Psychiatry

Introduction 

Clozapine is an atypical antipsychotic, it is the treatment of choice for treatment resistant schizophrenia and more effective than conventional neuroleptic medications. Clozapine is associated with potentially life-threatening side effects, some of which appear early in treatment. 

Myocarditis is an uncommon but serious early adverse event of Clozapine, the majority of reported cases occurring in the first 4-8 weeks.¹ Clozapine induced myocarditis (CIM) can present with mild symptoms, but can progress rapidly to fulminant symptoms and thereafter heart failure and death.¹  These symptoms and signs typically include dyspnoea, palpitations, chest pain, fatigue, flu-like symptoms, pyrexia and tachycardia.

Case Report

A 21-year-old Caucasian male with a two year diagnosis of schizophrenia and previously inadequate responses to Risperidone and Olanzapine was commenced on Clozapine. The patient had previously tolerated Risperidone and Olanzapine and did not experience adverse events, but there was inadequate therapeutic response to both; hence it was decided to commence Clozapine.

On admission, his physical examination, baseline blood investigations (these did not include cardiac markers such as troponin or C-reactive protein (CRP)) and electrocardiogram (ECG) were normal. His medical history was unremarkable and he did not have a family history of cardiac disease. He smoked 15 cigarettes per day.

A rapid Clozapine titration compared with the standard UK titration^[2] was commenced with a target dose of 200 mg/day on day 14. He was not on any other psychotropic medication.

The patient remained asymptomatic in the first 3 days. On day 4, he developed tachycardia (114 BPM). A repeat physical examination and ECG was normal, eventually his heart rate settled to 94 BPM. The tachycardia was deemed to be a benign side effect of Clozapine, and the rate of titration was slowed down as a precaution.

On day 12, the patient reported dizziness when standing and a ‘cold air’ sensation in his chest. Nurses reported that blood pressure was normal with a heart rate of 145 BPM but when reviewed clinically his heart rate was 89 BPM. His titration was continued. 

On day 14, the patient complained that his ‘internal organs were hurting’. His Clozapine dose was 125 mg/day at the time. He reported chest tightness with central pain, pain in his legs and abdomen, intermittent breathlessness and palpitations. The duration of his symptoms was 24-36 hours.  Examination was normal except for a heart rate of 110 BPM. His ECG showed sinus rhythm with no ST segment or T wave changes. Blood tests showed markedly elevated troponin I—1211.5 ng/L (normal range: <34.3 ng/L), CRP—176 mg/L (normal range: 0-10 mg/L) and eosinophil count —1.28 10⁹/L (normal range: 0.02-0.5 10⁹/L).  

The patient was afebrile throughout the titration period.

He was admitted to an acute hospital and a provisional diagnosis of Clozapine induced myocarditis was made. The echocardiogram did not reveal structural abnormalities or damage. An EBV (Epstein Barr Virus) serology was negative. Clozapine was withheld and the patient improved along with the blood markers, after 4-5 days he was discharged back to the psychiatric hospital.

Discussion

CIM is an often overlooked adverse event associated with Clozapine titration. Currently there is no mandatory requirement of laboratory monitoring for detecting myocarditis during Clozapine titration unlike the mandatory requirement for detecting neutropenia, despite roughly similar estimated incidence of the two adverse events at 3%.^[3,4]

This case was unusual because of the very early appearance of symptoms, the patient’s age and atypical symptom presentation. Although CIM is an early adverse event, the onset within 2 weeks of initiation was unusual. Literature suggests that myocarditis typically presents within 4-8 weeks.^[1] The patient was also younger than the reported median age of patients (30).^[1] The symptoms appeared at a low dose of 125mg/day which literature suggests is unusual, although CIM at doses of 50mg/day has been reported.^[5]

Tachycardia and fever are common early side-effects of Clozapine. Tachycardia usually settles after 4-6 weeks of treatment^[6] and fever typically for 2-3 days.^[7] Both symptoms can be suggestive of myocarditis, especially when they co-occur. CIM often presents in a non-fulminant form.^[8] As this case demonstrates many patients may not report symptoms when CIM is mild.  

Increasing age, concomitant administration of sodium valproate and increased rate of dose titration are significant risk factors for CIM.^[9] In this case, the patient was young and sodium valproate was not co-administered. The titration was originally intended to be rapid but slowed down soon after commencement.

Given the clinical difficulties in detecting mild CIM, we suggest that all patients have baseline troponin, CRP, heart rate, blood pressure, temperature, resipatory rate and ECG. If medical history reveals history of heart disease, a baseline echocardiogram can be obtained. If there is history of congestive cardiac failure, then baseline brain natriuretic peptide (BNP) or N-Terminal pro-B-type natriuretic peptide (NTproBNP) should be measured.^[10]

In clinically asymptomatic patients, if there is elevated baseline CRP (>100 mg/L), troponin, BNP or NTproBNP then Clozapine titration should not commence and further advice from cardiology should be sought. 

Weekly CRP and troponin should be done in the first month of titration and levels repeated once after stable dose of Clozapine is reached. The dose increase should not be rapid.

Tachycardia developed should be checked with reference to the baseline heart rate measured before commencing Clozapine. A heart rate of greater than 120 BPM or increase of more than 20 BPM over the baseline pulse rate should lead to the review of physical health, blood monitoring, ECG, and Clozapine titration rate.

An increase in troponin above upper limits or an increase in CRP should trigger consideration of CIM. Literature suggests that troponin levels greater than 2x the upper normal limit are indicative of acute myocarditis.^[9] CRP is raised on average 3 days before any increase in troponin levels is detected.^[9] If the troponin levels are within the normal range and the CRP levels are raised but less than 100 mg/L, clozapine titration can continue, but the pace must be slowed. Troponin levels and CRP levels should be monitored daily and the patient should be closely monitored for clinical signs of developing cardiotoxicity.

We do not recommend routine eaosinophil monitoring as the marker in 90% of cases does not exceed normal limits at the onset of CIM and typically peaks 7 days after cessation of Clozapine.^[11]

Conclusion

Clozapine induced myocarditis often presents with low level cardiotoxicity. Mild symptoms may be missed; however, progression to fulminant myocarditis can be rapid, with high mortality rates.^[1] Myocarditis, including clinically asymptomatic myocarditis remains a risk with Clozapine every time the patient is titrated onto this medication^[12]. Close clinical monitoring, high index of suspicion and monitoring of cardiac parameters will help early detection of adverse cardiac events.

Introduction

Insomnia is a disturbance of normal sleep patterns. It is characterised by sleep onset latency and/or sleep maintenance. Short term insomnia is defined as having symptoms for less than four weeks, whilst long term insomnia is symptoms lasting more than four weeks¹. Hypnotics can provide relief from the symptoms of insomnia; they do not treat any underlying cause.

Several hypnotic agents are licensed for the treatment of insomnia, including the benzodiazepines and Non-benzodiazepine hypnotics (Z-drugs⁾².

NICE guidance for Insomnia management states “After consideration of the use of non-pharmacological measures, hypnotic drug therapy is considered appropriate for the management of severe insomnia interfering with normal daily life; it is recommended that hypnotics should be prescribed for short periods of time only, in strict accordance with their licensed indications” ¹.

NICE guidance also advises to use the lowest effective dose of the hypnotic agent for the shortest time frame possible. The exact duration will depend on the underlying cause, but treatment should not continue for longer than two weeks. We should also inform the patient that further prescriptions for hypnotics will not usually be given, ensure that the reasons for this are understood, and document this information in the patient’s notes.

Side effects are common with hypnotic usage including, most importantly, the development of tolerance and rebound insomnia. Other side effects can occur such as daytime sedation, poor motor coordination, cognitive impairment, hallucinations, anxiety, delusions and sleep disorders².

Aims

To reduce the amount of hypnotic medication being prescribed to patients on an Acute Inpatient psychiatric ward in the Northwest of UK. The ward is in a semirural psychiatric hospital and is a Male ward containing 17 inpatient beds. The patients are 18 years old onwards with varying diagnosis including Generalised Anxiety Disorder, Bipolar Affective Disorder, Schizophrenia, Depression, and patients with mental and behavioural disorders due to psychoactive substance use.

The reason for doing this project was most importantly for improving patient safety by reducing unnecessary prescriptions and therefore administration of hypnotic medications, but also to reduce NHS expenditure and carbon footprint.

Inclusion criteria

Patients who have been an inpatient on the selected ward between the 09/12/2020-20/01/202 and 28/01/2020-10/03/2020.

Intervention

We developed a prescription aid flow chart (Appendix 1) for all newly admitted patients to the ward. This will guide doctors when making the decision if a hypnotic prescription is warranted.

All patients on the ward during this intervention period, who are currently on a hypnotic agent and are not newly admitted, will have their hypnotic prescription reviewed using the flow chart (Appendix 1) at their weekly consultant ward round.

We then decided on some interventions to fulfil our aims. The interventions were as follows:

1) Development of an educational presentation about Insomnia and sleep management.

2) Development of an Insomnia management Flow chart (Appendix 1) to be used at admission point.

3) Training sessions for ward staff.

4) Shared teaching programme with patients at their sleep management sessions.

5) Face to face and E-mail correspondence to inform medical trainees about this project.

6) Gather feedback from ward patients and staff before and after this project.

The Hypnotic prescription flow chart aid (Appendix 1), has been put on the ward office notice board, the clinic room and the On Call Doctors Room. It was also e-mailed out to the regular ward doctors, as well as all on-call doctors working during the intervention period.

As discussed above, we created an educational PowerPoint presentation entitled “Insomnia and hypnotic agents”. This included insomnia definitions and types, NICE guidance on insomnia, sleep hygiene advice, the medications used for insomnia, their mode of actions, side effects, cautions and cost of these medications. We also included our new hypnotic prescription flow chart aid (Appendix 1).

From the 21/01/2020-27/01/2020 we had two of these educational training sessions. This was to ensure that all staff working on this ward attended at least one of these sessions. Staff in attendance included the ward managers, nursing staff, health care assistants, the pharmacist, a junior doctor, and the ward consultant. This was very important as all these health care professionals are involved with the management of patients on the ward, and those suffering from insomnia. We felt that this session was vital as we wanted to ensure that all the staff knew the importance of this project and could raise their own concerns and issues that they have with regards to managing patients with insomnia. This proved to be very useful as we all brainstormed and voiced some realistic ward changes that could happen on an inpatient psychiatric ward. We also acknowledged that sleeping on the ward as an inpatient can often be disturbed, due to regular nursing checks and noise from the staff and other patients. We did however discuss some feasible interventions which included:

1) The time at which all the automatic ward lights are turned on in the morning could be delayed.

2) Caffeine –free coffee/tea available only after a particular time in the evening.

3) Discourage daytime napping.

4) Have regular sleep-hygiene sessions on the ward.

Between 28/01/2020 to the 10/03/2020 we started these interventions, and this is the time period for collection of our next six weeks of data. We had multiple patient group sessions on sleep hygiene during this time led by the occupational therapist. Other health professionals assisted with this, including the ward pharmacist and the junior doctor. During these sessions we asked for patients to give their feedback on the current management of insomnia on the ward. Some responses included:

· One patient with Severe Generalised Anxiety Disorder stated that he feels that the sleep hygiene advice is helpful, as he doesn’t like to “jump straight into taking tablets” and likes to “fix the root” of his sleeping problem.

· A second patient with a diagnosis of Mental and Behavioural Disorder due to use of cannabinoids, stated that he needs both sleeping medications and sleep hygiene advice, as sometimes he still cannot get to sleep on the ward by solely using relaxation methods.

· A third patient with Generalised Anxiety Disorder stated that he found the sleep hygiene sessions useful. He is now using relaxation methods and is trying to avoid daytime naps which are both helping with his sleep. However, he still on occasions struggles with sleep. He said it is important to have a tidy, clean and relaxing sleeping environment, which is sometimes difficult to implement on the ward.

Appendix 1

Results:

Data was collected prior to any intervention on the ward between the dates 09/12/2020 and 20/01/2020.

The table below (Table No.1) includes the type and number of sleeping tablets prescribed on the ward between the dates 09/12/2020 and 20/01/2020. The total number of patients treated from 9 December 2019 to 20 January 2020 were 28 and the total number of patients were prescribed hypnotic medication during this time were 14.

Table No.1 - Hypnotic medication prescribed:

The table below (Table No.2) includes the number of hypnotics prescribed and administered after the interventions mentioned above. The total number of patients treated from 28 January 2020 to 10 March 2020 were 25 and the total number of patients who had prescribed hypnotic medication were 11.

Table No. 2- Hypnotic medication prescribed:

With our ward interventions we have significantly reduced the amount of hypnotic tablets being administered. The total number of tablets administered during this 6 week period was 102. The total number of patients who were prescribed hypnotics was 11. Prior to our interventions the total number of tablets administered between 9^th December 2019 and 20^th January 2020 was 224 and 14 patients in total were treated. This demonstrates a 44.5% reduction in tablets which is significant.

Discussion

The total reduction in tablet administration was very significant with a 44.5% reduction post-intervention. This demonstrates the positive change in our clinical practice that has resulted from using the flow chart aid (Appendix 1) as well as patient and staff educational and feedback sessions. This will improve patient safety by reducing the risk of side effects. The risk of patients developing tolerance to hypnotic medications has been reduced, as well as reducing those being discharged on a regular prescription which will further improve long term expenditure of hypnotic medications for the NHS. With the changes that have occurred in our clinical practice, we have reduced the number of hypnotics being unnecessarily prescribed and administered.

Over prescribing/unnecessary prescribing is an issue within the NHS and is impacting negatively on the environment. The NHS constitution states that the NHS is ‘committed to providing the most effective, fair and sustainable use of finite resources’³. By reducing the number of inpatients being unnecessarily started on hypnotic medications, another positive from this project will be the reduction in the negative pharmaceutical impact on the environment. The number patients being discharged with hypnotic medications, who may no longer need them, due to their insomnia improving when they are discharged from the inpatient setting will also improve. Furthermore, if they are unnecessarily started on a hypnotic prescription as an inpatient, they may continue this prescription regularly and become tolerant, which will inevitably have an undesirable effect on the environment.

The feedback that we received from the educational insomnia teaching sessions also proved to be very useful. As stated above the staff sessions allowed us to brainstorm simple ward-based interventions, as well as discussing possible drawbacks which may result. This allowed us to modify the flow chart so that it worked for all staff effectively.

The feedback given from patients was also very encouraging. As health professionals we sometimes overlook how some patients want and need more involvement in making decisions on aspects of their care. Ensuring patients are informed about medications prior to prescribing, especially about side effects is something that is very important and allows patients to make informed decisions which is a more holistic approach to clinical practice. This is vitally important prior to prescribing any medications but especially medications with more severe side effects which some hypnotics have.

The patient educational sessions were a key part of this project. We gathered feedback and established that the patients involved found these sessions informative. Some, but not all, of the sleep hygiene advice was feasible to implement into their daily routine on the ward. The ward can be disruptive at night, due to other patients, or due to regular staff checks in patient rooms, as well as rooms not being familiar surroundings, were two of the difficulties raised from the patients. This is something that we appreciate can’t be changed, however with the interventions that can be feasibly made on the inpatient psychiatric ward, we continue to strive to implement and improve for patients. For these reasons both the staff and the patient educational sessions should be continued and proved a vital part of this project

Following on from this initial intervention, we feel that we can continue to make further changes and expand the changes we made on this ward, to other similar wards in our hospital and to other inpatient psychiatric wards in the Trust.

Introduction

Parkinson’s disease (PD) is the second most common neurodegenerative disease. It is associated with loss of dopamine leading to motor disorders ¹. However, non-motor symptoms such as anxiety, stress, and depression as well as cognitive impairment are also abundant among patients ². It has been hypothesized that non-motor symptoms can affect the quality of life in PD patients ³. The current therapeutic approach relies on dopamine substitution, which has no curative effect and does not improve non-motor symptoms. Studies have shown that meditation and other relaxation techniques can provide relief in non-motor symptoms. Mindfulness-based stress reduction (MBSR) is a technique used for improving stress-related symptoms in long-term conditions such as stroke, cancer, and PD ^4-6. It involves focused attention, open monitoring, and self-awareness of body movements in a non-judgemental state in the present moment. Studies have shown that mindfulness improves brain plasticity in some areas of interest. The areas of plasticity are involved in emotional regulation and processing ^{7, 8}. Thus, we hypothesized that mindfulness techniques could also have a positive effect on non-motor symptoms of PD patients which can enhance the quality of life after training sessions. This clinical trial aimed to investigate the impact of mindfulness training on the quality of life of PD patients.

Materials and Methods

Participants and Ethical issues

This randomized clinical trial was conducted at the neurology outpatient clinic of Imam Reza and Razi University-Hospital. Participants were 40 patients aged 67.95 ± 6.8 years (56-80) with a definite diagnosis of PD who were receiving dopaminergic drugs for at least one year. Twenty-seven of the patients were males, and 13 were females. They all were married, and 4 of them reported a family history of PD. Participants were randomly categorized into two experiment and control groups with 20 patients in each. For randomization, a list of random numbers was used based on the computer program and applied to the patients at the time of their neurologist visit at the clinic.

The inclusion criteria were: definite diagnosis of idiopathic PD based on UK Brain Bank criteria, mild and moderate forms of disease according to Hoehn and Yahr (HY) staging (1-3), stable and normal dosage of PD medications within last six months, normal cognitive function or mild cognitive impairment according to Mini-Mental State Examination (MMSE) score 17-30, enthusiasm and commitment to participate in mindfulness training sessions and to practice the required works at home.

The patients with the following criteria were excluded: focal neurologic deficit, abnormal brain imaging findings suggestive of brain lesions, other medical conditions that would affect the quality of life, use of antiepileptic drugs and symptoms of psychosis,

The protocol of the study was reviewed and confirmed by the local ethics committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1397.551). All patients received an informed written consent to participate in the study and to the use of their information. This trial was registered on the IRCT.ir website (IRCT20181007041258N1).

Mindfulness Training sessions

The interventions included 8-week mindfulness-based stress reduction (MBSR) sessions each for 2hours with a 15-minute break between the first and second hours. The sessions followed by a one-day retreat program between sixth and seventh sessions and took for 7 hours. The patients were asked to practice the requested homework at least for 30 minutes after each session. The protocol of the training sessions was conducted as per the steps described by Kabat-Zinn ⁹. The sessions were performed by a psychiatrist with over 5-year of experience in MBSR instructions. The instructions were based on the teaching of three techniques: body scanning, mindfulness meditation, and gentle yoga. The sessions focused on physical and mental awareness of body, how to diminish the physiological effect of pain and stress, how to perform less emotional reaction when facing distress, mental calmness in challenges through life, non-judgmental awareness, equity in stress management and joy of every moment.

Controls

The patients in the control group received eight 1-hour sessions during the same time as the experiment group. The sessions centered on basic information about PD based on brochures published by the American Parkinson Disease Association with topics: medications, symptoms of the disease, mood and sleep, and connecting with resources.

Assessments

All participant's general data, regarding age, gender, type of medication, and duration of disease were gathered according to patients' self-report and the information documented in patients' clinical records. Two neurologists assessed the HY stage, disease severity, and probable motor disturbance at baseline (within patient recruitment within one week before the initial session). The assessments of the quality of life were conducted at baseline (on the day of the first training session before the class), and after the experiment.

For the evaluation of the quality of life, the PDQ-39 questionnaire was used. PDQ-39 is a 39-item questionnaire based on the patient report of health status. It evaluates eight scales of daily activities including Mobility (MOB), Activities of daily living (ADL), Emotional well-being (EMO), Stigma (STI), Social support (SOC), Cognitions (COG), Communication (COM) and Bodily discomfort (BOD) and how these scales are being affected by PD. Participants are required to choose one of five orders of responses based on how often due to their disease, they have faced difficulties defined in each item. The final score of each item is calculated as a percentage score. The overall score is measured by calculating the mean percentage score of eight items as Parkinson`s disease summary Index(PDSI). The assessments were conducted in-person by the principal investigator (N.Gh) who was blinded about the group of study which patients were enrolled in.

Statistical Analysis

The scores of each item were described as mean ± SD. The between-group and within-group comparisons were made by the independent and sample T-test, respectively. The chi-square test was performed for the comparison of categorical variables. To investigate the change in the quality of life each PDQ-39 item scores and the PDSI scores were compared before and after the experiment in either control or experiment group by splitting the data into two study groups and comparing the mean scores of each item using independent T-test. All the analyses were performed using SPSS software version 19.0 (IBM Corp., Armonk, N.Y., USA). The boxplot figures were drawn using medCalc.ink software. Figures of the change in questionnaires' scores were provided by GraphPad.prism v.6.0.7 Ink software.

Results

All the 40 patients completed the training sessions in 8 weeks. The primary assessment was made after the last MBSR session and during their first neurologic visit at the clinic.

The general characteristics of the patients in each experiment and control group are shown in Table 1. The baseline characteristic data did not differ significantly between the two study groups.

As it is demonstrated in Table 2, at baseline, the PDQ-39 item scores did not differ significantly between two study groups, except for the SOC score, which was significantly higher in control subjects compared to the experiment group (35.80 ± 9.7 vs 29.11 ± 8.7, p = 0.02).

Quality of life assessment

The statistical analysis revealed a lower mean score in all PDQ-39 items in the experiment group compared to control subjects; however, the difference was insignificant for MOB, ADL, EMO, STI, COG, COM, and BOD and was only significant for SOC (34.13 ± 9.7 vs 26.19 ± 7.7 for control and experiment group, respectively. P = 0.007) (Table 2).

On the other hand, the within-group analysis yielded a significant improvement in the mean score of subjects in the experiment group. Their mean PDSI score was 31.88 ± 6.5 after one month compared to the baseline score of 33.93 ± 6.2 (p < 0.001). However, the mean scores of the participants in the control group did not significantly differ from the baseline.

A comparison of the delta values between the experimental and control groups showed MOB, ADL, and EMO to be significantly different.

The classification of the patients based on the stage of disease by HY revealed a significant improvement in PDSI score in patients in the experiment group at the severe stage (III). In contrast, the PDQ-39 item scores did not significantly differ (except for the ADL) after the training for mindfulness. The analysis also showed that patients in milder stages (I) have significant improvement after the experiment. However, the same improvement was noted in the control group (Table 3).

Table 1. Patients' demographic data in each study group

Note: Abbreviations: Female (F), Male (M), Hoehn Yahr (HY), Parkinson's disease (PD)

Table 2. PDQ-39 score items and PDSI before and after the mindfulness sessions in control and experiment group pf patients

Note: Abbreviations: Confidence Interval (CI), Mobility (MOB), Activities of daily living (ADL), Emotional well-being (EMO), Stigma (STI), Social support (SOC), Cognitions (COG), Communication (COM), Bodily discomfort (BOD), Parkinson`s disease summary Index (PDSI). ^ϯ: P value of the differences before and after the experiment in each group; ^*: P value of the differences between mean score of experiment and control group; ^€: 95% CI of the differences between mean score of experiment and control group.

Table 3. The quality of life in patients with different stages of PD before and after the mindfulness sessions in each experiment and control group

Note: Abbreviations: Confidence Interval (CI), Mobility (MOB), Activities of daily living (ADL), Emotional well-being (EMO), Stigma (STI), Social support (SOC), Cognitions (COG), Communication (COM), Bodily discomfort (BOD), Parkinson`s disease summary Index (PDSI)

Discussion

Significant improvement in the quality of life between the patients who received mindfulness training and the control group was observed in this clinical trial of people with Parkinson’s disease within eight weeks of trial.

Overall PDSI decreased modestly in the experiment group by 2.05 points and decreased in the control group by 0.27 points after the experiment.

Among the PDQ items, MOB, ALD, and EMO significantly improved in the experiment group compared to the control group. These results show that mindfulness training has a significant impact on not only motor symptoms of the disease but also the non-motor emotional wellbeing of the patients. The most significant effect of mindfulness training was on patients’ daily activity, which was also obvious in the severe cases of the disease.

Up to now, a few trials have been conducted on the effect of mindfulness training on PD ^10-13. The effect of mindfulness on different features of motor and non-motor symptoms has been measured. However, the outcome was discrepant regarding the time duration of the follow-up and improvement in the measured symptoms.

Similar to our findings, Geong son et al. found a significant difference in the quality of life and ADL of 33 experiment patients who received mindfulness training in comparison to 30 control subjects ¹³. Some other studies found mindfulness an effective modality for a few subscales of PDQ-39^{11, 12}.

In a clinical trial by Cash et al. 39 patients were enrolled in 8-week mindfulness sessions and their EMO and COG improved after the experiment¹¹. In a similar study conducted by Advocat et al., the effect of mindfulness training on the quality of life in 35 PD patients was compared with 37 control subjects within seven weeks and six months. In a two-step analysis, ADL was the only improved factor in experiment group ¹⁴.

In contrast, Dissanayaka et al. examined the effect of mindfulness on fourteen PD patients in the 8-week training program and compared the results with baseline at post-intervention assessment and 6-month follow up ¹⁵. Their results did not yield a significant improvement in any subscales of the quality of life in primary and secondary evaluation. Similarly, non-significant results were reported by Rodgers et al. and Pickut et al. ¹².

Birtwell et al. also assessed the long-term efficacy (16 weeks) of mindfulness training on STI and EMO in thirteen individuals with PD. They found an insignificant change in these two subscales of PDQ-39 ¹⁶.

In the present study, EMO and ADL were more subjective to the short-term effect of mindfulness training. The results of Rodger’s et al. study were consistent with our primary outcome. Their between-group analysis revealed a significant difference in depression subscale of DASS-21 after mindfulness intervention in PD patients ¹⁷. Cash et al. also found depression to improve after mindfulness interventions in PD patients ¹¹.

In contrary to our findings, the difference between PD experiment and control subjects was not meaningful in Pickut et al.'s study ¹². COG was unaffected to mindfulness training in our study. This finding was supported by the clinical trial of Cash et al. They found an insignificant change in PD patients' cognitive function in immediate pots-intervention assessment ¹¹.

On the other hand, Dissanayaka et al. found post-interventional improvement in PD patients' cognition by obtaining PD Cognitive Rating Scale (PDCRS), extended for six months ¹⁵.

Similarly, Geong son et al. showed a significant difference between experiments who received mindfulness training with controls in the mean score of Korean Montreal Cognitive Assessment ¹³.

As described above, there are discrepant results regarding the role of mindfulness stress reduction sessions on quality of life in PD patients. Our results were consistent with some studies and contrary to others. The main factors that might have affected these differences are the size of the sample, including a control group in the study, subjective mood changes in the patients, the severity of the disease, and the likelihood of practicing the Learned lessons at home.

Mindfulness-based interventions aim to improve the current wellbeing of the individuals by self-awareness of present emotions and body movements. It might also help individuals to manage daily stress, have a better judgment of their own, and adjust to daily life. There is also evidence suggesting that mindfulness training leads to neuroplasticity in the brain areas which are involved in emotions ¹⁸.

Studies have also suggested that early therapeutic interventions are more practical in terms of diminishing the probable severity of the disease in the future ^{13, 18}. In our study, patients in the early stages had improvement in their overall quality of life, which was also noted in controls of the same stage, too. However, a meaningful change in the quality of life of patients at the severe stage of PD was recorded after the training sessions. We suggest a long term follow up of the patients in each group and with different stages of the disease to find if the mindfulness training would help in diminishing the progress of the disease.

This study was a pilot study in which MBSR showed a great impact in improving the quality of life in PD patients. However, there were limitations in the study that must be considered. First, the sample size of the study was not large comparing to the prevalence of the disease, and it was constrained by other important factors such as disease severity and level of education. Patients needed to have a minimum level of education to be able to attend the sessions and apply them in their routine life. Second, the psychological nature of the intervention limited the blindness of the patients to the intervention.

We did not perform an intention to treat analysis or crossover randomization as all the randomly selected patients completed the trial, and none dropped out of the clinical trial.

Conclusion

In our study, mindfulness training improved the overall quality of life in PD patients. However, long-term follow up on a large-scale population is required to evaluate the impact of mindfulness-based stress reduction on each item.

Introduction

The creative process is an enigma; there are conflicting opinions about creativity and creative people. Research studies on creativity have produced contradictory results. The long-standing belief that creativity results from a strange clairvoyant state is still occasionally associated with psychiatric disorders. ¹ Although a decline in creativity with aging indicates that it is biologically based, a relationship between creativity and psychopathology is overstated in both print and media. Reductionism tends to misconstrue creativity as a product of psychopathology. Nonetheless, whilst psychopathology can facilitate creativity, it does not produce creativity. The inspirational characteristics of creativity remain shrouded in mystery.

Methodological issues that include both a definition and an evaluation of creativity impede the research into creativity. These challenges make the correlations between the studies problematic, and they deliver opposing outcomes. Although there is no confirmed relationship between psychopathology and creative accomplishment, the search for such a relationship hinders our understanding of human potential and the deeper levels of consciousness. Early detection of creative talents in children might enable providing them with special guidance, thereby averting potential psychiatric problems.

The superficial reductionism of 20th century biological psychiatry compressed all mental phenomena, including creativity, into compact neurobiological compartments, and the only way to achieve this was to medicalise it. Any assumed correlations between creativity and mental disorders will be clarified only when we gain a greater understanding of the creative process. In cases where creativity and mental illness indeed coexist, a psychiatric understanding of creativity may provide insights into patient functioning and assist in defining both normalcy and psychopathology.

Whilst human beings have existed on this planet for millions of years, the technological advancements of the last few centuries transpired without any perceptible changes in the development of the human brain. Historically, our ancestors were drawing two-dimensional pictures until just a few centuries ago. No one has hitherto been able to explain this sudden burst of creativity. An expanded model of brain-mind-consciousness that can appreciate the wonder of creativity is needed.

Defining Creativity

Researchers have long been interested in a potential connection between creativity and mental illness. The major challenge here is to define creativity and establish measurable indicators. Creativity has been described as the process of bringing something new into existence. It involves the capacity to take unrelated structures and combine them harmoniously in different ways for new purposes. The creative mind is alert to unexpected connections. An individual with a rich reservoir of knowledge is regarded as intelligent, whereas an individual who uses that knowledge in an original and constructive way is considered creative. ² The creative process is not fully understood; some even feel that a precise definition is unattainable.³ Nonetheless, creativity can be described as the process of bringing something new into being where the outcome is larger than the input received by the creative mind. ^4,5 Creative individuals are sensitive to gaps in human knowledge and these voids act as catalysts in their search for solutions. This is the highest form of human adaptation; whether to a greater or a lesser degree, it may exist in all people.

The creative process can be likened to a four-stage computer process. ⁶ If information processing and storage is the primary process, the second stage is the incubation or pondering phase, during which ideas germinate at a subconscious level. The third phase involves illumination, or flashes of insight, and the fourth is the period of elaboration during which the new idea is developed and tested. These stages can be additionally likened to the biological rhythm of conception, gestation, birth and infancy. This pattern is not strict. As a rule, the process of illumination is gradual with countless small bursts of insight, such as with Charles Darwin’s elaborations on his theory of evolution.

Dream processes shed some light on creativity. As with poetry, dreams are replete with visual and highly idiosyncratic metaphors. Dreams are the art of the unconscious; whilst dreaming, we tap into a creative source. The dreaming psyche has seemingly unlimited creative potential. An anecdote about Kekule, the chemist, recounts that he conceived the benzene ring after a dream in which he saw a serpent biting its tail.

The Creative Personality

Creative people must be assessed on an individual basis. Not all persons of superior intelligence are creative, and not all creative people have superior intelligence. Although creative potential is dependent on intelligence, actual creative achievement is independent of intelligence (e.g. one does not have to be tall to be a successful basketball player). Highly intelligent people are prone to self-criticism, which has an inhibiting effect on the development of creativity. A combination of high intelligence and special aptitudes appears to promote creativity. Unconventionality, egocentrism, flexibility, tolerance for ambiguity and a preference for complexity are among the attributes of creative individuals. ⁷ Psychological testing has shown that creative individuals are frequently more emotionally troubled than are non-creative individuals; however, they also have more ego strength for dealing with problems. Their personal qualities include imagination, persistence, perseverance, dedication and stamina. Creative children tend to be egotistic and gullible. This egotism provides them with the confidence to believe that they are capable of unique achievements, whilst momentary gullibility enables them to break through scepticism and into creativity.

McClelland illuminated a controversial notion when he described the creative individual as one who is characterised by competition, either with an external standard of excellence or with his or her own internal aspirations. ⁸ Driving absorption, the ability to ignore failure and adversity and tremendous curiosity are noted as a predictive set of personality traits.⁹Although creative individuals are difficult to live with, whether their creativity flourishes or not frequently depends on the support that they receive from others. ¹⁰ Among the characteristics of creative people, Tarlaci (2014) included openness to experimentation and change, rebelliousness, individuality, sensitivity, playfulness, self-assertiveness, curiosity and simplicity. ¹¹

Although there is a compulsion for order, symbolisation and communication are at the core of creativity. Intelligence, domain-specific knowledge/expertise, motivation and adaptive traits such as openness, broad interests and self-confidence are closely associated with creativity (Feist 1999). ¹² Despite the fact that these characteristics of creative people are obviously independent of psychopathology, they point towards better mental health. Research on creativity in neuroscience has revealed that creativity is associated with ‘ordinary’ rather than psychopathological brain processes.¹³

Psychopathology

Since the time of Plato, philosophers have debated a conceivable connection between creativity and psychopathology. He proposed a logical paradox when he stated that a poet does not know what he is going to write, and yet he cannot produce a poem if he has no picture of what he describes. As a Greek philosopher, Plato was a reincarnationist. He obviously solved his own riddle by attributing hidden creative knowledge to remembrances of a previous life and to springing from ‘Divine madness’. Aristotle noted the predisposition of great artists and poets to melancholia, but he perceived creativity as a rational process. Shakespeare repeated the older perspective through one of his characters who states, ‘the lunatic, the lover, and the poet are of imagination, all compact’. During the 20th century, systematic investigations into this relationship were unable to either support or refute this association. Cesare Lombroso failed to clarify this confusion in his book, Genius and Mental Illness. Nonetheless, his influence led to speculation that genius is an ‘ancestral gift’ transmitted in families in the same manner as mental disorders.

Recent empirical research has shown that creative individuals have a higher tendency towards psychopathology than those in non-creative professions. This propensity is expressed in personality traits, behaviours and experiences similar to those identified in clinically ill patients (Jamison 1989). The evidence has not clarified whether the psychopathology linked to creativity relates more closely to features of schizophrenia or affective disorders. Countless novelists and dramatists have family histories of psychiatric disorders. Severe personality deviations have been observed among visual artists and writers and possibly among thinkers and scholars as well. Jamison noticed mood disorders among writers and artists. ¹⁴

Bipolar disorder may be more frequent among creative individuals than in the normal population. One study reported a higher incidence of depression and bipolar disorder among creative people, and especially among writers.¹⁵Another study noted a higher incidence of depression and alcoholism among writers and artists. Following recent epidemiological studies with large samples, Kyaga et al. (2013) argued in favour of an association between professional authors and psychiatric disorders. ¹⁶ They illuminated familial associations between the creative professions and schizophrenia, bipolar disorder, anorexia nervosa and possibly autism. ¹⁶They noted that this association was more evident in cases of self-employed artists and less so in scientific creativity, where the subjects had passed through several professional screening procedures.

In another epidemiological study, Parnas et al. (2019) found that the relatives of academics have a significantly increased risk of suffering from schizophrenia or bipolar disorder. ¹⁷ In another study, they suggested that ‘creativity and an increased risk for mental disorders seem to be linked by a shared vulnerability that is not manifested by clinical mental disorders in the academics.’ ¹⁸ The literature has made significant connections between bipolar disorder and creative accomplishment, with much of the thinking inspired by biographical accounts of poets and musicians who presented with signs of bipolar disorder. ¹⁹ Studies by Burkhardt et al. (2018) suggest that, in persons at-risk for bipolar disorder, their mood swings are strongly associated with creativity, but whilst there is evidence of increased creativity, there is no evidence of higher creative achievement. ²⁰

Observations of the bipolar mood domain identify a high prevalence of changes in intuition, empathy, appreciation of danger and predictive capacity. However, these changes do not necessarily include supra-sensory changes in the primary senses of smell, taste, vision, touch or hearing. Parker et al. (2018) suggested that clinicians should be aware of non-psychotic, supra-sensory phenomena in patients with bipolar disorder and that the identification of such features could explain the increased creativity evident in those with a bipolar condition. ²¹

After examining the life of Charles Dickens, Longworth and Carlson (2018) maintained that there was very little historical evidence for the suggestion that he experienced bipolar disorder. ²² However, they did suggest that he displayed characteristic bipolar symptoms. They also maintained that his childhood was an outstanding example of personal resilience and that his own story was just as fascinating, if not even more intriguing, than any of those that he had created. Their investigations concluded that Dickens’ story confirmed the connection between writers, creativity and mood disorders. Retrospective psychiatric assessment of historical figures and the slotting of these celebrities into biological compartments may be risky. Biographical studies of creative people are criticised for having possible recall, interviewer, selection and cultural sampling bias. ²³

The suicide rate is high among artists, and this has been linked to manic depression. Adverse financial circumstances and disappointments due to the rejection of their artistic productions are sufficient to explain this apparently high rate. In contrast, musicians have a low suicide rate, very likely reflecting the healing effect of music. In addition to alcohol, opium has been a historical favourite addictive drug of writers, of which Charles Dickens is an example; opium addiction was partially responsible for his death. ²⁴ Ludwig’s study on 1000 outstanding individuals found an upsurge in alcohol abuse in artists, especially writers. ²⁵ Post (1994) found a similar result among prose writers and playwrights. ²⁶ Although Ernest Hemingway, the Nobel Prize winner for literature, may be a good example of this phenomenon, he committed suicide later in his life. Creative individuals may be notorious for their alcohol and drug misuse; however, it is not clear whether drug induced psychopathology promotes their creative expression. Whilst it is possible that the disinhibiting influence of mild psychopathology and the judicious use of alcohol or drugs could facilitate creativity, this phenomenon has potentially contributed to the confusion in which psychopathology is described as the ‘producer’ of creativity.

Absence of Psychopathology

Alongside these studies, other reports glorify the mental health of geniuses and eminent individuals. The Stanford 35-year follow-up study of over 1000 geniuses, the MacKinnon study of creativity in architects and Havelock Ellis’s psycho-biographical study of eminent men all emphasised the absence of psychopathology among these creative individuals. ²⁷

In an investigation on the prevalence of psychopathology, in a sample of 291 famous men, Post (1994) noted that they all excelled by virtue of their abilities, originality, drive, perseverance, industry and meticulousness. ²⁶Even though most of them had unusual personality characteristics and minor neurotic abnormalities, all of the subjects in this study were emotionally warm, with a gift for friendship and sociability. Post additionally noted that, among creative individuals, scientists show the fewest psychological abnormalities. Functional psychoses are less frequent than epidemiology would suggest. Depressive conditions, alcoholism and possible psychosexual problems are more prevalent than expected in some professional categories, particularly among writers. Hare (1987) noted that banning stimulant drugs in sports did not lower the achievements significantly, and that the same should be true of creativity. Poetic vision has been equated with psychedelic experiences. ²⁸ Creative activity has been observed to be at its highest level in patients who are moderately ill, and at its lowest level in groups identified as severely ill. ²⁹

Although there is no significant difference in the incidence of psychotic illness among males and females, there is less creativity among the latter. If the hypothetical connection between creativity and psychopathology were valid, the incidence of creativity should be proportional to gender. Historically, unfavourable social pressures and opposing cultural factors have represented major explanations for the lower incidence of creativity among women. This disparity points towards the fact that creativity has to be nurtured and is not automatically generated by psychopathology. Despite an equal incidence of mental illness in men and women, there have been few female geniuses in any culture; this challenge the probability of a clear connection between psychopathology and creativity. The same argument may be used against a pure biological view of creativity; both men and women have the same biological make up, yet fewer geniuses have been identified among female population.

Psychodynamic Perspectives

Psychoanalysts have postulated dynamic psychopathologies for the creative process. Analysts incline towards seeing artists as neurotics and their productions as sublimations of sexuality and regression in the service of the ego. ³⁰ They consider the motives for creative activity as impulses that compensate for dissatisfaction and as defences against depression. Some perspectives differ from traditional psychoanalytical ideas, emphasise the crucial role of synthetic ego operations and draw distinctions between psychopathology and creativity. ³¹Analysts suggest that novel ideas exist in the subterranean regions of the mind. Whilst the conscious mind has no access to these hidden areas in the normal state, it is easier for a disturbed mind to tap information from the unconscious or preconscious. ³² Sims suggests that the psychotic and the creative states are subjectively indistinguishable and that delusions arrive in the minds of the mad in the same manner that ideas drop into the minds of the creative.³³In contrast,Slater and Meyer report only minor psychiatric disorders among creative people. ³⁴Although it would appear that psychopathology does not preclude creative activity, it may release it. In general, the creative person enjoys conflict free intimacy with the preconscious and is a model of psychological health. ³⁵

Orderly Mind

The neurobiological model of schizophrenia suggests that a deficit in the systems involved in information-processing could contribute to its symptomatology. ³⁶It has been hypothesised that such a deficit could favour the creative association between information units.³⁷Psychopathology linked creativity has even been associated with abstract disciplines such as mathematics. If these views were accepted, creativity and schizophrenia would be separated only by a ’neurological difference’. Andreasen challenged the hypothesis of a connection between creativity and schizophrenia.³⁸He argued that the bizarre nature of schizophrenic experiences is far from original, and that the cognitive impairment of such patients inhibits their creativity.

The creative intelligent person experiences an attention surplus, whereas a schizophrenic patient suffers from an attention deficit. As a case in point, a creative child may figure out in two seconds what the teacher is going to say, after which he may be looking around, waiting for the teacher to finish and appearing as if he is not paying attention. In contrast, because of a failure in the normal filtering of stimuli, schizophrenics tend to make unusual associations that result from over-inclusive thinking in which countless disconnected elements are included in their reasoning. ³⁹ Although higher cognitive individuals also demonstrate ‘pseudo over-inclusive thinking’, this is due to their capacity to conceive and utilise two or more contradictory concepts simultaneously.⁴⁰

Bleuler (1950) described intellectual ambivalence as both characteristic of schizophrenia and as superficially similar to the janusian process of oppositional thinking that involves conceiving of two or more opposites simultaneously. ⁴¹ The Kent-Rosanoff word association test has been used to assess this process. ⁴² In contrast to the creative thinker who is fully aware of logical contradictions, the schizophrenic patient is unconscious of the contradictory nature of his or her utterances. For example, when Albert Einstein derived his theory of relativity, derived from the fact that a man falling from the roof of a house was both in motion and at rest, he was fully aware of the contradictory nature of his thinking. ⁴³ Another example is Frank Lloyd Wright’s revolutionary design of Falling water, in which nature and interior space coexist. The janusian process was initially identified in highly creative writers, visual artists and scientists. The fluency of association observed among creative individuals can be mistaken for over-inclusive thinking. ⁴⁴Since their brains process increased sensory input effectively without cognitive overload, creative individuals derive an advantage from their higher levels of associative thinking.

Contrary to popular belief, in their cognitive and conceptual style, creative writers resemble those suffering from the manic phase of affective disorders, rather than schizophrenics. However, whereas the over-inclusiveness of maniacs is based on bizarre associations, that of writers is due to an imaginative recognition of original associations. Whilst writers are capable of controlled flights of fancy, manic imaginations are bizarre and based on personalised reason. The racing thoughts of a creative intellect are productive, whereas those of the manic are destructive. Albert Einstein claimed that he discarded a new idea every two minutes.

Creative thinking is polythetic and should not be confused with flight of ideas. Schuldberg (1990) investigated the overlap between schizotypal and hypomanic traits and suggested that affective symptoms may be more important than primary process thinking in determining creativity within the general population. ⁴⁵ The fluctuation of thoughts experienced by higher cognitive ability individuals can be mistaken for mood swings. Fink et al. (2014) challenged the connection between creativity and psychopathology and proposed that the domains of artistic and scientific creativity should be analysed separately. ⁴⁶

Although the creative potential of autistic people has been recognised, they differ from over perceptive children in many respects. One fundamental difference is that the creative potentials of the latter are polythetic, whereas such potentials of the of autistic individuals are generally monothetic. A key diagnostic criterion for autism—restricted and repetitive behaviours and interests—combined with a small number of research studies, suggest that generating original ideas or artefacts may be challenging for autistic individuals. ⁴⁷Nonetheless, a minority within this population has exceptional artistic gifts, and a wider group embraces activities typically associated with creative expression, including visual art, music, poetry and theatre.

A three-level multilevel meta-analytic approach investigated the relationship between creativity and schizophrenia. The analyses of Acar et al. (2018), with 200 effect sizes gathered from 42 studies, detected a mean effect size of r =−0.324, 95%CI [−0.42, −0.23]. ⁴⁸When the analyses focused on the moderators, they found that the relationship between schizophrenia and creativity was moderated by the type and content of the creativity measure, the severity of the schizophrenia and the patient status. The negative mean effect size was firmer with semantic-category or verbal-letter fluency tasks than the divergent thinking or associational measures. They submitted that when these findings are analysed along with previous meta-analyses on the association between creativity, psychoticism and schizotypy, creativity and psychopathology appear to have an inverted-U relationship. Whilst a mild expression of schizophrenia symptoms may support creativity, a full demonstration of the symptoms challenges it.

Schizophrenia and schizotypy have frequently been associated with above average creativity; nonetheless, empirical studies on the relationship between schizophrenia spectrum disorders and enhanced creativity have generated inconsistent results. ⁴⁹ Even though some mental processes may appear to be similar in creative and psychotic thinking, the current literature challenges this conclusion. ^50,51,52Psychopathology does not play a role in the genesis of higher order creativity; nonetheless, the psychological defence mechanism of overcompensation goes some distance towards explaining the high achievements of mentally or physically disabled individuals. ⁵³

The Myth of Drug Induced Creativity

The belief that brain alone is the source of creativity led to the idea that altering brain chemistry could make people more creative. The truth may be that the gentle psychopathology created in the brain might serve as a facilitator of creativity rather than a producer of creativity. The psychopathology generated by the psychedelic drugs might help to open Aldous Huxley’s ‘doors of perception.’ Huxley (1954) proposed “Doors of Perception” to illustrate the enlightenment induced by LSD etc.⁵⁴ Interestingly, such a proposal is close to Zizzi and Pregnolato’s depiction of ‘very fast switches from the quantum logic of the unconscious to the classical logic of consciousness’ (Zizzi & Pregnolato,2012). ⁵⁵Those who glorify such drug induced creativity are unaware that long term substance misuse can only kill creativity as the ‘switches’ become permanently damaged and lead to psychopathological states.

When one’s sense of self is suspended and space-time sense dissolves, psychedelic experiences occur, and such experiences should not be confused for true mystical experiences. Psychedelic experiences are pseudo-mystical experiences. True mystical perceptions and cognitions relate to what is essentially ineffable, pertaining to the nature of existence rather than being limited to familiar objects that are intrinsic to everyday experience. The hallucinating drug user or alcoholic is functioning at the level of impaired consciousness, while the mystic is operating at a higher level of consciousness. Mystics have full awareness of their altered state of consciousness and they are also in a position to switch back to their ordinary mode of perception, unlike a hallucinating patient. It may be true that psychedelic experience has created an interest in artistic activity and the raw materials obtained in such experience may be useful in eventual artistic creation, but the psychedelic experience as such is not a creative experience because motor functioning is impaired during psychedelic experience and information flow to the hands and fingers are affected. ⁵⁶ The natural state of a relaxed, happy, and well-adjusted person is more creative rather than the perplexed psychedelic state. There may be ‘psychedelic artists,’ but not psychedelic scientists indicating the difference in the creative process of scientific generativity and artistic.

Drug induced creativity is a conundrum that need serious clarification as many young people are trapped in such faulty perceptions. Cannabis is the most widely used illegal substance globally. Schafer et al (2011) suggested that cannabis produces psychotomimetic symptoms, which in turn might lead to connecting seemingly unrelated concepts.⁵⁷Such divergent thinking is considered primary to creative thinking. They argue that a drug induced altered state of mind may indeed lead to breaking free from ordinary thinking and associations, thereby, increasing the likelihood of generating novel ideas or associations. But the harmful effects of cannabis use have been extensively evaluated.^{58,59,60,61,62,63}Cannabis abuse is quite unlikely to generate any sustainable creativity-‘the creative Big Bang’ would soon end up as a big crunch.

If creativity is a neurological phenomenon, creative people should have additional neural pathways, but psychedelic drugs have not been proven to create such new neural pathways. Speculations about specific brain regions promoting creativity is of great scientific interest. Creativity involve an architect and a set of engineers. According to Amit Goswami, quantum unconscious domain is the architect and the real source of creativity if brain does the engineering works. ⁶⁴ Psychoactive substances do not act directly on the quantum consciousness but may help to open the gates to the hidden dimensions of consciousness. When quantum views of creativity are given due significance, the neurologically based psychedelic promotional views of creativity crumble. If not having creative abilities is deemed as a ‘brain deficit,’ use of illegal drugs to promote creativity can be compared to using medications to treat ADHD. But only if we use the ‘brain disease model’ of psychiatry, the argument of ‘brain deficit model’ will hold water. It may be even true that psychedelic drugs may have a quick and transient destressing effect and that could promote a creative mental state, but the production of any direct creativity through the use of such drugs is questionable.

Problematic Childhood

Some children of superior intelligence attempt to mask their creativity by being over-talkative and overactive. Such children run the risk of being misdiagnosed as ADHD. Creative children frequently have a unique sense of humour that their peer group cannot appreciate. Creative children are every so often resented by peers because of crazy or unusual ideas and their forcefulness and passion in presenting them or for pushing their ideas on others. Their divergent thinking is not helpful in school examinations, which require convergent thinking, and this could explain the poor academic achievement of several geniuses. The divergent thought processes of creative children must be differentiated from inattention and underachievement. For example, a highly intelligent child might fathom out what the teacher is going to say next and become inattentive. Although creativity is associated with divergent thinking, this alone does not correlate well with creative achievement.⁶⁵ Creative children overflow with ideas and play with new ideas and concepts. They are not motivated or even concerned about high grades and need individualized attention lest they might fall on the wayside. There is nothing more frustrating than being a creative intelligent and become underachieved.

Creative children demonstrate certain unusual traits such as daydreaming, wanting to work alone, sharing bizarre thoughts and conflicting opinions. These qualities will not please the traditional teachers and bring them in conflict with them and their lack of conformity to the classroom structure can be even confused with attention deficit hyperactivity disorder. Highly critical parents kill creativity; unfortunately, countless creative individuals have chaotic childhoods leading to psychological problems in their adult lives. Mismatching due to variation in I.Q could lead to mismatching with parents and siblings. Mother and father may be of average intelligence, but the child can be above average intelligence, and could cause mismatching leading to behavioural problems.

There is a special group of children around the world who have high intelligence and intuition, healing abilities, and a strong spirituality and they are grouped as Indigo people in appropriate cultures. It can be stated that Indigo is people with high sensitivity level, unique creativity, high intuition ability, healer, and people with their own charisma for those around. ⁶⁶According to the proponents of these new ideas, these children are often mislabelled as having behaviour disorders. Little is known from scientific research about the Indigo phenomenon. Indigenous populations are familiar with Indigo-like children. The purpose of studying these children when they are adults is to better understand these children when they are older and advance behaviour health sciences by increasing awareness of the Indigo phenomenon and learning about their lived experiences. There has been hardly any serious scientific study on the Indigo phenomenon.

A phenomenological study looked at the lived experiences of 10 adult Indigos. The study explored the lived experiences of 10 adult Indigos on the island of Oahu, Hawai'i (> or = 18+ years old-7 females, 3 males; mean age = 52.4 + SD). ⁶⁷ Through in-depth semi-structured personal interviews, the experiences of these adults were analysed and interpreted to identify the common experiences faced during childhood, what worked for their assimilation into society, and recommendations for parents, educators, and health professionals on how to work with Indigos. Bioenergy field photographs of each participant were also taken. Statements related to the phenomenon were placed into themes, coded, and categorized as the investigators reached a consensus of common themes. Seven primary themes and nine secondary themes emerged from the findings.

The primary themes were: grandmother/mother had a similar gift; guided by a higher power to heal self and others; felt 'different' or misunderstood; did not openly share their unique abilities; having challenges with partner relationships; history of abuse/violence or frequently disciplined; and use of intuition at work and/or school. Secondary themes included: Using Hawaiian and cultural healing methods; everyone has a degree of intuition and the use of intuition to know when to see a doctor or not; various unique abilities from body and multiple careers; mental health institutions, and financial struggle. Self-reports on participants' life purpose, their unique abilities, and being misunderstood were also collected. It was concluded that Indigos felt mislabelled or misunderstood throughout their lives despite their belief that their life purpose was to help humankind.

Academic psychologists are sceptical about Indigo phenomenon and argue that the phenomenon is a cover up to normalise the odd behaviour of children who could otherwise be included under the category of attention deficit disorder, attention deficit hyperactivity disorder, autistic spectrum disorders and learning disabilities. Health experts are concerned that labelling a disruptive child an "indigo" may delay proper diagnosis and treatment that could help the child or investigate the parenting style that may be causing the behaviour.

Inspiration and Perspiration

Creativity is regarded as the product of inspiration or creative imagination combined with meticulous, disciplined effort. The Edisonian perception of invention as 1% inspiration and 99% perspiration is explained by the hypothesis of interactive creativity; it assumes that the inspirational aspect has a paranormal component. In his thesis on interactive creativity, Laszlo supported his hypothesis with observations on cultural creativity. ⁶⁸These observations included the collective advance of entire populations through the typical creative activity of their members and by documented incidents in modern science in which different investigators developed scientific insights simultaneously, without any known contact. ⁶⁸ Early cultures developed similar 7tools; calculus was discovered simultaneously by Newton and Leibni and biological evolution was described independently by Darwin and Wallace. Similarly, Graham Bell and Elisha Grey both applied to patent the telephone on the same day. The Rubic’s cube was conceived simultaneously and designed both by Rubic and a Japanese inventor. Nylon was discovered in both New York and London, hence, the name NyLon.

Jung’s research into the phenomenon of creative synchronicity helped him to formulate his concept of the collective unconscious. Psychological disturbances may represent the consequences of creative endeavour and Jung (1973) considered them the price to be paid for persistent exploration of the unknown.⁶⁹ Polayni (1994) suggested that scientific discovery is informed by the imagination and integrated by intuition, and vice versa.⁷⁰ This statement is close to the Edisonian perception of creativity: If imagination is a property of the brain, intuition occurs in the unconscious realm. Whilst Laszlo’s views are not definitive, they indeed supplement our existing knowledge about creativity. The inspirational aspect can be better explained by an expanded model of brain-mind-consciousness, and Xavier suggests a para-psychodynamic.⁷¹

Biological Perspectives

Particularly gifted individuals have determined the evolution of civilisation. Karlsson (1984) commented regarding creative individuals: ‘Without their genes, men might still live in caves’. ⁷²Nonetheless, countless gifted individuals have a very ordinary family background, with no ancestral history of creativity. For example, Newton came from an undistinguished family. Genetics researchers look for the biological roots of creativity, with some believing that the mind is reducible to chemistry. Whilst intelligence may be a trait that can be cloned, creativity may not be attached, and it may prove even more complex than genetic manipulation. Kelly et al. (2007) suggested that creative inspiration is akin to mysticism. ³⁵

Responses to both dopamine inhibiting drugs and to the psychoses triggered by the drugs that increase dopamine activity underlie the dopamine hypothesis of psychosis. However, dopamine over-activity in psychosis should not be confused with dopamine fluctuations in creative individuals. Dopamine diminishes with aging, which may explain the decreasing powers of creativity after the age of twenty.⁷³

The relationship between age and outstanding achievement has captured the attention of researchers into creativity.Whilst Lehman maintained the perspective that creative achievement has a curvilinear single-peak function for age, other researchers have described two separate age-peaks. ⁷⁴Outstanding contributions among mathematicians after the age of fifty are exceptions. The age-related observations support a biological basis for creativity.

Future Directions

Study of creativity is an important area of research where consciousness studies and psychopathology meet each other. Cognitive scientists have pondered over the link between psychopathology and creativity for a long time without making any firm conclusions and appear to be barking at the wrong trees. The very process of creativity ought to be explored before any progress in this area of research could be achieved and the current reductionist model of mind stands as a hindrance. The following suggestions may be helpful for future researchers.

1. Establish the psychopathology of psychotic disorders

2. Creativity linked genetic studies are warranted, biological correlates of creativity need further elucidation.

3. Expand the current model of brain-mind-consciousness complex so as to explain the inspirational element of creativity.

4. More longitudinal, international and multicultural studies recommended.

5. Given the affinity of psychosis-proneness to the artistic creativity domain,

studies should be focussing artistic creativity and scientific creativity separately.

Clinical Implications

The study of creativity has clinical implications: A) Psychiatric understanding of creativity provides a better picture of patient functioning that could assist in clarifying the definitions of both normalcy and psychopathology. B) Early detection of creative talents in children might help to give special guidance for such children and thereby prevent potential psychiatric problems. C) When they coexist, differentiating creativity and mental illness is useful: The former might require nurturing and the latter warrant clinical intervention.

Discussion

Whilst it is true that investigators have observed a high incidence of psychiatric symptomatology of an affective nature among creative writers and artists, it is debatable whether this relationship is causal, an effect or a contributory factor. The increased psychopathological states observed in artistic creative individuals suggest that art and science reflect two different arenas of creativity. The mechanism of generation of novel ideas may be identical in art and scientific creativity, but they are evaluated differently by the two groups resulting in different types of products. Creativity and mental illness can coexist, and the creative impulse has a therapeutic effect on the psychiatric condition. Creativity can be therapeutic for those who are already suffering from mental illness; creative art therapies applied in clinical and psychiatric settings report positive health-related outcomes. ⁷⁵ Even in rare cases of psychopathology induced creativity, the individual will require highly developed intellectual protective factors. It is the disciplined portion of the mind that enables outstanding creative achievements. Creativity of the highest order is a product of laborious intellectual effort. When they coexist, psychopathology is a mediator, not the producer of creativity, and the creativity may be cathartic.

There is no scientific consensus regarding the association between psychopathology and creative achievement. The literature does not substantiate the high reported incidence of mental illness among creative people. It is possible that predispositions to mental illness and creativity tend to co-occur because they reflect an underlying personality and cognitive style predisposed to both creativity and mood disorder. The high reported incidence of mental illness potentially signifies an ‘occupational hazard’ and creativity stands independent of psychopathology. The normal creative person can swing back to reality from a transient ‘creative psychical shift’ (e.g. such as a diver who searches for diamonds in the deep sea and then returns to the shore). The sensitivity and intensity that facilitate creative expression may additionally make highly creative people more susceptible to depression.

Early investigations of geniuses were retrospective. Formal meta-analyses were not considered justifiable. All forms of creativity were mixed in the studies, without distinguishing the different domains of creativity. Most of the studies were confined to English speaking people, whilst creativity is a global phenomenon. A multiplicity of literature does not mean that the ideas expressed are established scientific truth. This is true of creativity, which may be as mysterious as creation itself. The prevailing model of the mind may be inadequate for a full appreciation of the creative process. It would be easier for a ‘camel to pass through the eye of a needle’ than to explain creativity from a reductionist perspective. The inspirational component of creativity continues to be an enigma. It is my contention that creativity is essentially an inner, psychic phenomenon. We do not have even an approximate model of the brain-mind-consciousness complex, let alone know the true aetiology of schizophrenia and bipolar disorder. Therefore, it would be prudent to suspend our psychopathology allied perspectives of creativity until we develop a deeper understanding of consciousness.The association between creativity and psychopathology has soared to the level of cultural myth and this is evident in many films in which mentally ill persons are portrayed as extraordinarily creative. ⁷⁶

Schizophrenia (SCZ) is a chronic relapsing and remitting disorder with a lifetime prevalence of 4 per 1000 persons.¹Positive symptoms include delusions and hallucinations. Negative symptoms are characterised by deficits in normal behaviour, which are categorised into five domains: blunted affect, alogia, social withdrawal, anhedonia, and avolition. In clinical practice, when monotherapy fails multiple augmentation strategies – such as another antipsychotic, mood-stabilisers, benzodiazepines, lithium, electroconvulsive therapy, and repetitive trans-cranial magnetic stimulation – have been used to improve the clinical state of these patients, but evidence relating to the use of these interventions is lacking.²None of the regulatory bodies has openly endorsed polytherapy with antipsychotics.

The introduction of chlorpromazine in the 1950s revolutionised psychiatry, and the coming of slow-release, slow-acting forms (depot medication) contributed to the closure of asylums and paved the way to community psychiatry. Second-generation antipsychotics ameliorated the situation for a number of psychotic patients, but some remained resistant to all forms of psychopharmacology. In 1958, clozapine was formulated and marketed commercially in 1972. ³ The arrival of clozapine facilitated the rescue of some schizophrenia sufferers for a short time, but the drug disappeared from the scene because of initial untoward incidents. ^4,5 The observation that clozapine has the potential to control the motor symptoms of tardive dyskinesia and to treat the psychotic symptoms of patients already diagnosed with tardive dyskinesia, led to its reintroduction, but with restrictions. ^6,7,8 Clozapine is recommended for use only after a trial of two other antipsychotics. Combining depot antipsychotics with oral drugs of a different class has been the practice ever since the introduction of depot medications, and this practice has come to have general clinical acceptance.

Treatment resistance

Historically, it was observed that a specific group of chlorpromazine users remained symptomatic. They were considered to be refractory to phenothiazines. The availability of clozapine led to a better definition of treatment resistance. ‘Response to treatment’ means a reduction in the severity of symptoms, while ‘remission’ implies an absence of symptoms for a considerable period. ‘Recovery’ signifies absence of the disease for a long period.⁹‘Treatment resistant schizophrenia’ (TRS) is the term used for persistence of psychotic symptoms despite a certain number of adequate treatments. Since the introduction of first-generation antipsychotics, clinicians have been cognizant of TRS and operational definitions have been used such as those developed by Kane et al. ¹⁰ Sometimes, treatment has been based on algorithms such as the Texas Medication Algorithm Project (TMAP).

According to the most common definition of TRS, if patients present with persistent, moderate to severe, positive disorganization or negative symptoms together with poor social and work function over a prolonged period of time after at least 2 adequate trials of neuroleptic drugs, they may meet the criteria of having TRS. ¹¹ A common agreement is that adequate drug treatment requires a duration of 4 to 10 weeks, a dosage equivalent to 1000 mg/d of chlorpromazine, and trials of 2 to 3 different classes of antipsychotic drugs. ¹² The current treatment guidelines recommend 2 or more treatment trials of atypical antipsychotics at adequate dosages. Adequate response to treatment has been defined as at least a 20% reduction in symptoms as measured by rating scales. Typical antipsychotics can also be used for 4 to 6 weeks to screen for TRS.

Resistance to treatment and poor outcome are different from genuine TRS. Resistance to treatment may be defined as a state in which the patient has access to medication, but the effectiveness of the treatment is suboptimal. TRS may be conceptualised as a state in which medication has reached target receptors but does not seem to be effective. Chronicity has often been misconstrued with treatment-resistance. Schizophrenia is a chronic disorder that progresses to various levels of clinical deterioration without sustained remission or full recovery. Poor-outcome SCZ applies to 50% of patients, and TRS comprises a subset of such patients. In these, cognitive impairment, negative symptoms and mood symptoms are independent of positive symptoms, resulting in poor-outcome SCZ.

It is generally accepted that 30% of SCZ sufferers have TRS. Many people with SCZ do not achieve a satisfactory treatment response to their initial antipsychotic drug treatment. They may manifest a poor response to therapy because of intolerance to medication, poor adherence and inappropriate dosing, as well as true resistance of their illness to antipsychotic drug therapy. Assessing treatment resistance is a priority in the management of TRS. ¹³ TRS has to be closely evaluated before a comprehensive management plan is developed (Table 1). From a multidimensional point of view, TRS is dependent on manifold factors, such as longer duration, several episodes, gender, early onset, poor pre-morbid personality, family history, substance misuse, presence of soft neurological signs and a long untreated period.¹⁴ Genes are thought to be involved in the development of TRS; reliable genetic prediction of which patients will be TRS would have serious clinical implications. Structural neuroimaging techniques have revealed that TRS patients do not differ importantly than those responsive SCZ in terms of brain abnormalities.¹⁵

When clozapine fails or rejected

Clozapine may be the preferred drug for TRS – effectively the gold standard – but its side effects put off many patients to the extent that some of them refuse clozapine therapy. It is a unique atypical antipsychotic and there is robust evidence supporting its use in people with TRS. Though clozapine often represents the best hope for recovery, it is associated with severe and enduring adverse reactions that may delay its prescription and increase morbidity and mortality. The major side effects are a) agranulocytosis; b) metabolic side effects; c) myocarditis; d) seizures; e) severe constipation with gastrointestinal complications such as intestinal obstruction, bowel perforation, paralytics ileus and toxic megacolon; and f) sialorrhea. These side effects hinder the popular use of clozapine in TRS. It is a life-saving drug, but without extra care it may itself shorten the life span. Side effects are more common with higher doses. It has been estimated that between 10 and 60% of patients resistant or intolerant with other antipsychotic drugs respond to clozapine.

The side effects mentioned above are inevitably an impediment to its common use. When standard doses (300mg to 5oomg) do not produce the desired effects or patients develop unwanted effects, combining clozapine with other antipsychotics is a common practice for TRS. To mention a few antipsychotics, amisulpride and aripiprazole are atypical antipsychotics ordinarily used in combination with clozapine. The anti-salivatory effect of amisulpride and the alerting effect of aripiprazole are added advantages of such a combination, and these drugs are fairly weight neutral – in contrast to clozapine. Clozapine, representing a second generation of so-called atypical antipsychotic drugs, has shown positive effects in desperate cases of TRS. Furthermore, two epidemiological studies have shown that clozapine has the lowest mortality rate among antipsychotics.

Nevertheless, even supported by the literature as the best-known antipsychotic in terms of efficacy and rates of response, a sizeable number of patients remain resistant to clozapine therapy and continue as symptomatic and dysfunctional. It has been estimated that 40–70% of patients on clozapine may not respond satisfactorily to it.¹⁶ When patients do not respond to clozapine, they are categorised as super-refractory, but the very concept of super-refractory state is debatable. They do not differ from the refractory cases in terms of demographical factors but have high score of positive symptoms. It may be simply explainable that the aetiological mechanism of the illness of such patients may be different from the clozapine responders and that makes them unresponsive to clozapine. There are no operational definitions for super-refractory schizophrenia. According to the schizophrenia algorithm of the International Psychopharmacology Algorithm Project (www.jpap.org), persistence of psychotic symptoms after a trial with adequate doses of clozapine(300-900mg/day) for at least six months is designated as super-refractory cases. ¹⁷

Many predictors of clozapine response have been suggested without any firm ground. These include severe clinical symptoms, higher levels of functioning before the onset of schizophrenia, low levels of homovanillic acid and 5-hydroxyindoleacetic acid in cerebrospinal fluid, reduced metabolism in the prefrontal cortex, reduced volume of the caudate, and the improvement of P50 gating at the 500-ms prepulse interval. ¹⁸ However, none of these factors is consistent or specific as a predictor of clozapine response. More genetic and brain imaging studies are warranted with such patients. In these cases, augmenting strategies are necessary, and some have been in use: typical and atypical antipsychotics, mood stabilizers, antidepressants and electroconvulsive therapy. Some studies have favoured ECT, but no definitive conclusion has been drawn. So also, half of clozapine patients discontinue taking the medication on their own accord. In a retrospectively studied sample of patients who discontinued clozapine, the majority terminated the treatment as a result of their own decision or because of non-compliance with medical procedures such as blood sampling.¹⁹

There are currently no evidence-based pharmacotherapies for the TRS patients who do not respond to clozapine ^20,21 or those who terminate clozapine therapy due to adversative reactions. ²² In the nutshell, clinicians should be prepared to try different alternative treatment options for TRS and super-refractory cases. Thus, combination therapy may become a choice as pre-clozapine therapy or post-clozapine therapy. Clozapine is not a drug that could normally be imposed on patients, but it has to be earned by the patient.

Combination therapy

The range of antipsychotic medications available is wide, with variable effectiveness, and there are also differing profiles for typical and atypical agents, adding to a confusing array of terminologies and dilemmas regarding what the best drug for service users is.²³ Combination therapy involves the addition of a second antipsychotic to the therapy regimen. It is different from adjunctive therapy, in which a second agent is employed to reverse an emergent side effect or to obtain a complementary clinical effect. Augmentation involves the use of a non-antipsychotic along with the antipsychotic already in use. Combination therapy and augmentation therapy are sometimes used interchangeably. In general, ‘combination’ refers to the use of more than one type of disease-specific treatment to treat a particular illness.

A change from one antipsychotic to another in same class seldom produces any additional benefit, whereas switching to an antipsychotic with a different mechanism of action has proved to produce a more impressive response rate. Combination becomes desirable when the drug already in use produces some favourable effect, but that is not sufficient to control the symptoms. It is imperative to distinguish between partial response and no response when considering a change in medication. Past antipsychotic drug response, adverse effect profile differences, concomitant medical disorders and concurrent drug therapy are factors to be considered when choosing between switching and combination or augmentation approaches. A switch is indicated when there is no response to the drug and combination therapy; augmentation is recommended for partial response. Another antipsychotic combination may become necessary as an option for TRS patients who cannot be treated with clozapine for various reasons. It is common practice in such situations to add a second antipsychotic, in combination with the original one.

Clinical team do not have to be disheartened or disillusioned when clozapine therapy fails due to non-response or clozapine intolerance, and also when augmentation and combination therapies do not bring about the desired outcome. Switching back to atypical drugs once again may turn out to be effective in some cases and clozapine is not to be considered as the last resort. A multicentre open label 18-week trial evaluated a switch to olanzapine in 48 clozapine resistant or intolerant patients. ²⁴ Switching to olanzapine 5-25 mg per day resulted in a mean drop in total scores on the Positive and Negative Syndrome Scale (PANNS) and Brief Psychiatric Rating Scale (BPRS) of 17.7 (14.2%) and 9.8 points (20.2%) respectively.

Cautions

Monotherapy is the most desirable form of treatment for SCZ. There is no good objective evidence to support dual antipsychotic therapy except in combination with clozapine. The evidence base supporting such combinations consists mostly of small open-label studies and case series.²⁵ Combination therapy should be considered only when several attempts at monotherapy, including one atypical antipsychotic, fail. It is assumed that two different treatments together may have a different mechanism of action and therapeutic response from that of either drug alone. Studies have been conducted to determine whether treatment with antipsychotic combinations is effective for SCZ and whether such treatment is safe for the same illness. The results of trial studies are based on very low or low-quality results, and research that provides high-quality evidence is needed before firm conclusions may be drawn. The results so far show that there may be some clinical benefit in combination therapy in that more people receiving a combination of antipsychotics showed an improvement in symptoms. For other important outcomes – such as relapse, hospitalisation, adverse events and discontinuing treatment – no clear differences between the two treatment options were observed. Currently, most evidence regarding the use of antipsychotic combinations comes from short-term trials; the assessment of long-term efficacy and safety is limited. There is some very low-quality evidence that a combination of antipsychotics may improve the clinical response.

There are published case reports of serious side effects, such as a higher prevalence of extrapyramidal symptoms (EPS), metabolic side effects, paralytic ileus, grand mal seizures and prolonged QTc in association with a combination of antipsychotics.²⁶Combining three antipsychotics may be extremely dangerous; studies have revealed that such a procedure substantially increases mortality.²⁷A negative case control study exists.²⁸ It should be usual practice to document the rationale for combined antipsychotic use in individual cases in clinical records, along with a clear account of benefits and disadvantages, including side effects.

Newer combinations and augmentation strategies are supported only by case reports and open trial data. Along with advantages, a number of potential concerns regarding antipsychotic combinations have been identified (Table 2) and specific clinical cautions have to be implemented in combination therapy (Table 3). Yet, fixed combinations of drugs are common in medicine and at one time were common in psychiatry. An example is small doses of an antipsychotic in combination with an antidepressant for treating major depression; this lost popularity because of side effects. Also, SNRI-NaSSA combination therapy (e.g. California Rocket Fuel) is prevalently used for treatment-resistant depression.

Olanzapine–amisulpride combination

In spite of the objections put forward against combination therapy, there are isolated case studies favouring the olanzapine–amisulpride combination. Zink et al. (2004) performed a retrospective study, aiming at the systematic evaluation of patients on combined olanzapine and amisulpride. The open study designed as a retrospective chart review of Zink et al. concludes that the olanzapine–amisulpride combination for TRS is encouraging, but requires further evaluation in prospective and randomised studies.²⁹They point out that a reduction of the daily dose of both drugs helped to minimise the side effects of these drugs – such as weight gain and EPS – resulting in better compliance. They did not notice any additional side effects or undesirable drug interactions.

Within the heterogeneous group of atypical antipsychotics, the thienobenzodiazepine derivative olanzapine has a receptor profile that is quite similar to that of clozapine, indicated by having a greater affinity for serotonergic 5-HT_2A receptors than for dopaminergic D₂ receptors. The positive and negative symptoms of schizophrenic psychoses usually respond well to this drug. In contrast to clozapine, olanzapine does not induce major agranulocytosis but may, in a significant number of cases, lead to troublesome side effects including significant weight gain, type ii diabetes, sedation, anticholinergic effects and transient increases in liver enzymes. Assertive weight management from the start of treatment is recommended. Weight should be monitored and also waist circumference measurements made. In addition, blood lipids should be assessed routinely. A suggested schedule for these investigations would be at 3, 6, and 12-month intervals, and biannually thereafter.³⁰The pharmacology of antipsychotics is not the only factor that determines their effect on weight. Olanzapine has also been shown to elevate prolactin significantly in some patients.³¹ As indicated earlier, Olanzapine can succeed in some cases even where clozapine fails.²⁴

Amisulpride is an atypical antipsychotic of the benzamide class. It blocks D2 and D3 receptors (presynaptic in low doses, postsynaptic in higher). Unlike other atypical or typical antipsychotics, it has low affinity for serotonin, α-adrenergic, histaminergic, muscarinic and sigma receptors including D1, D4 and D5 receptors. It can lead to dose-related EPS that are significantly less than those of typical antipsychotics such as haloperidol and comparable to risperidone.³²It is recognised that amisulpride is only sparingly metabolised by liver enzymes, and thus it is not known to participate in many drug interactions.³³ Amisulpride may elevate prolactin, which may cause sexual dysfunction, osteoporosis, amenorrhoea, gynaecomastia or galactorrhoea. It is a weight-neutral compound and may ameliorate negative symptoms.³⁴ Both olanzapine and amisulpiride are not associated with QTc prolongation.

One advantage of the combination of these drugs is that when olanzapine and amisulpride are combined, they may be given at a lower dose, which will spare the patients from the main unwanted side effects of the individual drugs: the over-sedation and weight gain of olanzapine; and the hyperprolactinemia of amisulpride, resulting in sexual side effects of a particularly undesirable extent. Our limited studies have found that this combination was well tolerated by TRS patients and its efficaciousness was similar to that of clozapine, but without any major side effects. Patients have been fully compliant. The combination of these drugs is managed by slowly introducing them one at a time and has been transformative in many cases. More studies of the olanzapine–amisulpride combination are needed in order to report on such outcomes as relapse, remission, social functioning, service utilisation, cost-effectiveness, satisfaction with care, and quality of life.

Table 1. Assessing Treatment Resistance

Table 2. Advantages and disadvantages

Table 3 Physical cautions with combination

Summary

Combination therapies are the second choice when monotherapy fails. Clozapine is the first choice in severe cases of TRS, but there are super-refractory cases of TRS where clozapine fails. At least in isolated cases, the combination of olanzapine and amisulpride (Ami-olan combination) is worth considering for TRS patients who are reluctant to go on to clozapine therapy or in instances when clozapine failed, or patents dropped out. Combination therapies are normally avoided, but clinicians’ helplessness and patients’ despair justifies such measures in hard-to-treat cases of TRS. Only time will tell whether this combination will become an important part of clinical practice in future or will be ruled out as just another dual antipsychotic therapy.

The aetiology of SCZ remains obscure. The symptoms of different psychotic disorders are not clearly demarcated and there are no physiological parameters on which to make a firm diagnosis. In such a situation, the treatment of TRS has to be tailored on an individual basis. Even though it is normally well calculated, it may be somewhat hit and miss. Finding the right combination of antipsychotics or augmenting agents when the clinician is stranded and torn between monotherapy and polypharmacy is a gargantuan task. Clinical judgement along with patient preference must take over when treatment algorithms fall short. Given the data on polytherapy with antipsychotics that is available, it is hard to make any firm recommendation regarding its efficacy and safety of its use. Clinicians should be reminded that they should try monotherapy in adequate dosages before considering combinations.

For the management of TRS, comprehensive treatment strategies that integrate pharmacological, psychological, and psychosocial approaches are highly relevant and for that to happen, TRS should be clearly recognised. NICE offers very little guidance on clozapine resistant cases of SCZ. Combination of antipsychotics is not a panacea or a permanent solution for TRS. More investigation of schizophrenic illness is the only way forward. In comparison with other medical conditions (eg,HIV), research into it is making little progress. As it stands now, deconstructing clozapine’s unique pharmacology may offer ‘light at the end of the tunnel’ for patients who are clozapine intolerant or non-responders.

Introduction

Bipolar affective disorder (BPAD) is one of the commonest psychiatric disorders with a lifetime prevalence of about 3% in the general population and is the sixth leading cause of disability worldwide (1,2).This disorder is characterised by repeated episodes in which the patient’s mood and activity levels are significantly disturbed. This disturbance consists on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on other occasions of a lowering of mood and decreased energy and activity (depression) (3). As the illness starts early in life, i.e., during teens or early adulthood, persons suffering from BPAD have symptoms of illness for the major part of their life (4, 5).

In India, since professional services, both in public and private sectors are not adequately developed due to shortage of trained human resources and infrastructure, the family support system plays a major role in caring for people with mental illnesses (6). The primary caregiver is identified as an adult relative (a spouse, parent or spouse equivalent) living with a patient, who is involved in the care of the patient on a day-to-day basis, takes the responsibility for bringing the patient to the treatment facility, stays with the patient during the inpatient stay, provides financial support and/or is contacted by the treatment staff in case of emergency (7). Intensive involvement in the care of the patient is often associated with significant caregiver burden.

Caregiver burden can be defined as the presence of problems, difficulties or adverse effects which affect the lives of caregivers of patients with various disorders or illnesses, e.g. members of the household or family (8). Family burden is broadly divided into objective and sub­jective burden. While the notion of the objective family burden relates to measurable problems (e.g. patients’ troublesome behaviours), the idea of subjective family burden is bound to caregivers’ emotions arising in response to the objective difficulties (9). Multiple studies across the world have shown that bipolar disorder is associated with significant caregiver burden (10-31). In view of the high caregiver burden, it is now suggested that the emphasis in psychiatric rehabilitation needs to shift from a patient-focused approach to a combined patient and caregiver-focused approach. Although there are studies from different parts of the country, there is a lack of data on caregiver burden from Kashmir, which is often faced with turmoil, which can influence caregiver burden. The present study is an effort in this direction to assess caregiver burden and its correlates among primary caregivers of patients with bipolar disorder.

Methodology

The present study was conducted on primary caregivers of patients with BPAD. Primary caregivers were defined as those caregivers who were closely involved in the care of the patient during the acute episodes and during the maintenance period in terms of bringing the patient to the hospital, supervising the medications and liaison with the treating team.

The study sample comprised of 100 caregivers of 100 patients diagnosed with BPAD as per the International Classification of Diseases classification of mental and behavioural disorders, 10^th revision (ICD-10) (3), attending either the outpatient or inpatient services at the Department of Psychiatry, SKIMS, Bemina, Srinagar. The study was approved by the Ethics Committee of the institute and all the participants were recruited after obtaining written informed consent.

To be included in the study, the caregivers were required to be involved in the care of patients, aged 18 or above, living with the patient for at least 1 year and were a family member taking care of patients without any wages. Caregivers who were diagnosed with psychiatric illness and staying with the patient for less than 12 months were excluded.

The caregivers were assessed by following scales:

Family Burden Interview Schedule (FBIS) (32):This is a semi-structured interview schedule having 24 items, each of which is scored on a 3-point scale, i.e. 0 indicating no burden, 1 indicating a moderate level of burden and 2 suggesting severe burden. The items of the objective burden of the scale are divided into 6 domains, i.e. financial burden, disruption of routine family activities, disruption of family leisure, disruption of family interaction, physical health and mental health. Subjective burden is evaluated by a single item. This scale has been widely used in previous studies from India (26, 33-35).

DUKE-UNC Functional Social Support Questionnaire (FSSQ) (36):The Duke-UNC Functional Social Support Questionnaire (FSSQ) is an 8-item instrument to measure the strength of the person's social support network (36). Responses to each item were scored as 1 (‘much less than I would like’), 2 (‘less than I would like’), 3 (‘some, but would like more’), 4 (‘almost as much as I would like’) and 5 (‘as much as I would like’). The scores from all eight questions are summed (maximum 40) and then divided by 8 to get an average score. The higher score indicates better perceived social support. Cronbach’s alpha for this scale is 0.84.

Hindi General Health Questionnaire (GHQ-30) (37):The modified version of Goldberg's General Health Questionnaire (GHQ) (38) was used. This is a screening device for identifying minor psychiatric disorders in the general population and within the community or non-psychiatric clinical settings such as primary care or general medical outpatients. The self-administered questionnaire focuses on two major areas: the inability to carry out normal functions and the appearance of new and distressing phenomena. In each question of the 30-item GHQ, the caregivers were asked to choose among: Better than usual or same as usual = 0, less than usual or much less than usual = 1.The results were evaluated by the two-step assessment method (0-0-1-1-method). The minimum GHQ-30 total score was 0 and the maximum total score of GHQ-30 was 30. A cut-off of 6 was used to categorize those with and without psychiatric morbidity. Cronbach’s alpha value of the GHQ-30 was 0.93. The Kappa coefficient was 0.64 (p<0.001).

The recorded data was compiled and entered into a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 16.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were summarised in the form of means and standard deviations and categorical variables were summarised as percentages. Student’s independent t-test and Chi-square tests were employed for comparing caregiver burden with different variables. 

Results

Table 1: Description of socio-demographic variables of caregivers

Table 2: Clinical profile of patients.

Table 3: Caregiver burden, social support and psychological morbidity among caregivers

Table 4: Association of caregiver burden with socio-demographic variables of caregivers

Table 5: Clinical Profile of patients with bipolar disorder

Table 6: Clinical Profile of patients with bipolar disorder

The study included nearly equal number of male and female patients. About two-thirds of the patients were married (63%). About one-third of the patients had not received any formal education and another third had completed their secondary education and one-fourth had completed graduation (Table 1).

Description of socio-demographic variables of caregivers

The study included nearly equal numbers of male and female caregivers. The majority (55%) of the caregivers were spouses of the patient. The majority of the caregivers were married (93%). Nearly half of the caregivers had not received any formal education (48%), were homemakers (44%) and three-fifths of them were from low socioeconomic status (60%). The majority of caregivers (77%) had been caring for duration of one to five years (Table 1).

Clinical profile of patients.

In the present study, the majority of patients (77%) had duration of illness in the range of 1-5 years, nearly half of them were never hospitalised, the majority (55%) of patients had one to two manic episodes, most of them (64%) had three to five episodes of depression, and the majority (75%) of them never attempted suicide or homicide. The majority of patients (73%) were compliant with medication. (Table 2)

Caregiver burden, social support and psychological morbidity among caregivers

As is evident from Table 3, the highest burden was reported in the financial domain, followed by disruption in family routine activities, disruption of family leisure, disruption of family interactions, effect on physical health of others and least burden was reported in the form of effect on mental health of others. The mean DUKE UNC FSSQ score was 3.17 (SD=0.84) with range 1.75-4.75.

Mean GHQ-30 score was 13.14(SD=5.65) with a range of 2-25. Of the 100 caregivers, about one-fourth (N=23) had a GHQ-30 score of 6 or more, indicative of psychological morbidity.

Association of caregiver burden with demographic and clinical variables

As is evident from Table 4, higher caregiver burden was associated with higher age, female gender, lack of formal education, being a homemaker, lower socioeconomic status, a nuclear family set-up, being spouse of the patient and longer duration of being in the caregiver role.

Clinical Profile of patients with bipolar disorder

In terms of clinical variables, higher objective caregiver burden was associated with duration of illness more than 10 years, higher number of hospitalisations and higher number of manic and depressive episodes. Caregivers of patients consuming >75% of the prescribed medications reported lower caregiver burden (Table 5).

Advancing age of patient and caregiver, increasing duration of care, prolonged illness, greater number of hospitalisations and higher number of episodes of either polarity were significantly associated with higher caregiver burden. In terms of association of social support and caregiver burden, higher social support was associated with significantly lower caregiver burden, whereas higher caregiver burden was associated with higher psychological morbidity (Table 6).

Discussion

Families play an important role in care of patients with chronic mental illnesses. In the process of caring for such patients, relatives face a considerable burden.

Findings of the present study suggest that higher burden was seen among the caregivers who were relatively older, of female gender, uneducated or illiterate, homemakers and from nuclear families. Compared to parents and siblings, spouses reported significantly higher levels of caregiver burden. Furthermore, the caregivers involved in the care of the patient for longer durations reported significantly higher levels of caregiver burden.

In terms of clinical variables of patients, higher caregiver burden was associated with longer duration of illness, higher number of lifetime hospitalisations, higher number of manic and depressive episodes and poor medication compliance. Poor social support was associated with a higher level of caregiver burden. Higher caregiver burden was associated with higher psychological morbidity.

Many previous studies from India have evaluated caregiver burden among caregivers of patients with bipolar disorder (10-32). There is a lack of consensus with respect to caregiver variables and their association with caregiver burden (39). Some of the studies suggest that there is no significant difference in the caregiver burden as reported by caregivers of either gender (6), whereas others suggest that females report higher caregiver burden (13, 40). Our findings support the studies which have reported higher caregiver burden among female caregivers. This finding of ours could have been influenced by the relationship of caregivers with patients. In the present study, spouses of patients formed a large proportion of caregivers and they reported significantly higher burden, in contrast to parents and siblings. Cultural issues like restriction of females to household activities with lower opportunities to vent out their distress, inability to spend time on leisure activities, financial dependency and lack of independence could also be responsible for higher perceived burden. It was noticed that caregivers from nuclear families had higher caregiver burden as compared to those from joint families. The joint family system is considered to promote interdependence and possibly is associated with sharing of caregiver burden and this may explain why caregivers from joint families reported lower caregiver burden. Similar findings have been reported in earlier studies from India (41).

Findings of the association of higher caregiver burden with duration of illness are supported by existing literature (14). This finding suggests that possibly with passing time, frequent relapses of illness lead to caregiver burnout, which leads to higher caregiver burden. Previous studies have also noted an association of higher caregiver burden with higher numbers of hospitalisation (30). Findings of the present study too support this association. Higher caregiver burden with greater numbers of hospitalisations possibly indicate more severe episodes and hospitalisation associated with more expenditures and loss of earnings. This suggests that all efforts must be made to pick up relapses at the earliest and manage them effectively to minimise the chances of progression to severe episodes and resultant need for inpatient care. Previous studies have also reported association between higher caregiver burden and higher number of episodes, especially manic episodes (14) and more severe manic episodes (42). Manic episodes of the illness are very disruptive to daily life, work and family relationships. Due to this, these episodes place great demands on family members involved in caregiving. These demands can persist even during remission, where residual symptoms are often still present and lead to caregiver burden. Available data from India suggest that in contrast to patients from the West, patients from India have a higher number of manic episodes (43). Taken together, this finding has important implications as this suggests that efforts must be made to prevent frequent relapses in patients with bipolar disorder, especially in the Indian context to reduce the caregiver burden (44).

In the present study, higher burden was also associated with a higher number of depressive episodes and this finding is supported by existing literature (16).

Long-term management of bipolar disorder requires continuation of medications with good compliance. Poor medication compliance has been shown to be associated with many negative patient-related outcomes like higher risk of relapses, suicidality, poor quality of life, higher residual or sub-syndromal symptoms etc (45, 46). The present study adds to this body of literature and suggests that poor medication compliance in patients is also associated with higher caregiver burden and this finding is supported by the existing literature (11).

Among the demographic variables of caregivers, higher age of caregivers was associated with higher caregiver burden. This finding is also supported by existing literature (6). This association possibly suggests that with increasing age, the caregivers possibly experience more burnout, lose hope and also lose physical vigour to take care of the mentally ill relative.

Accordingly, it is important for the mental health professionals to support the ageing caregivers.

To conclude, the present study suggests that BPAD is associated with higher caregiver burden. Higher caregiver burden is associated with clinical variables of the patients and demographic variables of the caregivers. Among the patient-related variables, longer duration of illness, those with a higher number of lifetime episodes of either polarity and poor medication adherence are associated with higher caregiver burden. Hence, all measures must be taken to minimise relapse in patients with BPAD. Among the demographic variables of caregivers, higher caregiver burden is reported by caregivers who were relatively older, of female gender, uneducated or illiterate, homemakers and from nuclear families.

Our findings highlight the need for additional research on interventions to reduce burden among caregivers of patients with bipolar affective disorder. For better outcomes of disease, more attention needs to be given to the primary caregivers in terms of psycho-education and counselling.

Background and rationale

Psychiatric trainees in Iraq face many challenges that limit their immediate access to improved training opportunities. These include limited access to classroom teaching, regular clinical supervision meetings and fewer opportunities to attend international conferences and placements. These challenges are more acute in those specialities with the greatest shortage of consultants (for example, forensic and child and adolescent psychiatry).

Furthermore, the fragile security situation in the capital and larger cities and the post-conflict disruption to educational institutions consequent to these difficulties makes it difficult for those in the UK and elsewhere to visit the country and support educators and training on the ground.

Against this background and as a medical educational team in the UK (Oxford University Medical Education Fellows, OUMEF) with an interest in developing training opportunities for peers and colleagues in Iraq, we set up the Oxford Psychiatry in Iraq (OxPIQ) Project, beginning with a project development team that included Medicine Africa, an experienced online distance learning platform.

So what is the role of TEL in the delivery of online distance learning targeted at medical professionals in these circumstances?

Meeting the Challenge – the role of TEL

The concept of Technology-enhanced Learning (TEL), or Web-based learning (WBL), defined as the use of information and communication technologies in teaching and learning ¹, is a relatively new phenomenon. Nevertheless, there is a considerable body of evidence supporting the use of TEL in various clinical and non-clinical settings.

Mccutcheon et al. ² systematically reviewed thirteen studies and found that ten of these studies concluded that online learning is as effective as traditional or classroom teaching, despite the limitations of some of these studies.

In a large meta-analysis, Means and colleagues ³ concluded that students using online teaching performed modestly better compared to students learning similar material using face-to-face teaching. Combining face-to-face and online teaching resulted in larger benefit compared to the use of face to face methods only.

TEL can address the learning limitations in classroom settings due to expanding curriculum coverage and limits on contact time between students and lecturers/trainers alike. It can contribute to better use of such face-to-face classroom contact through the facilitation of the flipped classroom approach. ⁴ In this approach (also called inverted instruction and upside-down teaching), students acquire the basic information of the lesson outside the class (usually using online materials) and then develop their knowledge further in the class by sharing their learning, interacting with other classmates and teacher, and discussing various aspects of the study topic.These advantages have enabled TEL to revolutionise distance learning at many levels – enabling greater access to education by overcoming geographical and time-zone boundaries.

An allied concept within distance TEL is the concept of virtual teams ⁵ where health professionals come together to teach and learn from each other independent of location. Of itself, this offers some advantages. These include the possibility of addressing speciality-specific training gaps through the incorporation of the relevant expertise within the team - and to the creation of what is termed “connectivism”. This term refers to the use of internet technologies to enhance learning through online peer networks ⁶ and the development of communities of practice. ⁷ The latter allows for workplace-based learning with trainees learning from more experienced practitioners and moving towards the same through greater competency acquisition.

In a similar vein, creating networks of professionals may help to establish more longer-lasting relationships of mutual benefit between the UK and Iraqi professionals (e.g. through collaboration on training programmes, conferences, etc.). Also, cross-cultural online learning has been shown to be very useful in improving language skills and cultural awareness of learners and educators. ⁸ With language translation technology, any language difficulties can also be overcome, especially if the educator can observe the learners’ responses to the translated text and offered the opportunity to give further explanations and clarifications when necessary. ⁹ Finally, as well as sharing knowledge and experience within groups, TEL enables opportunities for mentoring and coaching individuals. ¹⁰

For our purposes, these findings and opinions support the use of online learning as a suitable distance learning “add-on” to existing training opportunities in Iraq.

TEL and Learning Theories

Learning theorists suggest that experiential and constructive learning theories are most appropriate to learning in the clinical context. Both are possible with TEL (as well as being facilitative of behaviourist and cognitivist approaches).

For example, the virtual classroom environment can enhance the learning experience of the participants by improving their analytical skills by thinking through case formulation and management plans. ¹¹ Participants in online learning could be assessed and receive the feedback immediately. Ideas can be shared, and there is no passive acquisition or transfer of knowledge as is the case with traditional lectures. These aspects have implications for the design of the educational sessions and are discussed below in the learning methods section.

Challenges of Online Distance Learning

There are many challenges associated with online distance learning. Firstly, there is the potential lack of the required technologies (internet access, laptops or desktop computers), the expenses of subscribing to these online learning templates, the need to have technical support, and similar technical and logistic issues. ¹² These technical problems may impair access to and functioning of the virtual team. The choice of an experienced online platform must, therefore, be considered carefully.

Secondly, there may be ethical issues about the protection of patients’ confidentiality in these sessions, especially when there are different laws of privacy that are applied in the UK and Iraq. This will require knowledge of the relevant professional requirements by the tutor team for example.

Furthermore, the student-teacher relationship has traditionally been underpinned by direct face-to-face contact and being present at the same time and place. ¹¹ Therefore, learners and educators might be less satisfied with online learning. For these reasons, the concept of blended learning (careful integration of online learning with face to face learning experience) has been developed to overcome the limitations of a standalone online or face to face learning and has been found effective and applicable in various settings. ¹³

Thirdly, any distance online learning programme must understand and support existing “local” training provision and arrangements, in the classroom and the workplace. This requires liaison and cooperation with the training providers and institutions on the ground.

For clinical training to be relevant, it needs to reflect the learning needs of trainees in the workplace – in keeping with adult learning principles and cognitive apprenticeship models of learning. ¹⁴ The latter includes the importance of clinical decision-making underscored by the higher levels of Bloom’s (1956) cognitive domain. ¹⁵ To this end, then appropriate learning and assessment methods are needed to enable effecting learning.

In other words, while necessary, TEL may be insufficient in enhancing learning outcomes if allied learning methods are not chosen appropriately. Also, in our view, TEL is not a substitute for bedside teaching.

Table 1 summarises this appraisal of online distance learning (using the online platform provided by MedicineAfrica).

Table 1 Strengths and limitation of using MedicineAfrica (web-based virtual classroom environment)

OxPIQ & Project Development Team

OxPIQ is a partnership between Medicine Africa and psychiatrist members of the Oxford University Medical Education Fellows, with experience of working in Iraq. The Oxford University Medical Education Fellows (http://OUMEF.org) is a group of trainees from across medical and surgical specialities with interest in medical education and training.

Medicine Africa (http://medicineafrica.com) is an innovative clinically targeted online platform developed in collaboration with King’s College London’s Centre for Global Health, within the King’s Somaliland Partnership. Built at low bandwidth, it enables collaboration between medical professionals in the UK and those in remote or fragile states to enhance education in various clinical specialities using online sessions (live courses and mentoring sessions). Please see Appendix 3 for a screenshot of one of the active sessions of OxPIQ.

Following the development of a project team, additional team members were added from the Subcommittee on Iraq of the Royal College of Psychiatrists (http://www.rcpsych.ac.uk/workinpsychiatry/internationalaffairsunit/iraqs...), thus completing the UK dimension.

The next step was to invite representation and support from the Iraqi Board of Psychiatry and the Medical Education Unit in Baghdad. These developments led to the formal launch of OxPIQ Partnership in March 2016. Later on, the many UK and Iraqi doctors joined the Partnership as tutors and learners.

The Virtual Learning Team: Trainees, Specialty Consultants & Tutors

Iraqi psychiatry trainees were then recruited, and their more pressing learning needs to be appraised based on their views and those of the Iraqi Board of Psychiatry supervisors. Learning needs to emerge included the management of older patients with dementia and functional disorders, assessment and management of children and adolescents (with autism and ADHD for example), forensic patients and those with drug and alcohol addiction. The team thus formed was composed of up to ten psychiatry trainees from Iraq and five senior psychiatrists/tutors each, from Iraq and the UK respectively. A schedule of fortnightly seminars was agreed and published on the learning platform. Case-based discussions were used as the main educational activity during these seminars.

Learning Methods and Processes

As noted earlier, the importance of experiential and constructivist learning methods are key to clinical education. Our literature appraisal revealed that they are essential elements of successful TEL in this context too. ^{16, 17} To these must be added learner engagement. ¹⁸

Virtual or online (anonymised) case-based discussions (CBDs) are valid and reliable learning tools. ¹⁶ They are interactive and centred around the students and their learning needs while a facilitator guides the process of learning. Learners are engaged through discussion of actual clinical cases, so preparing learners for real-life experience. ¹⁹ Also, expert facilitation and peer feedback to trainees promotes clinical knowledge and skills’ development. ^{20, 21}

Effective small group teaching is characterised by four main strengths: flexibility, interaction, reflexivity and engagement. ²² Flexibility is when the teacher responds to the needs and learning of the students dynamically and helps them to explore wider pedagogic spaces. A higher degree of interactivity is usually seen in small group teaching compared to a larger group. Teachers are better able to continually engage in self-reflection and listen sensitively to students in a small group and observe the dynamics between the members of the group, leading therefore to better reflexivity. Engagement refers to encouraging the students to develop their academic identity and engage in lively debate about the various aspects of the topic discussed.

We aimed to replicate these characteristics. For example, a small group discussion allowed better interaction with each participant (interactivity); the presence of chat windows enables the facilitator to self-reflect on the process, monitor engagement and respond reflexively using questions and answers to stimulate interest and respond flexibly to individual trainee knowledge gaps. Tutors are encouraged to identify trainees’ learning needs and facilitate interactivity, and timely feedback as these are highly valued by the participants and help to keep them motivated and engaged. ¹⁸

For further reading in this area, we recommend Brindly and colleagues’ ²³ ten strategies to increase students’ motivation towards and engagement with online learning (see table 2).

The focus of the Lesson Plan Design

To these ends, the focus on the lesson design was on using problem-based learning methods (e.g. CBDs) within a small group setting (between 4-12 members) and a format that promoted learner engagement. A sample lesson plan is provided in Appendix 1.

In practical terms, tutorials were held fortnightly in term-time. All participants received an email notification to inform them of the session topic, and the tutor uploaded the slides from the session to the website beforehand. Participants logged-in to the site (http://medicineafrica.com) and interact with the tutor by voice (requiring only simple microphone equipment) and by writing in a chat window.

Evaluation and feedback gathering

The evaluation of the effectiveness of these sessions was reliant originally on trainees’ immediate reaction (table 3, level 1 evaluation, Kirkpatrick ²⁴) using formal feedback tools provided online by MedicineAfrica. This feedback was shared with tutors and the Project Team. Please see Appendix 2 for the template used in collecting feedback after each session.

Subsequently, members of the project team approached trainee representatives, tutors and Iraqi Psychiatry Board leads separately for further feedback and appraisal of learning needs. Furthermore, some months after a tutorial we have asked trainees for evidence of learning across the higher levels of Kirkpatrick’s evaluation model.

Regular feedback from the Iraqi and UK participants has been positive. The sessions have been associated with improved clinical knowledge and skills of the Iraqi Psychiatry Trainees. Requests for certificates of tutorial participation have been agreed upon and provided by the project team addition, so supporting learners’ (and tutors) portfolio development.

Table 3 Kirkpatrick’s (1996) Levels of Training Assessment

Further cooperation

A surprising (and very welcome) outcome of the project was, through the facilitation and support of the Iraqi Board of Psychiatry, the introduction of educational workshops in Baghdad. These workshops were held in Medical City, Baghdad, in May 2017 and April 2018 and were facilitated by tutors (YH & H Al-T) from the OxPIQ Partnership. They covered targeted topics such as old age psychiatry, addiction, organic and forensic psychiatry. Trainees and senior psychiatrists from Iraq attended; their feedback showed how they valued the interactive nature of the teaching and use of CBDs as learning methods, resulting in high levels of engagement.

Conclusions

This paper describes the process of designing, delivering, and the early evaluation of an online distance TEL programme for mental health professionals based in the UK and Iraq.

TEL has had an important role in overcoming the geographical barriers and other challenges to developing training opportunities in Iraq and other developing countries. We are of the view that it could be used more often to connect professionals working in similar circumstances and with other disadvantaged groups, including refugee and asylum seekers. It is a flexible way of providing training to professionals working with those groups in relatively remote and resource-deprived environments.

Greenhalgh ²⁵ suggests that three factors are needed for the success of online educational activity: ease of access, perceived usefulness of the activity to the learning requirements of the students, and the interactivity of the session. In our experience, these are important. Also, we believe that additional consideration should be given to (i) working with an experienced online platform provider; (ii) working with local educational institutions, trainers and learners to identify unmet learning needs and support existing learning opportunities/programmes; and (iii) adopting an iterative approach to feedback and evaluation.

Appendix 1: Example of a Lesson Plan

Appendix 2: Feedback form to be completed by the participants after the session

Appendix 3: MedicineAfrica screenshot during an active session

INTRODUCTION

Several studies found that refugees develop post-traumatic stress disorder (PTSD) after having endured war trauma¹, or certain circumstances related to migration like moving to a new country, being unemployed and poor housing². PTSD is described as distress and disability due to a traumatic event that occurred in the past³. In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and PTSD was included in a new category, Trauma- and Stressor-Related Disorders⁴. All of the conditions included in this category required exposure to a traumatic or stressful event as a diagnostic criterion⁴. The person with PTSD often avoids trauma-related thoughts and emotions, and discussion of the traumatic event⁴. PTSD patients are invariably anxious about re-experiencing the same trauma. The trauma is usually re-lived by the person through disturbing, repeated recollections, flashbacks, and nightmares⁴. Symptoms of PTSD generally begin within the first 3 months after the provocative traumatic event, but may not begin until several years later⁴. A large number of children (10-40%), 16 or younger, who have experienced a traumatic event in their life, tend to develop PTSD later on⁵. Moreover, many families with children growing in war zones and then moving to safer places, experience trauma, stress and reduced functioning⁶. These families have different resilience rates in their survival mechanisms, coping strategies and adaptation levels⁷.

The latest war in Syria has led to the migration of large parts of the Syrian population to neighboring countries such as Lebanon, Jordan and Turkey⁸.The United Nations High Commissioner for Refugees (UNHCR) estimates that approximately 1.5 million refugees are located in Lebanon⁹. These refugees have been exposed to several types of traumatic events that may increase the incidence of mental health problems¹⁰.

We hypothesize that the proportion of positive PTSD screens would be high among Syrian refugees with the presence of some specific related risk factors. Thus, the objective of our study was to examine PTSD symptoms and to determine the associated risk factors in a sample of Syrian refugees living in North Lebanon.

METHODS

1. Study design and population

This was a cross-sectional study that aimed to assess the proportion of Syrian refugees in North Lebanon who were at high risk of developing PTSD, and to examine the association of PTSD high risk with other factors. The survey was carried out during February and March 2016. A convenient sample of Syrian refugees of both gender, aged between 14 and 45 years, living in North Lebanon, was selected out of a population of 262,151¹¹.

The estimated minimum sample size, calculated using Raosoft sample size calculator, with a margin of error of 5% and a confidence interval of 95%, was 384 refugees. A total number of 450 Syrian refugees, residing in individual tented settlements (ITSs), collective shelters (CS) or Primary Health Care Centers (PHCs) located in North Lebanon, was selected according to inclusion and exclusion set criteria.

The inclusion criteria were: Syrian refugees, aged (14-45 years), physically and mentally independent. Hence, all subjects that were younger than 14 or older than 45, speechless, deaf, physically and mentally dependent, or have undergone recent moderate or severe surgery (less than one week earlier), were excluded from the study.

2. Ethical considerations

The study protocol received approval from the Notre Dame University (NDU) Institutional Review Board (IRB). The approval comprised details about the procedure of the study and the rights of the participants. Informed consent was obtained from each participant. The questionnaires were answered anonymously, ensuring confidentiality of collected data.

3. The Interview questionnaire

The interview questionnaire was divided into six sections consisting of a total of 46 questions. The questions were dichotomous, close-ended and open-ended. A cover page described the purpose of the study, ensuring the anonymity and confidentiality, and soliciting the consent of participants. The questionnaire collected data on the demographic and socio-economic characteristics of the participants. Information about health status and stressful life events (SLE) were also obtained. The PC-PTSD (Primary Care Post-Traumatic Stress Disorder) tool was used to screen PTSD.

For the purposes of the study, subjects were classified as having/not having positive PC-PTSD. The results were used to calculate the proportion of Syrian refugees who are at high risk of developing PTSD.

PC-PTSD questionnaire: The PC-PTSD was initially developed in a Veteran Affairs primary care setting and is currently used to screen for PTSD, based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) diagnostic criteria¹². The screen consisted of 4 questions related to a traumatic life event: In the past month you (1) Have had nightmares about it or thought about it when you did not want to?; (2) Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?; (3) Were constantly on guard, watchful, or easily startled?; (4) Felt numb or detached from others, activities, or your surroundings? The answers to these questions were dichotomous (Yes/No) and the total screen was considered "positive" when a patient answered "yes" to three out of four questions. PC-PTSD showed a high sensitivity (86%) and moderate specificity (57%) when using a cutoff score of 2¹³.

In order to validate the Arabic version of the PC-PTSD questionnaire, it was translated into Arabic and translated back into English. The original version of the Arabic questionnaire was pilot-tested on 10 Syrian refugees to ensure the validity of the answers, and to guarantee its reliability.

Anthropometric measurements: The main anthropometric measurements were weight and height. Participants were dressed in light clothes and barefooted, and standing height was measured to the nearest 0.1 cm using a stadiometer. Body weight was measured to the nearest 100g using an electronic scale. Body Mass Index (BMI) is a measure of weight adjusted to height (kg/m²), calculated by dividing weight (in kilograms) by the square of height (in metres). For the purposes of the study, BMI was recoded into four categories: underweight, normal, overweight and obese.

4. Data entry and statistical analysis

The Statistical Package for Social Science (SPSS) for Windows (version 22) was used for data entry and analysis.

First, bivariate analyses of categorical variables were performed using the Fisher exact tests, Chi-squared tests and Student’s t-test. The dependent variable was the high risk of PTSD, using the PC-PTSD tool. Thus, the PC-PTSD score was considered the dependent variable: a dichotomous variable of PC-PTSD (-) and PC-PTSD (+), and all variables that might be a risk factor or might lead to PTSD were set as the independent variables. Two main independent variables were: age and gender. Other variables included: marital status, place of residence, number of people and families living in the same household (crowding index), income, education status, profession, work status, lifestyle habits, medical or psychological problems, medication taken and SLE. Frequencies and percentages were calculated for qualitative variables, and mean and standard deviations for quantitative variables (BMI, crowding index). A p-value of 0.05 or less was considered to be statistically significant.

RESULTS

Table 1: Socio-demographic characteristics of the 450 Syrian refugees

Table 2: Health characteristics and migration factors of the 450 Syrian refugees

Table 3: Socio-demographic characteristics associated with positive screen for PTSD among the 450 Syrian refugees (bivariate analyses)

*Significant with p-value < 0.05

Table 4: Health characteristics and migration factors associated with positive screen for PTSD among the 450 Syrian refugees (bivariate analyses)

* Significant with p-value < 0.05

All the socio-demographic, health and migration characteristics of our sample of Syrian refugees were described in Tables 1 and 2. Out of the 450 participants, 47.3% had positive PC-PTSD. In order to study the association between the socio-demographic characteristics among the Syrian refugeesand PTSD screening, abivariate association was explored as shown in Table 3. The results indicate a significant difference between gender groups, as almost half of the women (49.9%) had a positive screen for PTSD compared to 33.3% of the men (p=0.011). Mean age was significantly higher in refugees with positive PC-PTSD (28.9 ± 7.6 years) versus those with negative PC-PTSD (26.9 ± 8.5 years) (p=0.009). PTSD screening was shown to be significantly associated with marital status. In fact, positive PC-PTSD was mostly perceived in divorced participants (80%) compared to 69.2% of widowed, 50.5% of married, and 16.7% of single subjects (p=0.000). Yet, crowding index, current place of residence, educational level, employment status, and income were not significantly associated with positive PC-PTSD (p>0.05).

The association of health characteristics and migration factors among the Syrian refugees with PTSD screening was displayed in Table 4. A significant association was observed between the presence of medical condition and positive screen for PTSD, as 61.9% of subjects suffering from a medical condition had a positive PC-PTSD, compared to 42.4% of participants without medical conditions (p=0.000). However, BMI and tobacco consumption were not significantly associated with PTSD screening (p>0.05). PTSD screening was significantly associated with the presence of psychological disorders. Thus, 90.9% of refugees who sought professional help for psychological disorders had positive PC-PTSD, versus 46.2% of those who did not (p=0.003). Positive PC-PTSD was significantly associated with the increase in the number of SLE. In fact, none of the participants without any stressful event had a positive PC-PTSD, compared to 36.5% of participants with 1-2 SLE, 58.7% of participants with 3-4 SLE and 75% of participants with 5-6 SLE (p=0.000). On the other hand, no significant association was observed between PC-PTSD and migration status (p>0.05).

DISCUSSION AND CONCLUSION

PTSD represents the most frequently occurring mental disorder occurring among refugees¹⁴. PTSD prevalence rates ranging between 15% and 80% have been reported in refugees. A study of Cambodian refugees living in the Thailand-Cambodia border camp indicated that 15% had PTSD¹⁵. A cohort study aimed to show the prevalence of PTSD among Iranian, Afghani and Somalian refugees that have moved to the Netherlands at a 7-year interval [(T1=2003) - (T2=2010)]. Results displayed a high prevalence at both T1 (16.3%) and T2 (15.2%). The reason for this high unchanged prevalence may be due to the late onset of the PTSD symptoms, and the low use of mental health care centers¹⁶. De Jong and colleagues reported that 50% of the refugees in Rwandan and Burundese camps had serious mental health problems, mainly PTSD¹⁷. While Teodorescu and colleagues aimed to illustrate the prevalence of PTSD among refugees in Norway; results showed that 80% of the refugees had PTSD¹⁸. In our study, the high proportion of positive screen for PTSD among Syrian refugees was estimated at 47.3%. In 2006, a mental health assessment demonstrated that Lebanese citizens exposed to war were more likely to develop psychiatric problems such as PTSD¹⁹. Subsequently, a cross-sectional study was done in South Lebanon on 681 citizens in 2007 (1-year after the 2006 war in Lebanon). The aim of the study was to examine the prevalence of PTSD 12 months after 2006 war cessation. Results showed that the prevalence of PTSD was 17.8%¹⁹. A recent cross sectional study, aimed to show the prevalence of PTSD and explore its relationship with various variables. The study included 352 Syrian refugees settled in camps in Turkey. An experienced psychiatrist evaluated the participants, and results demonstrated that 33.5% of study participants had PTSD, mainly female refugees, people who experienced 2 or more SLE, or those who had a family history of psychiatric disorder²⁰.

PTSD has been associated with a wide range of traumatic events: emotional or physical abuse²¹, sexual abuse²², parental break-up²³, death of a loved one²⁴, domestic violence²⁵, kidnapping²⁶, military services²⁷, war trauma²⁸, natural disasters²⁹ and medical conditions including cancer³⁰, heart attack³¹, stroke³², intensive-care unit hospitalization³³, and miscarriage³⁴.

Our findings should be interpreted taking into account several limitations. The first limitation is the use of screening tools, instead of the more accurate diagnosis of the clinician, in order to detect PTSD. Given that a standardized screening tool for PTSD was used, our rates are likely an overestimate of the true prevalence rates. Secondly, this study was conducted with a limited sample of Syrian refugees and therefore should not be generalized to all refugees of other eras or from other countries. The third limitation is represented by the lack of information on the presence of other Axis I psychiatric comorbidities such as anxiety or mood disorder that could facilitate the development of PTSD or influence its manifestations^35-36.

Refugees are an important group to examine, given the high prevalence of mental health disorders. Although refugees are evaluated for health problems, currently there are no standardized screening and clinical practice guidelines for assessing PTSD in all refugees. Therefore, we may be missing opportunities to detect and treat these harmful and potentially fatal conditions. Our findings suggest the need to consider a standardized screening tool for PTSD in this population. In addition, a far greater percentage of patients may have “PTSD symptoms,” that are abnormal but do not meet full criteria of the DSM5 for PTSD diagnosis, but still cause functional impairment and may later develop into a diagnosable PTSD. Given the overall high prevalence, one possible model for evaluation would be a stepped screening approach: Positive screens for PTSD could trigger a standardized clinical diagnosis for PTSD with more comprehensive assessment and early intervention. Considering the high cost of treating individuals with PTSD, screening and intervention strategies should be addressed. Greater awareness among providers and increased targeted assessment and treatment efforts may increase early detection of a wide range of PTSD, preventing more serious future health problems and functional impairment among refugees.

Introduction

Depression is a clinical syndrome. The International Classification of Diseases (ICD) diagnostic classification systems describe three core symptoms of depression; low mood, anhedonia and reduced energy levels¹. Other symptoms include impaired concentration, loss of confidence, suicidal ideation, disturbances in sleep and changes in appetite. Symptoms must have been present for at least a period of two weeks for a diagnosis of depression to be made. Major depression refers to the presence of all three core symptoms and, in accordance with ICD criteria, at least the presence of a further five other symptoms¹. See Table 1 for severity criteria of a depressive episode according to ICD criteria.

Table 1: Severity criteria of a depressive episode according to ICD-10¹

Depressive symptoms, which can be clinically significant, can be present in the absence of a major depressive episode. Depressive symptoms are those that do not fulfil diagnostic criteria for a diagnosis of depression to be made. Depressive symptoms can be collectively referred to as sub-threshold depression, sub-syndromal depression or minor depression².

It has been proposed that there are two types of depression; early-onset and late-onset depression. Late-onset depression refers to a new diagnosis in individuals aged 65 years of age or older. Over half of all cases of depression in older adults are newly arising (i.e. the individual has never experienced depression before) and thus late-onset type depression. Late-onset type depression is associated more with structural brain changes, vascular risk factors and cognitive deficits. It has been suggested that late-onset depression could be prodromal to dementia³.

The Kings Fund has estimated that by 2032 the proportion of older adults aged 65-84 years old will have increased by 39% whereas the proportion over the age of 85 years will have increased by 106%⁴. This increase in population will consequently see the incidence and prevalence of depression rise. By 2020 it is estimated that depression will be the second leading cause of disability in the world regardless of age⁵. Recognising, and so diagnosing, depression in older adults will become more important because of a greater demand on existing healthcare services and provisions, due to physical health consequences, impact upon healthcare utilisation and greater economic healthcare costs.

Presentation of depression in older adults

The presentation of depression in older adults is markedly different to that in younger adults. The most significant and fundamental difference in presentation in older adults is that depression can be present with the absence of an affect component, i.e. subjective feelings of low mood or sadness are not experienced^3,6-9. The absence of an affective component is referred to as ‘depression without sadness’^8-9. It is common instead for older adults to report a lack of feeling or emotion when depressed^8-9.

Anhedonia is also less prevalent in this population. However, reduced energy levels and fatigue are frequently reported^8-9.

Compared to younger adults, psychological symptoms of depression occur more frequently and are more prevalent in older adults¹⁰. Such psychological symptoms include feelings of guilt, poor motivation, low interest levels, anxiety related symptoms and suicidal ideation. The presence of irritability and agitation are key features as well⁷. Hallucinations and delusions are also more common in older adults, particularly nihilistic delusions (i.e. a person believing their body is dead or a part of their body is not working properly or rotting).

Cognitive deficits are characteristic of depression in older adults^7,11 and are described as ‘substantial and disabling’¹². Such deficits mainly concern executive function^13-14. Pseudodementia is a phenomenon seen in older adults¹⁵. The term refers to cognitive impairment secondary to a psychiatric condition, most commonly depression¹⁶. Pseudodementia has become synonymous with depression. Pseudodementia can be mistaken for an organic dementia and so older adults who are depressed can present primarily to mental health services with memory problems. Pseudodementia is classically associated with ‘don’t know’ answers, whereas older adults with a true dementia will often respond with incorrect answers¹⁷.

‘Depression-executive dysfunction syndrome’ is a more specific and descriptive term to describe the cognitive deficits found in older adults with depression¹⁴. It is associated with psychomotor retardation, which can be a core feature of depression in this population^7,14,18. Psychomotor retardation describes a slowing of movement and mental activity¹⁹. Like pure cognitive deficits, psychomotor retardation contributes significantly to functional impairment¹⁹. Both executive dysfunction and psychomotor retardation have been found to be related to underlying structural changes in the frontal lobes^{14, 20-21}. Psychomotor retardation is further related to white matter changes in the motor system, which leads to impaired motor planning²¹. There is conflicting evidence of whether the presence of psychomotor retardation is related to depression severity^18-19.

Somatisation and hypochondriasis are associated with depression in older adults and increasing age in general^22-23. Somatisation is often overlooked in older adults by healthcare professional who actively search to attribute such symptoms to a physical cause. Somatisation is more common in those who have physical comorbidities. Somatisation in older adults is associated with structural brain changes and cognitive deficits²⁴.

Depression in older adults is associated with functional impairment cognitively, physically and socially^7,12,25. Such functional impairment is linked to loss of independent function and increased rates of disability²⁶. Withdrawal from normal social and leisure activities can be marked^7,25. Social avoidance reduces interaction with others and is often a maintaining factor for depression²⁵.

Self-neglect is a classical feature of depression⁷, with the presence of depressive symptoms in older adults being predictive of it²⁷. Behavioural disturbances can be a common mode of presentation, especially for older adults living in institutionalised care ^6-7. Behavioural disturbances include incontinence, food refusal, screaming, falling and violence towards others⁷.

Diagnostic difficulties

Depression in older adults has been a condition that has constantly been under-recognised. Several issues account for this. Firstly, phenomenological differences are present. Many have argued that phenomenological issues contribute heavily to diagnostic difficulties²⁸; both the DSM and ICD classification systems do not have specific diagnostic criteria for depression in older adults. Potentially invalid diagnostic criteria for depression in older adults could result in fundamental difficulties in understanding, with consequent impact on both clinical practice and research.

Diagnostic difficulties are also encountered because depression in older adults can present with vague symptoms, which do not correspond to the classical triad of low mood, low energy levels and anhedonia, which can all be cardinal symptoms in a younger population. Reports of fatigue, poor sleep and reduced appetite can be attributed to a host of causes other than depression and therefore it is no surprise that a diagnosis of depression is overlooked and goes undetected by healthcare professionals²⁹.

The absence of an affective component (i.e. low mood) can lead to healthcare professionals disregarding the potential for the presence of depression and consequently not exploring for other symptoms.

Furthermore, symptoms of depression, especially somatic ones, are often attributed to physical illnesses. Depressive somatic symptoms often lead to a diagnosis of depression being over looked; such symptoms ‘mask’ the clinical diagnosis of depression and hence the term ‘masked depression’³⁰. Depressive somatic symptoms – e.g. low energy levels, insomnia, poor appetite and weight loss - are often attributed to physical illness and/or frailty by both the individual and healthcare professional^{7-8, 31}.

Further complicating diagnostic difficulties and under-recognition is the fact that older adults are less likely to report any symptoms associated with mental health problems and ask for help in the first place^7,10,32; explanations for this include older adults being less emotionally open, having a sense of being a burden or nuisance, and believing symptoms are a normal part of ageing or secondary to physical illness^7,10,29,33.Older adults also have a reluctance to report mental health problems due to their perception of associated stigma; many older adults hold the view the mental health problems are shameful, represents personal failure and leads to a loss of autonomy⁷.

There is an overlap between symptoms of depression and symptoms of dementia. It is quite common for older adults with dementia to initially present with depressive symptoms. Depression has a high incidence in those with dementia, especially those with vascular dementia. Depression is particularly difficult to diagnose in dementia due to communication difficulties; diagnosis is often based on observed behaviours^8,33.

Depression and comorbidity in older adults

In those with pre-existing physical health problems, depression is associated with deterioration, impaired recovery and overall worse outcomes³⁴. For example, the relative risk of increased morbidity related to coronary heart disease is 3.3 in comparison to individuals without depression³⁵. Mykletun et al. established that a diagnosis of depression in older adults increased mortality by 70%³⁶. Several causative routes account for poor physical illness outcomes. Older adults with depression are less likely to report worsening health. Depressive symptomatology indirectly affects physical illness through reduced motivation (often secondary to feelings of helplessness and hopelessness) and engagement with management. Poor compliance with management advice, notably adherence to medications is observed³⁷. Feelings of hopelessness, helplessness and negativity will contribute to the failure to seek medical attention in the first place or report worsening health when seen by a healthcare professional.

Depression affects biological pathways directly, which impairs physical recovery. Such biological effects include pro-inflammatory factors, metabolic factors, impact upon the hypothalamic-pituitary axis and autonomic nervous system changes³⁸.

Older adults who are depressed are more likely to have existing physical health conditions and more likely to develop physical health conditions¹⁵. Depression is particularly associated with specific physical illnesses; cardiovascular disease and diabetes mellitus. A study by Win et al. found that cardiovascular mortality is higher in older adults with depression because of physical inactivity; the study established that physical inactivity was accountable for a 25% increased risk in cardiovascular disease³⁹. The relationships between depression and cardiovascular disease and depression and diabetes have been described as “bidirectional”³⁸.

Higher incidents of cardiovascular disease and diabetes mellitus are seen in people with depression regardless of age. A study by Brown et al. found that older adults with depression had a 1.46 relative risk increase for developing coronary heart disease compared to those without depression⁴⁰. The hypothalamic-pituitary axis dysfunction found in depression leads to increased levels of cortisol, which in turn, increases visceral fat. Increased visceral fat is associated with increased insulin resistance, promoting diabetes mellitus, and increased cardiovascular pathology³⁸.

Depression is a risk factor for the subsequent development of dementia; this is especially so if an older adult has no previous history of depression (i.e. depression is late-onset)¹³.

Healthcare utilisation and economic impacts

Older adults are less likely to report depressive symptoms to healthcare professionals explaining the under-utilisation of mental health services for depression^32,41. Despite older adults under-utilising mental health services they over utilise other healthcare services^26,41. For example, those presenting with non-specific medical complaints or somatisation have been found to have an increase use of healthcare services. Non-specific medical complaints and somatisation lead to an unnecessary use of resources, such as unnecessary consultations with healthcare professionals and investigations⁴¹. Increase in service utilisation means an increase in the associated economic cost of depression in older adults^41-43.

Healthcare costs of older adults with a comorbid physical illness and depression are far greater than those without depression – findings in diabetes mellitus are a good example⁴³. The majority of the increased healthcare costs are associated with the chronic physical disease and not the care and treatment of the depression⁴⁴. Poor compliance with physical illness management is associated with missed appointments and a greater number of hospital admissions, which both have financial implications.

Aetiology and associations of depression in older adults

Late-onset type depression in older adults has been associated with the term ‘vascular depression’^45-47. Studies have found a significant higher rate and severity of white matter hyperintensities on MRI imaging in older adults with depression compared to those without depression^46,48,50. White matter hyperintensities represent damage to the nerve cells; such damage is a result of hypo-perfusion of the cells secondary to small blood vessel damage⁴⁹. White hyperintensities are associated with vascular risk factors (e.g. age, hypertension, hypercholesterolaemia, obesity, diabetes mellitus, smoking) and are linked to cerebrovascular disease, such as stroke, vascular dementia. A relationship has been found between psychosocial stress and consequent development of vascular risk factors, which further supports the hypothesis of ‘vascular depression’⁴⁶. Clinically, ‘depression-executive dysfunction syndrome’ and psychomotor retardation are associated with vascular changes⁴⁸.

In older adults with depression, white matter hyperintensities are associated with structural changes to corticostriatal circuits and subsequent executive functional deficits. Loss of motivation or interest and cognitive impairment in depression are hallmark features of structural brain changes associated with the frontal lobes, which in turn are associated with a vascular pathology²⁰. A study by Hickie et al. established that white matter hyperintensities in older adults with depression are associated with greater neurological impairment and poorer response to antidepressant treatment⁵⁰. It is not fully understood why vascular depression responds less well to antidepressants; poor response has been linked directly to vascular factors but has also been associated with deficits in executive function^46-47.

The relationship between cerebrovascular disease and depression is described as ‘bi-directional’^45,51; depression has been found to cause cardiovascular disease and vice versa⁵¹. Baldwin et al. direct the reader to the presence of post-stroke depression and the occurrence of depression in vascular dementia⁴⁵.

Younger and older adults share a number of fundamental risk factors for depression; such as female gender, personal history and family history⁷. Older adults have additional risk factors related to ageing, which are not just physiological in nature.

Age related changes:

Age related changes occurring in the endocrine, cardiovascular, neurological, inflammatory and immune systems have been directly linked to depression in older adults³.

The normal ageing process sees changes to sleep architecture and circadian rhythms with resultant changes to sleep patterns⁵². Thus sleep disturbances are common in older adults and positively correlated to advancing age⁵²; over a quarter of adults over the age of 80 years report insomnia, and research has well-established that this is a risk factor for depression^53-54. A meta-analysis by Cole et al. found sleep disturbances to be a significant risk factor for the development of depression in older adults⁵³.

Sensory impairment:

Sensory impairments, whether secondary to the ageing or a disease process, are risk factors^53,55. Research has found that hearing and vision impairments are linked to depression⁵⁶. A sensory impairment can lead to social isolation and withdrawal, which, in turn, are further risk factors for depression.

Physical illness:

Physical illness, regardless of age, is a risk factor for depression. Older adults are more likely to have physical illnesses and so in turn are more at risk of depression. See Table 2. Physical illness is associated with sensory impairments, reduced mobility, impairment in activities of daily living and impaired social function, all of which can lead to depression. Physical illnesses associated with chronicity, pain and disability pose the greatest risk for the subsequent development of depression^7,53,55. Physical illness affecting particular systems of the body, such as the cardiovascular, cerebrovascular and neurological, are more likely to cause depression³. Essentially, however, any serious or chronic illness can lead to the development of depression. It should be noted that a large proportion of older adults have physical illness but do not experience depression symptoms, therefore other factors must be at play^5,57.

Treatments of physical illness are directly linked to aetiology in depression, for example, certain medications are known to cause depression; cardiovascular drugs (e.g. Propranolol, thiazide diuretics), anti-Parkinson drugs (e.g. levodopa), anti-inflammatories (e.g. NSAIDs), antibiotics (e.g. Penicillin, Nitrofurantoin), stimulants (e.g. caffeine, cocaine, amphetamines), antipsychotics (e.g. Haloperidol), anti-anxiolytics (e.g. benzodiazepines), hormones (e.g. corticosteroids), and anticonvulsants (e.g. Phenytoin, Carbamazepine)^7,29. Polypharmacy is present in many older adults further increasing the risk of depression. Pharmacokinetic and pharmacodynamic age related changes also contribute to an increased risk of medication induced depression in older adults.

Table 2: Table of physical illnesses associated with depression^3,7

Dementia:

Dementia is common in old age and those with dementia are at higher risk of developing depression compared to those who do not have it⁵⁸. 20-30% of older adults with Alzheimer’s disease have depression⁵⁹. Depression is a risk factor for the subsequent onset of dementia.

Psychosocial:

When compared to younger adults, older adults are at a greater risk of developing depression due to the increased likelihood of experiencing particular psychosocial stressors, in particular adverse life events. Stressors include lack of social support, social isolation, loneliness and financial hardship. Financial hardship and functional impairment often sees older adults downsizing in property. Deteriorating physical health often sees older adults no longer being able to manage living independently at home necessitating a move into institutional living. Bereavement, especially spousal, and the associated role change that follows this are risk factors for depression³.

Sub-threshold depression:

Sub-threshold depression is an established risk factor for major depression.

Prevalence and epidemiology

The prevalence of depression in older adults in England and Wales was found to be 8.7% in 2007; however, if those with dementia are included this figure rises to 9.7%⁶⁰. A meta-analysis by Luppa et al. established a 7.2% point prevalence of major depression and a 17.1% point prevalence of depressive disorder in older adults⁶¹. The projected lifetime risk of an older adult developing major depression by the age of 75 years old is 23%⁶².

Sub-threshold depression is 2-3 times more prevalent than major depression in older adults^26,63. These depressive symptoms are often clinically relevant^26,29. 8-10% of older adults per year with sub-threshold depressive symptoms go onto develop a major depressive episode⁶³.

Incidence and prevalence are greater in women; 10.4% of women over the age of 65 years have depression compared to 6.5% of men⁶⁰. Older women are more likely to experience recurrent episodes of depression compared to older men⁶². The gender gap in incidence and prevalence becomes narrower with increasing age³. It should be acknowledged however that women are more likely to present to healthcare services and seek help in comparison to men^64-65.

The prevalence of major depression in older adults varies by setting⁶⁶. Highest rates are seen in long-term institutional care and inpatient hospital settings⁶⁷. Table 3 summaries prevalence rates of major depression by setting.

Table 3: Prevalence rate of major depression by setting ^{7, 67}

Prognosis of depression in older adults

Depression in older adults is associated with a slower rate of recovery⁹, worse clinical outcomes compared to younger adults³ and is associated with higher relapse rates⁶⁸. Worse prognosis in older adults correlates with advancing age, physical comorbidities and functional impairment⁷⁰. The structural brain changes associated with depression in older adults are linked, as discussed, to poorer treatment response.

Morbidity and mortality associated with depression can be described as primary or secondary; primary morbidity and mortality arises directly from the depressive illness; whereas secondary morbidity and mortality arises from physical health problems, which are secondary to depression.

Outcomes from sub-threshold depression are on par with those of major depression; however sub-threshold depression which develops into major depression is associated with worse outcomes².

Proportionally more people over the age of 65 years commit suicide compared to younger people⁷¹. Depression is the leading cause of suicide in older adults^29,71; one study reports that 75% of older adults who killed themselves were depressed⁷².

The vast majority of older adults who commit suicide have had contact with a health professional within the preceding month⁹; this figure has been quoted as high as 70%³. This further supports and suggests the fact the depression is under-detected. Unlike younger adults, older adults are less likely to report suicidal ideation and can experience suicidal ideation without feeling low in mood^3,7. Older adults have few suicide attempts, compared to younger adults, because their suicide methods are more lethal¹³.

Introduction

In the UK, all newly graduated doctors spend their first two years of work rotating between different specialities, usually spending four months in each placement, before applying for speciality training. This period is called the Foundation Programme.

In January 2016, the Royal College of Psychiatrists published its first ever strategy on Broadening the Foundation Programme to address the need to improve the psychiatric training experience for foundation doctors. The strategy’s aim is to “ensure the delivery of a high-quality training experience in all psychiatry foundation placements”.¹

Over the last few years, the number of Foundation training posts in psychiatry in England and Wales has significantly increased. Health Education England aims that all Foundation doctors should rotate through a community or an integrated placement (psychiatry is considered as a community placement) from August 2017.²

As such, the College highlights the need to provide a supervised and well-structured psychiatric training experience for Foundation doctors. This aims not only to improve recruitment into psychiatry but also to ensure doctors have a good working knowledge and understanding of psychiatry and psychiatric services, no matter what career they pursue.

Mentoring provides an additional support and therefore can be helpful to improve the placement of Foundation doctors in psychiatry.

We implemented an ambitious mentoring scheme in Norfolk and Suffolk NHS Foundation Trust (the seventh largest mental health trust in the UK). The paper describes its essential component together with a brief review of the literature on mentoring in clinical settings, focusing on Foundation placements.

Why is mentoring is needed for Foundation doctors in psychiatry?

The literature on mentoring for medical professionals draws attention to the idea that it is beneficial to all doctors at all stages of their career to experience mentoring in some form or another. However, mentoring is of particular importance to doctors moving to a new job or organisation ³, thus making it highly relevant to Foundation trainees.

For newcomers, most of the mentoring support will focus on helping them settle into their new role, becoming familiar with, and developing an understanding of the expectations of their employers.⁴

Evidence shows that the quality of care in any organisation can be improved when clinical leaders support time for activities such as reflection, coaching and mentoring ⁵.

Most Foundation doctors will lack experience in psychiatry and will need a substantial amount of guidance from their supervisors and their teams.⁶ Research has shown that the transition from student to doctor is a difficult one and can be associated with significant levels of emotional stress.⁷

Foundation doctors find psychiatric assessments physically and emotionally challenging. They feel they lack the specialist knowledge and skills to deal with complex patients, especially concerning self-harm, personality and eating disorders. Dealing with such complex diagnostic categories requires knowledge, skill, understanding as well as physical and emotional robustness. Due to the relative lack of focus on such topics in most undergraduate medical training, a comprehensive support in psychiatric placements is essential.

Psychiatry is very different from other specialities in the way services are configured and delivered: junior doctors may face isolation as psychiatric units are typically spread across a wide geographical area and often lack a centralised meeting place for junior doctors (e.g. a doctors’ mess). In addition, they may find themselves the lone practitioner when on call, which can be daunting for many.

Clinical and Educational supervision is provided to Foundation doctors in similar ways to other rotations. However, the consultants delivering this essential support often focus only on clinical issues related to knowledge and skills. Furthermore, it is easy to see that the best guides to new trainees regarding the idiosyncrasies of the speciality and its services are likely to be trainees who have spent some time in those services and are more able to detect the specific stresses new doctors may experience and may find difficult to articulate.

Furthermore, mentoring fosters a productive peer-to-peer relationship. The learning needs of the Foundation doctor can be considered alongside their personal and professional interests and lifestyle. Questions can be posed in a non-judgmental forum, without fear of being ridiculed or condemned. The fundamentals of on-call systems, clinical cases and management options can all be considered at a level appropriate to their junior grade. Tips for examination success and information about essential courses and core texts can be shared. Job choices and research opportunities can be discussed. Day to day difficulties and mismatches between expectation and reality can be identified and possibly overcome. Where this is not possible next steps can be identified, and clinical and educational supervisors can be drawn in for higher level support. The benefits of the scheme are broad.

Finally, although mentoring is different from role-modelling (teaching by example and learning by imitation), it has been shown toserve some of the same aims of role-modelling, including enhancing problem-solving abilities of the mentee, improving professional attitudes, showing responsibility and integrity, and supporting career development. ⁸

What is mentoring?

Mentoring can mean different things to different people. There are various definitions which can create confusion between mentoring and other formal structures of support such as supervision, coaching, consultation, befriending or friend systems and even counselling. However, mentoring is none of the above but at the same time a combination of them.

The Standing Committee on Postgraduate Medical and Dental Education (UK) defined mentoring as ‘The process whereby an experienced, highly regarded, empathetic individual (the mentor) guides another individual (the mentee) in the development and re-examination of their ideas, learning, and personal and professional development”.⁹

The term “mentoring” takes us back to Greek mythology: Mentor was a person: he was the friend of Odysseus who was asked to look after Odysseus’ son Telemachus when Odysseus was fighting in the Trojan Wars. The name Mentor was later used to describe a trusted person, a supporter, or a counsellor.¹⁰

Mentoring as a professional developmental tool became popular in the private sector organisations in the USA during the 1970s and was introduced to the area of health during the 1990s ¹¹. Since then, it has been widely used in various organisations.

Aims of mentoring

Mentoring has the advantage of being a flexible supporting tool, unlike other structured processes (e.g., clinical supervision or coaching) where the goals are set clearly from the start of the relationship between the supervisor and supervisee. The aims of mentorship are summarised in Table 1.

Types of mentoring

Buddeberg-Fischer and Herta ¹¹ discussed various types of mentoring based on the numbers of mentors and mentees and their professional status or grade:

1. One to one mentoring (between a mentor and a mentee).
2. Group mentoring (one mentor and a small group of mentees)
3. Multiple-mentor experience model (more than one mentor assigned to a group of mentees).
4. Peer-mentoring (the mentor and mentee are equal in experience and grade): This mentoring is used mainly for personal development and improving interpersonal relationships. Mentor and mentee roles can be reversed. Also, called ‘co-mentoring’.

Distance or e-mentoring is becoming more popular, and it has the advantages of being “fast, focused, and typically centred on developmental needs”. ¹²

Structured vs. flexible mentoring

Evidence suggests that providing mentorship through a rigid and structured process can be counterproductive. ¹³ Mentors and mentees usually work in different locations, making it difficult for both to have a set of pre-planned meetings and topics for discussions.

Another advantage of the flexibility of mentoring is that it does not follow a “tick box” exercise but encourages informal discussions and exploration of whatever comes to mind during meetings. Doubtless, having some structure to the overall mentoring process is important as it ensures that the mentoring session doesn’t become an informal befriending or friend support system. Table 2 sets out the main benefits of mentoring.

Table 2-Benefits of mentoring. Developed from Mentoring – Chartered Institute of Personnel and Development (CIPD) Factsheet. Revised February 2009 ¹⁴. Available from: https://www.shef.ac.uk/polopoly_fs/1.110468!/file/cipd_mentoring_factsheet.pdf

Are there any Disadvantages of mentoring?

There is extensive literature on the benefits of mentoring, but is there any harm associated with it?

As with any intervention, it does carry some potentially adverse effects. Mentoring can be perceived to “infantilise” junior employees rather than empowering them ¹⁰. This perception is probably more common among employees who see themselves as senior or very competent and think of themselves as able to adapt to change very quickly.

Mentoring might hinder creativity in new employees and inhibit them from thinking “outside the box” as it might re-enforce the message that ‘this is how we do things here’. ¹⁰

Clashes of personalities or other interpersonal factors could lead to a troubled mentor-mentee relationship and cause distress to both parties. Hence, plans must be put in place in any formal mentoring scheme to ensure an amicable ending to this relationship. Multiple mentor allocation mentioned earlier could also prevent such interpersonal problems and help to tackle them early on.

Furthermore, some mentees may feel uncomfortable with the influence or authority of the mentor, and this may hinder the progress of the mentoring relationship. ¹³ This is particularly relevant when the mentor is also involved in the formal assessment of the performance of the mentee (e.g. being the line manager or supervisor) or when a mentee who lacks self-confidence is paired with an overconfident mentor.

Good mentors avoid common pitfalls in the mentoring process, such as a patronising attitude, breaches of confidentiality and offering direct advice to the mentees. Instead, they encourage the mentee to reflect and come up with their answers. ¹⁵

Finally, mentoring can be perceived as an additional demand on doctors during their training, and some may feel that they are forced to provide it or receive it during placement. However, it must be remembered that mentoring should always be voluntary and flexible to meet the individual’s needs and not an additional ‘box to tick’ or a portfolio enrichment exercise.

The Mentoring Scheme for Foundation Doctors in Psychiatry Norfolk:

The scheme started in December 2015 and initially ran as a pilot in Norfolk with the support of all stakeholders. The mentoring scheme coordinator (YH) contacted twelve Foundation doctors by email, welcoming them to the Trust and inviting them to participate. The welcome email contained information about mentoring, including the benefits it may offer.

The voluntary nature of this scheme was highlighted so that the doctors didn’t feel they were being pressured to be enrolled.

Of the 12 doctors invited, five took up this opportunity. Uptake has remained constant over the consequent cohorts of Foundation doctors for many reasons. Those deciding not to enrol in this scheme explained that they felt happy with the support provided by their clinical supervisors. However, some doctors asked for a mentor halfway through their placement when they felt that they needed additional support. In these instances, a mentor was allocated to them as soon as possible.

Mentors were core and higher trainees already involved in supporting more junior psychiatric trainees through informal mentoring. Their experience meant there was no need for formal training. However, reading material was circulated to them to highlight the roles and responsibilities of mentors and what to do if any problem arose during mentoring. Monthly mentors’ meetings were very helpful to discuss issues arising in mentoring and offer peer to peer support.

Also, there were regular meetings and discussions between the mentoring coordinator, the Director of Medical Education, and Medical Director of the Trust to resolve any issues facing the Foundation doctors and provide feedback to improve the Psychiatric placement.

During the first meeting, the mentors and mentees agreed on the aims of mentoring drawing up a list of objectives that the Foundation doctor would like to achieve by the end of the placement. Following this initial meeting, there should have been once monthly face to face meetings throughout the placement. The mentor and mentee agreed on the most convenient means of communication (e.g. using text messages, emails, etc.) outside scheduled meetings.

All mentors kept a record of the mentoring meetings, with the mentoring coordinator informed about these meetings. Issues discussed were confidential and not shared with the coordinator or supervisors unless the mentee gave specific consent.

At the end of the mentoring scheme, the coordinator collected feedback from mentees and mentors using a structured questionnaire that was designed by the coordinator using SurveyMonkey® website. The feedback highlighted the positive aspects of mentoring as well as areas for improvement.

End of mentoring survey

Mentors reported that acting as a mentor without being involved in clinical supervision allowed them to offer objective advice and support in a way that would have been harder if they were directly involved in the workplace. One Foundation doctor experienced bullying from another member of the team who was a locum doctor. The mentor supported the Foundation doctor, and the issue was addressed and resolved promptly. There was a significant risk that they would have been left isolated and unsupported during this time if the mentor scheme had not been in place.

The topics discussed were varied, and this suggested that mentoring was not limited to a aspect of the job (see Table 3)

Mentees reported that they found mentoring useful and supportive of learning and development. This was especially important in a speciality that they had little experience of as an undergraduate. With a mentor in Psychiatry, the Foundation doctors reported that they could identify areas of development, including leadership and teaching opportunities for Foundation doctors.

Overall, mentoring was shown to be a useful tool to improving Foundation doctors’ experience in Psychiatry by offering extra support during placement in a challenging medical speciality.

Table 4 summarises the areas of development suggested by the mentors and mentees.

Limitations

Feedback from mentors and mentees showed an overall satisfaction with the scheme, but it was not possible to measure such satisfaction quantitatively, this was expected from an approach which is willfully kept outside the realm of performance management.

According to the literature on mentoring, most mentoring schemes lack a clear structure, as well as a clear evaluation process of its short and long terms, benefits ¹¹.In our scheme, we addressed this by continually monitoring the mentoring process and collecting feedback from mentees and mentors. Another limitation involves training the mentor himself and finding the time in a highly pressurised and heavy workload environment.

There are many questions that the literature on mentoring is yet to answer. For example, what are the long-term benefits of mentoring? Would our Foundation doctors who received mentoring be more successful professionally and personally compared to their peers who decided not to participate? These questions remain unanswered as our pilot was not set up to address this general shortcoming of current knowledge and understanding.

Conclusions and recommendations

Mentoring provides a focused opportunity to target the wider needs of the trainee. Not only could this encourage Foundation doctors to pursue a career in Psychiatry, but it also provides the space for them to learn how to incorporate psychiatric skills into whatever speciality they choose to pursue.

As a new doctor in a novel environment, being expected, welcomed, and gently guided into the job is invaluable. With the hindsight of our training experiences (good and bad), junior doctors are ideally placed to support more junior colleagues at all levels.

There is a need to develop links with other mentoring schemes to exchange experiences and learn lessons from others. Research has shown the importance of supporting mentors in their roles through regular meetings where mentors learn from each other. ¹³

In our experience, the mentoring scheme worked both alongside and separately to clinical and educational supervision and the opportunity for reflective practice offered in Balint groups. Mentoring added another level of support for the Foundation doctors, which was deemed beneficial by those participating.

We recommend more research is required to determine whether mentoring will increase recruitment to psychiatry. Organisations responsible for the training of doctors should support formal mentoring schemes and supervisors should ensure that mentors and mentees have protected time in their timetable due to the benefits of the mentoring experience to the doctors and the employing organisations.

Finally, funding should be available to support training of mentors in their workplace and aim to develop their skills in helping their mentees. Many private organisations offer mentoring training packages (including classroom and online training) for competitive prices. These courses provide useful resources to mentors and may help to increase the motivation of mentors to continue their participations in mentoring.

Appendix:

How does mentoring work? A simple three stage model:

Figure 1- The three stage model of mentoring. Developed from Alred et al (1998). Alred, G., Gravey, B. and Smith, R, 1998, Mentoring pocketbook. Alresford: Management Pocketbooks.

One of the unique characteristics of mentoring is that it is a partnership between two individuals (mentor and mentee) where both contribute to its growth and sustainability. It is based on trust, eagerness to learn and mutual respect. ¹⁶

Alred et al (1998) ⁴ described a model of mentorship with three stages: exploration, developing new understanding and then action planning (Figure 1). Both the mentors and mentee have certain roles and responsibilities in each stage and it is only through their collaborative work that the benefits of mentoring can be obtained.

The stage of exploration is characterised by the building of a relationship between the mentor and the mentee. Trust, confidence and rapport start to develop and hopefully grow throughout the mentoring process. Methods such as active listening, asking open questions, and negotiating an agenda are essential to facilitate this growth.

The second stage is where new understanding develops, is characterised by showing support to the mentee, demonstrating skills in giving constructive feedback and challenging negative and unhelpful cognitions.

Key methods employed in this stage include recognition of the strengths and weaknesses of the mentee, giving them information, sharing experience and establishing priorities for the mentee to work on.

In the third and last stage of the mentoring, action planning, the mentee takes the lead in negotiating and agreeing on the action plan, examining their options and developing more independent thinking and decision-making abilities.

A good mentor should help the mentee to gain confidence and knowledge over time. In order to achieve this, the mentor helps the mentee to develop new ways of thinking and improve their problem-solving abilities.

Monitoring the progress and evaluating the outcomes of the mentoring process is essential to ensure that the mentoring relationship is going in the right direction.

Acknowledgement

We would like to thank Dr Stephen Jones (Consultant CAMHS and former Training Programme Director), Dr Trevor Broughton (Consultant Forensic Psychiatrist, Director of Medical Education), Dr Bohdan Solomka (Medical Director) from Norfolk and Suffolk NHS Foundation Trust for their unlimited support for the mentoring scheme.

We also would like to thank Dr Calum Ross (Foundation Training Programme Director-FY1) and Mr Am Rai (Foundation Training Programme Director -FY2), Norfolk and Norwich University Hospital for their support in implementing this scheme. Dr Srinaveen Abkari (Specialist Registrar, Norfolk, and Suffolk NHS Foundation Trust) is one of our mentors who also contributed useful ideas to the development of this paper.

Finally, we would like to thanks all our mentors who provided the support for the Foundation, without their efforts, this scheme would not have succeeded.

Background

Global recruitment in psychiatry has been falling for several decades because medical students and graduates have been finding it consistently unattractive ^1,2. An analysis of the career choices of newly qualified doctors in the United Kingdom (U.K.) found the same trend from 1974 to 2009; psychiatry was the first career choice for only 3-5% of medical graduates annually³. In the U.K., lack of recruitment into psychiatry had reached a crisis point by 2003 when 15% of all unfilled consultants posts in England were in psychiatry and the Royal College of Psychiatrists was finding recruitment into specialist psychiatry posts increasingly difficult^4,5. In 2012, only 78% of the Core Training year one (CT1) posts in psychiatry were filled; a serious shortfall which was overcome by overseas recruitment up until changes in immigration rules.

The factors that seem to dissuade medical students from taking up psychiatry as a future career may include: stigma, bad prognosis of psychiatric disorders, poor scientific base of psychiatry, ‘bad-mouthing’ from medical colleagues, lack of respect among peers & public, threats of violence from patients and lack of resources^1-5. However, there is evidence to suggest that many students’ attitudes towards career choice changed in a positive direction after working in psychiatry due to the perceived ‘job satisfaction’, ‘life-style’, ‘training available’ and ‘multidisciplinary approach’³.

Psychiatry has previously been ranked higher in career choice at the end of students’ clinical year⁶. To ensure a stable psychiatric workforce for the future, there is an obvious need to motivate current and future cohorts of young doctors to take up psychiatry as a career. Das & Chandrasena (1988) found that attitudes changed positively towards mental health following clinical placement in this specialty⁷. It is also known that medical students’ attitudes to psychiatry and career intentions can be improved by their experiences of teaching⁸. Students were found to develop more positive attitudes when encouraged by senior psychiatrists, had direct involvement in patient care, or saw patients respond well to treatment. Improvement in attitudes during the placement was also related to an increased intention to pursue psychiatry as a career.

Previous research into attitude to psychiatry as a specialty and career choice seems to have produced conflicting results and most of it was carried out among medical students. Since career choices in the U.K. are actually made in the first clinical year following graduation, we carried out a survey among a recent cohort of foundation year one (FY1) doctors in the South East England before and after their first clinical year.

Method

Our study sample consisted of all FY1 doctors (n=101) in one region of South East England. They participated in the study at the beginning and then at the end of their first clinical year. We used a 20–item questionnaire devised by Das & Chandrasena(1988) to ascertain their perceptions and attitudes towards psychiatry before they commenced their first clinical placement. The questionnaire was sent to them via their Medical Education Managers (MEMS). It was handed out to the FY1 doctors as part of their induction pack for completion along with a study information sheet.

At the end of their first year of working, the participants were asked to complete an amended version of the questionnaire. This included two additional questions which ascertained whether the doctor had an opportunity to work in a psychiatric post, or had any experience of psychiatry in practice (such as taster days or cases in A&E). These amended questionnaires were sent to the foundation doctors electronically via their MEMS for completion.

The data was collected and entered into a spreadsheet to prepare descriptive statistics. Comparisons for before and after exposure to psychiatry, and between the psychiatry and non-psychiatry groups were made using the chi-square test. As the data was binary, a latent class model was developed using LatentGOLD software⁹ to explore the associations between different items in the questionnaire. Responses from the questionnaires were coded as: responses which agree with a positive attitude to psychiatry or disagree with a negative attitude were coded as +1; those not sure were coded as 0; and responses which agree with a negative attitude to psychiatry or disagree with a positive attitude were coded as -1.

Results

A 100% (n=101) response rate was obtained for the first set of questionnaires completed at the beginning of the year. However, there was a significant drop in the number of questionnaires completed at the end of the year - a 53.5% response rate (n=54) generally but 61.1% (22 out of 36) for those FY1 doctors who had the opportunity or access to a post in psychiatry within their clinical year.

Initial cohort at beginning of the clinical year vs. those with no exposure to psychiatry at the end

Table 1 shows the group means for each questionnaire item, for the whole cohort at the beginning of the year compared to those with no exposure to psychiatry by the end of the year.

Table 1: All FY1 doctors before training placements started (initial cohort) versus FY1 doctors without a psychiatric post after FY1 training

Those FY1 trainees who had not worked in psychiatry during the year were significantly more positive (p = < 0.05) for psychiatry’s future, psychiatrist being better at patient communication and not over-medicating their patients. However, they remained significantly less convinced as compared to the whole cohort about psychiatry’s intellectual attraction or taking it up as a future career.

Initial cohort at beginning of the year vs. those with exposure to psychiatry at the end

Table 2 shows the group means for each questionnaire item, for the whole

cohort at the beginning of the year compared to those with exposure to psychiatry at the end of the year.

Table 2: All FY1 doctors before training placements started versus FY1 doctors with a psychiatric post during FY1 training