental illness and diabetes

mellitus are chronic and treatable

diseases. Hence, it can be deduced that

stigma appeared to arise out of the

psychiatric label and not the presence of

a chronic illness.

Stigma towards patients with psychiatric

illness is widespread both in western (2,


17

7, 12) and non-western countries (6, 11).

Evidence that stigma in mental illness

prevails in the Malaysian population

continues to accumulate (13-17).

It has previously been reported that

stigmatizing attitudes can be reduced by

increasing personal contact with patients

suffering from psychiatric illness (18,

19).. On the contrary, our findings have

shown that those most frequently in

contact with these patients could also be

significant sources of stigma. This was

evident in this study as higher

proportions of patients with psychiatric

illness reported experience of stigma

from family members for all of the

items, compared to patients with

diabetes. Although only ‘negative

comment from family members’ was the

only item significantly associated with

patients suffering from psychiatric

illness, the non-significant associations

for other items could be explained by

small sample size. Nevertheless, this

‘negative comments from family

members’ is also known to be one of the

main components of expressed emotion.

Phillips et al, 2002 (20) have found that

there is a strong relationship between

stigma and expressed emotions. The

causal link is uncertain. While stigma

magnifies the family’s expression of

expressed emotions (21), having low

expressed emotion leads to constructive

responses to stigma by the family (22).

There are several published studies

exploring the problems of stigma arising

from family members (6, 10, 23). Some

studies assessed stigma by interviewing

either the patient (9) or their family

members (10, 24), while other studies

assessed stigma by interviewing both

parties. Despite methodological

differences, the findings point to similar

conclusion, ie stigma arising from family

members is a significant problem. In

fact, this stigma had existed even from

the first psychiatric hospitalization (10).

Malaysian families embrace the

collectivist culture where group needs

are prioritized over individual needs. In

collectivist culture, relatives are

expected to look after an individual in

exchange for conforming to the group

norms (25). Hence, one would have

thought that living in a collectivist

culture would be protective for a patient

suffering from psychiatric illness. On the

other hand, it has been shown that the

stigma is not only attached to the

individual, but inevitably extends to the

rest of the family (26, 27). Such

experience known as ‘courtesy stigma’

(24) or ‘associative stigma’ (28) would

lead to an even more negative perception

particularly in a society where

acceptance to the group is vital. A

central area of social discrimination

experienced by patient and family

members would be related to marriage.

Not only patients’ chance of getting

married is being limited, the likelihood

is also reduced for other family members

due to fear of genetic transmission to

offspring (6). Hence, social isolation

experienced by the family unit as a result

of stigma is in turn demonstrated by

projection of anger towards the patient

(9).

Apart from anger, family members of

the psychiatric ill patient harbor feelings

of shame and guilt (29, 30). In parents

who attribute the psychiatric illness to

psychosocial factors, self-blame is

expressed from practicing poor parenting

skills on their mentally ill child.

However, parents who understood the

biological explanation for psychiatric


18

illness blamed themselves for possibly

contributing genes responsible for the

illness. Family members also go through

grieving process for the lost of a healthy

individual (29-33). Grieving for an

apparent loss can be difficult to express.

Such grief which is publicly

unrecognized has also been referred to as

disenfranchised grief (34). Suppressed

grief leads to prolong suffering in the

family members.

The points presented above are possible

explanations to the phenomenon where

family members, who are victim of

stigmatization themselves, eventually

become stigmatizers to the mentally ill

patient. Hence, management of stigma

among family members is an essential

step in promoting recovery of people

with mental illness. The acceptance of

family members towards patient’s illness

would contribute to more effective care

and encourage recovery. In Malaysia,

nationwide structured family psycho-

education programs have been ongoing

for the past eight years (35). It would

useful to study whether this intervention

has been effective in reducing the stigma

among Malaysian family members.

Limitations

There are a few limitations to this study.

Firstly, this study was carried in one

hospital and two primary health clinics;

the generalizability of the results is

therefore limited. Secondly, recall bias

particularly among patients with

psychiatric illness could have affected

the responses. Thirdly, the

administration of the questionnaires was

not standardized as some had to be

interviewed while others completed the

questionnaire as self-report. Thirdly, the

suitability of diabetics as controls can be

argued. Although both illnesses were

similar with respect to being physical

illness and chronic; they were from

different systems of the body. Perhaps a

more suitable control would be illnesses

that effect the nervous system and have a

similar age of onset and chronicity i.e.

epilepsy. Furthermore, as the controls

were unmatched, several demographic

variables between the two groups were

significantly different. Thus we

recommend that the controls are

matched for age, gender, race and

duration of illness in designing future

studies.

Conclusion

Family members are significant source

of stigma to the patient with mental

illness. Both, patients and family

members suffer silently when such

problem is overlooked. Hence, future

studies to assess the effectiveness of

ongoing Malaysian family intervention

program in reducing stigma among

family members are needed.

Acknowledgements The authors would to thank Dr. Riana

Abd Rahim (Consultant Psychiatrist,

Hospital Taiping), Dr. G. R. Letchuman

(Head of Department, Department of

Internal Medicine, Hospital Taiping),

staff of the respective study sites for

their support in making this study

possible.

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Corresponding author: Dr. Tuti Iryani Mohd Daud, Lecturer and Psychiatrist,

Department of Psychiatry, University Kebangsaan Malaysia Medical Centre, 56000

Kuala Lumpur



22

ORIGINAL PAPER

GENDER INFLUENCES ON PSYCHOPATHOLOGY AND FUNCTIONALITY IN SCHIZOPHRENIA IN UNIVERSITY MALAYA

MEDICAL CENTRE, KUALA LUMPUR, MALAYSIA

Zuraida NZ*, Gill JS*, Koh OH*, Kanagasundram S*, Saniah AR*, Sapini Y*,

Salina M*, Zuraida A*.

* Department of Psychological Medicine, Faculty of Medicine, University of

Malaya, Kuala Lumpur, Malaysia

Abstract

Numerous studies on gender differences in schizophrenia have been published to summarize the evidence from molecular to the clinical level. Female schizophrenics are found to have better skills then the males. In addition, it was described that the male schizophrenics exhibited more negative symptoms compared to the females. The aim of this study was to investigate the gender influences on psychopathology and functionality of schizophrenia patients in University Malaya Medical Centre. Methods: All patients diagnosed with schizophrenia who attended the outpatient psychiatric clinic during a two-month period were recruited into the study. The patients were assessed on their socio-demographic profile, clinical data, psychopathology according to Positive and Negative Syndrome Scale for Schizophrenia (PANSS) and functionality by using Personal and Social Performance Scale (PSP). Results: A total of 76 female and 74 male patients entered the study. Both genders were matched in age, ethnic groups, educational background and duration of illness. There were more singles among the male schizophrenics. 72% of the female schizophrenics and 87% of the males were on atypical antipsychotics (p<0.05). 57% of the female and 55% of the male schizophrenics hold a job. There were no significant differences in positive, negative and general psychopathology in both genders. The mean total score of PANSS was 46.5 in the females and 48.2 in the males. There was also no significant difference of PSP total score in both gender. The mean score of PSP was 73.0 for female schizophrenics and 70.0 for the males. PANSS scores was negatively correlated with PSP scores (r = -0.70, p<0.001). Conclusion: There were no gender differences in psychopathology and functionality among schizophrenia patients attending psychiatric outpatient clinic in University Malaya Medical Center. Both genders are functioning well and more than half are having a job. Keywords: Schizophrenia, Psychopathology, Functionality, Gender


23

Introduction Reviews on gender differences in

schizophrenia have been published

recently to summarize the evidence from

molecular to the clinical level1 Studies

also found that schizophrenic men show

more negative symptoms such as social

withdrawal, blunted affect, poverty of

speech and anhedonia2,3. A few studies

found schizophrenic women display

more affective, paranoid symptoms,

bizarre behaviour and impulsivity than

men 4,5. In contrast the severity of

positive symptoms in both sexes was

found to be equa.l6

In a major review of outcome studies,

about half, females had a better outcome

while the other half had no sex

differences in outcome.6 Female

schizophrenics had better outcome in

terms of better preserved social skills,

fewer and briefer hospitalization.7

A study on employment and psychiatric

disability in schizophrenia in Malaysia

recently found that both men and women

schizophrenics were largely unemployed

despite having mild psychotic symptoms

and had minimum psychiatric

disability8. This is an important finding

that needs to be re-looked whether there

will be different findings in our study.

Hence we can plan our management

strategies for schizophrenics according

to their gender.

Objectives of the study To determine whether female

schizophrenics have different

psychopathology presentation and level

of functionality than the males.

Methods The study was conducted in psychiatry

out-patient clinic University Malaya

Medical Centre (UMMC), Kuala

Lumpur for 3-month period. All adult

patients treated for schizophrenia, age of

18 to 60 years that came for follow-up

were recruited. Patients and relatives

were explained regarding the study and

verbal consent was obtained from them.

Assessment

1. Patients’ socio demographic profiles

such as age, sex, ethnic group, marital

status, education level, and current job

were obtained from the case notes and

from the patient.

2. The diagnosis of schizophrenia was

reconfirmed according to the DSM-1V

criteria.

3. The clinical data on duration of

illness, current psychiatric medications

and co-morbid medical illness were

recorded as well.

4. The psychopathology was assessed by

using the Positive And Negative

Symptoms Scale (PANSS), and the

functionality of the patients was assessed

according to Personal and Social

Performance Scale (PSP).

Statistical analysis SPSS was used for analyses.

Results A total of 76 female and 74 male

patients entered the study. Both genders

were matched in age, ethnic groups,


24

educational background and duration of

illness. Of all the male patients 87% are

singles compared to 65% of the females

(p<0.05) as in Figure 1.

Of the total for each gender, 72% of the

female schizophrenics and 87% of the

males were on atypical antipsychotics

(p<0.05) as shown in Figure 2.

0

10

20

30

40

50

60

70

Female Male

Single

Married

0

10

20

30

40

50

60

70

Female Male

Typical

Atypical

Figure 1 Figure 2

Gender distributions of the schizophrenia patients. Distribution of the type of antipsychotic used

Of the total female schizophrenics, 57%

held a job and so as in 55% of the male

schizophrenics (non significant

difference). As for the female, for those

who were well functioning as a

housewife was considered as holding a

job. The mean score of the PANSS and

PSP is shown in Table 1.

Table 1. Comparison of mean score of the PANSS and PSP scores in female and male

schizophrenics

Measurement Female (n=76) Male (n=74) p value

Mean score (+sd) Mean score (+sd)

Total PANSS 46.5 + 16.0 48.1 + 16.0 0.52

Positive symptoms 10.2 + 4..3 10.3 + 4.3 0.85

Negative symptoms 13.5 + 6.1 14.2 + 5.1 0.41

General psychopathology 22.8 + 7.1 23.4 + 8.3 0.55

PSP 73.0 + 14.0 70.0 + 14.0 0.14

The PANSS scores was negatively correlated with PSP scores (r = -0.70). p<0.001).


25

Discussion

In our study, while there was no

difference in functioning between males

and females it is interesting to note that

more females were married as compared

to men. This fact may actually denote

better function or may be due to the later

onset of the illness in the women thus

enabling them time to get married before

the illness develops. While ties such as

marriage might shield the patient from

the adverse effects of negative life

events, they also may act as stressful

factors9. Many studies in the past reveal

that there is a greater preponderance of

negative symptoms among males1.

Presence of negative symptoms is a poor

prognostic factor. However there was no

difference between both genders with

respect to the psychopathology in our

results. Perhaps this fact may also

explain why both genders function

equally well. Significantly more males

were on atypical antipsychotics which

are well known to improve negative

symptoms. This may be another reason

why males have as good an outcome as

the women. Results of this study suggest

that different management strategies are

not required between the two genders.

References

1. Leung A, Chue P. Sex

differences in schizophrenia, a review of

the literature. Acta Psychiatr Scand

2000; 101(suppl): 3-38

2. Tamminga CA. Gender and

schizophrenia. J Clin Psychiatry 1997;

58(suppl): 33-37

3. Schultz SK, Miller DD, Oliver

SE, Arndt S, Flaum M, Andreasen NC.

The life course of schizophrenia: age and

symptoms dimensions. Schizophr Res

1997; 23(1): 15-23

4. Murray RM, Van Os J.

Predictors of outcome in schizophrenia.

J Clin Psychopharmacol 1998; 18(suppl

1): 2S-4S

5. Franzek E, Beckmann H. Sex

differences and distinct subgroups in

schizophrenia. Psychopathology 1990;

25: 90-99

6. Szymanski S, Lieberman JA,

Alvir JM et al. Gender differences in

onset of illness, treatment response,

course and biologic indexes in first-

epidose schizophrenic patients. Am J

Psychiatry 1995; 183: 698-703

7. Angermeyer MC, Kuhn L,

Goldstein JM. Gender and the course of

schizophrenia: Differences in treated

outcomes. Schizophr Bull 1990; 16(2):

293-304

8. Mubarak AK. Employment

status, psychiatric disability and quality

of life: comparison of men and women

with schizophrenia in Malaysia. Int J

Soc Welfare 2006; 15(3): 240-246

9. Hamilton NG, Ponzoha CA,

Cutler DL, Weigel RM. Social networks

and negative versus positive symptoms

of schizophrenia. Schizophr Bull 1989:

15: 625-633.

Corresponding author: Prof Nor Zuraida Zainal, Department of Psychological

Medicine, Faculty of Medicine, University Malaya,Kuala Lumpur, Malaysia Email: [email protected]


26

ORIGINAL PAPER

RELIABILITY AND VALIDITY OF THE MALAY VERSION OF BRIEF COPE SCALE: A STUDY ON MALAYSIAN WOMEN TREATED WITH

ADJUVANT CHEMOTHERAPY FOR BREAST CANCER

N Yusoff*, WY Low**, CH Yip***

*Women Health Development Unit, School of Medical Science, Health Campus, Science University of Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.**Medical Education and Research Development Unit, Faculty of

Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. *** Department of Surgery, Faculty of Medicine, University of Malaya,

50603 Kuala Lumpur, Malaysia.

Abstract

This paper validates the Malay Version of Brief COPE Scale. Reliability was assessed using the test-retest method meanwhile internal consistency was indicated by the Cronbach’s alpha value. Sensitivity of the scale was expressed as the mean differences (and the Effect Size Index) from the evaluation taken at two/three weeks and ten weeks following surgery. Discriminant validity was evaluated by comparing two groups of women i.e. mastectomy and lumpectomy. Internal consistencies ranged from 0.51 to 0.99. In the meantime, the test-retest Intraclass Correlation Coefficient (ICC) ranged from <0.00 to 0.98. Sensitivity of the scale was observed in nearly all of the domains with Effect Size Index (ESI) ranged from 0.00 to 0.49. Significant differences between two groups of women (mastectomy and lumpectomy) were detected for Active coping, Planning, Positive Reframing, Religion and Self-distraction. Brief COPE Scale (Malay Version) confirms fairly good reliability and validity.

Keywords: Cronbach’s alpha, Malay Version, Brief COPE Scale, intraclass

correlation coefficient, test-retest reliability and validity.

Introduction Study on coping behavior among cancer

patients has grown enormously and urge

more attention for the specific

population1,2,3,4

. Coping strategies refer to

the specific efforts, both behavioral and

psychological that people employ to master,

tolerate, reduce or minimize stressful


27

events5. Psychologist has pointed out that

people use the strategies such as problem

solving and emotion-focused to deal with

stressful circumstances 6.

The Brief COPE scale was proposed to

assess a broad scope of coping behaviour

among adults for all condition, illnesses or

non-illnesses 7. The scale is rated by the

four-point likert scale and comprises 28

items, ranging from “I haven’t been doing

this at all” (score one) to “I have been doing

this a lot” (score four) 7

. The higher score

represents greater coping strategies used by

the respondents7. In total, 14 dimensions

(two items for every dimension) are put

forward by this scale7. They are self-

distraction, active coping, denial, substance

use, use of emotional support, use of

instrumental support, behavioural

disengagement, venting, positive reframing,

planning, humour, acceptance, religion and

self-blame7.

Several dimensions of coping behaviour

have been put forwarded by the earlier

psychologist such as active coping,

planning, seeking instrumental support etc8.

Active coping is the process of taking active

steps to try to eliminate the stressor or to

reorganize its effects8. Meanwhile, the

planning strategy is thinking about how to

handle a stressor which engages with the

action strategies, thinking about what steps

to obtain and how best to cope with the

problem8. Seeking instrumental support is

looking for advice, help or information8. In

the meantime, seeking emotional support is

attainment of moral support, compassion or

understanding8. Behavioral disengagement

is a dimension that reduces one’s effort to

deal with the stressor, even giving up the

effort to accomplish objectives with which

the stressor is interfering8. Behavioural and

mental disengagement apparently meaning

in coping as they do in other province, such

as test anxiety, social anxiety and in the self-

regulation of behaviour more commonly 9,10,11

.

Another dimension such as denial, is a

response that every so often appear in

primary consideration, practical, lowering

distress and in that way ease coping12,13,14

.

Acceptance is a functional coping reaction

whereby individual who acknowledge the

reality of a stressful situation would employ

in an effort to deal with the situation8.

Another important dimension i.e. religion is

proposed in the scale as it serves as a source

of emotional support8. It is noted that one

might turn to religion when under stress for

varying reasons.

The original report of Brief COPE Scale

exhibited excellent internal consistencies for

the dimension of Religion (α=0.82) and

Substance Use (α=0.90) 7

. Meanwhile, the

same report displayed the acceptable values

of Cronbach’s alpha for some domains i.e.

Active coping (α=0.68), Planning (α=0.73),

Positive Reframing (α=0.64), Acceptance

(α=0.57), Humor (α=0.73), Using Emotional

Support (α=0.71), Using Instrumental

Support (α=0.64), Self-distraction (α=0.71),

Denial (α=0.54), Venting (α=0.50),

Behavioral disengagement (α=0.65) and

Self-blame (α=0.69) 7.

Thus, this paper examines the reliability and

validity of the Malay Version of Brief


28

COPE Scale applied on Malaysian women

with breast cancer.

Methods

This study was carried out in three main

hospitals in Klang Valley namely The

University of Malaya Medical Centre

(UMMC), The Kuala Lumpur General

Hospital (KLGH) and The Hospital

Universiti Kebangsaan Malaysia (HUKM),

Kuala Lumpur. Ethical approval was

obtained from these various institutions as

well as from the Ministry of Health

Malaysia. The study inclusion criteria were

women who satisfied the following criteria:

new cases of breast cancer, had undergone

breast cancer surgery, were planned for

adjuvant chemotherapy and had no current

major diseases or chronic psychiatric

condition.

The translation of the original Brief COPE

scale (English Language) into Malay

Language was carried out based on the back

translation technique proposed by Brislin

(1970) and Koller et al. (2007). In this

procedure, two Malay native speakers who

were fluent English were used to do the

“Forward Translation” which was English to

Malay Language. Similarly, other two

Malay native speakers who can speak and

write English very well were employed to

carry out the “Backward Translation” which

was Malay to English Language. Women’s

feedback and comments on the difficulties in

understanding or ambiguous meaning of

certain words or sentences were recorded.

The backward translation was re-

implemented for the controversial words or

sentences reported. The Malay Version of

Brief COPE Scale were then pre-tested and

finalized before it can be used for this study.

The final Malay Version of Brief COPE

Scale was distributed on the sample of

women with breast cancer who were

approached in the Oncology Clinics, where

a list of eligible respondents was retrieved

from the oncologist and breast surgeon (Co-

author). After the respondents were

selected, they were briefed on the aim of the

study. Before the questionnaires were

distributed, the agreement of participation in

the pilot study was obtained from the

women with breast cancer, by getting a

signature for the consent form. The

information sheets for the patients followed

the standard format taken from the Ethics

Committee of the University Malaya

Medical Centre (UMMC), Kuala Lumpur,

Malaysia, were also attached to the consent

form.

Two different phases of evaluation were

undertaken in this study for the purpose of

reliability and validity analyses. Firstly,

prior-to chemotherapy i.e. before women

received the first cycle of chemotherapy, at

approximately two to three weeks after

surgery and; secondly, during chemotherapy

i.e. after the third cycle of chemotherapy, at

approximately ten weeks after surgery.

Eligible women who agreed to take part in

this study, completed the Malay Version of

Brief COPE Scale themselves at clinic.

Socio-demographic data was also gathered

from the patients such as age, ethnicity,

education, occupation, monthly income and

duration of marriage. Medical information

such as type of surgery, time since diagnosis


29

and stage of breast cancer were also

obtained and recorded.

Statistical Package of Social Science (SPSS)

version 15.0 was utilized in data analyzing.

Sixty eight of the women with breast cancer

agreed to participate, and answered the

Malay Version of Brief COPE Scale. The

internal consistency of the Malay Version of

Brief COPE Scale was assessed by

calculating the Cronbach’s alpha

coefficient15

. Meanwhile, the test-retest

reliability was assessed using the Intraclass

Correlation Coefficient (ICC) which ranges

from one (perfectly reliable) to zero16

.

Sensitivity of the scale was determined by

calculating the mean differences between

the evaluation at phase one (prior-to

chemotherapy) and phase two (during

chemotherapy) of the study, by means of a

paired t-test. The effect size of each domain

of the Malay Version of Brief COPE scale

was also reported15

. In addition, the ability

of the scale to differentiate the coping

strategies between women who had

undergone mastectomy and women who had

undergone lumpectomy (termed as

discriminant validity), was also presented by

the result of independent t-test.

Results

Table I presents the medical and bio/socio-

demographic background of the

respondents. The mean age of the women

was 46.91±7.65 years old. The majority of

the women had undergone mastectomy 53

(77.9%), as compared to lumpectomy 15

(22.1%). Majority of them were diagnosed

with stage two of breast cancer (54.4%,

n=37), followed by stage three (38.2%;

n=26) and stage one (7.4%, n=5). The time

of diagnosis to their participation in the

study was a mean of 52.04 (sd±2.47) days.

With regards to menopausal status, majority

of these women were pre-menopausal

(61.8%, n=42), followed by the post-

menopausal (30.9%, n=21) and the peri-

menopausal (7.4%, n=5) group. These

women had at least a secondary education

(64.7%, n=44), with a household monthly

income of at least RM3000 or USD854.94

(80.9%, n=55). Most of the women were

unemployed or housewives (58.8%, n=40).


30

Table I: Bio/socio-demographic and Medical Characteristics of the Women with Breast Cancer (N=68)

Age (mean ± sd)

46.91±7.65 years

Education Levels: Primary school 10 (15%)

Lower secondary 20 (29.4%)

Upper secondary 24 (35.3%)

Form 6/Diploma/Certificate 13 (19.1%)

Tertiary 1 (1.5%)

Household Monthly Income (RM3.80=USD1): Less than RM1000 17 (25.0%)

RM1001 to RM3000 38 (55.9%)

RM3001 to RM5000 6 (8.8%)

More than RM5000 7 (10.3%)

Occupation: Professionals 7 (10.3%)

Technicians and associate professionals 5 (7.4%)

Clerical workers 11 (16.2%)

Service workers/shop market sales workers 4 (5.9%)

Housewives 40 (58.8%)

Pensioner 1 (1.5%)

Types of Breast Cancer Surgery: Mastectomy 53 (77.9%)

Lumpectomy

15 (22.1%)

Menopausal Status:

Pre-menopausal 42 (61.8%)

Peri-menopausal 5 (7.4%)

Post-menopausal 21 (30.9%)

Stages of Breast Cancer: Stage 1 5 (7.4%)

Stage 2a 21 (30.9%)

Stage 2b 16 (23.5%)

Stage 3a 16 (23.5%)

Stage 3b 7 (10.3%)

Stage 3c 3 (4.4%)

Duration of Breast Cancer (mean ± sd) (From diagnosis to their participation in the

study)

52.04±2.47 days

Table II shows the internal consistency,

Intraclass Correlation Coefficient, sensitivity

and discriminant validity of the scale. The

internal consistency indicated by the

Cronbach’s alpha values ranged from 0.51

to 0.99. Meanwhile, the test-retest Intraclass

Correlation Coefficient (ICC) ranged from

<0.00 to 0.98. Sensitivity of the scale was


31

indicated by the mean differences as

observed in most of the domains i.e. Active

Coping (p<0.001), Planning (p<0.05),

Positive Reframing (p<0.001), Religion

(p<0.05), Using Emotional Support

(p<0.01), Using Instrumental Support

(p<0.05), Denial (p<0.05), Venting (p<0.05)

and Self-blame (p<0.01). In the meantime,

Effect Size Index (ESI) ranged from 0.00 to

0.49. In the analysis of discriminant

validity, the significant p-value was

observed for Active coping (p<0.01),

Planning (p<0.01), Positive Reframing

(p<0.05), Religion (p<0.05) and Self-

distraction (p<0.05), indicating the ability of

the scale to detect the differences of these

coping strategies between women who had

been treated with mastectomy and women

who had been treated with lumpectomy.

Table II: The Reliability and Validity of the Malay Version of the Brief COPE Scale (N=68)

Phase 1

Evaluation

Mean (SD)

Phase 2

Evaluation

Mean (SD)

Test-retest

(ICC)

Internal

consistency

(Cronbach’s

alpha)

Sensitivity to

change

Mean differences

(ESI)

Discriminant

Validity1

Brief COPE:

Active

coping

5.82 (±1.47) 7.32 (±1.11) <0.00 0.71 1.46 (0.49)*** p=0.002

Planning 5.81 (±1.49) 6.35 (±1.31) 0.06 0.60 0.54 (0.19)* p=0.008

Positive

reframing

5.13 (±1.33) 6.57 (±1.36) 0.10 0.67 1.46 (0.48)*** p=0.034

Acceptance 6.82 (±1.27) 6.81 (±1.30) 0.98 0.69 0.01 (0.01) NS

Humour 3.35 (±1.51) 3.35 (±1.89) <0.00 0.61 0.03 (0.01) NS

Religion 7.04 (±1.27) 7.51 (±0.70) 0.11 0.68 0.45 (0.21)** p=0.028

Using

emotional

support

5.31 (±1.37) 6.01 (±1.80) 0.18 0.57 0.69 (0.21)** NS

Using

instrumental

support

5.62 (±1.66) 6.40 (±1.60) 0.27 0.69 0.74 (0.22)** NS

Self-

distraction

5.90 (±1.50) 6.15 (±1.35) 0.06 0.72 0.25 (0.09) p=0.011

Denial 5.78 (±1.46) 6.04 (±1.59) 0.96 0.57 0.12 (0.04)* NS

Venting 5.93 (±1.59) 2.24 (±1.12) 0.95 0.63 0.12 (0.04)* NS

Substance

use

2.22 (±0.99) 4.54 (±1.08) 0.59 0.99 0.01 (0.01) NS

Behavioural

disengagem

ent

4.56 (±1.05) 4.63 (±1.11) 0.96 0.54 0.01 (0.01) NS

Self-blame 5.13 (±1.28) 5.31 (±1.51) 0.93 0.51 0.18 (0.06)** NS

***p<0.001; **p<0.01; *p<0.05 Phase 1 = Two/three weeks following surgery; Phase 2 = Ten weeks following surgery

ICC = Intraclass Correlation Coefficient ESI = Effect Size Index

1. Discriminant validity of the scale was calculated by comparing two groups of women

i.e. women with mastectomy and women with lumpectomy.


32

Discussion

Most of domains of the Malay Version of

the Brief COPE Scale indicated fair internal

consistencies. This finding could be

recognized as most of the subscales in the

original Brief COPE scale also presented

fairly internal consistencies with Cronbach’s

alpha value which was less than 0.757.

Domains such as Acceptance (0.98), Denial

(0.96), Venting (0.95), Behavioural

Disengagement (0.96), Substance Use (0.59)

and Self-blame (0.93), suggesting an

excellent agreement as compared to Active

coping (<0.00), Planning (0.06), Positive

Reframing (0.10), Humour (<0.00), Religion

(0.11), Using Emotional Support (0.18),

Using Instrumental Support (0.27), Self-

distraction (0.06) showed poor ICC values,

which showed low agreement between the

evaluation done at prior-to and during

chemotherapy phases. This could probably

be due to the fact that the coping strategies

which were based on the element of “action”

were influenced by the phases of the

treatment (pre- and during chemotherapy),

while the coping strategies which were

based on the element of “psychology” were

found to be the contradictory.

The Malay Version of Brief COPE scale

showed a range of effect size, from trivial to

moderate (0.00 to 0.49), which illustrates

that the effect of treatment phases on

women’s coping strategies is associated with

the nature of the coping behaviour itself,

when dealing with the life crisis. Variations

in the sensitivity of the scale was perhaps

due to the treatment situation measured

prior-to and during chemotherapy phases,

and not because of the low sensitivity of the

scale to detect a change.

It was observed that the Malay Version of

Brief COPE Scale discriminated the

strategies of Active coping, Planning and

Positive Reframing between the groups of

women who had undergone mastectomy and

women who had undergone lumpectomy.

Nevertheless, no differences were observed

between the mastectomy and lumpectomy

groups in other domains, which is in lieu

with some previous findings 17,18

. This

could mean that the psychosocial aspect

between women who had mastectomy and

women who had lumpectomy were almost

similar.

In conclusion, the Malay Version of Brief

COPE Scale is a reliable and valid

instrument which could be applied for the

Malaysian population, with regards on its

acceptable internal consistency and the

ability of the scale to detect the changes as

indicated by the mean differences and the

value of Effect Size Index (ESI).

Nonetheless, the low values of Intraclass

Correlation Coefficient (ICC) and a small

sensitivity of some of the domains could be

due to the different treatment phases and the

nature of the coping behavior itself. In

addition, findings from previous studies

should also be referred to in order to support

and justify the current finding of the study7,

17.

Acknowledgements

Special acknowledgements are dedicated to

University of Malaya (UM), Kuala Lumpur,

Malaysia, for the financial support


33

(Fundamental Grant: FP058/2005C) and to

all the women with breast cancer who had

willingly taken part in this study.

References

1. Link LB, Robbins L, Mancuso CA

and Charlson ME. How do cancer patients

choose their coping strategies? A qualitative

study. Patient Education and Counseling

2005; 58: 96-103.

2. Li J and Lambert VA. Coping

strategies and predictors of general well-

being in women with breast cancer in the

People's Republic of China. Nursing and

Health Sciences 2007; 9 (3): 199-204.

3. Anagnostopoulos F, Vaslamatzis G

and Markidis M. Coping strategies of

women with breast cancer: A comparison of

patients with healthy and benign controls.

Psychotherapy and Psychosomatics 2004; 73

(1): 43-52

4. Barez, M., Blasco, T., Fernandez-

Castro, J. and Viladrich, C. A structural

model of the relationships between

perceived control and adaptation to illness in

women with breast cancer. Journal of

Psychosocial Oncology 2007; 25 (1): 21-43.

5. John D and MacArthur CT.

Research Network on Socioeconomic Status

and Health [Online] 1998; Available

at:http://www.macses.ucsf.edu/Research/Psy

chosocial/n ial/notebook/coping.html.

[Assessed 19 March 2008]

6. Folkman S and Lazarus RS. An

analysis of coping in a middle-aged

community sample. Journal of Health and

Social Behavior 1980; 21: 219-239

7. Carver CS. You want to measure

coping but your protocol’s too long.

Consider the Brief COPE. International

Journal of Behavioral Medicine 1997; 4 (1):

92-100.

8. Carver CS, Scheier MF and

Weintraub JK. Assessing Coping Strategies:

A Theoretically Based Approach. Journal of

Personality and Social Psychology 1989; 56

(2): 267-283.

9. Carver CS and Scheier MF. A

control-theory model of normal behavior,

and implications for problems in self-

management. In Kendall PC, ed. Advances

in Cognitive-behavioral Research and

Therapy. New York: Academic Press, 1974:

127-194

10. Carver CS and Scheier MF.

Analyzing shyness: A specific application of

broader self-regulatory principles. In Jones

WH, Cheek JM and Briggs SR, eds.

Shyness: Perspectives on Research and

Treatment. New York: Plenum Press, 1986:

173-186

11. Scheier MF and Carver CS. A

model of behavioral self-regulation:

Translating intention into action. In

Berkowitz L, ed. Advances in Experimental

Social Psychology, New York: Academic

Press, 1988; 303-346


34

12. Breznitz S (ed). The Denial of

Stress. New York: International Universities

Press, 1983

13. Cohen F and Lazarus RS. Active

coping process, coping dispositions and

recovery from surgery. Psychosomatic

Medicine 1973; 35: 375-389

14. Wilson JF. Behavioural preparation

for surgery: Benefit or harm? Journal of

Behavioral Medicine 1981; 4: 79-102

15. Cohen, J. Statistical power analysis

for the behavioral analysis. Academic Press:

New York, 1977

16. Deyo RA, Dichr P and Patrick DL.

Reproducibility and responsiveness of health

status measures. Control. Clin. Trials 1991;

12 (Suppl.1): 142-158

17. Buddeberg C, Riehl-Emde A,

Landont-Ritter C et al. The significance of

psychosocial factors for the course of breast

cancer-results of a prospective follow-up

study. Schweizerische Archive Neurology

Psychiatry 1990; 141 (5): 429-55.

Corresponding author: Dr Nasir Yusoff , Women Health Development Unit, School of

Medical Science, Health Campus, Science University of Malaysia, 16150 Kubang Kerian,

Kelantan, Malaysia

Email address: [email protected] or [email protected]

Tel : +609 7664934

Fax: +603 7645887


35

ORIGINAL PAPER

SERVICE UTILIZATION AND COSTS ASSOCIATED WITH SWITCHING TO RISPERIDONE FROM PREVIOUS TREATMENT

WITH TYPICAL ANTIPSYCHOTIC AGENTS

A Hatim*, J Tan*, Mas Ayu**, H Habil*

*Dept. of Psychological Medicine, University of Malaya Medical Centre, Kuala Lumpur. **Dept. of Social and Preventive Medicine, Faculty of

Medicine, University of Malaya, Kuala Lumpur

Abstract

This study determined medical service utilization and costs associated with switching to risperidone from previous treatment with typical antipsychotic agents. 62 adult outpatients diagnosed with schizophrenia were identified from pharmacy records, with complete information regarding medical service utilization for one year before and after treatment with risperidone. Information on hospitalization, use of day care hospital, electroconvulsive therapy, emergency department, outpatient clinic services and functional parameters were collected. Cost of treatment, cost of unemployment and cost of lost productivity due to suicide were calculated. The results showed significant fewer hospitalization days, ECT sessions and emergency department visits were observed one year after switching to risperidone (p<.05). The total treatment costs associated with risperidone after one year was 88.8% higher than costs during the previous year of treatment with typical antipsychotic agents. Keywords: risperidone, schizophrenia, cost analysis

Introduction

Schizophrenia is a serious mental illness.

For majority of patients it is a lifetime

condition, characterized by intermittent

episodes of hospitalization due to relapse or

acute symptom exacerbation(1, 2). The

nature and course of the disorder impose

significant social and economic burden.

Relapse is costly, with hospitalization

accounting for a substantial portion of

healthcare expenses. Periods of acute

episodes are strongly linked with

unemployment. Other costs include loss of

productivity among unpaid family

caregivers(3). In UK, the estimated of direct

cost of treatment and care of schizophrenia

was about 2 billion pounds in 2004/05. The

burden of indirect costs was amounting to

nearly 4.7 billion pounds. The cost of lost

productivity due to unemployment, absence

from work and premature mortality of

patients was 3.4 billion pounds.(4) In the

U.S., of the estimated direct costs in 2002 of

schizophrenia treatment amounted to

US$22.7 billion. The indirect costs,


36

including losses due to unemployment were

$32.4 billion.(5) The hospitalization cost

associated with antipsychotic nonadherence

was much higher ranging from $1392

million to $1826 million in 1995(6).

Antipsychotic pharmacotherapy continues to

play an important role in reducing acute

symptoms, improving functioning and

preventing relapse among patients with

schizophrenia(7-9). Risperidone, an atypical

antipsychotic agent, has demonstrated

efficacy in improving schizophrenia

symptoms in both short and long-term

studies(10, 11). It also has been associated

with a relatively smaller risk of relapse at 1

year follow-up compared with haloperidol

(1, 12-14). However, the higher acquisition

cost of this drug compared to typical

antipsychotic medications remains a limiting

factor to its use.(15-17)

Nevertheless it has been suggested that net

savings due to reductions in service

utilization mediated by risperidone use may

compensate for the drug’s high acquisition

cost(18-21). Comparison of hospitalization

rates before and after initiation of

risperidone in clinical trials has shown

reduction in number of days hospitalized by

as much as 31% – 73% (22-27). In the

systematic review by Hudson and colleagues

of 22 economic evaluation studies on novel

antipsychotic agents(28), ten retrospective

studies compared costs associated with use

of risperidone versus conventional

antipsychotic drugs. One study estimated

costs of clinical data gathered in an

experimental setting(29), while 9 studies

used data gathered from patient records(29-

37) . Decreased in total costs were noted in 5

studies(29, 30, 33, 36, 37), while increased

in total costs were reported in 4 studies (31,

32, 34, 35). Using scores on clinical

improvement as measures of effectiveness

and decrease in service utilization as proxy

indicators of improvement, three studies

documented improved effectiveness and

lower total costs associated with risperidone

use(29, 30, 33). The review also noted that

all of the 7 studies that used simulation

models to estimate costs associated with use

of atypical antipsychotic drugs, indicated

cost advantages (28).

However these studies dealt primarily with

patients in developed countries. Data on the

economic impact of schizophrenia in

developing countries was limited. Given the

economic burden of schizophrenia,

evaluating the costs associated with use of

particular drugs was really vital. The

objectives of this study was to compare

medical service utilization and costs

associated with switching to risperidone

from previous treatment with typical

antipsychotic agents among outpatients in

the University of Malaya Medical Center.

Materials and Methods

Study Design and study subjects

This was a cross-sectional study of before

and during risperidone treatment. The

eligible study subjects were outpatients,

aged 18 years and above and have a

diagnosis of schizophrenia according to

DSM IV criteria. All outpatients treated with

oral risperidone from January 2001 to

January 2005, were identified from the

pharmacy records of the University of

Malaya Medical Center (UMMC). The

UMMC is the oldest teaching hospital and

acts as a referral center for Klang Valley

(Kuala Lumpur), Malaysia. It attends to

approximately 24,000 psychiatric

outpatients and 800 psychiatric inpatients a

year.


37

The selection criteria was each patient must

have been treated with the same typical

antipsychotic agent for at least one year. The

patients later were switched to oral

risperidone and maintained as outpatient for

at least one year. The follow-up information

for at least one year must be available from

the medical records for each type of

antipsychotic drug treatment.

Patients with other than Axis I diagnoses,

less than one year of treatment with

risperidone, taking atypical antipsychotic

agents other than risperidone, or with

inadequate follow-up data were excluded

from the study.

Data collection

For each patient, a structured questionnaire

was used to collect data for the last 12-

month period prior to risperidone treatment,

which was during treatment with a

conventional antipsychotic drug, and for the

12-month period immediately after initiation

of risperidone. All information was obtained

from patients’ medical record. The

questionnaire was divided into three

sections; demographic characteristics,

medical service utilization and functional

parameters during treatment.

The first section was to describe the

demographic data of the study population,

i.e. age, sex, race, education level and

marital status. The second section was

regarding medical service utilization for

both treatment periods, mainly to describe

the number of days hospitalized, number of

electroconvulsive therapy sessions

undergone, number of days spent in day care

hospital, number of emergency department

visits, number of scheduled clinic visits and

number of unscheduled clinic visits. Number

of scheduled clinic visits attended was used

as an indicator of compliance to therapy.

The third section was regarding functional

parameters which included the use of

institutional residential care, employment,

showing of violent episodes requiring

restraint, attempted suicides at least once

and police reports against the patient at least

once. The third section was used as

indicators of indirect consequences of

schizophrenia. Ethical approval was

obtained from UMMC Ethical Committee.

Cost for treatment with typical

antipsychotics and risperidone

The cost stated was the fee that needed to be

paid by patients after medical service

utilization. Cost of medical service

utilization was calculated separately for

treatment with typical antipsychotics and

risperidone. It was the total cost of each type

of medical services. Medical service

utilization cost for hospitalization was

computed by multiplying total admission

day and hospitalization charges, whereas

day care hospital cost was obtained by

multiplying total day and day charges. Other

medical service utilization was derived by

multiplying the frequency of utilization and

the charges of each service. Cost estimation

for treatment was obtained by summation of

cost of medical services and cost of

medication. The hospital charges of medical

service in UMMC were based on 2005 rates.

Cost estimation in lost of productivity

The functional parameters measured during

treatment were employment status and

attempted suicide. A further analysis was

done to quantify the economic loss due to

unemployment and suicide attempt using

procedures described in a previous study

(38, 39) The employment rate loss due to

schizophrenia was calculated based on the

difference between employment rates in the

general population, reported by Department


38

of Statistics, Malaysia in 2005(40) and

employment rates for each antipsychotic

therapy, later multiply with monthly per

capita income in 2005. Economic loss of

suicide was assessed in terms of lost of

employment, with the assumption that there

would be lost of productivity for 6 months

period in view of recovery from injury and

rehabilitation. (39)The calculation of lost

productivity due to suicide equal to attempt

rate multiply by employment rate for each

antipsychotic multiply 6-montly per capita

income. The per capita income RM18,040

was used based on report by the Department

of Statistics, Malaysia in year 2005(40, 41).

Statistical Analysis

Raw data obtained were coded and entered

into Statistical Package for Social Sciences

(SPSS) Version 15.0. For categorical

variables, they were described in the form of

frequencies and percentages. For continuous

variables, they were summarized and

described as means, standard deviations,

median and range.

Differences in characteristics between

groups were compared using Chi-square

tests for categorical variables. 2-tailed paired

t test was used for continuous variables and

Wilcoxon Singed Ranks test was used for

skewed distribution. Subsequently the

continuous variables were recategorised and

further tested by Pearson’s Chi-square test.

An alpha level of 0.05 was set for all

analyses.

Results Out of 400 patients that have been screened,

who were initially on typical antipsychotic

medication and later switched to risperidone,

only 62 patients fulfilled the selection

criteria. Characteristics of selected patients

were shown in Table 1.

From Table 1, 56.5% were female patients;

majority was between 20 to 59 years old

(89%), which was also productivity age

group. There was no statistically significant

difference between the mean age of male

and female patients. Further stratification

analysis showed more female patients

(30.6%) were married as compared to the

males (12.9%). However, the difference was

not statistically significant.

Table 1. Characteristics of patients (n = 62) Variable n (%)

Gender

Male 27 (43.5)

Female 35 (56.5)

Age group

20-29 6 (9.7)

30-39 12 (19.4)

40-49 23 (37.1)

50-59 14 (22.6)

60-69 4 (6.5)

70 and above 3 (4.8)

Race

Malay 6 (9.7)

Chinese 46 (74.2)

Indian 10 (16.1)

Level of Education

No formal education 3 (4.8)

Primary 13 (21.0)

Secondary 38 (61.3)

Tertiary 8 (12.9)

Marital Status

Single 32 (51.6)

Married 27 (43.5)

Divorced 3 (4.8)

Data on medical service utilization for

typical antipsychotic medication and

risperidone were shown in Table 2. Overall

duration for hospital stay for risperidone was

shorter and less frequent visit for multiple

hospital services compared to typical

antipsychotics. The number of patients

hospitalized at least once declined from 17

patients during typical antipsychotic

medication, to only 3 patients after the first

year of treatment with risperidone. During

the 1-year period of treatment with typical


39

antipsychotic drugs, the cumulative number

of days spent as in-patient was 372 days.

This would also equivalent to an average

hospital stay of 6.0 + 2.4 days per patient

during typical antipsychotic medication.

During treatment with risperidone,

hospitalization decreased to 51 days and the

reduction in the number of days was 86%.

Table 2. Comparison between typical antipsychotic medication and risperidone for medical service utilization, n=62 Index of Service Utilization

Typical

antipsychotic Risperidone p

Hospitalization(day) <0.001*

Median 0 0

Range 0 - 83 0 - 28

Total 372 51

No. of admitted patients n(%) 17 (27.4) 3 (4.8)

Electroconvulsive therapy (ECT) sessions 0.017*

Median 0 0

Range 0 - 8 0

Total 45 0

No. of patients required ECT n(%) 7 (11.3) 0

Day care hospital(day) 0.107

Median 0 0

Range 0 - 68 0 - 63

Total 196 96

No. of day care patients n (%) 7 (11.3) 3 (4.8)

Emergency department visits 0.007*

Median 0 0

Range 0 - 3 0 - 1

Total 20 4

No. of patients visited emergency

department n(%)

13 (21.0) 4 (6.5)

Outpatient clinic visits (unscheduled visit) 0.883

Median 0 0

Range 0 - 7 0 - 5

Total 52 53

No. of patients visited unscheduled clinic

n(%) 29 (46.8) 27 (43.5)

Outpatient clinic visits (scheduled follow-up) <0 .001**

Mean(SD) 3.02(1.49) 4.0(1.93)

Median (Range) 3 (0 – 6) 4 (0 – 10)

Total 187 248

No. of patients visited scheduled clinic

(n,%) 58 (93.5%) 58 (93.5%)

*Statistically significantly with Wilcoxon Signed RanksTest

**Statistically significantly with Paired t Test

The most remarkable finding was the use of

electroconvulsive therapy (ECT), as none of

patients on risperidone required the therapy.

The visit to emergency department has also

significantly reduced with risperidone. The

proportion of patients making an

unscheduled outpatient clinic visit at least

once was almost similar during typical

antipsychotic drugs and after changing to

risperidone. However, in terms of

compliance with scheduled outpatient clinic

visits, the data showed significantly


40

increased attendance during treatment with

risperidone.( p<0.05)

The distribution of patients on functional

parameters in Table 3 showed there was

improvement in functioning with risperidone

treatment compared to typical antipsychotic

drugs. It also noted that during treatment

with risperidone, employment increased by

80% and the violent behaviors as indicated

by needed for restraint decreased by 82%. In

addition, there were no reports of suicide

attempts and problems with the law during

risperidone treatment, compared with

reports of attempted suicide among 5

patients and documented legal problems

among 7 patients during treatment with

typical antipsychotic agents. Economic loss

related to unemployment and suicide

attempts with typical antipsychotic drugs

was RM 403,374 per month, while treatment

with risperidone had lower cost at RM

79,677 per month.

Table 3. Distribution of patients on functional parameters, cost of unemployment and suicide during treatment with typical antipsychotic drugs and risperidone, n=62

Typical antipsychotic Risperidone

n % n %

Residing in nursing home 3 42.8 4 57.2

Employed 15 35.7 27 64.3

Showing violent behavior requiring restraint 11 84.2 2 15.8

Attempted suicide at least once 5 100.0 0 0

Reported to police at least once 7 100.0 0 0

Employment rate 24.2 43.5

Suicide attempt rate 8.1 0

Cost (RM)

Unemployment/per month 108,691 79,677

Lost productivity due to suicide/6 month 1,768,100 0

The employment rate loss due to schizophrenia = the employment ratea – employment rate for each antipsychotics therapy

Lost productivity due to suicide = attempt rate x employment rate for each antipsychotic therapy x 6-monthly income aThe employment rate for general population was 96.5% in 2005(From Department of Statistics, Malaysia)

Costs associated with each treatment were

shown in Table 4. Reduction in costs due to

decrease in frequency of utilization were

noted for most services. After risperidone

initiation, the most substantial cost reduction

was observed in hospitalization expenses.

There was 86.3% decreased in cost,

representing a cumulative saving of RM

25,680 for the study subjects in the first year

of risperidone treatment. This can be

translated as an average saving in

hospitalization of RM 414.19 per patient for

1 year of risperidone treatment.


41

Table 4. Comparison of costs during treatment with typical antipsychotic drugs and risperidone, n=62

Service Category

Hospital

Charges

(RM)

Typical antipsychotic

Risperidone

Difference Frequenc

y

Total(R

M) Frequency

Total(R

M)

Hospitalization¶ 80 372 29,760 51 4,080 -25,680

Electroconvulsive therapy 175 45 7,875 0 0 -7,875

Day care hospital ¶ 35 196 6,860 96 3,360 -3,500

Emergency department services 50 20 1,000 4 200 -800

Outpatient clinic services 35 239 8,365 301 10,535 +2,170

Scheduled visit 35 187 6,545 248 8,680

Unscheduled visit 35 52 1,820 53 1,855

Medical service utilization cost 53,860 18,175 -35,685

Antipsychotic medication

Typical antipsychotic

Risperidone

744* 14,880

744*

111,600

+96,720

20/month

150/month

Total treatment cost 68,740 129,775 +61,035 * 62 patients for 12 months treatment ¶ the frequency for hospitalization and day care hospital counted as day

The increased number of scheduled

outpatient clinic visits has shown the

improvement in compliant with the follow

up. Cumulative 1-year cost for outpatient

clinic services increased from RM 8,365

during treatment with typical antipsychotic

drugs to RM 10,535 during risperidone

medication. As for the actual expenditure of

antipsychotic medication, the cost for typical

antipsychotic drugs and risperidone were

approximately RM 5 and RM 300 per month

respectively. However, patients were

charged for RM 20 for typical antipsychotic

drugs and RM 150 for risperidone. In one

year, the charges per patient for typical

antipsychotic drugs were RM 240 and RM

1,800 for risperidone.

In term of total medical service utilization

cost for risperidone, there was 66.3%

decreased in cost as compared to typical

antipsychotic drugs. However with the

higher charges on risperidone, the overall

total treatment cost after switching to

risperidone increased by 88.8%. The

cumulative total treatment cost during

treatment with typical antipsychotic drugs at

RM 68,760 (RM 1,108.71 per patient), and

RM 129,775 (RM 2,093.15 per patient)

during treatment with risperidone.

Discussion In many studies, atypical antipsychotic

drugs had been proven to have better

effectiveness compared to typical

antipsychotics (42, 43). For this study, 62

outpatients with history of previous

treatment with typical antipsychotic drugs,

showed significantly fewer days for

hospitalization, less Electroconvulsive

Therapy(ECT) sessions, emergency

department visits, after one year switching

to risperidone. The total treatment cost was

88.8% higher after 1 year of risperidone

treatment compared to treatment with

typical antipsychotic drugs.

Some studies have shown a similar trend for

increased costs with risperidone use (32-35),

while other studies have shown contrary


42

findings (31, 44). The reason for higher cost

of risperidone for this study was due to

prescribing of original drug for risperidone

and generic drug for typical antipsychotics.

Although the reduction in expenses

associated with these lower utilization rates

could compensate for the acquisition cost of

risperidone, the real treatment cost was

much higher as the price of risperidone was

double from what has been paid by the

patients.

In this particular study however, the

increased in total treatment cost with

risperidone use was observed despite

substantially lower service utilization costs.

This suggested that antipsychotic medication

expenses in developing countries account

for a greater proportion of total direct costs,

as opposed to developed countries. A cost-

of-illness study of schizophrenia in Nigeria

illustrated this point, with results showing

that the main predictor of treatment

expenses was the cost of the antipsychotic

agents’ used (39, 45).

In this study, the most significant reduction

in medical service utilization cost was

hospitalization. The common reason for

hospitalization was relapse among

schizophrenic patients, (46-49) with the

reduction of hospitalization after switching

to risperidone, this indicated that relapse has

reduced and patients were able to have a

better quality of life and be productive for

their community. Several studies had also

demonstrated lower risk of relapse with

risperidone use compared with typical

antipsychotic drugs such as haloperidol (1,

12). It has been estimated that risk of relapse

in patients with schizophrenia was 3.5% per

month (27). Repeated relapses might

adversely affect future remission, level of

disability, and heighten treatment resistance

(50-53). Thus risperidone was superior in

preventing relapse and providing important

clinical benefits to patient and cost-savings

due to fewer rehospitalization.

All functional parameters such as

institutionalized residential care,

employment, violent episodes, suicide

attempts and police reports at least once

showed improvement during treatment with

risperidone. Further, when unemployment

and suicide attempts during the two

treatment periods were analyzed as lost

productivity and valued in terms of per

capita income, the economic loss during

treatment with typical antipsychotic drugs

were higher than costs associated with

risperidone treatment. The percentage of

employment with risperidone treatment in

this study (64.3%) was higher than 2004

employment rates (48%) gathered by the

Malaysian National Mental Health Registry

among patients with schizophrenia (54).

However as overall particularly in Malaysia,

the social stigma attached to mental illnesses

limited the employment opportunities of

patients with schizophrenia (55, 56).

The findings in this study can be utilized for

future implementation of National

Healthcare Financing in Malaysia and

strengthening the insurance coverage for

patients with mental illness. This study

provided information for the ability of

patients and family members to pay out-of-

pocket for the antipsychotic medication and

utilization of medical services. Although the

costing of this study for both treatments

were only based on hospital charges, not the

analysis of hospital costs based on direct and

indirect cost, the decision on healthcare

financing and insurance coverage not only

aiming at cost-saving, the policy maker

should also consider patients’ well being and

the quality of life, and beyond the calculated

hospital costs. The findings on functional

parameters in this study has proved that the

social and economic gain were vast more


43

with risperidone than typical antipsychotics.

There were limitations to the present study

that should be taken into consideration when

interpreting the results. Although this study

utilized secondary data from patients’

medical record, recalled bias was overcome.

There would be selection bias of the

participant, as only subjects with complete

information for one year with typical

antipsychotic and later one year with

risperidone were selected. Subjects who had

been treatment less than one year for both

treatments might have more information

regarding medical service utilization and

functional parameters. The results for this

group can be interpreted as cost of treatment

per month. The cost of concomitant

treatment should be included in the cost of

medication because the information was

available in the medical record.

Conclusions The present study suggested that switching

to risperidone after treatment failure or

treatment intolerance of previous typical

antipsychotic agents might provide clinical

advantages, but not the cost of treatment.

Further studies were required to investigate

the relationship between the apparent

clinical benefit and cost limitations of

risperidone use. The findings will clarify the

real impact of newer antipsychotic agents on

mental health patients in developing

countries.

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Schizophrenia: a review of

neuropharmacology. Ir J Med Sci. 2004 Jul-

Sep;173(3):155-9.

44. Finley PR, Sommer BR, Corbitt JL,

Brunson GH, Lum BL. Risperidone: clinical

outcome predictors and cost-effectiveness in

a naturalistic setting. Psychopharmacol Bull.

1998;34(1):75-81.

45. Shah A, Jenkins R. Mental health

economic studies from developing countries

reviewed in the context of those from

developed countries. Acta Psychiatr Scand.

2000 Feb;101(2):87-103.

46. Morken G, Widen JH, Grawe RW.

Non-adherence to antipsychotic medication,

relapse and rehospitalisation in recent-onset

schizophrenia. BMC Psychiatry. 2008;8:32.

47. Ucok A, Polat A, Cakir S, Genc A.

One year outcome in first episode

schizophrenia. Predictors of relapse. Eur

Arch Psychiatry Clin Neurosci. 2006

Feb;256(1):37-43.

48. de Sena EP, Santos-Jesus R,

Miranda-Scippa A, Quarantini Lde C,

Oliveira IR. Relapse in patients with

schizophrenia: a comparison between

risperidone and haloperidol. Rev Bras

Psiquiatr. 2003 Oct;25(4):220-3.

49. Doering S, Muller E, Kopcke W,

Pietzcker A, Gaebel W, Linden M, et al.

Predictors of relapse and rehospitalization in

schizophrenia and schizoaffective disorder.

Schizophr Bull. 1998;24(1):87-98.

50. Turner MS, Stewart DW. Review of

the evidence for the long-term efficacy of

atypical antipsychotic agents in the

treatment of patients with schizophrenia and

related psychoses. J Psychopharmacol. 2006

Nov;20(6 Suppl):20-37.

51. Perkins DO, Gu H, Boteva K,

Lieberman JA. Relationship between

duration of untreated psychosis and outcome

in first-episode schizophrenia: a critical

review and meta-analysis. Am J Psychiatry.

2005 Oct;162(10):1785-804.

52. Leucht S, Barnes TR, Kissling W,

Engel RR, Correll C, Kane JM. Relapse

prevention in schizophrenia with new-

generation antipsychotics: a systematic

review and exploratory meta-analysis of

randomized, controlled trials. Am J

Psychiatry. 2003 Jul;160(7):1209-22.

53. Huxley NA, Rendall M, Sederer L.

Psychosocial treatments in schizophrenia: a

review of the past 20 years. J Nerv Ment

Dis. 2000 Apr;188(4):187-201.

54. Ministry. of Health

Malaysia.National Mental Health Registry’s:

Report 2003-2004.

55. Mubarak AR, Baba I, Chin LH, Hoe

QS. Quality of life of community-based


47

chronic schizophrenia patients in Penang,

Malaysia. Aust N Z J Psychiatry. 2003

Oct;37(5):577-85.

56. Mubarak AR. Social functioning and

quality of life of patients with schizophrenia

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2006]; Available from:

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k.pdf

Corresponding author: Ahmad Hatim Sulaiman, Department of Psychological Medicine,

University of Malaya Medical Centre, Kuala Lumpur


Tel: +6012 2310252

Fax: +603 79571058


48

ORIGINAL PAPER

EARLY READMISSION IN PATIENTS AFTER ELECTROCONVULSIVE

THERAPY IN A UNIVERSITY HOSPITAL SETTING - A RETROSPECTIVE STUDY

Ng CG*, Amer Siddiq AN*, Salina M*, Koh OH*, Zuraida NZ*

*Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur

Abstract

Electroconvulsive therapy (ECT) is an effective treatment for major mental illnesses. It is used to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options have proven ineffective. Relapse rates following ECT are high and leading to early readmission. Objective: To study the early readmission rate in patients had received ECT and its relation with age, gender, race and clinical diagnosis. Methods: This is a retrospective descriptive study of patients who had received ECT in 1-year period. Subjects were identified from the ECT record book. Case notes of these patients were then traced and reviewed. Clinical diagnosis and demographic data were collected. Patients readmitted within 6 months after being discharged were identified. The data was compared for the readmitted and not readmitted group. Result: A total of 156 subjects who had received ECT were included in this study. Mean age was 40 years old, 51% were female and the main diagnosis was bipolar affective disorder (42.9%). Early readmission rate was 30.1%. Mean time to relapse was 5.3 months. Chi Square analysis indicated that younger age was significantly associated with early readmission among ECT patients. Conclusion: ECT patients had high early readmission rate. Adequate post ECT psychosocial intervention and pharmacotherapy may help to reduce the readmission rate.

Keywords: electroconvulsive therapy, early readmission, mental illness

Introduction

Electroconvulsive therapy (ECT) is a

treatment for mental illness, which involves

the application of electrodes to the head to

induce a generalized seizure. It was

introduced in the 1930s as another treatment

for psychiatric illnesses when psychotherapy

fails. Its introduction was rife with

controversy but its conception has helped

psychiatrists then and today in treating some

refractory psychiatric illnesses. 1

In the past,


49

this treatment was often administered to the

most severely disturbed patients residing in

the large mental institutions. 2

In the mid –

1950s, the use of ECT began to decline due

to the discoveries of various psychotropic

drugs and the stigma attached on ECT1.

However, of late, the use of ECT has

increased due to improved delivery method

and safety. This modest resurgence was also

due to the acceptance by psychiatrists that

despite psychotropic medications, some

illnesses remained drug refractory3.

Furthermore, the speed of action of ECT

with respect to alternative treatments has

become of increasing interest in the present

era of managed care and the ever increasing

lengths of stay in hospital4.

Electroconvulsive therapy (ECT) is highly

effective for treatment of major depression,

however, without active treatment, virtually

all remitted patients relapse within 6 months

of stopping ECT with a relapse rate of 84%5.

The Royal College of Psychiatrists’ fact

sheet states that more than 8 out of 10

depressive patients who receive ECT

responded well. 6

Similarly, for mania, ECT

is associated with remission or marked

clinical improvement in 80% of manic

patients and it is an effective treatment for

patients who responded poorly to

pharmacotherapy7. ECT has been suggested

to be use in patients with severe risk of

suicide 8,9

.

The National Institute for Clinical

Excellence (NICE)10

recommended that

electroconvulsive therapy (ECT) is used

only to achieve rapid and short-term

improvement of severe symptoms after an

adequate trial of other treatment options has

proven ineffective and/or when the

condition is considered to be potentially life-

threatening, in individuals with severe

depressive illness, catatonia and a prolonged

or severe manic episode. ECT combined

with treatment with antipsychotic drugs may

be considered an option for people with

schizophrenia, particularly when rapid

global improvement and reduction of

symptoms is desired as well as for those

with schizophrenia who show limited

response to medication alone. 11

Financial constraints on health care and the

increasing number of psychiatric patients in

the last decade causes the hospitals struggle

to reduce inpatients length of stay.

Electroconvulsive therapy (ECT) has been

widely acknowledged as an effective and

appropriate acute treatment for psychiatric

illnesses which fail to respond to

conventional treatment12

. The prompt

effectiveness of ECT shortened the duration

of stay of the patients in the hospital12

. One

of the major drawbacks, however, is the

high relapse rate in the use of ECT5.

Reported relapse rates range widely,

exceeding 50% in 6 to 12 months in (acute)

ECT up to 95%13. Using adequate

pharmacotherapy after index ECT relapse

rates between 20% and 68% have also been

reported14.

Readmission is commonly used as an

outcome and quality indicator for inpatient

services.15,16

Hospital readmission,

particularly when it occurs within a

relatively short time after previous

discharge, is often seen as a failure of the

earlier hospital admission. 17

In Malaysia,

early readmission (within 6 months) is used


50

as one of the two National Indicators in

Psychiatry (NIP-2). 18

The main objective of this study was to

determine the rate of early readmission in

patients who had received ECT in

psychiatric ward in University Malaya

Medical Centre (UMMC) Kuala Lumpur.

We also aimed to study the relation of

clinical diagnosis and certain demographic

factors with early readmission.

Method

Sample

The study was conducted at the psychiatric

ward of UMMC. UMMC is a teaching

hospital situated in Kuala Lumpur. Its

patient catchment area includes those living

in Kuala Lumpur and also Petaling Jaya,

Selangor. Most of these patients are

urbanized, young and affluent. UMMC

psychiatry department is also one of the

oldest in the country and the pioneer of

psychiatrist training for Malaysia.

It has close to 15 consultant and specialist

psychiatrists and 25 medical officers, all

whom are in the postgraduate training

program in psychiatry. UMMC on the

average, has close to 25000 outpatient visits

and 1275 inpatients a year. 19

Study..design

This is a retrospective descriptive study of

patients who received ECT in UMMC from

1st January 2007 till 31st December 2007.

ECT is conducted 3 times per week in

UMMC. Decision to provide ECT treatment

is made by a team of psychiatrists after

discussion in the management rounds.

Subjects were identified from the ECT

record book. Case notes of these patients

were then traced and reviewed. All patients

receiving ECT during the study period were

included. Subjects were then determined

whether they were readmitted within 6

month after being discharged. Those who

were readmitted for clinical drug trial, for

maintenance electroconvulsive therapy

(ECT) and forensic case were excluded. The

relevant demographic and clinical data

including age, race, sex and diagnosis were

collected.

Analysis

Data were analyzed using Statistical

Package for Social Sciences (SPSS) version

13.0. To test the statistical significance of

difference, Chi Square test was used for

categorical variables. All test of significance

were two-tailed, with an alpha level of 0.10.

Results

A total of one hundred and fifty six cases

were identified and included in the study.


51

Sample Description

Table 1: Descriptive characteristics of the subjects

Characteristic (N = 156) Mean (SD)

Age 40.0 (13.8)

n (%)

Sex

Male

Female

77 (49.4)

79 (50.6)

Race

Malay

Chinese

Indian

Others

36 (23.1)

86 (55.1)

30 (19.2)

4 (2.6)

Diagnosis

Schizophrenia

Bipolar Disorder

Major Depressive Disorder

51 (32.7)

67 (42.9)

38 (24.4)

SD = standard deviation

Table 1 shows the descriptive characteristics

of the 156 subjects. The average age was 40

years (range =13-78). The study group was

predominantly Chinese. 49% were males

and 51% of them were females. Most of the

patients were admitted with a primary

diagnosis of bipolar disorder. They were

discharged well from the ward after

completed a course of ECT.

Early Readmission

A total of 47 (30.1%) cases readmitted

within 6 months after being discharged.

Result also showed the mean duration until

readmission was 5.3 months (SD = 5.7,

range = 0.43 – 21.37).


52

Table 2 Relationship between the descriptive variables and early readmission

Descriptive Variables

Readmission

Yes No

n (%) n (%)

OR

95% CI

p

value

Age

Less than 40 years

40 years and above

30 (36.6)

17 (23.0)

52 (63.4)

57 (77.0)

1.93

0.96-3.91

0.06*

Sex

Male

Female

26 (33.8)

21 (26.6)

51 (66.2)

59 (73.4)

1.41

0.71-2.80

0.33

Race

Malay

Non Malay

14 (38.9)

33 (27.5)

22 (61.1)

87 (72.5)

1.68

0.77-3.66

0.19

Diagnosis

Schizophrenia

Mood Disorder

32 (30.5)

15 (29.4)

74 (69.5)

36 (70.6)

1.05

0.50-2.19

0.89

OR = odds ratio

* p < 0.1

Table 2 shows the Chi Square analysis of the

relationship between the descriptive

variables and early readmission. Younger

age was the only factor significantly

associated with early readmission (p < 0.1).

Discussion

The characteristics of the sample of current

study were comparable with the previous

retrospective study done in the same

centre20

. The mean age of the patients in the

psychiatric ward, UMMC was about 40

years old. Majority of the patients were

found to be Chinese descent. This study

revealed that there was not much difference

between male and female subjects needing

ECT who were admitted in UMMC. In

contrast, study done by Bloch et al (2005),

suggested that a possible gender difference

in the implement of ECT treatment. Result

of the study illustrated that hospitalized

women were referred earlier to ECT. 21


53

Those subjects who received ECT in

UMMC in this study were noted to be

diagnosed mostly with bipolar mood

affective disorder, followed by

schizophrenia and major depressive disorder

at 42.9%, 32.7% and 24.4%, respectively.

When mood disorder diagnosis were

summed up as a single entity i.e. both

bipolar mood affective disorder and major

depressive disorder, it made up 67.3% of

those receiving ECT. Volpe et al (2004)

suggested that manic episode usually yield

severe psychological, moral and economic

consequences. It causes more disruption to

marital relationship and higher divorce rate.

It might explain the higher rate of ECT use

in bipolar patients. 22

Besides, in the same

study conducted by the authors previously,

UMMC has an annual admission of 1275 for

which 47.6% of them were patients with

mood disorders and 37.5% of them were

psychosis related disorder mainly

schizophrenia type. 19

The evidence for the

use of ECT in mood related disorders were

plenty23,24

with even some calling for more

aggressive management i.e. earlier

intervention as opposed to most guideline

recommendations. The evidence for the use

of schizophrenia was however not as

convincing. 12

The result of the current study shows that

the early readmission rate in ECT patients

within 6 months was 30%. It was two times

higher than the readmission rate of 16% in

the previous study conducted by the same

authors. 20

In the previous study, the authors

studied the early readmission rate of all

psychiatric patients after discharged from

UMMC. The higher readmission rate in

ECT patients was reported in other studies.

22,23 Volpe et al (2004) found that if

readmission occurred after ECT, it took

place 6 months after the index episode. 22

Devanand et al (1991) reported that relapse

rate following ECT are high and clustered in

the first 4 months following clinical

response. 23

An explanation for the higher relapse rate is

related to the severity of illness in those

patients underwent ECT. They usually are

the more unmanageable ones with more

chronic and severe illnesses. 12

For those

with psychosis it may usually mean

treatment refractory type. Often this group

of patients did not do well with oral

medication even after the ECT5. Therefore

this results them to relapse earlier.

The result of current study illustrated that

younger age was associated with higher

early readmission. The similar finding was

found in other study. 25

It might relate with

higher risk of co-morbid substance abuse in

younger age-group. Another possible

explanation was that the levels of treatment

adherence or insight had not been modified

in the early stage of illness. 26

The current

study found that gender, race and clinical

diagnosis had no significant effect on early

readmission in ECT patients. This was

similar to the finding of the authors’

previous study.20

Dixon et al (1997) and

Lyons et al (1997) also reported that there

was no significant association between

socio-demographic predictors with

readmission. 17,27

Limitation

This is a retrospective study with small

sample size. There was lack of information


54

on the psycho-social intervention and

patients’ psychopathology during discharge.

In addition, the author surmises the final

finding of significant predicting variable

(young age) at the p < 0.1 in Chi Square

analysis represent a fairly debatable

conclusion.

Conclusion

This study showed that 30% of patients

underwent electro-convulsive therapy will

be readmitted within 6 months after

discharged from a psychiatric ward in

UMMC. Younger age was significantly

associated with higher early readmission in

ECT patients. It also illustrated that gender,

race and clinical diagnosis did not have

significant effect on the early readmission

rate. Adequate post ECT psychosocial

intervention and pharmacotherapy may help

to reduce the readmission rate.

Acknowledgement

We would like to take this opportunity to

thank sister Jamilah Suleiman who was

involved in data collection for the study.

Reference:

1. Babigian HM, Guttmacher LB

(1984). Epidemiologic considerations in

electroconvulsive therapy. Archives of

General Psychiatry. 41: 246-253.

2. Lalitanatpong D (2005) The use of

electroconvulsive therapy and the length of

stay of psychiatric inpatients a King

Chulalongkorn Memorial Hospital, Thai

Red Cross Society. J Med Assoc Thai 88

(Suppl 4): S142-8.

3. Thompson JW, Weiner RD, Myers

CP (1994). Use of ECT in the United States

in 1975, 1980, and 1986. American Journal

of Psychiatry. 151: 1657-1661.

4. Beyer JL, Weiner RD, Glenn MD

(1998). Electroconvulsive therapy: A

programmed text. Washington: American

Psychiatric Press.

5. Sackeim HA. Haskett RF. Mulsant

BH. Thase ME. Mann JJ. Pettinati HM.

Greenberg RM. Crowe RR. Cooper TB.

Prudic J (2001) Continuation

pharmacotherapy in the prevention of

relapse following electroconvulsive therapy:

a randomized controlled trial, JAMA,

285(10):1299-307.

6. Royal College of Psychiatrists

(1995) Fact sheet on ECT. London: RCP.

7. Mukherjee S. Sackeim HA. Schnur

DB (1994). Electroconvulsive therapy of

acute manic episodes: a review of 50 years'

experience. American Journal of Psychiatry,

151(2):169-76.

8. Maris RW (2002). Suicide. Lancet,

360:319-26.

9. Tharyan P, Adams CE (2005).

Electroconvulsive therapy for schizophrenia

(Cochrane Review). In: The Cochrane

Library, Issue 2. Oxford: Update Software.

10. National Institute for Clinical

Excellence (NICE) (2005). Guidance on the

use of electroconvulsive therapy.

11. Taylor MA, Fink M (2006).

Melancholia: The Diagnosis,

Pathophysiology, and Treatment of


55

Depressive Disorders. Cambridge, England:

Cambridge University Press.

12. American Psychiatric Association

(2001) Committee on Electroconvulsive

Therapy. The Practice of Electroconvulsive

Therapy. Recommendations for Treatment,

Training and Privileging: A task force

Report of The American Psychiatric

Association, 2nd edition.

13. Bourgon LN, Kellner CH (2000)

Relapse of depression after ECT: A review.

Journal of ECT. 16(1):19-31

14. Petrides G, Dhossche D, Fink M,

Francis A (1994) Continuation ECT: relapse

prevention in affective disorders. Convuls

Ther 10(3):189-94.

15. Jenkins R (1991) Towards a system

of outcome indicators for mental health care.

Jenkins R, Griffiths (eds) Indicators for

mental health in the population. Department

of Health, London

16. Craig TJ, Kline NS (1982) Factors

associated with recividism: Implications for

a community support system. Community

Support Serv J 2 : 1-4

17. Lyons JS, O’Mahoney MT, Miller

SI, Neme J, Kabat J, Miller F (1997)

Predicting readmission to the psychiatric

hospital in a managed care environment:

Implications for quality indicators. Am J

Psychiatry 154 : 337-340

18. Malaysia National Indicator in

Psychiatry (NIP-2)

19. Aida SA, Ng CG, Amer Siddiq AN

(2007) Patterns of Admission in Psychiatric

Ward, University Malaya Medical Centre.

Presented in Young Research Award

Competition at the Post Graduate

Conference, Sept 2007.

20. Amer Siddiq AN, Ng C G, Aida SA,

Zainal NZ, Abdul Kadir (2008) Factors

Affecting Readmission in A Teaching

Hospital in Malaysia. R. Australian And

New Zealand Journal Of Psychiatry (2007)

41 (Suppl. 2). Malaysian Journal of

Psychiatry , 2008.

21. Bloch Y, Ratzoni G, Sobol D,

Mendlovic S, Gal G, Levkovitz Y (2005)

Gender differences in electroconvulsive

therapy: a retrospective chart review.

Journal of Affective Disorders 84:99-102.

22. Volpe FM, Tavares A (2004) Manic

patients receiving ECT in a Brazilian

sample. Journal of Affectiv Disorders 79:

201-8.

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(1991) Electroconvulsive therapy in the

treatment resistant patient. Psychiatr Clin

North Am 14(4):905-923.

24. Rose D, Fleischmann P, Wykes T,

Leese M, Blindman J (2003) patients’

perspectives on electroconvulsive therapy:

systematic review. BMJ 326:1363.

25. Sanguineti VR, Samuel SE,

Schwartz SL, Robeson MR (1996)

Retrospective Study of 2,200 involuntary

psychiatric admissions and readmissions.

Am J Psychiatry 153 : 392-396

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Kalmi E, Desage A, Misdrahi D, Brun-

Rosseau H, Verdoux H (2006) Pattern of


56

health service utilization and predictors of

readmission after a first admission for

psychosis: a 2 year follow up study. Acta

Psychiatr Scand: 113; 340-9.

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Oyebode F (1997) Risk factors for acute

psychiatric readmission. Psychiatr Bull 21 :

600-603

Corresponding author: Dr Ng Chong Guan, Department of Psychological Medicine, Faculty

of Medicine, University of Malaya, 50603, Kuala Lumpur



57

ORIGINAL PAPER

DEPRESSION, ANXIETY AND STRESS IN WOMEN WITH BREAST

CANCER: EFFECT OF A 4-WEEK SELF MANAGEMENT INTERVENTION

Loh SY*, Tan FL**, Xavier M***

*Department of Rehabilitation, Faculty of Medicine, University Malaya, 50630 Kuala Lumpur.**Department of Occupational Therapy, Kuala

Lumpur Hospital. ***Department of Occupational Therapy, Hospital Sg Buluh, Selangor.

Abstract

Objective: This study examined the relationship between depression, anxiety and stress before and after a patient self-management intervention in a cohort of women newly diagnosed with breast cancer. Methods: A clinical trial on women diagnosed with breast cancer was conducted at University Malaya Medical Centre. The experimental block underwent a 4-week self management program, followed by the control block who underwent usual care. Participants were assessed on their levels of depression, anxiety and stress at baseline (T1), at 4 weeks (T2) and at 8 weeks (T3) after the intervention. Analyses of variances on the repeated measures were conducted to examine the differences between the two groups. Results: There were significant differences in the change-scores between the experimental and control groups at post test and at follow up. Levels of depression, anxiety and stress generally decreased significantly in the experimental groups but either maintained or increase in the control group. Significantly lower stress was also found in women with higher level of self-reported physical activity than women with low physical activity. Conclusion: The depression, anxiety and stress level of women with breast cancer can be ameliorated with a 4 week self management intervention. Women with higher physical activity also show significantly lower stress. Intervention should consider factors that ameliorate distress level of women with breast cancer so that they can better go through adjuvant therapy.

Keywords: Depression, anxiety, stress, breast cancer, patient self-management, clinical trial


58

Introduction

Breast cancer, among all cancers, is the

leading cause of cancer mortality in women

worldwide. Out of the 35 million people

who died from chronic disease in 2005, half

were under 70 years and half were women

(1). Breast cancer is primarily a woman’s

disease, although among males there is a

minimal risk of developing breast cancer as

well, with a ratio of 1:100 as reported by

the American Cancer Society (2). Earlier

research have documented that up to 50%

of women with breast cancer experience

psychiatric morbidity (3), coupled with

anxiety and depression commonly faced

right from the moment they are diagnosed

with breast cancer (4). Recently, emotional

distress as a core indicator of a patient’s

wellbeing has been promoted as the sixth

vital sign in cancer care (5).

Emotional distress varies in level of

intensity, depending on severity of disease

and phase of treatment (6). It has also been

reported that the onset of reactive anxiety

and depression also often coincides with the

fatigue experienced with daily radiation

treatments (7). Thus, management of

emotion is crucial as one quarter to one third

of women undergoing chemotherapy

experienced distress (8, 9). Patient self

management support (10, 11) has the

potential for enabling women with breast

cancer with the necessary knowledge and

skills to manage the medical, emotional and

role tasks of living with breast cancer. The

intervention provided the knowledge and

skills for women to self manage the medical,

emotion and role tasks in a group of about 6-

10 people. This paper presents the

depression, anxiety and stress of women

newly diagnosed with breast cancer who

participated in a 4 week self management

clinical controlled trial in University Malaya

medical Centre.

Methods

Design & Subjects

A time series clinical trial (n=147) with an

experimental block (n=69) followed by a

control block (n=78), and involving women

newly diagnosed with breast cancer (within

one year) was conducted between December

2006 to February 2008 in University Malaya

Medical Centre. The experimental block

undertook the 4-week self management

sessions which was led by health

professionals and the aim was to enable

women to self manage in partnership with

health professionals. The control block

consisted of women who underwent their

usual-care group. Both groups filled up the

repeated measures questionnaires at

baseline, 4 weeks and at 8 weeks from

baseline. The participants were selected

based on the following eligibility criteria: I)

more than 18 years of age, ii) confirmed by

physician, a diagnosis of Stage 1-III (within

one year since diagnosis), iii) completed

surgery, may or may not be undergoing

chemotherapy and/or radiotherapy, iv) may

or may not be undergoing Tamoxifen (or

other endocrine therapy), v) can read and

understand English, and vi) give informed-

consent. The exclusion criteria are I) marked

cognitive impairment or learning disabilities

(through observation/ interview) and ii) has

other form of medical problem interfering

with participation and attendance (from self

report).


59

Tools

The Hospital Anxiety Depression scale

(HADS) has been used for screening

purposes, in diverse range of clinical groups,

for both symptom severity and detecting

anxiety disorders and depression (12).

Specific to breast cancer, the use of HADs

in women with breast cancer was questioned

(13), and it was found inadequate in

detecting depression (14, 15). Rodger and

Martin (16) proposed that if HADs is used

as a screening tool for anxiety and

depression in breast cancer patients, it must

be enhanced using a modified scoring

method based on a tripartite model of

psychological distress, but the efficacy of

such scoring system is not only time

consuming but has yet to be established.

Thus the Depression, Anxiety and Stress

(DASS) tool was selected for this study on

women with breast cancer. DASS measure 3

distinct items - the depression, anxiety and

stress. DASS-21 is a self report

questionnaire (17) which allows

simultaneous assessment of three emotional

states - depression, anxiety (hyper arousal)

and stress. A Likert-type scale is used to rate

items according to symptoms experienced in

the past week, ranging from 0 (not at all) to

3 (most of the time). The DASS tool has

been established as having excellent

psychometric properties (18).

Alpha value for the 7-item scales ranged

from 0.73 (anxiety), 0.81 (depression) and

0.81 (stress) and has adequate convergent

and discriminate validity (17, 18). It is a

valid, reliable routine clinical outcome

measure of these constructs in clinical and

non-clinical groups (19, 20) and for

inpatient setting (21). A Patient Information

Questionnaire (PIQ) was also designed to

collect data on the demographic and

background of the participants.

Data analysis:

The data was entered into the SPSS (Version

16). All missing data from participants was

imputed using the last observation carried

forward method (for those missing at later

time) and mean substitution for those with

missing at earlier time. Participants on the

experimental arm who attend at least three

out of the four sessions were included, with

missing data imputed and data accepted for

analysis. Descriptive statistics and analysis

of variance were conducted.

Results

Demographic data obtained from the PIQ

were tabulated in Table 1 below. A total of

147 women participated in the study. The

majority of the participants were Chinese

(65%), with a mean age of 50 years (+ 9 SD)

and within a range of 25-75 years. Most

were married (76%), living with spouse and

children (68%), had less than 2 children

(42%), and had at least a secondary

education (44%). Most had no extra role

looking after aged parents (73%). Only

about 6.8 percent were living alone, the rest

were living with someone, indicating the

traditional Asian trend of living within an

extended family system is still highly

prevalent, although the family today have

fewer children. More than half the women

had some form of insurance policy (53%)

and had a household income of 1000-5000

ringgit per month (55%). The independent

Chi-square tests (p<0.05) showed that the


60

demographic variables i.e. age range

(p=0.02), ethnicity (p=0.04), insurance

status (p= 0.005) and physical activity status

(p=0.02), were significantly different .at

baseline between the experimental and

control groups. These variables were entered

into the model to be adjusted for and

accounted for in the analyses.

Table 1 Demographic of participants. Variables ALL

n=147

Experiment

n=69

Control

n=78

Test

p-value

Age Range

20-49

50-79

n % n % n % X 2

72

75

49.0%

51.1%

31

38

44.8 %

55.1 %

41

37

52.5 %

47.4 %

0.022*

Ethnicity

Chinese

Indian

Malay(22) & Others(9)

95

21

31

64.6 %

14..3 %

21.1 %

54

7

8

78.3 %

10.1 %

11.6 %

41

14

13

52.6 %

17.9 %

29.5 %

0.040*

Marital Status

Single

Married

Widowed/Divorced

26

111

10

17.7 %

75.5 %

6.8 %

9

56

4

13 %

81.2 %

5.7 %

17

55

6

21.8 %

70.5 %

7.7 %

0.312

Living Companion Alone

Spouse, kids & parent

Parents & siblings

Friends/Others

11

108

12

16

7.5 %

73.5 %

8.2 %

10.9 %

5

51

6

7

7.2 %

73.9 %

8.7 %

10.1 %

6

57

6

9

7.7%

73.1%

7.7 %

11.3 %

0.989

Additional Roles

Yes

No

40

107

27.2 %

72.8 %

16

53

23.2 %

76.8 %

24

54

30.8 %

69.2 %

0.303

No of Children

None

<2 kids

> 3kids

33

62

52

22.4 %

42.2 %

35.4 %

14

30

25

20.3 %

43.5 %

36.2 %

19

32

27

24.4 %

41 %

34.6 %

0.840

Education Level

Nil -Primary

Secondary

College

University

7

65

39

36

4.8 %

44.2 %

26.5 %

24.5 %

2

30

21

16

2.9 %

43.5 %

30.4 %

23.2 %

5

35

18

20

6.4 %

44.9 %

23.1 %

25.6 %

0.999

Insurance

Yes

No

78

69

53.1 %

46.9 %

45

24

65.2 %

34.8 %

33

45

42.3 %

57.7 %

0 .005*

Physical activity level

Sedentary-low

Moderate -high

92

55

62.6

37.4

30

39

43.5

56.5

62

16

79.5

20.5

0.02


61

Prior to the analysis the baseline differences

between the two groups were assessed using

t-test. There were no statistical significant

differences in the mean scores of the two

groups for stress (p=0.08), anxiety

(p=0.299) and depression (p=0.44)

suggesting that the two groups are from the

same population. Thus any changes in the

findings can be interpreted with confident as

changes due likely to the intervention.

Descriptive statistic (Table 2) shows that on

the experimental group, a favourable

decrease on all three scales ranging from -

19.8 percent (stress) to 33.3 percent

(depression) at T1 to T2 and a further

decrease of 13.7 percent anxiety to 17.1

percent stress at T2 to T3. On the control

group, all three scales had unfavourable

increase with higher measures on

depression, anxiety and stress with a

percentage ranging from 8.9 percent to 14.9

percent on T1 to T2 period and 4.5 percent

to 4.4 percent stress improves slightly with a

decrease mean score of 2.5 percent for T2 to

T3. Overall, the trend of change from

baseline T1 to Post test T2 was favourable

for experimental group, but unfavourable in

control group.

Table 2: Descriptive (mean +SD) at repeated measures with percentages of change scores

Exp= experimental arm [n=69], ctrl=control arm [n=77] DASS =Depression, anxiety, stress scale

Significant at p<0.05

Changes over time between the two groups for depression, anxiety and stress Using the change scores (T2-T1), analysis of

variances shows significant differences

between groups for stress [F(1,140) =13.68,

p<0.0001)], anxiety [F(1,140) = 8.44,

p<0.004)] and depression [F(1,140) =11.57,

p<0.0001)]. Figure 1 showed the changes

over time in the experimental and control

groups. Between the experimental and

control group, there were no significant

differences in the age group, marital status

and ethnic groups. The women’s self

reported level of physical activity were

categorised into 4 levels (sedentary =no

exercises, low =1-2 hours per week,

moderate =2-5 hours per week and

high=more than 5 hours per week).

Significant differences between groups were

DASS

subscales

Repeated measures Change Score (T2-T1)

%

change

scores

(at T2)

Change Score (T3-T1)

%

change

scores

(at T3)

Baseline

(T1)

Post-test

(T2)

Follow Up

(T3)

Mean SD Mean SD Mean SD Mean SD Mean SD

Stress exp 12.67 8.22 9.86 7.21 8.29 6.98 -2.81 6.9 -22.2* -4.38 8.15 -34.6*

ctrl 10.31 8.05 11.92 9.82 11.33 9.89 1.62 6.60 15.7 1.02 8.27 9.9

Anxiety exp 9.13 7.57 7.16 6.45 6.64 6.90 -1.97 5.37 -21.6* -2.49 5.46 -27.3*

ctrl 7.92 6.47 9.05 7.95 8.97 7.84 1.13 5.45 14.3 1.05 5.75 13.3

Depression exp 9.28 8.7 6.09 6.59 5.54 6.33 -3.19 7.21 -34.4* -3.74 7.04 -40.3*

ctrl 8.21 8.04 9.26 9.53 9.41 9.92 1.05 6.46 18.3 1.21 8.16 14.7


62

found between the low (sedentary to light

physical activity) and high (moderate to

active) group for stress (p=0.031) but not for

depression and anxiety. The women who

exercise showed lower stress compared to

those who do not exercise (p<0.05). The

within subject repeated measure

(experimental group, n=69) showed that the

changes were statistically significant

(p<0.001) for all three variables on.

Figure 1 Line graph of repeated measure between experimental and control arms

Anx=Anxiety, dep= depression

T1 = Time 1 (baseline), T2= posttest at 4 weeks, T3 = Posttest at 8 weeks

Discussion

At baseline the levels of depression, anxiety

and stress of women with breast cancer who

were allocated to a 4 weeks self

management program were comparable to

the control group. The pattern of

progression appears significantly favourable

over the repeated measures for experimental

but unfavourable for the control arm. In the

control arm, the increased distress

(depression, anxiety and stress) was noted

with time. The 4-week self management

intervention, developed from insights

derived from four focus groups (22)

provided the knowledge and skills for

women to self manage the required tasks.

Thus, although there were extra demands for

them to attend the sessions, the women

reported feeling supported by the health

team and, the unavailability of information

(22) which was a barrier to self management

as well as a stressor was mediated by the

group sessions, and the support from their

peers' (buddies) and from the health team.

This perhaps leads to the favourable

outcomes in the experimental group.

The depression profile of the control block

continued to have a sharper rise even at the

third repeated measure. One study has

shown that in a large cohort of breast cancer

patients (n=2943), the post-hoc multivariate

analysis revealed that chemotherapy (HR:

1.2; 95% CI: 1.0 – 1.5), and hormonal

receptor positive status (HR: 1.2; 95% CI:

1.0 – 1.5) were significantly and

independently associated with an increased

risk for developing depression (23). Another

significant finding was that women who

reported higher physical activity level

showed significant difference in terms of

stress, whereby they had significantly

(p<0.05) lower stress. This could be

explained by the slightly greater number of

women who reported lower physical activity


63

level (at baseline) in the control group.

However, one limitation of the study was it

utilised self report measures and the sample

size was not large enough. Thus, a larger

study is needed to confirm the beneficial

role of physical activity in buffering stress

during treatment. These findings suggest

that women with breast cancer needs support

in managing the multiple tasks even after the

breast surgery, as chemotherapy and

radiation can be equally distressing and it

alters participation in life because of its

duration of treatment.

Conclusion Women with breast cancer who went

through a 4-week patient self management

led by health professionals showed

significant reduction in distress (depression,

anxiety and stress) over time. In contrast,

women who were in the usual care group

showed unfavourable increased in distress

over time. Having a higher physical activity

level is also significantly associated to a

lowered stress, and as such exercise as a

lifestyle strategy should be counselled to

women newly diagnosed with breast cancer.

Having a diagnosis of breast cancer is

distressing to most women but women who

were offered the self management support as

they go through the multiple appointments

for treatment, showed reduced psychological

distress. Rehabilitation of women with

breast cancer needs to be emphasised as

increasingly more women are living with

this condition.

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Atlanta, Georgia: ACS; 2005 Contract No.:

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When breast cancer recurs: A 3-year

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[updated 2000; cited 2006 jun 6]; Available

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5. Bultz BD, Carlson LE. Emotional

Distress: The Sixth Vital Sign in Cancer

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Psychological aspects of mind-body

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cancer. (pp. 188–207). New York:: Oxford

University Press.; 1990.

8. Newell S, Sanson-Fisher R, Girgis

A, Ackland S. The physical and

psychosocial experiences of patients

attending an outpatient medical oncology

department: A crosssectional study.

European Journal of Cancer. 1999;8(2):73-

82.

9. Campora E, Naso C, Vitullo M. The

impact of chemotherapy breast cancer


64

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1992;4(1):59-63.

10. Holman H, Lorig K. Patient Self-

management: A key to effectiveness and

efficiency in care of chronic disease. . Public

Health Reports. 2004;119(May-Jun

2004):239-43.

11. Bodenheimer T, Lorig K, Holman H,

Grumbach K. Patient Self-management of

Chronic Disease in Primary Care JAMA

2002;288:2469-75

12. Bjelland I, Dahl A, Haug T,

Neckelmann D. The validity of the hospital

Anxiety and depression Scale: an updated

review. J Psychosom Res. 2002

2/2/2004;52(2):69-77.

13. Hall A, A'Hern R, Fallowfield L. Are

we using appropriate self-report

questionnaire for detecting anxiety and

depression in women with early breast

cancer? Eur J Cancer. 1999;35:79 - 85.

14. Martin R. What does the Hospital

Anxiety and Depression Scale (HADS)

Really Measure in Liaison Psychiatry

Settings? Current Psychiatry Reviews. 2005

Jan 2005;1(1):69-73.

15. Leung C, Wing Y, Kwong P, Lo A,

Shum K. Validation of the Chinese-

Cantonese version of the hospital anxiety

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the Hamilton Rating Scale of Depression. .

Acta Psychiatr Scand. 1999;100(6):456-61.

16. Rodgers J, Martin C, al. e. An

investigation into the psychometric

properties of the Hospital Anxiety and

Depression Scale in patients with breast

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Outcomes. 2005;3:41.

17. Lovibond S, Lovibond P. Manual for

the Depression Anxiety Stress Scales (2nd.

Ed.). 2nd ed. Lovibond SH, editor. Sydney:

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Depression Anxiety Stress Scales

(DASS):Normative data and latent structure

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M, Swinson R. Psychometric properties of

the 42-item and 21-item versions of the

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Swinson, R P Psychol Assess. 1998;10(176-

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21. Ng F, Berk M, Campbell S, Callaly

T, Dodd S, Trauer T. The 21-item

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Perceived Barriers to Self Management in

Malaysian Women. Asia Pacific Journal of

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23. Lee K, Ray G, Thomas H, Finley P.

Tamoxifen Treatment and New-Onset

Depression in Breast Cancer Patients.

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24. Osborn R, Demoncada A, Feuerstein

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Boyers A, Culver J, Alferi S, et al.

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Depression and Enhances Benefit Finding

Among Women Under Treatment for Early-

Stage Breast Cancer. Health Psychology.

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K, Bernaards C, Rowland J, Ganz P.

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Corresponding author: Dr Siew_Yim Loh, Department of Rehabilitation, Faculty of

Medicine, 50630 Kuala Lumpur, Malaysia.



66

CASE REPORT

RECHALLENGING CLOZAPINE AFTER AN EPISODE OF ANGRANULOCYTOSIS

Mohamed S*, Lockman H*

*Department of Psychological Medicine, Faculty of Medicine,

University Malaya, 50603 Kuala Lumpur, Malaysia

Abstract Clozapine induced agranulocytosis occurs in 1% of patients treated with clozapine. Rechallenging with clozapine has been shown to be successful in several studies done recently.We reported a 34 year old Chinese gentleman who developed clozapine induced agranulocytosis after being stable on clozapine for many years. After the clozapine was stopped, he was put on several antipsychotics and also undergone maintenance electroconvulsive therapy, however, he did not recovered. His family requested for clozapine to be rechallenge but due to the episode of agranulocytosis the family was advised against clozapine. In our centre, the patient was rechallenged with clozapine with full explanation of the potential severe recurrence of agranulocytosis to the family and the patient. The patient was closely monitored and there was no episode of agranulocytosis noted. Keywords: Clozapine, agranulocystosis, rechallenge

Introduction

Clozapine is an antipsychotic that is

recommended for use in the treatment of

treatment resistant schizophrenia (TRS).

In treatment resistant schizophrenia

studies have demonstrated a significant

clinical improvement with clozapine

treatment in 30-50% of treatment

resistant patients, and up to 80% of

patients intolerant of typical

antipsychotics (1). Despite its good

efficacy profile, Clozapine has adverse

side effects notably neutropenia and

agranulocytosis.

The risk of this reversible but fatal

reaction is greatest in the first 18 weeks

of treatment and falls to 0.7% for

developing neutropenia and 0.07% for

developing agranulocytosis during the

second year of treatment (2). When this

happens, clozapine must be

discontinued, however, this carries a risk

of symptoms recurring. Most clinicians

would not consider to rechallenge the

patient with clozapine for fear of

provoking further blood dyscrasias.

There was no clear risk of further blood

dyscrasias on clozapine rechallenge

identified (3). Furthermore, there are


67

several studies reported that Clozapine

rechallenge was a success (3, 4).

Case report

This is a case of a 34 year old Chinese

male who is single and unemployed. He

was diagnosed as having Schizophrenia

since 1990. He was later diagnosed as

treatment resistant schizophrenia after a

trial of several typical (Chlorpromazine,

Haloperidol, Sulpiride) and atypical

antipsychotics (Risperidone, Olanzapine,

Quetiapine). He was maintaining well on

Clozapine 500mg per day until

November 2007.

The patient was admitted due to relapse

of his illness after he defaulted

Clozapine. He had disorganized thoughts

and auditory hallucinations. Clozapine

was restarted however, the patient

developed agranulocytosis with total

white cell count of 2.2 and neutrophil of

1.2 X109. The Clozapine was stopped

and he was given tablet Olanzapine 20

mg daily. After 2 months in the ward,

the patient was still unwell where he was

having auditory hallucinations, nihilistic

delusions and disorganized thoughts.

Subsequently, a decision was made to

send him to a mental institution for long

stay treatment in January 2008.

Over there, the patient’s Olanzapine was

stopped and tablet Sulpiride 400mg daily

started and later increased to 900mg per

day. The patient’s condition did not

improve and he became catatonic.

Decision was made to stop the Sulpride

and Perphenazine 12mg daily was

commenced. At the same time, a family

meeting was done to discuss regarding

electroconvulsive treatment for his

catatonic state.

The patient responded to a course of

electroconvulsive therapy (ECT),

however, he relapsed after 3 weeks. Post

ECT, his medications were Perphenazine

16mg daily and Flupenthixol depot

20mg fortnightly. The patient then had

maintenance electroconvulsive therapy

where he was given 3 ECTs for every

three weeks. However, the family

decided to withdraw electroconvulsive

therapy consent and requested to

rechallenge the patient on Clozapine.

The family was very concerned about

the effects of maintenance ECT on the

patient . After further discussions, it was

then decided that the patient were to

have fortnightly ECT, which he had until

early October 2008. The family during

this time would frequently request for

Clozapine rechallenge but they were

advised against it as the patient had a

history of agranulocytosis.

On discharge to our unit, the patient was

on Aripriprazole 30mg Nocte,

Perphenazine 24mg daily,

Zuclopenthixol depot 200mg monthly,

Fluvoxamine 50mg Nocte, Benzhexol

2mg and Lorazepam 2mg as needed.

Patient was also recommended to have

maintenance ECT 2 weeks post

discharge. On discharge the patient was

mentally stable.

A discussion with the family was made

at our unit on the possibility of

rechallenging the patient on Clozapine.

The family was informed on the side

effects and potential complications of

Clozapine. The need of weekly blood

monitoring as well as close supervision

to ensure compliance was presented to

the family. The patient was put under

nursing home care and Clozapine was

rechallenged with all the baseline blood


68

investigations and ECG. His baseline

white cell count was normal.

Clozapine was increased by 25mg daily

and titrated slowly. During review in the

outpatient clinic, the patients’s white cell

count remained normal and as he was

still having bizarre delusion, the

Clozapine was increased to 200mg while

his other medications were slowly

tapered down. Currently the patient

Clozapine dose is 275mg and his white

cell count has remained stable after 6

weeks of Clozapine rechallenge.

Aripriprazole, Perphenazine, injection

Flupentixol and maintenance ECT has

now been stop.

Discussion

The decision to rechallenge the patient

with Clozapine was not made without

due consideration. The risks and benefits

were considered by the patient and the

clinician with the family involved. The

family was concerned about the effects

of continuous fortnightly

electroconvulsive therapy on the patient

as well as the polypharmacy in this

patient. Apart from the concerns of

adverse reaction to the triple

antipsychotics that the patient was on,

the family was also concerned about the

cost of the medications. It seemed that

despite the medications, the patient had

not improved. In the past, the patient

maintained well on Clozapine.

Therefore, after extensive discussion

with the family and weighing the risks

versus benefits, the patient was

rechallenged with Clozapine with full

understanding that weekly monitoring is

required.

Despite vigilant blood monitoring,

agranulocytosis ..and ..neutropenia... can

occur in about 1% of patients treated

with Clozapine. Most clinicians would

not rechallenge a patient with Clozapine

once blood dyscrasia occurs. The

potential re-complication with blood

dyscrasia should be taken seriously as

there has been finding that it may recur

at a more severe form and earlier in the

course of treatment (3). However, for

some patients there is no alternative to

clozapine and for some of them the drug

may make the difference between

institutional care or a life in the

community (5). As for this patient, only

after much deliberation and as family

was very involve with his management,

then it was decided for the patient to be

rechallenged with the Clozapine.

There are studies that report the use of

granulocyte colony-stimulating factor

(Filgrastim or Neupogen) in the

management of clozapine induced

agranulocytosis (5,6). It was reported

that there was improvement in the white

cell count and absolute neutrophil count

after 5 to 8 days of treatment with

Filgrastim (6). Treatment with filgrastim

appears to be safe and effective in

decreasing the duration of clozapine-

induced agranulocytosis (6). This was

supported by another study done earlier

which also concluded that granulocyte

colony-stimulating factor may shorten

hospital stays for neutropenia and may

reduce morbidity (7).

Therefore, the use of granulocyte colony

stimulating factor may be considered in

patients with clozapine-induced

agranulocytosis who require clozapine

for treatment. With our patient we need

not resort to using Neupogen as his

WBC has remain normal through out.


69

Conclusion

This case report illustrate the reservation

of clinicians to rechallenge the patients

who has developed Clozapine induce

agrunolocytosis. Evidence now shows

that it is possible to increase the white

cell count by using the granulocyte

colony-stimulating factor. It is also

important to explain the risk and involve

family members in the management.

References

1. Coffey I (1994). Options for the

Treatment of Negative Symptoms of

Schizophrenia. CNS Drugs,1, pp 107-

118.

2. Anon. Clozaril Primary Care

Reference Guide Sandoz 1995

3. Dunk L, Annan L, Andrews C

(2006). Rechallenge with clozapine

following.. leucopenia…or.. neutropenia

during previous therapy. British Journal

of Psychiatry, 188, pp 255-263.

4. Ghaznavi S, Nakic M, Rao P, Hu

J, Brewer J, Hannestad J, Bhagwagar Z

(2008). Rechallenging with clozapine

following neutropenia: treatment options

for refractory schizophrenia. American

Journal of Psychiatry, 165, pp 813-818.

5. Safferman A, Lieberman J, Alvir

J, Howard A (1992). Rechallenge in

clozapine-induced agranulocytosis. The

Lancet, 339, pp 1296-1297.

6. Lamberti JS, Bellnier TJ,

Schwarzkopf SB, Schneider E (1995).

Filgrastim treatment of three patients

with clozapine-induced agranulocytosis.

Journal of Clinical Psychiatry, 56 (6), pp

256-259.

7. Gerson S (1993). Clozapine:

deciphering the risks. New England

Journal of Medicine, 329 (3), pp 204-

205.

Corresponding author: Dr Hazlin Lockman, Department of Psychological Medicine,

Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia



70

CASE REPORT PAPER

A CASE OF SUSPECTED CLOZAPINE RELATED MYOCARDITIS

Thanasan S*, Rusdi AR*

*Department of Psychological Medicine, Faculty of Medicine, University Malaya, 50603 Kuala Lumpur, Malaysia

Abstract The atypical neuroleptic clozapine is known to have considerable advantages over typical neuroleptics in the treatment of Schizophrenia. It has been used successfully to treat children and adults. However, generally psychiatrists resort to it only after trying many other antipsychotics. This presentation will include a case report of a 37-year-old Chinese man who developed palpitations, headache, and fever of sudden onset. An illustration of the subsequent clinical features and laboratory investigation will be given. Increased usage in the future may be brought about by enhanced knowledge on the early signs and symptoms of cardiac related side effects, stringent monitoring for cardiac related side effects and a deeper understanding of its pathophysiology. Keywords: clozapine, myocarditis, schizophrenia

Introduction Clozapine is known to cause cardiac side-

effects, including myocarditis, pericarditis

and cardiomyopathy. Prompted by a case of

clozapine related myocarditis in our ward

we decided to publish this report. Clozapine

is known to be more efficacious than typical

neuroleptics such as haloperidol in the

treatment of schizophrenia1. Not

withstanding this fact clozapine has been

associated with the multiple side-effects,

such as leucopenia, elevated transaminase

serum levels, seizures, tachycardia,

hypotension, constipation, hypersalivation,

and sedation. It is known to cause the most

weight gain among all the neuroleptics .

The most notable of all potential side-effects

of Clozapine is agranulocytosis 1,2. Thus

treatment with clozapine therefore requires

careful monitoring of patients in order to

ensure that serious side-effects are detected

at an early stage3. Below is a case

illustration of a case that was recently

diagnosed with possible myocarditis after

being on the drug for 8 years.

Case Report

The patient is a known case of

Schizophrenia on clozapine since the last 8

years. He had experienced no side effects of

the drug during that time and his psychotic

symptoms were well controlled. He is a 37

year old Chinese man who developed

palpitations, headache, and fever of sudden

onset. He was on clozapine 700mg (generic)

at that time. He had been on this dose over


71

the last two years. On admission he had

tachycardia, 137 bpm. There was no other

abnormality in his ECG. At this time his

WBC was in the normal range. The

clozapine was stopped immediately. He was

then put on another antipsychotic during his

admission. On discharge seven days later he

was restarted on 200 mg of clozapine. His

heart rate was 100 bpm on discharge.

However follow up at the out patient clinic

two days later the patient complained of

palpitations and his heart rate was noted to

be 132. He also had leucocytosis at this

time. WBC count was 12.5. His medication

was further reduced to 100 mg of clozapine

per day but his heart rate remained elevated

at 127bpm when he was seen one week

later. This time the WBC count was further

increased to 16. No other cause for the

elevated WBC was found. The clozapine

was then stopped completely. He was put on

Risperidone and 9 days later his heart rate

reduced to 115bpm and his WBC returned to

normal. 13 days after the clozapine was

stopped the heart rate reduced further to 86

bpm. Unfortunately he developed akathisia

and a recurrence of his psychotic symptoms.

He was readmitted and the medication was

abilify titrated till 20 mg. However this did

not control his psychosis. Finally he was

restarted on original clozapine 50 mg bd but

he experienced elevated heart rate once

again 100 bpm the very next day. He was

discharged well after being given olanzapine

20 mg. The patient was also referred to the

physicians. The cardiac enzymes and the

CKMB were in the normal range. Chest X

ray showed no evidence of cardiomegaly.

Serum Thyroid hormones were in the

normal range at all times.

This case is one of the very few cases of

suspected myocarditis in a patient treated

with clozapine at the UMMC. There are

about 200 patients on clozapine at the

moment in UMMC. This case has been

reported to the drug company. However no

other information on clozapine related

cardiac side effects in Malaysia were

obtained as reporting of serious side effects

was not practiced by many doctors.

Discussion

Clozapine is known to cause myocarditis,

pericarditis as well as cardiomyopathy.

Clinical features in this patient suggesting

clozapine induced myocarditis were fever,

dose dependant tachycardia and

leucocytosis.

Reviewing the literature it was found that

myocarditis can start as early as 15 days4

after starting treatment and on dose as little

as 50mg5. Our patient has been on clozapine

for the last 8 years before developing this

side effect. This is not a common occurrence

as most patients develop this side effect

within 1 to 2 months of after starting the

drug6.

In very few cases the patient has been

known to tolerate a rechallenge of clozapine.

However our patient did not tolerate

rechallenge either with the generic or

original drug.

Clozapine is also known to cause various

ECG-changes in patients. A 44-year-old

man was reported to have developed

Premature Ventricular Contractions (PVC)

19 days after starting on clozapine (350

mg/day) 7.

Kang et al. have reported on 53 patients

started on clozapine, of which 13 developed

new ECG abnormalities. In six cases, the

abnormalities were of little clinical

significance and in the remaining seven

cases the potentially significant changes

were later considered benign. None of the


72

patients complained of subjective symptoms

or objective signs of cardiovascular

dysfunction requiring specific intervention8.

Cohen et al 9 have reported the reversal of

ECG abnormalities (including a prolonged

QT-interval) following transition from

clozapine to olanzapine in a 30-year-old

man who had been treated with clozapine

for 2 years.

Although these ECG changes are not

specific for any particular adverse events

related to clozapine, they must be

considered potential indicators for

myocarditis, pericarditis or cardiomyopathy.

It has been suggested that a lack of

metabolic enzymes (CYP450-1A2 and

CYP450-1A3) results in extreme clozapine

concentrations or direct cardiotoxic effects

of eosinophils through blockage of

cholinergic M2-receptors or high ion

centrations of atmospheric ozone resulting

in cholinergic receptor dysfunction, causing

cardiac side effects10. Killianet al

speculated that clozapine-associated

myocarditis may be caused by an

immunoglobulin E–mediated

hypersensitivity11. Treatment of clozapine-

related myocarditis with corticosteroids has

been suggested as an option 6. However,

frequently the patients recover when the

drug is discontinued as in our patient.

Details of the molecular mechanisms by

which myocarditis, pericarditis and

cardiomyopathy are precipitated are still not

very understood.

Due to the potential risk to patients, it is

important to make the diagnosis at an early

stage. While the risk of fatal myocarditis is

most in the first month of treatment with

clozapine, it is not limited to this period, and

patients may be at increased of myocarditis

risk as long as they are taking the drug12.

Careful monitoring of cardiac function in

patients started on clozapine would therefore

have to be considered an important part of

ensuring safety in the use of this very

efficacious atypical neuroleptic. At present

ECG monitoring is done only before starting

the drug at our hospital. Perhaps more

frequent monitoring of the ECG is

warranted. However, due to time constraints

this is not the practice. More stringent

monitoring would include, patients being

assessed for clinical symptoms of

compromised cardiac function (such as

palpitations, chest pain, dyspnoea), signs of

an immune response (such as fever,

leucocytosis, eosinophilia), evidence of

direct damage to the myocardium (such as

elevated levels of CK, LDH, AST), and

signs of cardiac dysfunction using

techniques such as ECG and

echocardiography.

It has been suggested that patients on

clozapine are assessed for myocarditis in the

first month of treatment and frequently for

cardiomyopathy. Inspite of all monitoring

strategies, it is essential to maintain a high

degree of clinical suspicion in patients on

clozapine who develop cardiac symptoms.

Clozapine should be discontinued

immediately in such patients and assessment

for cardiac adverse events should ensue.

Given such precautions, prompt treatment

following early detection should reduce the

number of patients suffering from clozapine-

related myocarditis, pericarditis and/or

cardiomyopathy. Side effects such as these

prevent psychiatrists from prescribing this

wonderful drug freely. With more stringent

safety measures for example more frequent

ECG and a better idea of the clinical picture

such as onset and progression as well as

blood parameters perhaps more patients can

benefit from this drug.


73

References

1. Miller DD. Review and management

of clozapine side effects. Journal of Clinical

Psychiatry. 2000; 61(Suppl. 8): 14-17.

2. Alvir JMJ, Liberman JA.

Agranulocytosis: incidence and risk factors.

Journal of Clinical Psychiatry. 1994;

55(Suppl. B): 137-138.

3. Baker S. Myocarditis with clozapine

[Letter]. Australian Journal of Hospital

Pharmacy.2000; 30: 28-29.

4. Committee on Safety of Medicines.

Myocarditis with antipsychotics: recent

cases with clozapine (Clozaril). Current

Problems in Pharmacovigilance, 19: 9–10.

5. Merrill, David B. MD, G. William

MD, Goff, Donald C. Adverse Effects

Associated With Clozapine. Journal of

Clinical Psychopharmacolgy. 2005; Vol

25(1): 32-41.

6. Hagg S, Spigset O, Bate A, et al.

Myocarditis related to clozapine treatment.

Journal of Clinical Psychopharmacology.

2001; 21: 382-388.

7. Aronowitz JS, Umbricht DSG,

Safferman AZ. Clozapine and new-onset

ECG abnormalities [Letter].

Psychosomatics. 1995; 36: 82-83.

8. Kang UG, Kwon JS, Ahn YM,

Chung SJ, Ha JH, Koo YJ, Kim YS

Electrocardiographic abnormalities in

patients treated with clozapine. Journal of

Clinical Psychiatry. 2000; 61: 446.

9. Cohen H, Loewenthal U, Matar MA,

Kotler M. Reversal of pathologic cardiac

parameters after transition from clozapine to

olanzapine treatment: a case report. Clinical

Neuropharmacology. 2000; 24: 160-168.

10. Devarajan S, Kutcher SP, Dursun

SM. Clozapine and sudden death [Letter].

Lancet. 2000; 355: 841.

11. Kilian JG, Kerr K, Lawrence C, et al.

Myocarditis and cardiomyopathy associated

with clozapine. Lancet. 1999; 354: 1841–5.

12. La Grenade L, Graham D, Trontell

A. Myocarditis and cardiomyopathy

associated with clozapine use in the United

States [Letter]. New England Journal of

Medicine. 2000; 345: 224-225.

Corresponding author: Dr Sharmilla Thanasan, Department of Psychological Medicine,

Faculty of Medicine, University Malaya, 50603 Kuala Lumpur, Malaysia

E-mail: [email protected]


74

EDUCATION PAPER

MODEL ANSWER FOR CRITICAL REVIEW PAPER: CONJOINT EXAMINATION MASTER OF MEDICINE (PSYCHIATRY) AND

MASTER OF PSYCHOLOGICAL MEDICINE MAY 2008

Prepared by Dr Hatta Sidi, Professor and Senior Consultant Psychiatrist,

Department of Psychiatry, UKM Medical Center (UKMMC)

THE FEMALE SEXUAL FUNCTION INDEX (FSFI): VALIDATION OF THE MALAY VERSION

Journal of Sexual Medicine Mac 2007; 4: 1642 - 1654 (Epub 30 June 2007)

Summary of Paper

The objective of this research paper is to

validate the Malay version of Female Sexual

Function Index (MVFSFI).

Methods & Results

This was a cross-sectional study conducted

between March to June 2005. This study

was conducted at one of the government

primary health care clinic located in Bandar

Tun Razak, Cheras (BTR) a busy urban area

in Kuala Lumpur, the capital city of

Malaysia. This study used a non-probability

sampling (universal sampling) method. Due

to limitation in time, resources and effort, all

female patients who attended the BTR

Primary Care Clinic during the study period

that fulfilled the inclusion and exclusion

criteria were included in this study.

Collection of data for this study was

conducted in two stages. This was done by

one of the authors (a medical doctor in her

final year of master degree psychiatric

training who was also trained to use the

Diagnostic and Statistical Manual, DSM-IV

and the Mini International Neuropsychiatric

Interview, M.I.N.I). (i) First stage: All

patients that fulfill the inclusion and

exclusion criteria were given an explanation

about the study and written consent obtained

from them. They were assured of their

anonymity and the confidentiality of the data

obtained. A coding system was used to

identify the subject. After the MVFSFI was

completed, respondents were interviewed

using the clinical interview, DSM-IV and

M.I.N.I. for exclusion of the other

psychiatric illnesses. (ii) Second stage: Patient was asked to come again after about

2 to 4 weeks after the first interview to fill

up the same MVFSFI for test-retest validity.

Translation of Female Sexual Function Index: The original (English version) of

FSFI was translated into the Malay language

by the first author (a trained psychosexual

medicine specialist) who was also bilingual

in both English and Malay. The back

translation was done by two psychiatrists

who were also bilingual in both languages.

Both the original and back-translated

version, were compared to determine

accuracy of translation. The translated

version was examined by a panel of

psychiatrists to be used in the sample


75

population without giving much difficulty in

understanding it. No factor structure (factor

analysis) was done on the MVFSI as the

expert committee (later referred as expert

panel of psychiatrist) was satisfied with the

conceptualization of sexual dysfunction for

Malaysian women compared to their

Western counterpart.

Validity study of the MVFSFI: Face

validity of MVFSFI was tested during its

pilot study. Twenty female staff nurses were

given the MVFSFI for evaluation of its face

validity. The MVFSFI were observed

whether "on its face" it seems to be a good

translation of the construct. , the MVFSFI

was presented to a panel of 4 psychiatrists in

Psychiatry Department, National University

of Malaysia Hospital. They included the first

author (a senior consultant psychiatrist who

received a formal training in psychosexual

medicine) and 3 other senior consultant

psychiatrists with at least 15 years clinical

experience in general psychiatry. the

sensitivity and specificity of MVFSFI

against DSM-IV, as the “gold standard”

instrument. The total scores of the MVFSFI

were calculated by summing all the scores

of all items in the scale. The scores of each

domain were calculated by summing the

score of each item in the domains. The

minimum total score was 4 and the

maximum was 95. Multiple cut off scores

from the MVFSFI scoring were compared

against DSM-IV diagnosis to determine the

most sensitive and specific cut off score for

the questionnaire to pick up female sexual

dysfunction. Similar procedure was carried

out for each domain. Discriminant validity

was also done but not shown in the text.

Frequency of each diagnosis in the sample,

MVFSI cut-off scores vs. DSM-IV clinical

diagnosis are shown on table 2. Table 1. The frequency of DSM-IV clinical diagnosis of sexual dysfunction (gold standard) in women compared to MVFSFI.

DSM-IV

clinical

MVFSFI diagnosis

Normal

Sexual

dysfunction

Total

Normal

(scores > 55)

161 1 162

Sexual dysfunction

(scores < 55) 2

66

68

Total

163

67

230


76

Table 2. Sensitivity and specificity of MVFSFI total score based on Receiver Operating Characteristic (ROC) curve.

MVFSFI SCORES SENSITIVIY SPECIFICITY 1-SPECIFICITY AUC

TOTAL

SCORES

35 0.76 1 0 0.619

40 0.82 1 0 0.739

45 0.9 1 0 0.866

50 0.94 1 0 0.925

55 0.99 0.97 0.03 0.986

60 1 0.8 0.2 0.948

65 1 0.59 0.41 0.856

70 1 0.47 0.53 0.767

(AUC = area under the curve)

The table 2 above shows the calculation of

sensitivity and specificity of MVFSFI

toward the diagnosis of female sexual

disorder with DSM-IV. The sensitivity and

specificity values above were plotted using

ROC curve as shown in figure 1.

Figure 1. ROC curve for total score of MVFSI

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

1- SPECIFICITY

35

60

5 655

70

40

55

SE

NS

ITIV

ITY

45


77

Answer ALL Questions. Please bring along your calculator. (overall 20 marks)

1. In this paper, it is assumed that the MVFSI is a valid means of identifying sexual dysfunction

among Malaysian women.

(a) What is the definition of validity and reliability of a study?

Validity of a study= ability of the study to measure what it supposed to measure;

reliability of a study = ability of the study to replicate the tests and giving

similar results.

(1 mark)

(b) Face and content validity was done in this study. What is the meaning of the face and

content validity?

Face validity concerns whether the questionnaire (MVFSFI) appears to be

measuring what it says it does on “face value” ; and

content validity of the questionnaire refers to the accuracy with which the

questions adequately represent the qualities they are presumed to measure and

these was established by referring to an expert committee.

(2 marks)

2. The researchers used sensitivity and specificity of the psychometric tool, MVFSI against

“gold-standard” interview of DSM-IV.What is the definition of sensitivity and specificity of a

psychometric tool?

Sensitivity = ability to detect true positive (TP) rate; and

Specificity = ability to detect true negative (TN) rate.

(2 marks)

3. Based on table 1,

(a) calculate the true positive and true negative rate for MVFSFI.

TP rate = Sensitivity = 66/67 x 100% = 98.5%; and

TN rate = Specificity = 161/163 x 100% = 98.7%.

(2 marks)

(b) calculate the positive predictive value (PPV) of MVFSI and

explain the meaning of the given PPV.

Positive predictive value (PPV) of MVFSI = 66/67 x 100% = 97.0%

ie. 97% of those women scoring positive on MVFSFI will actually

have female sexual dysfunction.

(2 marks)


78

(c) what would happen to PPV if the prevalence of sexual dysfunction

in women was studied in an inpatient psychiatric settings (eg.hospital)

rather in a general community? Explain.

PPV value would increase (PPV was dependence on the prevalence of a

disease, ie. as the prevalence in an inpatient psychiatric was rather lower

if to be compared to the community survey, and the PPV value would

also reduce).

(2 marks)

(d) calculate the likelihood ratio of a positive test (LR+ve

) on MVSFI and

explain the meaning of LR+ve

. [Formula of LR+ve

= sensitivity ]

(1 – specificity)]

Likelihood ratio of a positive test (LR+ve

) on MVSFI:

LR+ve

= 0.985/ 1-0.987 = 0.985/0.013 = 757

ie. a positive result is 757 times or more likely to be found in a women

with the sexual dysfunction rather than one without.

(2 marks)

(e) given the prevalence of the FSD is 30%, calculate the post-test odd ratio (for positive

likelihood of the MVFSI).

[Post-test odd ratio (for positive likelihood of the MVFSI)

= pre-test odd ratio x LR+ve

.]

Prevalence, P = 0dds / 1 + 0dds and 0dds = P/ 1-P

=> The prevalence = 30%, then the pretest odd = 0.3/1 -0.3 = 0.3/0.7 = 3/7;

Then the post-test odd ratio (+ve test) = 3/7 x 757 = 324.

(3 marks)

4. (a) Based on table 2, what will happen if you choose the total score of MVFSI as 35

instead of 55 or 65 (with sensitivity of 0.76 and AUC = 0.619) as a purpose

to detect caseness of FSD?

If I choose the total score of MVFSI as 35 instead of 55 (with sensitivity of 0.76

and AUC = 0.619), then MVFSI would be very sensitive less specific for

sexual dysfunction in Malaysian women and it serves as screening rather than

diagnosing tool.

(2 marks)


79

(a) Based on table 2 and figure 1, if you are applying the MVFSI toidentify sexual

dysfunction among Malaysian women in primary care setting, which cut-off point would

predict best could you select? (2 marks)

Corresponding author: Dr Hatta Sidi, Professor and Senior Consultant Psychiatrist,

Department of Psychiatry, UKM Medical Center (UKMMC) Email: [email protected]


80

EDUCATION PAPER

ASSESSING PERSONALITY: A GUIDE FOR STUDENTS

Saxby Pridmore

University of Tasmania, Australia.

A good understanding of personality is

fundamental to all psychiatric assessments

and management. The aim of this paper is to

present some basic information on

personality which may be useful to students.

What is personality?

Personality can be defined as “those features

of the individual which determine that

individual’s unique response to the

environment”. There are other longer

definitions, but this one is very appropriate

to psychiatry. It tells us why an

understanding of personality is fundamental

to the field. It tells us that when we have a

good understanding of the personality of the

individual we are better able to predict

his/her future behavior. In particular, it helps

us to look forward, to predict (to some

extent) his/her response to treatment. It tells

us whether he/she will be able to form a

trusting relationship with a therapist,

whether he/she will co-operate with

recommendations, keep appointments, and

comply with medication directions.

Armed with this definition and knowledge

of the personality of the individual, we are

also in a better position to look backwards,

to understand the factors which contributed

to the presenting complaints. For example,

the dependant individual will present early,

as soon as symptoms appear, and the

avoidant individual will present late, only

after great suffering. Protracted suffering

may complicate the picture, what began as a

mild anxiety problem may later present as

severe depression. The suspicious individual

is likely to interpret psychotic symptoms in

a paranoid manner, while others are more

likely to find psychotic symptoms

perplexing.

Many descriptions state that personality 1) is

“lifelong and persistent”, and 2) involves

“enduring characteristics and attitudes”

which influence the individual’s ways of

thinking, feeling and behaving. This is

consistent with the notion that personality

represents the predictable responses of the

individual to the environment. The first

point, that personality is “lifelong and

persistent” is generally correct, however,

personality often does change somewhat

over time; this is particularly the case with

young aggressive men who mellow over

time (the vast majority of people goaled for

violence are young). And of course,

personality can change through sustained

psychotherapy, in fact, personality change is

a central aim of dynamic psychotherapy.


81

“Normal personality”

The term “normal personality” must be used

with caution. As we have been looking at

personality in terms of responses, we need to

take culture and circumstances into account.

What may be an adaptive response to an

insult in Beirut may be maladaptive in KL,

what is humorous in KL may be insulting in

Kota Bharu. And “normal people”

have different attitudes and responses; two

colleagues may fanatically support opposing

football teams, while a third may have no

interest in sport and may have never

watched a game of football in his/her life.

“Normal” is sometimes taken to mean with

no impediment whatsoever. This meaning is

central to the World health Organization

definition of health, which is “a state of

complete mental and physical well-being”.

This is an optimal and unrealistic state, and

probably none of us are without some

personality features which could be

improved.

“Normal” may also mean average, and this

essentially statistical use of the word is more

helpful in considering personality. As

mentioned below, personality features (e.g.,

extraversion, impulsivity) can be measured

by psychological tests and fit the normal

distribution curve, with the majority of the

population registering in the middle. But we

need something more practical in ordinary

clinical practice.

It has been suggested that the average

person has the ability to work and love, and

this is a useful starting point. To be able to

work means to be able to accept

responsibility for one’s actions, follow

instructions, expend effort in spite of lacking

energy and to delay gratification (delay

having what we would like to have/do for a

time, while other things such as education

are achieved). To be a able to love means to

be able to be warm, supportive,

encouraging, intimate, forgiving and

respectful of others. Thus, important

features of the normal personality are 1) to

accept responsibility for our actions, and 2)

to support others and behave as positive

member of the community.

Measuring personality

It is possible to measure certain dimensions

of personality. This has importance in

research, but it is rarely used in busy clinical

practice.

A major problem has been to decide what

are the central dimensions of personality.

The Eysenck Personality Inventory (EPI)

measures two separate dimensions:

extraversion-introversion (which measures

outgoing attitude) and neuroticism (which

measures the tendency to anxiety and

depression). The Cattell 16 Personality

Factor test (16PF) measures 16 different

dimensions, and the Minnesota Multiphasic

Personality Inventory (MMPI) (probably the

most widely used test) measures 10 different

dimensions.

McCrae & John (1992) developed a five-

factor model (FFM) of personality which

has been widely accepted. It employs the

personality dimensions of, openness,

conscientiousness, extraversion,

agreeableness, and neuroticism, known by

the acronym OCEAN.


82

Cloninger et al (1993) described four

temperamental dimensions (novelty-seeking,

harm avoidance, reward dependence, and

persistence), which are present from birth

and are stable over time, and three character

dimensions (self-direction, co-operation, and

self-transcendency) which are variable and

modified by experience.

Personality disorder

“A Personality disorder is an enduring

pattern of inner experience and behaviour

that deviates markedly from the expectations

of the individual’s culture, is pervasive and

inflexible, has an onset in adolescence or

early adulthood, is stable over time and

leads to distress and impairment” (DSM-IV-

TR).

This definition is not particularly helpful,

and clearer markers of personality disorder

would be useful. In term which came from

psychoanalysis, people with personality

disorders have “alloplastic defences”

meaning they react to stress by attempting to

change the external environment (rather than

themselves), and have an “ego-syntonic”

view of themselves, meaning they find all

aspect of themselves to be acceptable, and

not in need of change. People with

personality disorder believe the world

should change to suit them. But, this does

not happen and consequently, people with

personality disorder are frequently

distressed.

Personality disorder is marked by failure of

the two important features of personality

mentioned above, 1) acceptance of

responsibility for actions, and 2) supporting

others and behaving as positive member of

the community. Thus, in personality

disorder there is frequent blaming of others

and the making of excuses, along with a

self-centeredness, and little consideration of

others. Another feature of personality

disorder is that these people are capable of

making only a limited number of responses

to the world. The well adjusted individual

can deal with problems using a technique

which is appropriate to the situation. In

different situations, the adaptive individual

will need to work harder, be more friendly

or thoughtful, save money, negotiate,

explain feelings of frustration or

disappointment, reduce his/her expectations

or make other appropriate responses. The

person with a personality disorder lacks this

range of responses and responds to all

situations in much the same way (e.g., with

aggression or seduction). Accordingly,

problems arise in all areas of life (family,

community and work).

Personality disordered is important in

psychiatry for two reasons. First, people

with personality are frequently in conflict

with others and frequently present to doctors

complaining about anger and distress. That

is, the personality disorder is the direct cause

of the presentation. Second, when people

with a major psychiatric disorder (e.g.,

depression or schizophrenia) also have a

personality disorder, the management of the

major psychiatric disorder is much more

difficult and the prognosis is less favourable.

Assessing personality

It is necessary to form an opinion about each

patient, because the personality may lead

directly to the complaint, or may influence


83

(positively or negatively) the management

of another disorder.

Unlike any other part of the psychiatric

assessment, personality is assessed in both

the history and the mental state examination.

There are three main sources of information

about the personality. First, the history.

Given that personality determines the

characteristic responses of the individual to

the world, a detailed history of the events of

the life of the individual will tell a huge

amount about the personality. Asking about

how well the individual managed school

work, how they got along with other

children, and how they got along with

teachers, in both primary and secondary

school is most useful. If the individual did

not cope well with school work, even at

primary school probably has a low IQ (of

course, other factors such as an unsupportive

home situation must be excluded). If the

individual did not make friends at primary

school, this suggests difficulties with

relationships beginning at an early age.

Asking about relationships with teachers

gives an idea of how the individual deals

with authority figures (and obeying rules).

The challenge of primary and secondary

school are different, and it is worth asking

about both. We are then interested in the

work history. We want to know whether the

individual displayed the initiative to find

work, and then to know how long they

worked for various employers. A history of

being sacked or long periods of

unemployment without effort to find work

are also of interest. We want to know if the

individual is able to maintain close

relationships with members of their family

of origin, or any other family relationships

they have formed (spouse, children). We

want to know about their hobbies and things

they enjoy doing, and their strengths and

weaknesses. We want to know if they blame

others, and what they think are there

strengths and weaknesses.

Second, information from others. If we can

speak with a family member or friend we

want to hear their opinion of how the

individual responds to the challenges of life.

Does he/she blame others, does he/she

respond with anger, is the individual

sociable and helpful to others. Does he/she

waste money or take drugs.

Finally, the mental state examination. Here

we have a clear example of the personality

(like testing the reflexes, here we can see for

ourselves). Is the individual open and

cooperative (other causes of lack of

cooperativeness, such as paranoid psychosis

must be taken into consideration). Is the

individual intimidating, seductive, evasive,

and does he/she blame others excessively

and make excuses for him/herself.

When we put the information from these

three sources together we have a better idea

of the personality and how it may influence

presentation and management.

References

1. Cloninger C, Svrakic D, Przybeck T.

A psychobiological model of temperament

and character. Archives of General

Psychiatry 1993; 50:975-990.

2. McCrae R, John O. an introduction

to the five-factor model and its applications.


84

Journal of Personality 1992; 60:175-

213.World Health Organization.

Constitution. Geneva. World Health

Organization. 1948.

Further reading

Chapter 10. Download of Psychiatry, a free

web-based textbook of psychiatry at:

http://eprints.utas.edu.au/287/.

Corresponding author: Saxby Pridmore, Professor of Psychiatry, University of Tasmania,

Australia. Discipline of Psychiatry. Private Bag 27 Hobart, Tasmania 7001, Australia


Mobile: +0409 825 029


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