Sep

Online Interview with Dr David Fearnley

Article Citation and PDF Link

BJMP 2010;3(3):a334

http://bjmp.org/files/2010-3-3/bjmp-2010-3-3-a334.pdf

Dr David Fearnley, aged 41, is a Consultant Forensic Psychiatrist at Ashworth Hospital, a high secure psychiatric hospital in Merseyside, UK. He is also the Medical Director of Mersey Care NHS Trust, which is a large mental health and learning disability trust and one of three in England that have a high secure service. As Medical Director he is responsible for the performance of over 175 doctors, 50 pharmacists and has the lead responsibility for R&D and information governance. He is the College Special Advisor on Appraisal at the Royal College of Psychiatrists and has an interest in the development of management and leadership skills in doctors.

How long have you been working in your specialty?

I started training in psychiatry in 1994, and undertook specialist registrar training between 1998 and 2001. I became a consultant forensic psychiatrist in a high secure hospital in 2001 and medical director for the wider trust in 2005.

Which aspect of your work do you find most satisfying?

I have always found clinical work satisfying, and particularly when it becomes linked to wider service changes. I think this is why I decided to take on management responsibilities in addition to my clinical work so that I could continue to work at this interface.

What achievements are you most proud of in your medical career?

I have been particularly pleased whenever I have passed my exams and I have been able to make progress in my career. Also, in 2009 I won the inaugural Royal College of Psychiatrists Psychiatrist of the Year award, largely because of my innovative approach to involving service users and carers in their treatment.

Which part of your job do you enjoy the least?

I find that I dislike having to read poorly written reports because of the limited time available to do other things!

What are your views about the current status of medical training in your country and what do you think needs to change?

In my view, medical training in England is of an exceptionally high standard although more emphasis will need to be brought into training around management and leadership.

How would you encourage more medical students into entering your speciality?

I think medical students should be exposed to mental health services as soon as possible, to see not only the clinical aspects but appreciate the organisational structures.

What qualities do you think a good trainee should possess?

I think trainees should develop a sense of respect for everybody they work with including the service users and carers, particularly when they feel under pressure. This is, in my opinion, the hallmark of somebody who will make a great clinician.

What is the most important advice you could offer to a new trainee?

I think new trainees should create habits in terms of acquiring new knowledge (particularly evidence based knowledge) so that they build up a sense of lifelong learning that extends beyond clinical examinations.

What qualities do you think a good trainer should possess?

A good trainer should be approachable and accessible, with a willingness to challenge the status quo but also show interest in the life of the trainee.

Do you think doctors are over-regulated compared with other professions?

The medical profession is entering the phase of increased regulation through revalidation. I think this is an acceptable position in view of the enormous privilege that practicing medicine offers and the need to assure the public that doctors are fit to practise.

Is there any aspect of current health policies in your country that are de-professionalising doctors? If yes what should be done to counter this trend?

I think doctors are becoming better at identifying certain tasks that others are equally capable of undertaking. I think doctors should be continually seeking out areas of healthcare that they alone have the skills, knowledge and attitude to be responsible for.

Which scientific paper/publication has influenced you the most?

I have found the work of the Cochrane Collaboration (rather than a single publication) to influence me considerably because it made me aware, through the work of the Archie Cochrane, the importance of standing back and comparing more than one study whenever possible.

What single area of medical research in your speciality should be given priority?

I think the overlap between mental illness and personality disorder is not understood well enough and yet is a major reason for patients remaining in secure care longer than perhaps they might need to in the future.

What is the most challenging area in your speciality that needs further development?

As a medical manager, I think that more needs to be done to encourage doctors to see management and leadership as part of their role as a professional and to gain competencies and confidence in these areas during their undergraduate and postgraduate training.

Which changes would substantially improve the quality of healthcare in your country?

Healthcare delivery in the UK is undergoing change following the publication of the coalition government’s White Paper in health, and it is encouraging clinicians, particularly GPs, to take part in commissioning. I think this, alongside a focus on better outcome measures is likely to improve the quality of healthcare.

Do you think doctors can make a valuable contribution to healthcare management? If so how?

I think doctors are in a unique position following years of clinical training to make decisions in terms of management and leadership. They should be able to transfer their ability to manage particular cases over time to managing projects and resources both in operational and strategic terms.

How has the political environment affected your work?

The NHS has an element of political oversight that does influence the work, particularly in the high secure service where public protection is a key factor.

What are your interests outside of work?

My time outside work is spent almost exclusively with my family.

If you were not a doctor, what would you do?

I would like to be a writer (although I doubt I have the skills to do so successfully!)

Post MTAS: A Survey of the first MMC Surgical Trainees in the Oxford Deanery

Authors

Khurram K Khan, Karen A Eley, Bettina Lieske, and Mr Bob Soin

Article Citation and PDF Link

BJMP 2010;3(3):a333

http://bjmp.org/files/2010-3-3/bjmp-2010-3-3-a333.pdf

Abstract / Summary

Abstract:

Introduction: The nationwide implementation of ‘run-through’ training in 2007, based upon the new system of postgraduate medical training known as Modernising Medical Careers (MMC), was the subject of much debate as to the suitability of the selection process, and the feasibility of the new system itself. One year after the start of the new Speciality Training (ST) grade this study obtains the views of core surgical trainees in the Oxford Deanery.

Methods: Forty-six trainees in ST1, ST2, Fixed Term Specialty Training Appointment (FTSTA) 1 and FTSTA2 posts completed questionnaires at three and nine months from appointments in August 2007.

Results: Fifty two percent (n=24) of respondents were appointed to their training posts from Round 1a, with 67% (n=16) to ST1 or ST2 level. Despite 61% (n=28) having initially selected Oxford as their first choice deanery, 93% (n=43) now wished to remain in the region for further training, with 57% (n=27) of all trainees satisfied with their current position. At three months, only 9% (n=4) felt well informed regarding their surgical training, and 28% (n=13) well supported by their seniors; however, six months later these figures had risen to 64% (n=29) and 60% (n=24) respectively. Nearly half (43%, n=20) of surgical trainees had looked into moving abroad to train, and two thirds had considered leaving surgery all together. From August 2008, 70% (n=9) of ST2 trainees and 57% (n=4) of FTSTA2 trainees had obtained ST3 positions, with all but one in their desired surgical specialty.

Conclusion: Despite MMC’s difficult introduction into higher specialist training, the majority of trainees surveyed expressed encouraging levels of job satisfaction, felt increasingly well informed and well supported, and had successfully negotiated the initial stages of the ‘run-through’ track. With continuing debate surrounding how MMC-based surgical training will work within the confines of National Health Service (NHS) provision and the European Working Time Directive, we present the opinions and outcomes of the first cohort of ‘run-through’ surgical trainees.

Keywords:

Surgical training, MMC, ST trainee, FTSTA trainee

Introduction

The Department of Health’s Modernising Medical Careers (MMC) has been uniformly implemented into specialty training across the United Kingdom (UK). This began with the controversial and subsequently redundant Medical Training Application System (MTAS) selection process in Spring 2007, and ended with the first MMC specialty training posts commencing in August 2007. During the application process itself one preliminary study reported that 85% of candidates demonstrated decreased levels of enjoyment in their work, and 43% caring less about patient care.1 The emergency introduction of the ‘golden ticket’ Round 1b guaranteed interview - though arguably justified in the face of a flawed application system - was a cause of further discontent and division amongst junior trainees and the consultants responsible for appointing them.

For surgical training in particular, the advent of the MMC initiative combined with the European Working Time Directive (EWTD) represents an estimated 50% reduction in the amount of specialist training hours when compared to the previous system.2 This has raised concerns not only from current consultants, but also from the already increased number of surgical trainees having to share the same caseload. A previous survey of Ear, Nose, and Throat senior house officers reported 71% were willing to opt out of the EWTD to safeguard their training and patient care.3

In the Oxford Deanery the selection process of shortlisted surgical trainees in Rounds 1a and 1b consisted of six stations assessing curriculum vitae, portfolio, clinical examination, data interpretation, and pre- and post-operative management (totalling one hour). Candidates were offered generic or specialty themed Core Training (CT) posts at Speciality Training (ST) 1 or 2, or Fixed Term Speciality Training Appointments (FTSTA) 1 or 2, depending upon the candidate’s ranking at interview (plus application form for Round 1a) irrespective of speciality preference. Following acceptance, individual appointments were made based on candidates ranking job preferences. Round 2 appointments were made at a local level via traditional selection methods. The most recent information from the deanery states that those trainees who received an offer of run-through training in the region will be guaranteed an interview for an ST3 post in surgery, however individual specialty preference and job allocation will be determined by re-ranking based on continuous appraisal during the core surgical training years, further Higher Specialist Training interviews, and training numbers available.

The media coverage that surrounded MTAS clearly highlighted the dissatisfaction amongst trainees and consultants leading up to and during the application process,4, 5 but no study has yet assessed the views of surgical trainees following the start of their new MMC-based training posts. This survey aimed to obtain the views and outcomes of core surgical trainees in the Oxford Deanery.

Methods

At three and nine months following the commencement of speciality training posts, questionnaires were distributed to junior surgeons (CT 1-2) in the Oxford Deanery School of Surgery. Questions were structured to obtain information about level of experience and qualification(s), current and desired surgical speciality, job satisfaction, attitudes towards ‘run-through’ training and levels of support. In the Oxford Deanery there were 40 appointments at CT1 (18 ST1 and 22 FTSTA), and 29 at CT2 (17 ST2 and 12 FTSTA) in August 2007. Data were expressed as the mean ± standard deviation (SD). Statistical comparison was performed using Mann-Whitney’s U test, with the significance level at p<0.05.

Results

The questionnaire was completed by a total of 46 and 45 surgical trainees at three and nine months respectively. At the three-month time point this represented 67% of all trainees in the Oxford Deanery School of Surgery (male: female, 33:13) and included 11 at ST1, 16 at ST2, 11 at FTSTA1, and 8 at FTSTA2. Of these 52% (n=24) had obtained their post via Round 1a, 41% (n=19) via Round 1b, and 7% (n=3) via Round 2. At both CT1 (ST1 & FTSTA1) and CT2 (ST2 & FTSTA2), trainees were on average 3.7 ± 1.9 years post graduation (from time surveyed; CT1 range 1-11 years, CT2 range 3-8 years); 16% (n=7) of all trainees had previously studied Medicine at Oxford University, and 93% had studied medicine in the UK. (Figures 1a, b). Most popular desired specialties at three and nine months are displayed in figure 2. Of the 46 respondents, all had worked in the speciality of their career choice during the course of the year.

Figure 1a. Number of trainees selected in each MTAS round

Figure 1b. Surgical trainee graduating medical school distribution

At time of appointment, 52% of trainees had completed the Membership to the Royal College of Surgeons (MRCS) exams, and 35% (n=16) of all trainees had completed a higher degree. (Figure 3). Furthermore, 22% (n=10) felt that there should be a further exam in addition to the MRCS to rank candidates for appointment to higher specialist training (ST3 onwards), with half of this number having already obtained their MRCS.

Figure 2. Desired surgical specialty at three and nine months

Figure 3. Trainee postgraduate qualifications at time of appointment

Those who had been allocated to ‘run-through’ ST posts were more satisfied with the concept of run-through training than those in FTSTA posts (where scores were assigned on a scale from 1 - very unsatisfied, to 5 - very satisfied), with the mean score at three months for ST trainees 4.1 ± 1.4, and FTSTA trainees 2.0 ± 1.4 (p<0.01), and at nine months 3.7 ± 1.1 for ST trainees versus 2.1 ± 1.1 for FTSTA trainees (p<0.01). Job satisfaction levels between these two groups of trainees were similar: at three months, mean score 3.5 ± 1.3 in ST posts versus 4.1 ± 0.8 in FTSTA posts (p>0.05), and at nine months, mean score 3.5 ± 1.0 in ST posts versus 3.2 ± 1.3 in FTSTA posts (p>0.05). In addition, a similar comparison between ST and FTSTA trainees was found when determining if trainees had thought about leaving surgery. On a scale where a score of 1 – never thought of leaving surgery to 5 – very frequently thought of leaving surgery, the mean score at three months was 2.3 ± 1.4 for ST trainees versus 3.0 ± 1.6 for FTSTA trainees (p>0.05), and at nine months 2.2 ± 1.4 for ST trainees versus 2.9 ± 1.5 for FTSTA trainees (p>0.05). (Figures 4a, b).

Figure 4a. Trainee attitudes at three months

Figure 4b. Trainee attitudes at nine months

In fact, 43% (n=20) of all trainees surveyed reported having enquired about surgical training in another country, with 4% (n=2, both UK Medical School graduates) stating that if unsuccessful in securing a training post in their desired specialty for August 2008, they would move abroad to train.

At three months, 9% (n=4) of all trainees felt well-informed about what will happen in the future regarding their training, with 20% (n=9, ST to FTSTA ratio 2:7) responding that had they been better informed prior to August 2007, then they would not have accepted their current post, and 28% (n=13) felt well-supported by their senior colleagues with regard to their future training. However at nine months from appointment, 69% (n=29) of all trainees felt well informed, and nearly two thirds well supported by their seniors (n=27). (Figure 5). Ninety three percent (n=43) of applicants wished to remain in the region for their future training, with 61% (n=28) having initially selected Oxford as their first choice deanery.

Figure 5. How well informed and supported trainees felt at three and nine months

The majority of both ST2 (85%, n=11) and FTSTA2 (71%, n=5) trainees secured ST3 posts from August 2008, mainly within the Oxford Deanery, and all within their desired surgical specialty. All ST1 (n=16) trainees successfully moved into ST2 posts, and the majority of FTSTA1 (78%, n=7) trainees secured CT positions. (Table 1).

Grade (n)	August 2008 Post (n)
ST1 (16)	ST2 (16)
FTSTA1 (9)	CT1 (3) CT2 (4) FTSTA (2)
ST2 (13)	ST3 (11) Research Fellow (1) GP Trainee (1)
FTSTA2 (7)	ST3 (5) ST1 Radiology (1) CT2 (1)

Table 1. ST2 and FTSTA2 trainee outcomes from August 2008

Discussion

MMC has and will have profound implications on the way junior doctors will henceforth be trained in the National Health Service (NHS). Last year’s difficult introduction into specialist training, has for obvious reasons, directly affected the perceptions of trainees having to negotiate their careers through the ‘transition’ period.1, 6 This survey provides an interesting insight into the demographics, current viewpoints, and outcomes of the first cohort of MMC surgical trainees in the Oxford Deanery.

Just over half of all trainees in the survey were appointed after Round 1a (52%, n=24) of which two thirds (n=16) were to ST posts: a further 41% (n=19) were appointed after Round 1b, of which roughly half (n=9) were to ST posts. This highlights the large number of very good surgical trainees that may have been left unemployed had MTAS interim measures not been introduced to permit all candidates the opportunity of at least one interview, and that in the Oxford Deanery at least, candidates were given an equal chance of obtaining a ‘run-through’ post between the two rounds. Despite MMC person specifications at the time of application stating that MRCS was not an absolute requirement for entry at ST1-2, 52% (n=24) had completed their MRCS, with a further 20% (n=9) having completed at least Part I or more.

Overall job satisfaction levels were good amongst all trainees (mean score 3.7 ± 1.1), with 57% (n=26) still agreeing with the concept of ‘run-through’ training, and hence MMC. This view is maintained despite the problems associated with last years application process, and in the face of an uncertain future. However, nearly half (43%, n=20) of trainees had enquired about training abroad, with several committed to leaving the UK next year if unable to obtain their desired surgical specialty. With the average cost to train a UK medical graduate being at least £150,000,7 and the amount of dedication and effort needed to embark on a surgical career thereafter, care must be taken to improve morale amongst junior surgeons, and to provide adequate and timely information. Encouragingly, between the two time points surveyed, levels of senior support and how well informed surgical trainees felt with regards to their training, increased from 28% to 60% and from 9% to 69% respectively; this may be secondary to a combination of extensive effort from the Deanery and the Royal College of Surgery to address trainee concerns.

The realistic future of those in FTSTA posts is cause for concern. This is highlighted in the recently released Tooke Report, in which it is stated they are “in danger of becoming the next ‘lost tribe’, the very category of doctor MMC sought to avoid”, but at the same time that “core [training] should not repeat the errors of previous SHO arrangements and must be time limited”.6 Those in FTSTA posts face higher levels of future uncertainty than their ST colleagues, and this was reflected in reporting a higher likelihood of consideration of alternative careers outside of surgery. However, both groups of trainees demonstrated statistically similar scores when questioned about how frequently they had thought of leaving surgery (2.3 ± 1.4 for ST trainees versus 3.0 ± 1.6 for FTSTA trainees, p>0.05), and 71% of FTSTA2 trainees surveyed within the Oxford Deanery went on to secure ST3 level posts in their desired specialty.

The authors note the limitations inherent to surveys in general namely the validity and reliability of responses obtained to questions asked due to the self-report method of data collection, the questionnaire entirely constructing the information obtained, and that the data does not capture the decision process that produced the observed outcomes and is therefore descriptive rather than explanatory. More specifically, the authors note that candidates who were successful in obtaining an ST3 post may have been more likely to complete the questionnaire, leading to further potential bias.

Conclusion

MMC has crossed the threshold into higher specialist training, and the first cohorts of MMC surgeons are being trained. The majority of trainees we surveyed expressed good levels of job satisfaction, had successfully negotiated their first year of the new system, and encouragingly felt better informed and supported over the course of their first year. However, this study encompassed a proportion of surgical trainees in one Deanery in the UK, and further study on a larger scale at regular time intervals is certainly warranted. Consequent to the problems of MMC’s difficult introduction, positive steps included travelling tours by the Royal College of Surgeons (England), and in the Oxford Deanery at least, regional meetings to address concerns and expectations, and outline the realistic future for surgical trainees. Perhaps a key determinant of sustainability for MMC in surgery in 2008 and beyond will be the relative success of the Intercollegiate Surgical Curriculum Programme (ISCP), and this represents a significant area for further study.

Acknowledgements / Conflicts / Author Details

Competing Interests:

None declared

Details of Authors:

KHURRAM K KHAN, MRCS, BSc. ST3 trainee, Department of Plastic Surgery, Salisbury District Hospital. KAREN A ELEY, MBChB, MRCS(Ed), PGCTLCP, FHEA, MSc. Research Fellow & Doctoral Candidate, Oxford Radcliffe Hospitals & University of Oxford. BETTINA LIESKE, MRCS. Specialist Registrar, Department of General Surgery, Royal Berkshire Hospital. BOB SOIN, MA, MBBChir(Hons), FRCS(Gen Surg), MD. Consultant General Surgeon, Department of General Surgery, Heatherwood & Wexham Park Hospitals.

Corresponding Author Details:

KHURRAM K KHAN, MRCS, BSc. ST3 trainee, Department of Plastic Surgery, Salisbury District Hospital

Corresponding Author Email:

drkkhan@gmail.com

References

References:

1. Lydall GJ, Malik A, Bhugra D. MTAS: Mental health of applicants seems to be deteriorating. Br Med J 2007; 334(7608):1335.

2. Devey L. Will modernised medical careers produce a better surgeon? Br Med J 2005; 331:1346.

3. Anwar M, Irfan S, Daly N, Amen F. EWTD has negative impact on training for surgeons. Br Med J 2005; 331(7530):1476.

4. Brown MJ. Raging against MTAS (UK Medical Training Application Service). Br Med J 2007; 334(7593):549.

5. Coombes R. How specialist training reform sparked crisis of confidence. Br Med J 2007; 334(7592):508-9.

6. Tooke J. Aspiring to Excellence. Final Report of the Independant Inquiry into Modernising Medical Careers. In Inquiry M, ed. London: Aldridge Press, 2008.

7. Jefferis T. Selection for specialist training: what can we learn from other countries? Br Med J 2007; 334:1302-1304.

Vitiligo Management: An Update

Authors

Imran Majid

Article Citation and PDF Link

BJMP 2010;3(3):a332

http://bjmp.org/files/2010-3-3/bjmp-2010-3-3-a332.pdf

Abstract / Summary

Abstract:

Vitiligo is one of the commonest skin disorders with a presumed autoimmune aetiology. The management options for this disease have undergone a sea of change over the last two or three decades and we are now in a much better position to treat this disease than in the past. Treatment options such as Narrowband Ultraviolet B (NB-UVB), Targeted Phototherapy, and Excimer laser on the medical front, in addition to epidermal cell transplantation and melanocyte culture transplants on the surgical front, have all revolutionized the management of this psychologically devastating disease.

Introduction

Vitiligo is one of the oldest and commonest skin disorders affecting approximately 1-2% of the human population.¹The disease shows no regard to the ethnic, racial or socioeconomic background of the affected sufferers. The cosmetic impact of this disease is tremendous and its psychological impact devastating particularly in coloured races.^2,3,4 The aetiopathogenesis of this disease is now much better understood (table 1)⁵ compared with a decade earlier but much remains unknown. In parallel with these developments on the aetiological front, a lot of new advances have been made on the therapeutic front as well. With these new therapeutic options, we are currently in a much better position to treat this disease than we were a decade or two earlier. So, how far and how satisfactorily are we able to treat this disorder now? What are the new treatment options available for this disorder and how far have they helped a dermatologist to claim a cure for this disorder? These are some of the questions that will be addressed in this paper.

New advances in management

Medical therapies

The most recent advances on the medical front have been Narrowband Ultraviolet B (NB-UVB) therapy, Targeted Ultraviolet B (UVB), Excimer laser therapies, topical immunomodulator treatment in the form of topical calcineurin inhibitors, topical pseudocatalase, and topical Vitamin D analogues in combination with Ultraviolet (UV) light.

NB-UVB

NB-UVB, using UV-lamps with a peak emission of around 311nm has now emerged as the treatment of first choice in generalized vitiligo as well as vitiligo vulgaris (patchy vitiligo).^6,7,8The efficacy of NB-UVB in vitiligo was first demonstrated by Westerhof and Nieuwboer-Krobotova in 1997.⁹ Since then there have been a large number of clinical studies that have demonstrated the therapeutic benefit of NB-UVB in vitiligo patients. The mechanism of action of NB-UVB in vitiligo is through induction of local immunosuppression and stimulation of the proliferation of melanocytes in the skin and the outer root sheath of hair follicles.⁶ There is a stimulatory effect on melanogenesis and on the production of Melanocyte Stimulating Hormone (MSH).⁶Comparison studies have shown a significantly enhanced rate of repigmentation with NB-UVB compared with topical Psoralen and Ultraviolet A (PUVA) therapy.¹⁰Furthermore, the incidence of adverse effects seen commonly with topical PUVA, such as phototoxicity, is significantly reduced with the use of NB-UVB.

NB-UVB has shown a number of advantages over PUVA in vitiligo patients in addition to its excellent efficacy. These advantages include its extremely low side-effect profile particularly on the systemic front, its established safety in children, and safety in pregnant females. NB-UVB also has considerably better patient compliance as there is no need to time the exposure with any drug intake or any need for eye protection beyond treatment exposure time. A recent double-blind randomized¹¹ study comparing NB-UVB with PUVA demonstrated a much better efficacy with NB-UVB. The study found that repigmentation achieved with NB-UVB was much better with respect to colour matching with uninvolved skin, and this was also more persistent than that achieved with PUVA.¹¹

In addition NB-UVB has been used in childhood vitiligo with excellent results.¹² No additional adverse effects were seen in children with NB-UVB as compared with those in adults. Furthermore, given the long-term safety profile of NB-UVB in comparison with PUVA as far as skin malignancies are concerned,¹³ NB-UVB is now preferred over all other treatment options in the management of generalized vitiligo in both adults and children.

Table 1: Aetiological hypothesis of vitiligo⁵

Aetiological hypothesis	Brief explanation
Autoimmune hypothesis	Believes that vitiligo occurs because of destruction of melanocytes by an immune mechanism. Most favoured theory at present, supported by many recent in-vitro studies.
Auto-cytotoxic hypothesis	Believes that vitiligo occurs because of accumulation of toxic metabolites in the melanocytes secondary to a defect in their metabolic clearance of the toxins.
Neurogenic hypothesis	Believes that vitiligo is because of an altered reaction to neuropeptides, catecholamines and their metabolites by epidermal melanocytes.
Biochemical hypothesis	Believes that over-secretion of hydrobiopterin, a cofactor of tyrosine hydroxylase results in accumulation of catecholamines that in turn results in formation of reactive oxygen species in the melanocytes. These reactive oxygen species are thought to cause destruction of affected melanocytes in vitiligo patients.

NB-UVB has been used in combination with different topical agents to increase its efficacy and thus shorten the total duration of treatment. Treatment options that have been used with NB-UVB in vitiligo till date include topical tacrolimus,^14,15 pimecrolimus,¹⁶ Vitamin D analogues^17,18 and even topical pseudocatalase.¹⁹ While some studies have shown a synergistic effect with these combinations, others have found the efficacy of the combinations to be similar to NB-UVB alone. In one half-body comparison study, topical placental extract was used in combination with NB-UVB but the combination was shown to offer no added benefit than NB-UVB alone.²⁰Therefore, the ideal topical agent to be combined with NB-UVB remains unknown.

Laser Therapy

Excimer laser, which uses Xenon-Chlorine (Xe-Cl) gas and produces a monochromatic laser light of 308nm wavelength, is another innovative treatment option for vitiligo. The laser system has been used with increasing frequency over the last few years for targeted treatment of individual vitiligo lesions.²¹ The laser is used either alone or in combination with topical immunomodulator or PUVA-sol therapy.^22,23 Treatment with this laser is claimed to give extremely good and early results in both localized and segmental vitiligo. In a pilot study²¹ on 18 patients with 29 affected areas 57% of lesions showed varying degrees of repigmentation after just six exposures over two weeks. The figure was increased to 87% after 12 treatments over four weeks.²¹ Another recent study has reported a repigmentation of >75% in 61% of lesions after 30 treatments with Excimer laser. Repigmentation was found to be better on the face and trunk than on the extremities.²⁴

Topical therapies, particularly topical tacrolimus, have been used in combination with Excimer laser. This combination has been claimed to be more effective than Excimer laser alone.²² In a randomized right-left comparison study²² with 14 patients, Excimer light monotherapy was compared with a combination of Excimer laser with topical tacrolimus. While 20% of lesions treated with Excimer laser alone achieved >75% repigmentation, the same degree of repigmentation was obtained in 70% lesions with the combination treatment.²² Topical methoxsalen has also been used in combination with Excimer laser phototherapy and this has been claimed to have worked better than laser therapy alone.²³

The advantage of Excimer laser therapy over conventional UVB therapy is the targeted mode of treatment with no exposure of the uninvolved skin. Moreover, the onset of repigmentation is earlier with Excimer laser therapy than with UVB therapy.

Targeted UVB therapy

This is another recent innovation in vitiligo management that has arrived over the last few years. The beauty with this therapy is that it delivers high intensity UVB light only to the affected vitiliginous areas, avoiding any exposure to the uninvolved skin. This not only decreases the cumulative UVB dose received by an individual patient, but is also claimed to improve the efficacy of treatment quite significantly.

Targeted UVB therapy, as expected, finds its use more in the treatment of focal and segmental types of vitiligo. In fact, the first study²⁵ with targeted UVB therapy was done on eight patients with segmental vitiligo. Five of these patients achieved >75% repigmentation of their lesions with this therapy.²⁵

Targeted UVB therapy offers certain advantages over Excimer laser phototherapy. The treatment is safer and more efficacious compared with conventional UVB therapy, and almost as efficacious but much less costly than Excimer laser therapy.²⁶

Systemic immunomodulator therapy

Vitiligo is thought to be an immune-mediated disease and thus immune-suppressive and immunomodulator agents have been used on a regular basis in this disease. Among the immunosuppressants, systemic steroids have been the most commonly used. However, systemic steroid therapy has always been associated with a high incidence of adverse effects especially in children which is the age-group most commonly affected. To overcome this limitation, steroids have been given in pulse or even in mini-pulse form. A prospective study involving 14 patients with progressive or static vitiligo showed cessation of disease activity and a repigmentation rate of 10-

60% after high-dose methylprednisolone pulse therapy administered on three consecutive days.²⁷ Systemic steroids have also been administered in a mini-pulse form on two consecutive days every week, known as Oral Minipulse (OMP) therapy. The first study demonstrating the efficacy of OMP with oral betamethasone (0.1mg/kg with a maximum of 5mg) was described in 1991.²⁸ In a later study²⁹ on childhood vitiligo, betamethasone was replaced by oral methylprednisolone and combined with topical fluticasone ointment on the vitiligo lesions. The disease was arrested in >90% of patients, and >65% of children achieved good to excellent (>50%) repigmentation of their vitiligo lesions.²⁹

Topical Vitamin D analogues

Vitamin D analogues, particularly Calcipotriol, have been used topically either alone or in combination with topical steroids in the management of vitiligo. The basis for the use of these agents is that Vitamin D₃ affects the growth and differentiation of both melanocytes and keratinocytes. This has been further proved by the demonstration of receptors for 1 alpha-dihydroxyvitamin D3 on the melanocytes. These receptors are believed to have a role in stimulating melanogenesis.²⁹ Vitamin D analogues have given variable results in the treatment of vitiligo in different studies. These agents have also been used in combination with UV-light (including NB-UVB) and topical steroids with variable results.^30,31,32

Topical immunomodulators

Topical immunomodulators, such as tacrolimus and pimecrolimus, have been the most promising recent additions to topical vitiligo therapy. In fact because of their efficacy and a remarkable safety profile the use of these agents in vitiligo has shown a consistently increasing trend over the last few years. These agents can be safely administered in young children, as they don’t cause any atrophy or telangiectasia of the skin even after prolonged use. There is also no risk of hypothalamic-pituitary-adrenal (HPA) axis suppression as seen with the widespread use of potent topical steroids.³³ The first study that demonstrated the efficacy of tacrolimus in vitiligo was published in 2002.³⁴ In this study tacrolimus was used in six patients with generalized vitiligo and five of them achieved >50% repigmentation of their lesions by the end of study period.³⁴ Since then many additional studies have been published on this subject and have clearly demonstrated the role of topical tacrolimus in vitiligo. The best results with topical immunomodulator therapy have been seen on exposed parts of the body such as the face and neck and, as with any other therapy, the acral parts of the body respond the least.^34,35Similar results were obtained with the use of topical pimecrolimus in vitiligo patients.³⁶

Pseudocatalase

Pseudocatalase has been used in combination with Dead Sea climatotherapy or UVB exposure for the treatment of vitiligo. The basis for the use of this agent in vitiligo is the evidence of oxidative stress and high H₂O₂ levels in the lesional skin.³⁷ While some earlier studies³⁷demonstrated excellent results with this agent in inducing repigmentation in vitiligo, later studies have cast doubts on its efficacy.³⁸ Pseudocatalase is used topically on the lesional skin, and this is followed by UVB exposure to the whole body or to the lesional skin. The combination is claimed to correct the oxidative stress on melanocytes in vitiligo patients and thus lead to correction of the depigmentation.

Topical 5-Fluorouracil

Topical 5-fluorouracil is supposed to induce repigmentation of vitiligo lesions by overstimulation of follicular melanocytes which migrate to the epidermis during epithelialization.³⁹ This form of topical therapy can be combined with spot dermabrasion of the vitiligo lesions to improve the repigmentation response. In a study by Sethi et al,⁴⁰ a response rate of 73.3% was observed with a combination of spot dermabrasion and topical 5-fluorouracil after a treatment period of six months.⁴⁰

Surgical therapies

Surgical therapies for vitiligo have further increased the percentage cure of the disease by an appreciable degree, with the consequent increase of their use in the management of unresponsive vitiligo both in India and abroad. These surgical therapies, as a rule, are indicated in those patients who have a stable (non-progressive) disease of at least one year and not responding to medical treatment. In general the most important advantage with these procedures is that the chances of repigmentation of lesions are in the range of 90-100%. Moreover, these interventions are becoming better and easier to perform with every passing day.

Different surgical therapies that have been attempted in the management of vitiligo include autologous suction blister grafting, split-thickness grafting, punch grafting, smash grafting, single follicular unit grafting, cultured epidermal suspensions and autologous melanocyte culture grafting. All these grafting procedures, except the melanocyte culture grafting, are easy to perform and do not require any sophisticated instruments. These grafting techniques have now been divided into two types, tissue grafts and cellular grafts, depending on whether whole epidermal/dermal tissue is transplanted or the individual cellular compartment.

Tissue grafting technique

Suction blister grafting

Here, thin epidermal grafts are taken from suction blisters on the donor site, usually on the buttocks or thighs. These suction blisters are produced by applying sufficient negative pressure on the skin at the donor site by using a suction apparatus or syringes with three-way cannulae. The epidermal grafts are then transplanted on to dermabraded vitiligo lesions. This leads to repigmentation of the recipient areas with an excellent cosmetic matching. The ease of the procedure, the high success rate and the excellent cosmetic results have all made suction blister grafting the procedure of choice in vitiligo grafting.⁴¹

Split thickness grafting

In this grafting technique a thin split thickness graft is taken from a donor site with the help of a dermatome, Humby’s knife, Silver’s knife or a simple shaving blade. This graft is then transplanted on to dermabraded recipient areas. This technique also gives excellent cosmetic matching after repigmentation and the incidence of repigmentation in this technique is also quite high. In fact, most comparison studies on grafting techniques in vitiligo have shown that maximum repigmentation is achieved with either suction blister grafting or split thickness grafting.⁴¹ The advantage of partial thickness grafting over the suction blister method is that a relatively larger area of vitiligo can be tackled in a single sitting. Both partial thickness skin grafting as well as suction blister grafting can be followed up by NB-UVB to achieve faster and better results.

Miniature punch grafting

Here full-thickness punch grafts of 1.0 to 2.0 mm diameter are taken from a suitable donor site and then transplanted on to similar punch shaped beds on the recipient vitiligo lesions. The recipient area is then treated with either PUVA/PUVA-sol or topical steroids leading to spread of pigment from the transplanted punches to the surrounding skin. With time the whole of the recipient area gets repigmented. The advantages of this procedure are that it is easy to perform and can take care of a relatively larger vitiligo area compared with the above two procedures. Also vitiligo lesions with irregular or geographical shapes can be treated with this procedure. However there are certain limitations. There is the risk of ‘cobblestone appearance’, ‘polka-dot appearance’, and hypertrophic changes at the recipient site.⁴² All these side effects can be minimized by proper patient selection and by use of smaller sized punches of 1.0 to 1.5 mm diameter. Miniature punch grafting is presently the commonest surgical procedure performed in India on vitiligo patients.

Follicular unit grafting

In this technique, single-hair follicular units are harvested/prepared from a suitable donor area as in the case of hair transplantation. These follicular units are then cut above the level of the follicular bulb and then transplanted into vitiligo lesions. The idea behind this technique is that the melanocytes in the follicular unit are ‘donated’ to the vitiliginous skin and serve as a source of pigment at the recipient site. The repigmentation process here simulates the normal process of repigmentation of vitiliginous skin quite closely and thus gives an excellent cosmetic result. This procedure combines the advantages of punch grafting with the excellent cosmetic results of split thickness or blister grafting techniques.⁴³ The procedure is however tedious and needs good expertise on the part of the cosmetic surgeon.

Smash grafting

In this technique, a partial thickness graft is taken and is ‘smashed’, or cut into very small pieces, by means of a surgical blade on a suitable surface such as a glass slide. This ‘smashed’ tissue is then transplanted on to the dermabraded recipient skin and covered with a special powder or corrugated tube dressing so as to keep the smash-graft undisturbed on the recipient area. The advantage of this technique, over a simple partial thickness grafting, is that thicker grafts can be used with a good cosmetic result. The procedure has been indicated for those who are relatively inexperienced and cannot take an ideal, thin and transparent partial thickness graft from the donor area.⁴⁴

Cellular grafting techniques

Non-cultured epidermal suspensions

Here a split-thickness graft is taken from a donor area and then incubated overnight. On the next day the cells are mechanically separated using trypsin-EDTA solution and then centrifuged to prepare a suspension. This cell suspension is then applied to the dermabraded vitiligo lesions, and a collagen dressing is applied to keep it in place. A relatively large area of vitiligo, about ten times the size of the donor graft can be taken care of with this procedure.⁴⁵ The recipient area however has to be treated with either NB-UVB or PUVA for two to three months to achieve the desired pigmentation.

Melanocyte culture transplantation

This is a relatively more advanced grafting procedure where, once again, a split-thickness graft is taken from a donor area and incubated in an appropriate culture medium to grow the melanocytes or the keratinocytes-melanocyte combination in vitro. The cultured cells are then applied onto laser dermabraded, or even mechanically abraded, lesional skin.^46,47 The procedure is obviously more difficult to perform, as it needs the advanced laboratory facilities for melanocyte culture. However the results with this procedure are excellent and a relatively large area of involved skin can be tackled by a single donor graft.

Summary

Table 2 summarises the above discussion of treatment options in vitiligo.

Table 2: New treatment options in vitiligo

Medical therapies and phototherapy	Surgical therapies
Narrowband UVB therapy either alone or in combination with immunomodulators, Vitamin D analogues etc. Excimer laser therapy Targeted UVB phototherapy Topical immunomoulators Topical Vitamin D analogues Topical pseudocatalase with UVB Oral minipulse steroid therapy	Suction blister skin grafting Partial thickness skin grafting Miniature punch grafting Follicular skin grafting Smash grafting Non-cultured epidermal cell transplant Melanocyte culture transplant

Acknowledgements / Conflicts / Author Details

Competing Interests:

None Declared

Details of Authors:

IMRAN MAJID, MD, MBBS. Assistantt Professor in Dermatology, Govt Medical College, Srinagar Kashmir, India

Corresponding Author Details:

Dr Imran Majid, Department of Dermatology, Governmentt Medical College, Srinagar, India

Corresponding Author Email:

imran54@yahoo.com

References

References:

1. Lerner AB. Vitiligo. J Invest Dermatol 1959;32:285-310.

2.      Hautmann G, Panconesi E. Vitiligo: a psychologically influenced and influencing disease. Clin Dermatol 1997;15:875-78.
3.      Mattoo SK, Handa S, Kaur I, Gupta N, Malhotra R. Psychiatric morbidity in vitiligo: prevalence and correlates in India. J Eur Acad Dermatol Venereol 2002;16:573-8.
4.      Aghaei S, Sodaifi M, Jafari P, Mazharinia N, Finlay AY. DLQI scores in vitiligo: reliability and validity of the Persian version. BMC Dermatol 2004;4:8.
5.      Kostovic K, Pasic A. New treatment modalities for vitiligo: focus on topical immunomodulators. Drugs 2005;65:447-59.
6.      Njoo MD, Spuls PL Bos JD et al. Nonsurgical repigmentation therapies in vitiligo: meta-analysis of the literature. Arch Dermatol 1998;134:1532-40.
7.      Scherschun L, Kim JJ, Lim HW. Narrow-band ultraviolet B is a useful and well-tolerated treatment for vitiligo. J Am Acad Dermatol 2001;44:999-1003.
8.      Njoo MD, Boss JD, Westerhof W. Treatment of generalised vitiligo in children with narrow-band (TL-01) UVB radiation therapy. J Am Acad Dermatol 2000;42:245-53.
9.      Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vs topical psoralen plus UV-A. Arch Dematol 1997;133:1525-28.
10.   Natta R, Somsak T, Wisuttida T, Laor L. Narrow-band ultraviolet B radiation therapy for recalcitrant vitiligo in Asians. J Am Acad Dermatol 2003;49:472-76.
11.   Yones SS, Palmer RA, Garibaldinos TM, et al. Randomized double-blind trial of treatment of vitiligo: Efficacy of psoralen-UVA therapy vs. narrowband-UVB therapy. Arch Dermatol 2007;143:578-84.
12.   Njoo Njoo MD, Boss JD, Westerhof W. Treatment of generalised vitiligo in children with narrow-band (TL-01) UVB radiation therapy. J Am Acad Dermatol 2000;42:245-53.
13.   Hearn RMR, Kerr AC, Rahim KF Ferguson J, Dawe RS. Incidence of skin cancers in 3867 patients treated with narrowband ultraviolet B phototherapy. Br J Dermatol 2008;159:931-5.
14.   Fai D, Cassano N, Vena GA. Narrowband UVB phototherapy combined with tacrolimus ointment in vitiligo: a review of 110 patients. J Eur Acad Dermatol Venereol 2007;21:916-20.
15.   Mehrabi D, Pandya AG. A randomized, placebo-controlled, double-blind trial comparing narrowband UV-B plus 0.1% tacrolimus ointment with narrowband UV-B plus placebo in the treatment of generalized vitiligo. Arch Dermatol 2006;142:927-9.
16.   Esfanduarpour I, Ekhlasi A, Farajedah S, Shamsadini S. The efficacy of 1% pimecrolimus cream plus ultraviolet B in the treatment of vitiligo: a double-blind, placebo-controlled clinical trial. J Dermatolog Treat 2009;20:14-18.
17.   Goktas EO, Aydin F, Senturk N, Canturk MT, Turanli AY. Combination of narrow-band UVB and topical calcipotriol for the treatment of vitiligo. J Eur Acad Dermatol Venereol 2006;20:553-7.
18.   Leone G, Pacifico P, Lacovelli P Vidolin A Paro, Picardo M. Tacalcitol and narrow-band phototherapy in patients with vitiligo. Clin Exp Dermatol 2006;31:200-05.
19.   Schallreuter KU, Wood JM, Lemke KR, Levenig C. Treatment of vitiligo with a topical application of pseudocatalase and calcium in combination with short-term UVB exposure: a case study on 33 patients. Dermatology 1995;190:181-82.
20.   Majid I. Topical placental extract: Does it increase the efficacy of Narrowband UVB therapy in vitiligo. Indian J Dermatol Venereol Leprol 2010;76:254-8.
21.   Baltas E, Csoma Z, Ignacz et al. Treatment of vitiligo with the 308nm xenon chloride excimer laser. Arch Dermatol 2002;138:1116-20.
22.   Kawalek AZ, Spencer JM, Phelps RG. Combined excimer laser and topical tacrolimus for the treatment of vitiligo: a pilot study. Dermatol Surg 2004; 30: 130-35.
23.   Grimes PE. Advances in the treatment of vitiligo: targeted phototherapy. Cosmet Dermatol 2003;140:1065-69.
24.   Zhang XY, He YL, Dong J, Xu JZ, Wang J. Clinical efficacy of a 308nm excimer laser in the treatment of vitiligo. Photodermatol Photoimmunol Photomed 2010;26:138-42.
25.   Lotti TM, Menchini G, Andreasi L. UV-B radiation microphototherapy: an elective treatment for segmental vitiligo. J Eur Acad Dermatol Venereol 1999;113:102-08.
26.   Menchini G, Tsoureli-Nikita E, Hercogova J. Narrowband UV-B microphototherapy: a new treatment for vitiligo. J Eur Acad Dermatol Venereol 2003; 17: 171-77.
27.   Seiter S, Ugurel C, Pfohler W, Tilgen W, Reinhold U. Successful treatment of progressive vitiligo with high-dose intravenous methylprednisolone pulse therapy. Dermatology 1999;199:261-62
28.   Pasricha JS, Khaitan BK. Oral minipulse therapy with betamethasone in vitiligo patients having extensive or fast spreading disease. Int J Dermatol 1993;31:753-7.
29.   Majid I, Masood Q, Hassan I, Khan D, Chisti M. Childhood vitiligo: Response to methylprednisolone oral minipulse therapy and topical fluticasone combination. Indian J Dermatol 2009;54:124-7.
30.   Prasad D, Saini R, Nagpal R.Topical Calcipotriol in vitiligo: a preliminary study. Pediatr Dermatol 1999;16:317-20.
31.   Prasad D, Saini R, Verma N. Combination of PUVAsol and topical Calcipotriol in vitiligo. Dermatology 1998;197:167-70.
32.   Baysal V, Yildirim M, Erel A, Yilmaz E. Is the combination of Calcipotriol and PUVA effective in vitiligo? J Eur Acad Dermatol Venereol 2003;17:299-302.
33.   Plettenberg H, Assmann T, Ruzicka T. Childhood vitiligo and tacrolimus. Immunomodulatory treatment for an autoimmune disease. Arch Dermatol 2003;139:651-54.
34.   Grimes PE, Soriano T, Dytoc MT. Topical tacrolimus for the repigmentation of vitiligo. J Am Acad Dermatol 2002;47:789-91.
35.   Xu AE, Zhang DM, Wei XD, et al. Efficay and safety of tacrolimus cream 0.1% in the treatment of vitiligo. Int J Dermatol 2009;48:86-90.
36.   Mayoral FA, Gonzalez C, Shah NS, Arciniegas C. Repigmentation of vitiligo with pimecrolimus cream: a case report. Dermatology 2003;207:322-23.
37.   Schallreuter KU, Moore J, Behrens Williams S et al. Rapid initiation of repigmentation in vitiligo with Dead Sea climatotherapy in combination with pseudocatalase. Int J Dermatol 2002;41:482-87.
38.   Patel DC, Evans AV, Hawk JL. Topical pseudocatalase mousse and narrowband UVB phototherapy is not effective for vitiligo: an open, single-centre study. Clin Exp Dermatol 2003;28:562-63.
39.   Tsuji T, Hamada T. Topically administered fluorouracil in vitiligo.Arch Dermatol 1983;119:722-27.
40.   Sethi S; Mahajan BB; Gupta RR; Ohri A. Comparative evaluation of the therapeutic efficacy of dermabrasion, dermabrasion combined with topical 5% 5-fluorouracil cream, and dermabrasion combined with topial placentrex gel in localized stable vitiligo. Int J Dermatol 2007;46:875-9.
41.   Njoo MD, Westerhof W, Bos JD, Bossuyt PM. A systematic review of autologous transplantation methods in vitiligo. Arch Dermatol 1998;134:1543-49.
42.   Falabella R. Treatment of localized vitiligo by autologous minigrafting. Arch Dermatol 1988;124:169-55.
43.   Rusfianti M, Wirohadidjodjo YW. Dermatosurgical techniques for repigmentation of vitiligo. Int J Dermatol 2006;45:411-17.
44.   Patwardhan N. Conference report ACSICON 2008. J Cutan Aesthet Surg 2009;2:47-8.
45.   Mulekar SV. Long-term follow-up study of segmental and focal vitiligo treated by autologous, noncultured melanocyte-keratinocyte cell transplantation. Arch Dermatol 2004; 140: 1273-74.
46.   Chen YF, Yang PY, Hu DN et al. Treatment of vitiligo by transplantation of cultured pure melanocyte suspension: analysis of 120 cases. J Am Acad Dermatol 2004;51:68-74.
47.   Piangiani E, Risulo M, Andreassi A et al. Autologous epidermal cultures and narrow-band ultraviolet B in the surgical treatment of vitiligo. Dermatol Surg 2005;31:155-59.

Psychological Distress in Carers of People with Mental Disorders

Authors

Aadil Jan Shah, Ovais Wadoo and Javed Latoo

Article Citation and PDF Link

BJMP 2010;3(3):a327

http://bjmp.org/files/2010-3-3/bjmp-2010-3-3-a327.pdf

Abstract / Summary

Abstract:

The recent literature on carers’ burden in mental disorders is reviewed. Families bear the major responsibility for such care. Carers face mental ill health as a direct consequence of their caring role and experience higher rates of mental ill health than the general population. The production of burden in carers is a complex process and is related to gender, age, health status, ethnic and cultural affiliation, lack of social support, coping style, in addition to the stressors of the disorder itself. Carers appear to suffer from at least moderate levels of psychological symptomatology. The behavioural problems associated with mental disorders further increase the stress levels of carers. The findings from the review afford a comprehensive understanding of the care-giving situation with its outcomes, and its practical application in devising effective support strategies for family carers.

Keywords:

Carers, caregivers, care recipients, psychological distress, burden, stress, mental disorders.

Introduction

Carers play a vital role in supporting family members who are sick, infirm or disabled.¹ There is no doubt that the families of those with mental disorders are affected by the condition of their near ones. Families not only provide practical help and personal care but also give emotional support to their relative with a mental disorder. Therefore the affected person is dependent on the carer, and their well-being is directly related to the nature and quality of the care provided by the carer. These demands can bring significant levels of stress for the carer and can affect their overall quality of life including work, socializing and relationships. Research into the impact of care-giving shows that one-third to one-half of carers suffer significant psychological distress and experience higher rates of mental ill health than the general population. Being a carer can raise difficult personal issues about duty, responsibility, adequacy and guilt.² Caring for a relative with a mental health problem is not a static process since the needs of the care recipient alter as their condition changes. The role of the carer can be more demanding and difficult if the care recipient’s mental disorder is associated with behavioural problems or physical disability. Over the past few decades, research into the impact of care-giving has led to an improved understanding of this subject including the interventions that help. It has now been realized that developing constructive working relationships with carers, and considering their needs, is an essential part of service provision for people with mental disorders who require and receive care from their relatives.

The aim of this review was to examine the relationship between caring, psychological distress, and the factors that help caregivers successfully manage their role.

‘Family burden’ - The role of families as carers

Caring for someone with a mental disorder can affect the dynamics of a family. It takes up most of the carers’ time and energy. The family’s responsibility in providing care for people with mental disorders has increased in the past three decades. This has been mainly due to a trend towards community care and the de-institutionalization of psychiatric patients.³ This shift has resulted in the transferral of the day-to-day care of people with mental disorders to family members. Up to 90% of people with mental disorders live with relatives who provide them with long-term practical and emotional support.^{4, 5} Carer burden increases with more patient contact and when patients live with their families.⁶ Strong associations have been noted between burden (especially isolation, disappointment and emotional involvement), caregivers’ perceived health and sense of coherence, adjusted for age and relationship.⁷

‘Family burden’ has been adopted to identify the objective and subjective difficulties experienced by relatives of people with long-term mental disorders.⁸ Objective burden relates to the practical problems experienced by relatives such as the disruption of family relationships, constraints in social, leisure and work activities, financial difficulties, and negative impact on their own physical health. Subjective burden describes the psychological reactions which relatives experience, e.g. a feeling of loss, sadness, anxiety and embarrassment in social situations, the stress of coping with disturbing behaviours, and the frustration caused by changing relationships.⁹ Grief may also be involved. This may be grief for the loss of the person’s former personality, achievements and contributions, as well as the loss of family lifestyle.¹⁰ This grief can lead to unconscious hostility and anger.^9,10

The impact of caring on carers’ mental health

The vehicles of psychological stress have been conceptualized as adjustment to change,¹¹ daily hassles,¹² and role strains.¹³ Lazarus and Folkman (1984)¹⁴ define stress as ‘a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well being.’ The association between feelings of burden and the overall caregiver role is well documented.¹⁵ Caregivers provide assistance with activities of daily living, emotional support to the patient, and dealing with incontinence, feeding, and mobility. Due to high burden and responsibilities, caregivers experience poorer self-reported health, engage in fewer health promotion actions than non-caregivers, and report lower life satisfaction.^{16, 17}

The overarching theme from the findings is that carers and care recipients do not believe that care recipients’ basic needs are being met, which causes them a great deal of distress and anger towards services and increases carer burden. Carers assert that the needs of care recipients and carers are interconnected and should not be seen as separate.¹⁸The stress in carers is best understood by Pearlin`s stress-process model as shown in Figure 1.

Figure 1: Pearlin’s stress–process model of stress in carers (adapted from Pearlin et al, 1990)

The burden and depressive symptoms sustained by carers have been the two most widely studied care-giving outcomes. Reports indicate that depressive symptoms are twice as common among caregivers than non-caregivers.¹⁹ Family caregivers who have significantly depressed mood may be adversely affected in their ability to perform desirable health-maintenance or self-care behaviours in response to symptoms.²⁰ Family caregivers experience more physical and mental distress than non-caregivers in the same age group.¹⁶ Several studies suggest that many caregivers are at risk of experiencing clinical depression.²¹ Nearly half of the caregivers in some studies were reported to meet the diagnostic criteria for depression when structured clinical interviews were used.²² There is also some evidence to suggest that a diagnosis of depression can be causally related to the care-giving situation. Dura et al (1991)²³ found that nearly one quarter of caregivers met the criteria for depression whilst in the care-giving role, although they had never been diagnosed with depression prior to their assumption of this role. It has been proven that if the problem behaviours and the functional impairment in the care recipients is worse, the strain score is higher and the carer is more likely to be depressed.²⁴ The societal implications of this are underscored by reports indicating that the stressed caregiver is more likely to institutionalize the care recipient.^{25, 26}

The impact of caring for different mental disorders

The impact of caring for different mental disorders, and associated risk factors, is shown in table 1. Although only limited data is available on the psychological distress experienced by the carers of people with other mental disorders, it seems that these disorders have a significant impact on families. Obsessive-compulsive disorder has a considerable impact on families and can lead to a reduction in social activities, causing isolation over time.³⁸ People with obsessive-compulsive symptoms frequently involve their relatives in rituals.³⁸ This can lead to an increase in anger and criticism towards them which has a negative impact on treatment outcomes.³⁸ Caring for patients with eating disorders can be overwhelming for the carer. Available data suggest that the impact on carers of persons with anorexia nervosa may be even higher than for psychoses.³⁹ Studies on bulimia nervosa indicate that carers have significant emotional and practical needs.⁴⁰

Table 1: The impact of caring for different mental disorders and associated risk factors
Mental Disorder	Risk factors	Impact on the carer
Schizophrenia²⁸	High disability, very severe symptoms, poor support from professionals, poor support from social networks, less practical social support, violence.	Guilt, loss, helplessness, fear, vulnerability, cumulative feelings of defeat, anxiety, resentment, and anger are commonly reported by caregivers.
Dementia ^29,30	Decline in cognitive and functional status, behavioural disturbances, dependency on assistance^.31	Anger, grief, loneliness and resentment.
Mood disorders	Symptoms, changes in family roles, cyclic nature of bipolar disorder, moderate or severe distress.³²	Significant distress,³³ marked difficulties in maintaining social and leisure activities, decrease in total family income, considerable strains in marital relationships.^{34, 35} Psychological consequences during critical periods also persisting in the intervals between episodes in bipolar disorder,³⁶ poorer physical health, limited activity, and greater health service utilization than non-caregivers.³⁷

Table 2: Risk factors for carer psychological distress
Caregiver factors	Research findings
Gender	· Women have higher rates of depression than men in the care-giving role.⁴² · 39% of female caregivers, compared to 16% of male caregivers, qualified as being at-risk for clinical depression on The Center for Epidemiologic Studies-Depression Scale (CES-D).⁴³ · A randomized controlled trial⁴⁴found that women were more likely than men to comply with a home environmental modification intervention, implement recommended strategies, and derive greater benefits. · Male carers tend to have more of a ‘managerial’ style that allows them to distance themselves from the stressful situation to some degree by delegating tasks.⁴⁵
Age	· Age-associated impairments in physical competence make the provision of care more difficult for older caregivers. · There is a positive association of age and caregiver burden in Whites, but a negative association for African-Americans suggesting that older African-Americans are less likely to experience care-giving as physically burdensome.⁴⁶
Caregiver health	^·Caregiver health has also been identified as a significant predictor of caregiver depression.⁴⁶ ^·Poorer physical health among caregivers than age-matched peers. Such health problems are linked to an increased risk of depression.⁴⁷ ^·Longitudinal studies demonstrated that caregivers are at a greater risk, than non-care-giving age-matched controls, for developing mild hypertension and have an increased tendency to develop a serious illness⁴⁸ as well as increased risk for all-cause mortality.⁴⁹
Ethnicity	· Ethnicity has substantial impact on the care-giving experience.⁴¹ · Comprehensive reviews of the literature have identified differences in the stress process, psychological outcomes, and service utilization among caregivers of different racial and ethnic backgrounds.⁵⁰ · Studies consistently show important differences in perceived burden and depression among African-American, White, and Hispanic family caregivers.⁵¹ · Caucasian caregivers tend to report greater depression and appraise care-giving as more stressful than African-American caregivers.⁵² · Hispanic caregivers report greater depression and behavioural burden than Caucasians and African-Americans.⁵³
Social support	^·Social support has profound effects on caregiver outcomes. ^·More social support corresponds to less depressive symptomatology⁴⁷ and lower perceived burden.⁵⁴ ^·Care-giving is associated with a decline in social support, and increased isolation and withdrawal.⁵⁵ ^·Social support and caregiver burden have been found to mediate depression in caregivers.⁵⁵ ^·Social support has other important functions in that carers may find out about services from people who have used them before and form a network with others in similar situations.⁴¹

Factors associated with psychological distress of the carer

Risks for carer psychological distress or depression are related to gender, age, health status, ethnic and cultural affiliation, lack of social support, as well as certain other characteristics related to the caregiver (table 2).⁴¹

Some of the patient factors related to psychological distress in carers are: behavioural disturbances, functional impairments, physical impairments, cognitive impairments, and fear that their relative may attempt suicide.

The frequency with which behavioural disturbances are manifested by the patient has been identified as the strongest predictor of caregiver distress and plays a significant role in the caregivers decision to institutionalize the patient.²⁵ The literature consistently demonstrates that the frequency of behavioural problems is a more reliable predictor of caregiver burden and depression than are the functional and cognitive impairments of the individual.⁵⁶ Carers face unfamiliar and unpredictable situations which increases stress and anxiety. Anxiety may be increased by behavioural problems of patients who cannot be successfully managed on a consistent basis.⁵⁶ Anxiety is associated with depression, stress, and physical ill health.⁵⁶

Findings regarding the relationship of functional impairment and negative caregiver outcomes have been inconclusive. Some studies document a weak association of objective measures of patient functional status and caregiver burden/depression,⁵⁷ whereas others report a stronger relationship.⁵⁴ Carers have reported great anxiety due to fear that their relative may attempt suicide.⁵⁸ Carers of people with both physical and cognitive impairments have higher scores for objective burden of caring than those caring for people with either type of impairment alone.⁵⁸ In contrast, scores for limitations on their own lives were higher among women caring for people with cognitive impairments (with or without physical impairments).⁵⁹

Coping styles and interventions to reduce psychological distress in carers

There is increasing interest in examining the factors that help caregivers successfully manage their role, while minimizing the effect on their mood and general well-being.⁶⁰ Much of this research has been done within the general framework of stress and coping theory,⁶¹ examining coping styles of caregivers and the relationship between types of coping styles and reported symptoms of depression.⁶² A variety of interventions have been developed which support caregivers (table 3). Interventions include: training and education programs, information-technology based support, and formal approaches to planning care which take into account the specific needs of carers, sometimes using specially designated nurses or other members of the health care team.⁶³

Ballard et al (1995)⁶⁴ demonstrates that a higher level of carer education regarding dementia increases carers’ feelings of competency. This is more likely to reduce their expectations of their dependents’ abilities. Previous studies which have looked at these coping strategies and feelings of competence have shown that unrealistic expectations of a dependant increases carers’ risk of depression,⁶⁵ and conversely a reduction of carers’ expectations is associated with lower rates of depression.⁶⁶ Caregivers who maintain positive feelings towards their relative have a greater level of commitment to caring and a lower level of perceived strain.⁶⁷ Furthermore, carers who experience feelings of powerlessness, lack of control, and unpreparedness have higher levels of depression.⁶⁵ The most effective treatments in depression of carers appear to be a combination of education and emotional support.⁶⁸

Spiritual support can also be considered a coping resource and has been studied in older African-Americans and older Mexican-Americans.⁶⁹ Previous work examining the role of spiritual support observed that African-American caregivers report higher spiritual rewards for caregiving,⁷⁰ and reliance on prayer and church support.⁷¹

Religious coping plays a paramount role, and it is often present at higher levels for African-Americans and Hispanics. For REACH caregivers, Coon et al (2004)⁷² found that religious coping is greater for Hispanic and African-American than for White caregivers. Religious involvement is frequently associated with more access to social support as well.⁷³

Anecdotal literature⁷⁴ suggests that caregivers who use more active coping strategies, such as problem solving, experience fewer symptoms of depression than do those who rely on more passive methods. Significant associations have been reported between positive strategies for managing disturbed behaviour, active strategies for managing the meaning of the illness, and reduced levels of caregiver depression. An important role for health-care professionals is in helping caregivers enhance their coping skills, supporting existing skills, and facilitating the development of new ones.⁶⁶

Table 3: Coping styles and interventions to reduce psychological distress in carers

An important role for health-care professionals is in helping caregivers enhance their coping skills, supporting existing skills and facilitating the development of new ones.

· Training and education programs

· Information-technology based support

· Formal approaches to planning care

· Combination of education and emotional support

· Spiritual support

· Religious coping

· Positive strategies for managing disturbed behaviour

· High quality of informal relationships and presence of informal support

· Psychotherapy

· Cognitive-behavioural family intervention

Care-giving has some positive associations for caregivers, including pride in fulfilling spousal responsibilities, enhanced closeness with a care receiver, and satisfaction with one's competence.⁷⁵ These perceived uplifts of care-giving are associated with lower levels of caregiver burden and depression.⁷⁶However perceived uplifts are more common among caregivers of colour than among Whites.⁷⁷

High quality of informal relationships, and the presence of informal support, is related to lower caregiver depression⁷⁸ and less deterioration in the emotional health for African-American caregivers, but not for Whites.⁷⁹ Support of caregivers by others help to alleviate stress if the supporter is understanding and empathic.⁷⁴ In one study, caring for a family member was not perceived to be a burden, and caregivers reported notable limitations on their social networks and social activities. They reported higher levels of unemployment than would be expected for the general population and were over-represented in lower income groups. Family carers are at high risk of social and economic disadvantage and at high risk of mental health challenges.⁸⁰ Highly stressed persons may not be able to benefit from attempted social support of others as much as moderately stressed persons.⁸¹

Caregivers need to have the opportunity to learn more effective ways of coping with stress. If they can learn new ways to cope, they can reduce their anxiety and reliance on treatments.⁴¹ Bourgeois et al (1997)⁸² report that caregiver’s behavioural skills and effective self-management training programmes result in a lower frequency of patient behavioural problems and helps to improve the caregiver’s mood. Stevens and Burgio (2000)⁸³ designed a caregiver intervention that teaches caregivers behavioural management skills to address problem behaviours exhibited by individuals with dementia, as well as problem-solving strategies to increase pleasant activities for the caregiver. Passive coping styles have been associated with greater burden. Persons who use an escape-avoidance type of coping are known to have more depression and interpersonal conflicts.⁴¹

Psychotherapy may be of some benefit in patients with early dementia but, due to cognitive loss, some adaptation of the technique is required and the involvement of carers is often necessary.⁸⁴ Cognitive-behavioural family intervention can have significant benefits in carers of patients with dementia and has a positive impact on patient behaviour.⁸⁵ From a cognitive perspective, care-giving plays an important invisible part, which consists of interpreting the care receiver's behaviour, reflecting on the best way to adjust to it, and defining care objectives.⁸⁶ The interventions requiring active participation by the caregivers and those based on cognitive behavioural therapy can produce significant reductions in burden, anxiety and depression than those focused on knowledge acquisition.⁸⁷

Among caregivers with depressive symptoms, 19% used antidepressants, 23% antianxiety drugs, and 2% sedative hypnotics. African-American caregivers were less likely than Whites to be taking antidepressants.⁸⁸ In their study, Kales et al (2004)⁸⁹ reported use of herbal products in 18% of elderly subjects with depression and/or dementia and in 16% of their caregivers.

In the Burdz et al (1988)⁹⁰ study, respite care proved to have a positive effect on the burden experienced by the caregivers, and it also had a positive effect, against all expectations, on the cognitive and physical functioning of the persons with dementia.

There are more than twenty instruments that could be used as outcome measures with mental health carers and have good psychometric properties. They can measure (i) carers' well-being, (ii) the experience of care-giving and (iii) carers' needs for professional support.⁹¹ The caregiver burden scale and the sense of coherence scale seem to be highly useful for identifying carers at risk of stress, the pattern of burden, and coping strategies. Nurses can help family caregivers to identify their negative experiences about care-giving and can help them reflect upon their coping strategies to find balance in their situation. Risk groups of caregivers may be identified, especially those with a low perceived health and sense of coherence, for early interventions to reduce burden.⁷

Conclusion

The impact of caring for someone with mental illness brings the risks of mental ill health to the carer in the form of emotional stress, depressive symptoms, or clinical depression. Most individuals with mental disorders live in their own homes and are cared for by a family member. The caring process can be very taxing and exhausting, especially if the care recipient has a severe mental disorder. Providing such long-term care can be a source of significant stress. The behavioural problems associated with mental disorders further increase the stress levels of the carer and therefore impacts significantly on their mental health.

Carers face mental ill health as a direct consequence of their caring role and experience higher rates of mental ill health than the general population. This leads to negative effects on the quality of life of the carer and the standard of care delivered. Efforts to identify and treat caregiver psychological distress will need to be multidisciplinary, require consideration of the cultural context of the patient and caregiver, and focus on multiple risk factors simultaneously. The findings of the review underline the importance for early identification of carers, effective carer support, health promotion, monitoring high-risk groups, and timing appropriate interventions.

Acknowledgements / Conflicts / Author Details

Competing Interests:

None Declared

Details of Authors:

AADIL JAN SHAH, MBBS, MRCPsych, Cheshire and Wirral Partnership NHS Foundation Trust, UK OVAIS WADOO, MBBS, MRCPsych, Mersey Care NHS Trust, UK JAVED LATOO, MBBS, DPM, MRCPsych, North East London NHS Foundation Trust, UK

Corresponding Author Details:

Dr. Aadil Jan Shah, MBBS, MRCPsych, Speciality Registrar, General Adult Psychiatry, Cheshire and Wirral Partnership NHS Foundation Trust, Address: Early Intervention Team, Cherry Bank Resource Centre, 85 Wellington Road, Ellesmere Port, Chester CH65 0BY

Corresponding Author Email:

aadilshah@nhs.net

References

References:

1. Singleton, N., Maung, N. A., Cowie, J., et al. Mental Health of Carers. London: Office for National Statistics,2002.2. Oyebode JR.Carers as partners in mental health services for older people. Advances in Psychiatric Treatment.2005; 11: 297-3043. Magliano L., McDaid D., Kirkwood S. and Berzins K. Carers and families of people with mental health problems. In: Mental health policy and practice across Europe (eds). M. Knapp, D. McDaid, E. Mossialos, G. Thornicroft), pp. 374-396, McGraw-Hill: Berkshire.2007.4. Ostman M. and Hansson L. Stigma by association. British Journal of Psychiatry.2002; 181: 494-498.5. Lauber C., Eichenberger A. and Luginbuhl P. Determinants of burden in caregivers of patients with exacerbating schizophrenia. European Psychiatry.2003; 18: 285-289.6. Schulze, Beate. Caregiver Burden in Mental Illness: Review of Measurement, Findings and Interventions, 2004-2005. Current Opinion in Psychiatry.2005; 18(6).7. Andren, Signe,Elmstahl, Solve. The relationship between caregiver burden, caregivers' perceived health and their sense of coherence in caring for elders with dementia. Journal of Clinical Nursing,2008;vol./is. 17/6(790-799), 0962-1067;1365-2702.8. Hoenig J. and Hamilton M. The schizophrenic patient and his effect on the household. International Journal of Social Psychiatry.1966; 12: 165-1769. Ostman, M. and L. Hansson. Appraisal of caregiving, burden and psychological distress in relatives of psychiatric inpatients. European Psychiatry.2004; 19: 402-407.10. Magliano L., Fiorillo A., De Rosa C., Malangone C. and Maj M. Family burden in long-term diseases: a comparative study in schizophrenia vs. physical disorders. Social Science and Medicine.2005a; 61: 313-322.11. Holmes, T .H., and Rahe,R.H.The social readjustment rating scale.J.Psychosom.Res.1967; 11:213-218.12. Kanner,A. D.,Coyne, J.D.,Schaefer, C., and Lazarus,R. S.Comparison of two modes of stress measurement: Daily hassles and uplifts versus major life events.J.Behav.Med.1981;4:1-39.13. Pearlin,L.I.Role strains and personal stress. In Kaplan, H.B. (ed.), Psychosocial stress: Trends in Theory and Research, Academic Press, New York, pp.3-32.1983.14. Lazarus, R.S., & Folkman, S. Stress, Appraisal and Coping. New York: Springer.1984.15. Deimling,G.T;Bass,D.M;Townsend,A.L;and Noelker,L.S.Care Related stress: A comparison of spouse and adult child caregivers in shared and seperate households. Journal of Ageing and health.1989;1,67-82.16. Amirkhanyan, A.A., & Wolf, D.A. Caregiver stress and noncaregiver stress: Exploring the pathways of psychiatric morbidity. Gerontologist.2003; 43, 817-827.17. Danhauer, S.C.,McCann, J.J., Gilley,D.W., Beckett, L.A., Bienias, J. L., & Evans, D.A.Do behavioural disturbances in persons with Alzheimer's disease predict caregiver depression over time? Psychology and Aging.2004; 19, 198-202.18. Askey, Ryan,Holmshaw, Janet,Gamble, Catherine,Gray, Richard.What do carers of people with psychosis need from mental health services? Exploring the views of carers, service users and professionals. Journal of Family Therapy.2009;vol./is. 31/3(310-331), 0163-4445;1467-6427.19. Canadian Study of Health and Aging Working Group.Canadian Study of Health and Aging: Study methods and prevalence of dementia. Canadian Medical Association Journal.1994a; 150, 899-913.20. Yvonne Yueh-Feng Lu and Mary Guerriero Austrom. Distress Reponses and Self- Care Behaviours in Dementia Family Caregivers With High and Low Depressed Mood: J Am Psychiatr Nurses Assoc, 2005; 11(4), 231-240.21. Gallant, M.P., & Connel, C.M.Predictors of decreased self-care among spouse caregivers of older adults with dementing illnesses. Journal of Aging and Health.1997;9, 373-395.22. Gallagher,D.,Rose,J.,Rivera,P.,Lovett,S.,&Thompson,L.W.Prevalence of depression in family caregivers.The Gerontologist.1989;29,449-456.23. Dura,J.R;Stukenberg,K.W;and Kiecolt-Glaser,JK..Anxiety and depressive disorders in adult children caring for demented parents.Psychology and ageing.1991;6,467-473.24. Molyneux, C. J,McCarthy, G. M,McEniff, S,Cryan, M,Conroy, R. M. Prevalence and predictors of carer burden and depression in carers of patients referred to an old age psychiatric service. International Psychogeriatrics.2008; vol./is. 20/6(1193-1202), 1041-6102;1741-203X25. Cohen,D; Luchins,D; Eisdorfer,C;Paveza,G; Ashford,J.W;Gorelic,P; Hirsehman,R;Freels,S;Levy,P;Semla,T;&Shaw,H.Caring for relatives with Alzheimers Disease:The Mental Health Risks to Spouses,Adult children and other family caregivers.Behaviour,Health,and Ageing.1990;1,171-182.26. Colerick,E.J;&George,L.K.Depression among Alzheimer's caregivers:Identifying risk factors.American Journal ..Journal of the American Geriatrics Society.1986;34,493-498.27. Magliano L., Marasco C., Fiorillo A., Malangone. C., Guarneri M. and Maj M. The impact of professional and social network support on the burden of families of patients with schizophrenia in Italy. Acta Psychiatrica Scandinavica.2002; 106: 291-298.28. Lefly H.P. (1997). Synthesizing the family caregiving studies: implications for service planning, social policy, and further research. Family Relations.1997; 46:443–450.29. Cohen C.A., Colantonio A. and Vernich L. Positive aspects of caregiving: rounding out the caregiver experience. International Journal of Geriatric Psychiatry.2002; 17: 184-188.30. Thomas P., Hazif-Thomas C., Delagnes V., Bonduelle P. and Clement J.P. La vulnérabilité de l’aidant principal des malades déments à domicile. L’étude Pixel. Psychologie et Neuropsychiatre Vieilissement.2005; 3: 207-220.31. Wittmund B., Wilms H.U., Mory C. and Angermeyer M.C. Depressive disorders in spouses of mentally ill patients. Social Psychiatry and Psychiatric Epidemiology.2002; 37: 177-182.32. Perlick D.A., Rosenheck R. R., Clarkin J.F., Raue P. and Sirey J. Impact of family burden and patient symptom status on clinical outcome in bipolar affective disorder. Journal of Nervous Mental Disorders.2001; 189: 31-37.33. Sartorius N. The economic and social burden of depression. Journal of Clinical Psychiatry.2001; 15: 8-11.34. Jungbauer J., Wittmund B., Dietrich S. and Angermeyer M.C. The disregarded caregivers: subjective burden in spouses of schizophrenia patients. Schizophrenia Bulletin.2004; 30: 665-675.35. van Wijngaarden B., Schene A.H. and Koeter M.W. Family caregiving in depression: impact on caregivers' daily life, distress, and help seeking. Journal of Affective Disorders.2004; 81: 211-222.36. Perlick D.A., Hohenstein J.M., Clarkin J.F., Kaczynski R. and Rosenheck R. A. Use of mental health and primary care services by caregivers of patients with bipolar disorder: a preliminary study. Bipolar Disorders.2005; 7: 126-135.37. Baldassano,C. “Reducing the Burden of Bipolar Disorder for Patient and Caregiver,” Medscape Psychiatry & Mental Health.2004; 9(2).38. Amir N., Freshman B.A. and Foa E. Family distress and involvement in relatives of obsessive-compulsive disorder patients. Journal of Anxiety Disorders.2002; 14: 209-217.39. Treasure J., Murphy T., Szmukler G., Todd G., Gavan K. and Joyce J. The experience of caregiving for severe mental illness: a comparison between anorexia nervosa and psychosis. Social Psychiatry and Psychiatric Epidemiology.2001; 36: 343-347.40. Perkins, S., S. Winn, J. Murray, R. Murphy and U. Schmidt. A qualitative study of the experience of caring for a person with bulimia nervosa. Part 1: The emotional impact of caring. International Journal of Eating Disorders.2004; 36(3): 256-268.41. Gruetzner, H.M. Alzheimer's: A Caregiver's Guide and Sourcebook. Wiley.2001.42. Mc Grath, E., Puryear Keita, G., Stricland, B.R., and Felipe Russo, N. Women and Depression: Risk Factors and Treatment Issues, American Psychological Association, Washington, DC.1992.43. Schulz, R., and Williamson, G.A Two-year longitudinal study of depression among Alzheimer's caregivers. Psychol. Aging.1991; 6:569-578.44. Gitlin, L.N., Corcoran, M., Winter, L., Boyce, A., & Marcus, S.Predicting participation and adherence to a home environmental intervention among family caregivers of persons with dementia .Family Relations.1999; 48, 363-372.45. Draper, B. Dealing With Dementia: A Guide to Alzheimer's Disease and Depression in Caregivers of Patients with Dementia.2004.46. Lawton,M.P., Rajgopal,D., Brody,E., & Kleban,M.H.The dynamics of caregiving for a demented elder among Black and White families.Journal of Gerontology:Social Sciences .1992;47, S156-S164.47. Baumgarten, M., Battista, R.N., Infante-Rivard,C.,Hanley, J.A., Becker, R.,& Gauthier, S.The Psychological and Physical health of family members caring for an elderly person with dementia. Journal of Clinical Epidemiology.1992; 45,61-70.48. Shaw WS,Patterson TL,Semple SJ,et al.Longitudinal analysis of multiple indicators of health decline among spousal caregivers.Ann Behav Med .1997;19:101-109.49. Schulz, R., O'Brien, A.T., Bookwala, J.,& Flessiner, K. Psychiatric and physical morbidity effects of dementia caregiving : Prevalence, correlates, and causes. Gerontologist.1995; 35, 771-791.50. Connel, C.M., Janevic, M.R., & Gallant, M.P.The costs of caring: Impact of dementia on family caregivers. Journal of Geriatric Psychiatry and Neurology.2001; 14, 179-187.51. Calderon, V., & Tennstedt, S. Results of a qualitative study. Journal of Gerontological Social Work.1998;30, 159-178.52. Farran, C.J., Miller, B.H., Kaufman, J.E., & Davis, L. Race, finding meaning, and caregiver distress.Journal of Aging and Health.1997; 9, 316-333.53. Harwood DG, Barker WW, Cantillon, et al.Depression symptomatology in the first-degree family caregivers of Alzheimer disease patients: A cross-ethnic comparison. Alzheimer Disease & Associated Disorders.1998; 4: 340-346.54. Gallant, M.P., & Connel, C.M.Predictors of decreased self-care among spouse caregivers of older adults with dementing illnesses. Journal of Aging and Health.1997;9, 373-395.55. Clyburn L, Stones M, Hadjistavropoulos T, et al.Predict depression in caregiver burden and in Alzheimer's disease.J Gerontol B Psychol Sci Soc Sci.2000; 55:S2-S13.56. Williamson, G.M.,& Schulz, R. Coping with specific stressors in Alzheimer's Disease caregiving. The Geronotologist.1993;33, 747-755.57. Russo,J.,Vitaliano,P.P.,Brewer,D.D.,Katon,W.,&Becker,J.Psychiatric disorders in spouse caregivers of care recipients with Alzheimer's disease and matched controls:A diathesis-stress model of psychopathology,Journal of abnormal psychology.1995;104,197-204.58. McDonell M.G ., Short R.A ., Berry C.M ., Dyck D.G. Burden in Schizophrenia Caregivers: Impact of Family Psychoeducation and Awareness of Patient Suicidality. Family Process.2003; Vol. 42, No. 1.59. Tooth, Leigh,Russell, Anne,Lucke, Jayne,Byrne, Gerard,Lee, Christina,Wilson, Andrew,Dobson, Annette. Impact of cognitive and physical impairment on carer burden and quality of life. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care & Rehabilitation.2008;vol./is. 17/2(267-273), 0962-9343;1573-264960. Quayhagen. M.P.,& Quahagen. M.Alzheimer's stress: Coping wih the caregiving role. The Geronotologist.1998; 28, 391-396.61. Lazarus,R. S., and Folkman,S.Stress,Appraisal,and Coping,Springer Publishing Company,New York.1984.62. Fingerman, K.L., Gallagher-Thompson, D., Lovett, S., & Rose, J. Internal resourcefulness, task demands, coping, and dysphoric affect among caregivers of the frail elderly. International Journal of Aging &Human Development.1996; 42, 229-248.63. Woods RT, Wills W, Higginson IJ, Hobbins J, Whitby M.Support in the community for people with dementia and their carers: a comparative outcome study of specialist mental health service interventions. International Journal of Geriatric Psychiatry .2003;18:(4):298-307.64. Ballard, C.G., Saad,K., Patel, A., Gahir,M., Solis, M., et al. The prevalence and Phenomenology of psychotic symptoms in dementia sufferers. International Journal of Geriatric Psychiatry.1995a; 10, 477-485.65. Coppel, D.B., Burton, C., Becker, J. and Fiore, J. Relationships of cognitions associated with coping reactions to depression in spousal caregivers of Alzheimer's disease patients. Cog. Ther. Res.1985; 9, 253-266.66. Saad, K.,Hartman, J.,Ballard, C., Kurian, M.,Graham, C.and Wilcock, G.Coping in the Carers of dementia sufferes. Age Ageing.1995; 24 , 495-498.67. Horowitz, A. and Shindelman, L.W. Reciprocity and affection: Past influences on current caregiving. J. Gerontol. Soc. Work.1983; 5, 5-20.68. Lawton, M.P. Interventions in Dementia Care: Toward Improving Quality of Caregiving.200069. Levin, J.S.,Chatters,L.M., and Taylor, R.J. Religious effects on health status and life satisfaction among Black Americans. J.Gerontol. Soc. Sci.1995;50B: S154-S163.70. Picot, S.J, Debanne, SM., Namazi, K.H., and Wykle, M.L. Religiosity and perceived rewards of Black and Anglo caregivers. Gerontologist.1997; 37: 89-101.71. Dilworth-Anderson, P., Williams, I.C.,& Gibson, B.E.Issues of race , ethnicity, and culture in caregiving research :A 20-year review (1980-2000).The Gerontologist.2002; 42, 237-272.72. Coon, D.W., Rubbert, MP., Solano,N., Mausbach,B., Kraemer, H., Arguelles, T., et al.Well-being, appraisel, and coping in Latina and Caucasian female dementia caregivers:Finding from the REACH study. Aging and Mental Health.2004, 8(4), 330-345.73. Walls,CT.,&Zarit SH. Informal Support From Black Churches and the Well-Being of Elderly Blacks.The Gerontologist.1991; .31(4):490 495.74. Haley, W, E., Levine, E, G., Brown, S, L., Bartolucci, A, A. Stress appraisal, coping and social support as predictors of adptational outcome among dementia caregivers.Psychology and Aging.1987; 2, 323- 330.75. Kramer, B.J.Gain in the caregiving experience: Where are we ?What next? Gerontologist.1997; 37, 218-232.76. Pinquart, M., & Sorensen, S. Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: A meta-analysis. Journal of Gerontology: Psychological Sciences & Social Sciences.2003;58B, 112-128.77. Haley, W.E., Gitlin, L.N., Wisniewski, S. R., Mahoney, D.F., Coon, D.W.,Winter, L., et al. Well-being, appraisal, and coping in African- American and Cuacasian dementia caregivers: Findings from the REACH study. Aging & Mental Health.2004; 8(4), 316-329.78. Cox, C.Comparing the experience of Black and White Caregivers of dementia patients. Social Work.1995;3, 343-349.79. Alten, G.J. Racial variations in caregiver stress and burden among informal caregivers of impaired elderly persons.University of Florida, Gainesville.1993.80. Burton-Smith, Rosanne,McVilly, Keith R,Yazbeck, Marie,Parmenter, Trevor R,Tsutsui, Takako.Quality of life of Australian family carers: Implications for research, policy, and practice. Journal of Policy and Practice in Intellectual Disabilities.2009; vol./is. 6/3(189-198), 1741-112281. Rivera De J.L.G. Factores de estrés y enfermedad médica. Actas Luso-Españolas de Psiquiatría y Neurología.1991; 19: 290-297.82. Bourgeois,MS.,Burgio,LD.,Schulz,R.,Beach,S, and Palmer,B. Modifying repetitive verbalizations of community-dwelling patients with AD. The Gerontologist.1997; Vol 37, Issue 1 30-39.83. Stevens, A.B. & Burgio, L.D. Issues in training home-based caregivers of individuals with Alzheimer’s disease. Alzheimer’s Care Quarterly.2000; 1(1):55-68.84. Cheston, R. Psychotherapeutic work with people with dementia: a review of the literature. British Journal of Medical Psychology.1998; 71, 211-231.85. Marriott,A., Donaldson,C.,Tarrier,N and Burns,A. Effectiveness of cognitive-behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer's disease,British Journal of Psychiatry.200086. Rigaux, Natalie. Informal care: Burden or significant experience? Psychologie & NeuroPsychiatrie du Vieillissement.2009; vol./is. 7/1(57-63), 1760-1703.87. Yarnoz, Adelaida Zabalegui,Diez, Montserrat Navarro,Torres, Esther Cabrera et al.Efficacy of interventions aimed at the main carers of dependent individuals aged more than 65 years old. A systematic review. Revista Espanola de Geriatria y Gerontologia.2008; vol./is. 43/3(157-166), 0211-139X.88. Sleath,B.,Thorpe,J.,Lawrence,MPH.,Landerman,R.,Doyle,M.and Clipp,E. African-American and white caregivers of older adults with Dementia:Differences in Depressive Syptomatology and Psychotropic Drug Use.2005; By the American Geriatrics Society.89. Helen C.Kales, MD, Frederic C. Blow, PhD, Deborah E.Welsh, MS, and Alan M.Mellow,MD, PhD. Herbal products and other Supplements: Use by Elderly Veterans With Depression and Dementia and Their Caregivers: J Geriatr Psychiatry Neurol 2004;17:25-31.90. Burdz, M.P., Eaton, W.O. and Bond, J.B.Effect of respite care on dementia and nondementia patients in caregiver', Psychology and Aging.1988; 3, 1:38-42.91. Harvey, K,Catty, J,Langman, A,Winfield, H,Clement, S,Burns, E,White, S,Burns, T. A review of instruments developed to measure outcomes for carers of people with mental health problems. Acta Psychiatrica Scandinavica.2008;vol./is. 117/3(164-176), 0001-690X;1600-0447.

BJMP September 2008 Volume 1 Number 1

BJMP Sept 2008 Volume 1 Number 1 : Full Issue booklet

PDF

EDITORIAL
Language and Psychiatry: An Argument for Indeterminism Saad F. Ghalib	Full Text	PDF
REVIEW ARTICLES
Polypharmacy: To Err Is Human, To Correct Divine Nasseer A. Masoodi	Full Text	PDF
Dementia with Lewy Bodies: Clinical Review Javed Latoo, Farida Jan	Full Text	PDF
Anaesthetic Management of Obese Parturient Nimit Shah, Yaqub Latoo	Full Text	PDF
VIEWPOINT
Depression and Iatrogenic Hopelessness Jaleel Khaja	Full Text	PDF
CASE SERIES
Pathological Fractures as the Presenting Symptom of Parathyroid Adenoma: A Report of Three Cases Rajesh Rachha	Full Text	PDF
AUDIT
Quality of Electronic Discharge Summaries at Newham University Hospital: An Audit Syeda M. B. Kazmi	Full Text	PDF
MISCELLANEOUS
Upcoming Medical Courses and Conferences	Full Text	PDF