Factors Contributing to Burnout among Healthcare Workers during COVID-19 in Sabah (East Malaysia).

The third wave of COVID-19 in Malaysia has significantly strained the healthcare system of the country and increased the level of burnout among the healthcare workers (HCWs) in the country. Therefore, this study aimed to identify the various factors associated with burnout among HCWs. A cross-sectional study was conducted among 150 HWCs in Kota Kinabalu, Sabah, Malaysia. An online survey was administered using the Copenhagen Burnout Inventory, Multidimensional Scale of Perceived Social Support, Brief COPE, and Fear of COVID-19 scales. Pearson correlations were assessed amongst all variables. Subsequently, a multiple linear regression analysis was performed using burnout dimensions as dependent variables. Multiple linear regression results showed: (a) lower work-related burnout (ß = −0.217, p < 0.01) among married HCWs; (b) higher personal-related burnout (ß = 0.228, p < 0.01), work-related burnout (ß = 0.425, p < 0.01), and client-related burnout (ß = 0.359, p < 0.01) among doctors; (c) fear towards COVID-19 was significantly associated with client-related burnout (ß = 0.243, p < 0.01); (d) an avoidant coping strategy was significantly associated with personal-related burnout (ß = 0.322, p < 0.01); (e) social support from family was significantly associated with personal-related burnout (ß = −0.264, p < 0.01), work-related burnout (ß = −0.186, p < 0.05), and client-related burnout (ß = −0.326, p < 0.01);(f) and social support from friends was significantly associated with work-related burnout (ß = −0.202, p < 0.05). This study demonstrated significant theoretical contributions and clinical implications in the healthcare system in Sabah by addressing the impact of various factors on burnout among HWCs.

Validation of the Malay Self-Report Quick Inventory of Depressive Symptomatology in a Malaysian Sample.

Depression is ranked as the second-leading cause for years lived with disability worldwide. Objective monitoring with a standardized scale for depressive symptoms can improve treatment outcomes. This study evaluates the construct and concurrent validity of the Malay Self-Report Quick Inventory of Depressive Symptomatology (QIDS-SR16) among Malaysian clinical and community samples. This cross-sectional study was based on 277 participants, i.e., patients with current major depressive episode (MDE), n = 104, and participants without current MDE, n = 173. Participants answered the Malay QIDS-SR16 and were administered the validated Malay Mini-International Neuropsychiatric Interview (MINI) for DSM-IV-TR. Factor analysis was used to determine construct validity, alpha statistic for internal consistency, and receiver operating characteristic (ROC) analysis for concurrent validity with MINI to determine the optimal threshold to identify MDE. Data analysis provided evidence for the unidimensionality of the Malay QIDS-SR16 with good internal consistency (Cronbach's α = 0.88). Based on ROC analysis, the questionnaire demonstrated good validity with a robust area under the curve of 0.916 (p < 0.000, 95% CI 0.884−0.948). A cut-off score of nine provided the best balance between sensitivity (88.5%) and specificity (83.2%). The Malay QIDS-SR16 is a reliable and valid instrument for identifying MDE in unipolar or bipolar depression.

The Role of Oxidative Stress in Suicidal Behaviour Among Bipolar Patients: A Cross-Sectional Study in a Malaysian Sample.

Background: Oxidative stress markers are found to be linked with depression and suicide attempts in bipolar disorder (BD), although the role of DNA damage as a marker of suicidal ideation and attempt has yet to be determined. We aim to investigate the association between DNA damage and suicidal behaviour, i.e., suicidal ideation and suicide attempt, among suicidal ideators in BD patients while accounting for clinical and psychosocial risk factors. Methods: A cross-sectional study was conducted in the Universiti Kebangsaan Malaysia Medical Centre on 62 consecutive BD patients diagnosed using the M.I.N.I. Neuropsychiatric Interview and 26 healthy control participants. Socio-demographic and clinical assessments were performed using the Columbia Suicide Severity Rating Scale (C-SSRS) for lifetime suicidal ideation and attempt, Quick Inventory of Depressive Symptomatology (QIDS) for depression severity, Clinical Global Impression for Bipolar Disorder (CGI-BD) for illness severity [both mania (CGI-Mania) and major depressive episode (CGI-MDE)], Social Readjustment Rating Scale (SRRS) for change in life events, and Barratt Impulsiveness Scale (BIS) for behavioural impulsivity. The degree of DNA damage in peripheral blood samples was determined using a standard protocol of comet assay. Results: Multivariable logistic regression revealed higher scores of CGI-MDE as the sole significant factor for lifetime suicidal ideation (OR = 1.937, 95% CI = 1.799-2.076). Although initial bivariate analysis showed a significant association between DNA damage, malondialdehyde (MDA), catalase (CAT), and suicidal behaviour, the findings were not seen in multivariable logistic regression. Bivariate subgroup analysis showed that moderate and severe DNA damage (p = 0.032 and p = 0.047, respectively) was significantly associated with lifetime suicide attempts among lifetime suicidal ideators. The study is the first to look at the connexion between DNA damage and suicidal risk in bipolar patients. It is limited by the small sample size and lack of information on illicit substance use. Conclusions: More severe DNA damage was significantly associated with lifetime suicide attempts among lifetime suicidal ideators in BD. However, the severity of depression was found to be independently associated with lifetime suicidal ideation per se rather than DNA damage in BD. Larger prospective studies are required to ascertain the potential of DNA damage as a biomarker for the transition from suicidal ideation to a suicide attempt.

A pilot project to introduce the multiple mini interview (MMI) at a Borneo medical school: The universiti Malaysia Sabah experience- a cross-sectional study.

INTRODUCTION: The Multiple Mini Interview (MMI) demonstrates efficacy and superiority over traditional medical interviews in assessing non-cognitive domains during the recruitment of medical undergraduates. At Universiti Malaysia Sabah (UMS), a five-station MMI was piloted in 2019, featuring a mix of three examiner-driven stations (assessing professionalism, ethics, and motivation to study medicine), and two roleplayer-driven stations (assessing empathy and science communication specifically, and communication skills in general). METHODS: 260 candidates were grouped into two separate geographical groups - urban and suburban/rural. Descriptive analysis, skewness and kurtosis were performed for normality assessment, whereas Cronbach's alpha, McDonald's omega, and Greatest lower bound assessed internal consistency. For validity measures, correlations were calculated between scores for separate stations, overall scores, urban and suburban/rural status. Also, exploratory factor analysis was performed on the five stations as validity measures. Difficulty and discrimination indices were calculated as quality measures. Qualitative analysis was performed on "red flag" comments detailing grossly unsuitable candidates. RESULTS: Roleplayer-driven stations yielded more red flags than examiner-driven stations. The three examiner-driven stations were significantly and moderately correlated (rho between 0.602 and 0.609, p < 0.001). The Empathy roleplayer-driven station was not correlated with two examiner-driven stations and only weakly correlated with the Ethics examiner-driven and the Science Communication roleplayer-driven station. Factor analysis suggests a three-factor model. The two roleplayer-driven stations stood as independent factors, and the three examiner-driven stations coalescing as one factor provided the best explanatory model. Quality measures suggest all five stations had suitable discriminatory properties (all >0.530), whereas the stations were distributed equally in difficulty index. CONCLUSION: The UMS MMI has identified specific skillsets that may be in short supply in our incoming medical students. Also, it illustrates the yawning gap between academic knowledge and 'translational' scientific knowledge and communication skills.

Flying solo in Myanmar: case study on challenges and important lessons learned by an early career psychiatrist in a district setting.

The transition from trainee early career psychiatrist (ECP) to independent practitioner can be challenging. Upon completion of training in well-equipped academic settings, an ECP from Myanmar is required to serve in a divisional hospital for at least 3 years. Significant challenges are faced by ECPs practising solo in divisional hospitals, including inexperience in administrative aspects, lack of future-proof training, scarcity of resources and facilities, struggles in the provision of holistic biopsychosocial treatment, work-life imbalance, and limited career advancement and access to continuous training. The solutions tried thus far include the incorporation of information and communication technology in training, gathering support and distant supervision from both local and international settings, and task shifting. Bigger challenges are often rewarded by faster growth, and difficult times stimulate creative solutions. The sacrifice of these solo ECPs has significantly improved the mental health service of Myanmar district regions.

Atraumatic trismus induced by duloxetine: an uncommon presentation of acute dystonia.

Atraumatic trismus can be one of the presentations of medication-induced acute dystonia, particularly by antipsychotics and less commonly antidepressants. A case of an unusual emergency presentation of atraumatic trismus on initiation of duloxetine is reported. The patient was a 40-year-old woman experiencing sudden difficulty in mouth opening and speaking due to a stiffened jaw after taking 5 days of duloxetine prescribed for her fibromyalgia-related chest pain. Assessment of vital signs is prudent to ensure there is no laryngeal involvement. Other physical examinations and her recent investigations were unremarkable. She was treated for acute dystonia and intravenous procyclidine was given together with oral diazepam. Her symptoms improved immediately and her duloxetine was suggested to be stopped. To our knowledge, this is the first case of isolated trismus induced by duloxetine. Clinicians should be aware of this risk, especially considering the limitation of important physiological functions (such as swallowing, eating, etc) associated with this condition.

Dialectical behavior therapy in the Asia-Pacific Rim region.

BACKGROUND: Borderline personality disorder (BPD) contributes to suicide-related morbidity and mortality and requires more intensive psychotherapeutic resources due to its high mental health service usage. Accessibility to an evidence-based treatment program is a cornerstone to support patients with BPD and part of broader suicide prevention efforts as well as improving their quality of life. AIMS: In this article, the authors aim to discuss and review available dialectical behavior therapy (DBT) and DBT-informed services of selected countries in the Asia-Pacific Rim, namely Singapore, Malaysia, and Mexico. MATERIALS & METHODS: We contacted providers of different services and gathered information on the process of setting up the service and adapting the treatment, in addition to reviewing the available literature published in the countries. RESULTS: To date, there have been a pair of DBT-informed services in Singapore, four in Malaysia, and several in Mexico with a few of them offering standard DBT. Different efforts have been put in place to increase the accessibility to training and also the number of DBT practitioners. DISCUSSION: Important considerations during the process of setting up new services include the use of domestic examples and local language that are contextually appropriate for the local community. Selected challenges faced in common include shortage of workforce, affordability of training programs, and the need for language adaptation with or without translation. CONCLUSION: Further long-term evaluation of locally adapted DBT-informed mental health services will help to elucidate the effectiveness and efficacy of the program which will potentially serve as a guide for other resource-scarce regions.

The Behaviour Changes in Response to COVID-19 Pandemic within Malaysia.

The novel coronavirus infection, COVID-19, is a pandemic that currently affects the whole world. During this period, Malaysians displayed a variety of behaviour changes as a response to COVID-19, including panic buying, mass travelling during movement restriction and even absconding from treatment facilities. This article attempts to explore some of these behaviour changes from a behaviourist perspective in order to get a better understanding of the rationale behind the changes.

Medical record abstraction in a hospital with paper-based records: experience of early career psychiatrists in northern Borneo.

We used medical record abstraction to conduct research in a psychiatric hospital with paper-based medical records. The challenges we encountered included: the difficulty in retrieving files; the extensive effort and time needed to extract clinical information; the lack of a standardised documentation system of medical records; and the need for advanced computer literacy. To promote future research using electronic medical records, potential solutions include creating a registry of all patients receiving treatment, as well as equipping busy clinicians with computer skills.

Aphagia in frontal lobe syndrome following traumatic brain injury: Delightful lessons from olanzapine treatment.

A case of persistent aphagia in frontal lobe syndrome after traumatic brain injury (TBI) with successful use of olanzapine to improve the eating disorder is presented. A 20-year-old man suffered a severe TBI with right frontal intracerebral haemorrhage At four-month post-TBI, he had agitation, concurrent apathy with constant refusal for oral swallow despite gustatory sensory stimulation, hence the needs for nasogastric tube (NGT) feeding. He was diagnosed with frontal lobe syndrome and prescribed olanzapine 5mg daily that was optimised to 10mg due to worsened aggression. One month later, the aggression reduced with gradual improvement in oral intake. Percutaneous enterogastrostomy (PEG) tube insertion was cancelled and the NGT was sucessfully removed. Olanzapine prescription in this case improved aggression and aphagia simultaneously. Although olanzapine is proven beneficial and surgical intervention for long-term enteral feeding was avoided in this case, its usage requires judicious judgement.

Is Ketamine the Future Clozapine for Depression? A Case Series and Literature Review on Maintenance Ketamine in Treatment-resistant Depression With Suicidal Behavior.

Ketamine has shown effectiveness as a rapid-acting antidepressant with antisuicidal effects in terms of reduction of suicidal ideation in the short term. However, the evidence for long-term maintenance ketamine therapy for treatment-resistant depression (TRD) and suicidal behavior is limited. This case series (N=13) highlights the role of adjunctive serial maintenance ketamine infusions in restoring functionality in treatment-resistant unipolar and bipolar (mixed) depression with significant suicide risk and multiple comorbidities, including alcohol dependence. Two cases of TRD achieved functional remission with long-term maintenance ketamine treatment. The first case illustrates the potential synergistic interaction between ketamine and lamotrigine to achieve a sustained antidepressant response in the patient for 7 months. The second case may possibly be the longest reported case of maintenance ketamine therapy, with treatment continuing for 5 years to date. Ketamine treatment showed acute effectiveness in another 7 cases, especially in terms of reduction of suicidal ideation, albeit without significant long-term antidepressant effect. Factors that may contribute to lack of effectiveness of serial ketamine include inadequate mood stabilization in TRD in bipolar spectrum diagnoses, concomitant benzodiazepine use, complex comorbidities, and adverse effects such as significant hypertension and severe dissociation. Future systematic controlled studies are warranted to establish the efficacy and safety profile of long-term ketamine as maintenance therapy for TRD with suicidal behavior.

Learning Psychodynamic Psychotherapy in Southeast Asia.

The subjective nature of psychodynamic psychotherapy (PP) makes training and supervision more abstract compared to other forms of psychotherapy. The issues encountered in the learning and supervision process of PP of Malaysian psychiatry trainees are discussed in this article. Issues of preparation before starting PP, case selection, assessment of patients, dynamic formulations, supervision, anxieties in the therapy, countertransference, termination of therapy, the treatment alliance, transfer of care, the therapeutic setting, and bioethical considerations are explored. Everyone's experience of learning PP is unique and there is no algorithmic approach to its practice. With creative thinking, effort, and "good enough" supervision, a trainee can improve PP skills, even in underserved areas of the world.