Virtual Reality Cognitive Remediation in Older Adults with Bipolar Disorder: The Effects on Cognitive Performance and Depression in a Feasibility Randomized Controlled Trial.

INTRODUCTION: Dementia, depression, and cardiovascular disease are major public health concerns for older adults, requiring early intervention. This study investigates whether a virtual reality cognitive remediation program (VR-CR) can improve cognitive function and depressive symptoms in older adults, and determines the necessary sample size for future studies. Integrated VR and CR interventions have shown promising outcomes in older adults with neurodegenerative and mental health disorders. METHODS: This secondary analysis of a randomized controlled trial involves adults aged 58-75 years with bipolar disorder, excluding those with acute episodes, epilepsy, or severe eye diseases. The experimental group received standard treatment plus VR-CR, while the control group received only standard treatment. RESULTS: No baseline differences were found between the experimental and control groups. No significant improvement was observed in the overall cognitive function test (p = 0.897) or in depressive symptoms (p = 0.322). A phase III efficacy study requires a sample size of 28 participants (alpha = 0.05, beta = 0.20). CONCLUSIONS: VR-CR can potentially treat depressive symptoms in adults and older adults, but the results support conducting phase III studies to further investigate these outcomes. However, the improvement in cognitive performance in the elderly is less pronounced than in younger individuals.

Immigration bias among medical students: a randomized controlled trial.

BACKGROUND AND IMPORTANCE: Racial bias is found in both physicians and medical students. Immigrants in many parts of the world face challenges similar to racial minorities. Identification of immigrants might however be more subtle than identification by race, and currently, no data are available on a possible bias against the large minority group of migrants in Europe. DESIGN: Randomized control trial. SETTINGS AND PARTICIPANTS: Second-year medical students were randomized into four groups to watch a video of either a male or female patient with pain, with or without immigrant status. INTERVENTION: Students were asked whether they would administer pain medication (primary outcome). OUTCOME MEASURES AND ANALYSIS: Immigrant status, patient's gender, student's gender, age, and language skills were covariates in a logistic regression model. Secondary outcomes included pain medication potency and the student's rating of the patient's pain intensity. MAIN RESULTS: We recruited 607 students [337 females (56%), 387 (64%) between 18 and 22 years old]. Analgesia was administered in 95% (n = 576). Immigrant status was not associated with the probability of receiving pain medication [95 vs. 95%, odds ratio (OR) 0.81, 95% confidence interval (CI) 0.39-1.70, P  = 0.58]. Immigrants received high-potency analgesia less often (26 vs. 33%, OR 0.69, 95% CI 0.50-0.96, P  = 0.03). Female students administered pain medication more frequently (96 vs. 93%, OR 2.29, 95% CI 1.05-5.02, P  = 0.04), and rated the patients' pain higher (mean numeric rating scale 7.7, SD 0.9 vs. 7.4, SD 1.0, OR 1.36, 95% CI 1.16-1.60, P  < 0.001). CONCLUSION: Medical students showed no immigration bias with regard to administering pain medication but were less likely to choose high-potency analgesia in immigrants. We also found a gender difference in pain management. These results demonstrate the importance of including knowledge about immigration bias in medical training.

Female participation or "feminization" of medicine.

More and more women chose medicine as their profession. Female students and graduates outnumber their male colleagues in Austria and the EU. However, the career paths of men and women differ after a certain point, and more and more female talent is lost along the career stages. Women hold only 30% of professor positions at state medical universities in Austria and only 11.9% of all chief physicians are female. Motherhood and related absence is the main career obstacle, but gender bias and missing role models are also factors hindering women to thrive. Improved working conditions would be beneficial for all members of the medical profession. Future generations (Generation Y, Generation Z) will likely expedite changes toward a better work-life balance and claim the right to find fulfillment besides work. Compatibility of family and work and the chance to individualize career paths could be important factors for employers to find and bind their employees. Additionally, (gender) diverse teams improve the group process and collective intelligence. Therefore, patient care and innovation can only benefit from a diverse medical workforce.

'Good' and 'bad' doctors - a qualitative study of the Austrian public on the elements of professional medical identity.

Professional identity formation has become a key focus for medical education, but there is still much to learn about how to help students develop their professional identity. At a time when influential concepts such as public- and patient-centered care have become common values, there is little research on the conceptions of the public that trainees might adopt during their training. Defining characteristics of 'good' and 'bad' physicians can be a starting point when considering how to incorporate aspects of professional behavior into medical curricula. Therefore, this study examined the essential elements of physician identity from the public's perspective. This study aimed to describe the Austrian public's viewpoint about the characteristics of 'good' and 'bad' doctors. Using a qualitative research design, interviews were conducted with the Austrian public (n = 1000, mean age 46.4 ± 15.8 years). Interviews were transcribed verbatim and analyzed via qualitative content analysis. The respondents stated 2078 answers for 'good' and 1728 for 'bad' doctors. The content analysis produced seven categories: 'social skills' (36.3%), 'professional competence' (30.2%), 'personality' (10.8%), 'communication' (6.3%), 'practice organization' (5.9%), 'ethical and moral behavior' (5.7%), and 'I do not know, or I have no idea' (4.9%). The public can help medical students to construct their professional identity by supporting the exploration of and commitment to professional values that society expects of physicians. Ideally, fusing medical expertise with social skills will fulfill the ideal of what the public considers a 'good' doctor. This shared definition of a 'good physician' has several implications for medical education. Future physicians can benefit from education about the general population's medical needs as well as personal needs, fears, and concerns.

You are exactly my type! The traits of a good doctor: a factor analysis study on public's perspectives.

BACKGROUND: A multiplicity of qualities and behaviours are considered essential in a good doctor and are identified in various medical profession frameworks. However, there is no consensus as to their meaning or even agreement on fundamental qualities. The authors wanted to examine the importance placed by the Austrian public on the professional and personal traits of ideal physicians. Competencies were used to create different types of 'good doctor' and then examined to discover how these can be integrated into existing medical professionalism frameworks. METHODS: A 69-item Likert scale-based questionnaire was developed and administered via telephone interview to 1,000 subjects. Computer-assisted telephone interviews (CATI) were carried out by the Austrian GALLUP-Institute. An explorative factor analysis with promax rotation was undertaken to summarise the interrelationships among variables. RESULTS: Factor analysis identified six interpretable factors which we define as six different types of doctors: the dutiful doctor, the online health-celebrity, the medical expert, the service physician, the medical altruist, and the ethical agent. The items perceived as most important were 'takes time', 'listens', and 'makes correct diagnoses'. Outcome measures of internal consistency and reliability estimates (Cronbach´s alpha, 0.69-0.86) for each element. CONCLUSIONS: The six types of physicians may be a step toward recognizing the professional behaviour of all physicians, their actions as healers, and their commitment to moral concepts, values, and needs of their patients, and society. According to our results, the public has expectations of good doctors that go beyond the scope within the medical professionalism frameworks. Therefore, these guidelines should be adapted in light of the changing expectations and needs of the general population.

Now, I think doctors can be heroes Medical student's attitudes towards the COVID-19 pandemic's impact on key aspects of medical education and how the image of the medical profession has changed due to the COVID-19 pandemic.

BACKGROUND: The COVID-19 (coronavirus disease 2019) pandemic hit the world in early 2020 and influenced medical education worldwide. Distance learning, risk of infection and patient care, telehealth literacy, medical ethics and research in medical education are key factors of medical education challenged by the pandemic. Additionally, the following question arises: "What do medical students think about their future profession in the face of this crisis?" METHODS: A cross-sectional survey was conducted among all undergraduate medical students of the Medical University of Vienna. 872 students answered the self-developed questionnaire. Qualitative and quantitative data analyses were conducted. RESULTS: The data show that the COVID-19 pandemic has raised awareness for the key aspects. In all areas of interest, students' feeling of petaredness is limited. Limitations in practical training and distance learning as well as social isolation concern a majority of students. Neutral, positive, and negative themes emerged in qualitative data analysis. Only 8% of the students of the first 3 years of study versus 13.4% of the students in higher years commented negatively. 18.7% of male vs. only 12.5% of all female students' comments were positive. A large proportion of positive comments were dedicated to the relevance and deeper meaning of the medical profession. Infection risk and the demanding nature of the medical profession were predominant in negative comments. CONCLUSION: The COVID-19 crisis has turned the spotlight on several aspects of medical education in need of reform. In addition, the occupational image of the medical profession seems to shift under the weight of this pandemic.

The Quality of Life of People with Solid Cancer is Less Worse than Other Diseases with better Prognosis, Except in the Presence of Depression.

Background: Suffering from Solid Cancer (SC) may adversely impact the Health-related Quality of Life (H-QoL). The aims of this study are to measure the H-QoL in a sample of people suffering from SC and to clarify the role of the co-occurrence of depressive episodes. Results were compared with a healthy control group and with groups of other disorders. Methods: In 151 patients with SC (mean±sd age 63.1±11.5; female 54.3%), H-QoL was assessed by SF-12, depressive episodes were identified by PHQ-9. The attributable burden of SC in impairing H-QoL was calculated as the difference between SF-12 score of a community sex and age » matched healthy control group and that of the study sample. The attributable burden of SC was compared with other chronic diseases using specific diagnostic groups drawn from case-control studies that used the same database for selecting control samples. Results: H-QoL in people with SC was significantly worse than in the healthy control group (p<0.0001). The attributable burden in worsening the H-QoL due to SC was similar to those of severe chronic diseases, but lower than Multiple Sclerosis (p<0.0001) or Fibromyalgia (p<0.00001). Having a depressive episode was a strong determinant of decreasing H-QoL, regardless of the severity of cancer. Conclusion: The findings confirm a strong impact of SC but showed that H-QoL in SC was higher than in chronic diseases with better "quoad vitam" outcome. Since depression was a strong determinant, its prevention, early detection and therapy are the main objectives that must be reached in cancer patients.

Pursue today and assess tomorrow - how students' subjective perceptions influence their preference for self- and peer assessments.

BACKGROUND: Alternative assessments engage students in the assessment process to improve both short- and long-term outcomes by developing their judgments and responsibility about their own learning, and that of their peers. In this study, we investigated students' perception towards self- and peer-assessment, their objectivity and impact on students' learning. METHODS: The study was conducted at the Medical University of Vienna. Attitudes of second year undergraduate medical students towards self- and peer-assessment, and their objectivity, appropriateness, and the impact of these assessments on students' learning activities, was inquired using a self-developed questionnaire. RESULTS: Four hundred twenty-three students participated in this study. Self-assessment was found more appropriate method to assess students' knowledge. Most of students agreed that peer-assessment is not objective (M = - 0.07). Majority of students evaluated that peer assessment has no or little impact on their active and passive learning (M = - 0.23, - 0.35), on the other hand self-assessment was reported as a helpful tool for gaining long-term knowledge (M = 0.13) and following the content of courses (M = 0.16). CONCLUSION: Based on our results, students' perspective on peer assessment were negative, on the whole, students had positive attitudes towards self-assessment and negative attitudes towards peer-assessment. This study also determined that self-assessment leads to the promotion of students' learning.

Migrant Women-experiences from the Mediterranean Region.

INTRODUCTION: The phenomenon of migration is characterized and influenced by a number of different variables; and the different stages of journey are related to different levels and types of psychological distress. Women, in particular, are exposed to further specific risks during migration. AIM: To determine the factors that affect the psychological health of migrant women during the different stages of the migration journey. METHODS: We provide a narrative review of the literature around the experiences of women during migration process, with a geographical focus on women migrating to the Mediterranean area. RESULTS: Little data is currently available on the burden of mental health disorders for female migrants. Most studies about the mental health status of migrants were not gender-disaggregated or focused specifically on migrant women's experiences of violence. Sexual and Gender-Based Violence (SGBV) was found to be a common risk factor faced by all the women who leave their native country to migrate to other countries. CONCLUSION: Despite the importance of the issue and the gender-specific variables related to the experience of migrant women, few studies have looked specifically at psychological variables and mental health status in the female migrant population. It is crucial that future studies are conducted around female migration, violence towards women, and women's mental health, in order to provide an evidence-base for promoting adequate policies and prevention/treatment programs for women.

How to assess? Perceptions and preferences of undergraduate medical students concerning traditional assessment methods.

BACKGROUND: Medical students' perception of traditional assessments have an important impact on their approaches to learning. Even though these assessment formats such as Multiple-Choice Question (MCQ), Short Answer Question (SAQ) or oral examinations, are frequently used in medical curricula, only little is known about student's perceptions of these assessments. The objective of this study was to assess perceptions and preferences of undergraduate medical students concerning traditional assessment formats. METHODS: The study was conducted at the Medical University of Vienna. Attitudes of 2nd year undergraduate medical students towards traditional assessment formats, and their relation to students' learning, and students' attitude towards objectivity, was inquired using a self-developed questionnaire. RESULTS: 459 students participated in this study. MCQs examinations were the most preferred assessment format and were chosen as the most objective format. Most students agreed that oral examinations are more appropriate for achieving long-term knowledge. Female students showed higher preference for oral examinations than male students. Students would prefer an assessment mix of 41.8% MCQs, 24.0% oral examinations, and 9.5% SAQs, if they were free to choose the assessment tools. CONCLUSION: Students prefer MCQ format over SAQs/oral examinations. Students' subjective perception of the importance of gaining long-term knowledge through an assessment has no influence on their assessment preference.

Focus gender - medical students' gender-specific perception and attitudes towards the burdens of everyday student life.

Introduction: The aim of this study was to investigate if female and male medical students perceive burdens differently and if students of both sexes assess their capability to stand performance pressure differently. Material and Methods: In 2017, 2nd (n=424, 53% female) and 6th (n=161, 46.6% female) year students at the medical university of Vienna were surveyed using a fully structured questionnaire. Results: In 2nd year, female students felt significantly more often that they could not measure up to study requirements than male students (87,5% vs. 94,4%). Performance pressure was perceived as major problem by male (45,5%) and female (50,9%) students while in 6th year the number was only half as high than in 2nd (24%, 18,4%). In 6th year significantly more female than male students were complaining about competition between students (33,3% vs. 8%). Half of the students shared the view that there is no difference between men and women in the capability to deal with performance pressure. Most of the other half state that men are superior to women in handling performance pressure. In both groups significantly more male than female students were convinced that they are superior to the other sex in handling performance pressure. Conclusion: Perception of problems is similar in male and female students. While in objective assessments female students perform equally to male students they consider themselves less competent and are more inclined to doubt their capability.

Mental health care in Italy: Basaglia's ashes in the wind of the crisis of the last decade.

BACKGROUND AND AIMS: The purpose is to highlight the legal and ethical principles that inspired the reform of mental health care in Italy, the only country to have closed its psychiatric hospitals. The article will also try to verify some macro-indicators of the quality of care and discuss the crisis that the mental health care system in Italy is experiencing. METHODS: Narrative review. RESULTS: The principal changes in the legislation on mental health care in Italy assumed an important role in the evolution of morals and common sense of the civil society of that country. We describe three critical points: first, the differences in implementation in the different Italian regions; second, the progressive lack of resources that cannot be totally attributed to the economic crisis and which has compromised application of the law; and finally, the scarce attention given to measurement of change with scientific methods. CONCLUSION: Italy created a revolutionary approach to mental health care in a historical framework in which it produced impressive cultural expressions in many fields. At that time, people were accustomed to 'believing and doing' rather than questioning results and producing research, and this led to underestimating the importance of a scientific approach. With its economic and cultural crisis, Italy has lost creativity as well as interest in mental health, which has been guiltily neglected. Any future humanitarian approach to mental health must take the Italian experience into account, but must not forget that verification is the basis for any transformation in health care culture.

How to Cope with the Challenges of Medical Education? Stress, Depression, and Coping in Undergraduate Medical Students.

OBJECTIVES: Up to 90% of medical students experience stress. Studies have observed a relationship between stress and depression. Coping strategies to deal with stress and depression are of great interest. This study aimed to evaluate the prevalence of stress and depression and the efficacy of coping strategies in undergraduate medical students. METHODS: This survey was conducted with 589 second-year and sixth-year students in 2017 at the Medical University of Vienna. The questionnaire included a stress and coping questionnaire, depression screening, substance use questionnaire, and questionnaire concerning leisure time activities. RESULTS: The coping strategies were included in a regression model to assess their predictive value for stress and depression screening scores. The most common stressor was performance pressure overload (92.1%). Overall, 52.4% of the participating students reached critical scores in the depression screening. Positive thinking and active coping were associated with lower stress scores. Positive thinking also was a protective factor against depressive symptoms. Less than 2% of all students reached high-risk values for substance use. CONCLUSION: Accessible counseling for students in need of psychological care should be provided. Different interventions of positive psychology showed a positive impact on depression screening scores.

Knowledge, application and how about competence? Qualitative assessment of multiple-choice questions for dental students.

Background: Many medical schools train their faculty members to construct high cognitive level multiple choice questions (MCQs) that demand a great deal of analytical and critical thinking, application, and competence. The purpose of this study is to determine the cognitive levels of MCQs by using Moore's Expanded Outcomes Framework and to understand whether the quality of MCQs has an effect on students' assessment performance.Methods: Four trained faculty members analysed 100 randomly selected questions developed at the University Clinic of Dentistry (UCD) and 100 questions developed by the National Board of Dental Examinations (NBDE). Moore's framework was applied to assist the review process.Results: The majority of questions was at the level of declarative knowledge followed by questions at the level of procedural knowledge. The cognitive level of UCD questions from 2002 to 2009 was significantly lower than that of NBDE questions but increased in questions written from 2010 to 2018. The improvement of quality of MCQs had no impact on assessment performance of students.Conclusion: The enhanced cognitive levels of UCD MCQs written 2010-2018 coincides with the implementation of a faculty training program for writing high-ordered MCQs. In addition, this study shows that the use of Moore's expanded framework is on par with other known taxonomies in supporting educators in writing items and reviewing the process.Abbreviations: MCQs: Multiple Choice Questions; UCD: University Clinic of Dentistry; NBDE: National Board of Dental Examinations.

Attitudes of dental students towards patients with special healthcare needs: Can they be improved?

INTRODUCTION: Lack of knowledge and skills as well as negative attitudes towards patients with special healthcare needs may adversely affect the services available to this group. In 2010, a line on the treatment of patients with special healthcare needs has been implemented in the dental curriculum at the Medical University of Vienna, including five seminars and a practical course. In this study, we examine to what extent the programme helps improve attitudes towards persons with special healthcare needs and positively impacts the readiness to engage in treating this clientele. MATERIALS AND METHODS: In 2017 and 2018, all students who were in their fourth study year participated in the study. Students' attitudes were assessed before the first seminar, after the last seminar and after the practical course. At all three time points, the same fully structured questionnaire was used, including established instruments for the assessment of emotional reactions and the desire for social distance plus ad hoc questions for assessing students' future intention to treat patients with special healthcare needs. The data were analysed by means of linear fixed models. RESULTS: At the end of the line devoted to patients with special healthcare needs, students tended less to express negative emotions and showed more positive emotional reactions than before the start of the programme. However, students' social acceptance of such patients and their readiness to engage in treating them did not change significantly. DISCUSSION: While our programme was able to improve students' emotional reactions to people with special healthcare needs, it proved unable to reduce the desire for social distance and to lower the barrier when it comes to treatment. It is planned to further develop our programme which, hopefully, will then succeed in increasing students' readiness to treat this clientele. CONCLUSION: Improving dental students' emotional reactions to patients with special healthcare needs does not necessarily translate into greater readiness to treat this clientele.

Practice makes perfect! Patient safety starts in medical school: Do instructional videos improve clinical skills and hygiene procedures in undergraduate medical students?

Introduction: In 2012 safety strategies were defined in five intervention areas to improve patient safety in Austria. Regarding policy development, patient safety should be mandatory part of education of all healthcare sectors, and measures to improve hygiene standards are to be included in organizational development. The aim of this project was to achieve sustained improvement in routine procedures and anchor patient safety in the undergraduate medical curriculum by making online instructional videos on clinical skills and hygiene procedures permanently available as preparation for the first clinical clerkship. Method: Short films explaining how to insert urinary catheters in women and men were produced and provided online. These videos were shown to medical students shortly before the practical Objective Structured Clinical Examination (OSCE). After viewing the videos, all of the students were surveyed using an online questionnaire with 15 questions regarding quality and acceptance. The effect of the videos on learning success was determined by the assessment outcome through red cards in the practical exam. A red card for behavior endangering the doctor or others meant zero points and discontinuation of the assessment at that particular OSCE station. Results: A total of 647 students viewed one of the two videos on urinary catheters, 623 responded to the online Moodle questionnaire completly. 551 (85.2%) reported being better able to recall individual steps and procedures, 626 students (96.7%) positively rated the fact that instructional videos were available on the Medical University of Vienna's website. More than half of the respondents (56.6%) were better able to remember critical hygiene practices. The comparison of the assessment outcomes on the OSCE for 2016 and 2013, a year in which the instructional videos were not yet available, shows no significant (chi2=3.79; p>0.05) but a trend towards improvement. The chance of getting a red card in 2013 was 3.36 times higher than in 2016. Conclusion: Even if our study was unable to show significant improvements in the OSCE as a result of viewing the videos, it appears that clearly imparting medical skills and hygiene standards-including in visual form-is still important prior to the first clerkship to ensure the highest level of patient safety possible. The combination of teaching and learning formats, such as videos on online platforms with textbooks or lecture notes, is well suited to increase effectiveness and efficiency in learning. There is a need for further studies to investigate and analyze the effects of instructional videos in more detail.

[Doctor-Patient Communication Training in Simulated Situations: Emotions and Perceptions of Simulated Patients during Patient-Centered Conversations]. / Ärztliches Gesprächsführungstraining in simulierten Situationen: Wahrnehmungen und Empfindungen von Simulationspatienten bei patientenzentrierter Gesprächsführung.

INTRODUCTION: The use of simulated patients (SPs) for doctor-patient communication training has been established in medical curricula as an important didactic method. The study addresses the question, if patients' emotions and perceptions are represented adequately in patient-centered communication. MATERIALS AND METHODS: 22 of 37 SPs of the Medical University of Vienna (12 women, 10 men) were asked openly about their feelings after having acted as an SP in a semi-structured interview, which employed the Critical Incident Technique. The interviews were recorded, transcribed, separated into situational analysis units und analyzed deductively; we used the evidence based qualities of patient-centered communication and the "Nationaler Kompetenzbasierter Lernzielkatalog Medizin" as a guideline. RESULTS: Out of 192 analysis units, 67 were evaluated as positive and 125 as negative. The SPs reported positive feelings, such as perceiving "stability and trust in relationships" (22%), perception of congruence (15%), acceptance (27%) and empathy (36%). As to negative feelings, SPs reported "perceiving instability" (18%), "incongruence" (11%), "lack of acceptance" (40%) and "lack of empathy" (30%). Additionally, 50% of SPs were positively affected when observing students' learning success. DISCUSSION: When SPs perceived patient-centered communication, they reported positive emotions. A lack of patient centeredness, on the contrary, provoked negative emotions. An empathic attitude, as well as a "lack of acceptance" with contrary effects had the strongest influence on the SPs' mental state. The reaction of SPs to patient centeredness is sufficiently authentic to reach learning objectives, however it is also affected by reactions of SPs to the learning success of students, which is irrelevant for the real-life doctor-patient interaction. CONCLUSION: SP reactions are affected by students' attitudes. Students should therefore be prepared well before interacting with SPs in a roleplay setting. While SPs' behavior is authentic in patient-centered communication in general, SPs should be trained to hide their positive emotions concerning students' learning success during roleplay.

What is a good doctor?

Changes in medical curricula have led to a shift of focus in medical education. The goal was to implement a more practical approach to teaching and thereby create better doctors. However, the question of what makes a good doctor is not easy to answer. This article gives an overview on the literature about this topic. A systematized review and narrative synthesis were conducted including 20 articles about the features of good doctors. Qualitative and quantitative studies as well as questionnaires were included. These studies reported research involving students, doctors, patients, and nurses. The resulting characteristics of good doctors fell into six categories: (1) General interpersonal qualities, (2) Communication and patient involvement, (3) Medical competence, (4) Ethics, (5) Medical management, (6) Teaching, research, and continuous education. The different stakeholders showed different ideas of the concept of a good doctor. Interestingly, patients had a stronger focus on communication skills, whereas doctors put more emphasis on medical skills. Balancing this discrepancy will be a challenge for future medical education.

The diffusion of the diagnostic term bipolar disorder among the German public.

In 2005, 15 years after the introduction of the diagnosis in DSM-III, a telephone survey in Germany revealed that the public was still unfamiliar with the term bipolar disorder. Only 5.3% of those questioned knew at the time that it denotes a mental illness. In the meantime, efforts have been made to spread the concept among the public. In the media there has been increasing mention of the disorder. Another telephone survey in 2017 showed that familiarity with the diagnostic term has grown substantially. 54.0% of respondents now connected the term bipolar disorder with a mental illness.