A cross-sectional study of burnout and its associations with learning environment and learner factors among psychiatry residents within a National Psychiatry Residency Programme.

BACKGROUND: Multiple studies have reported high burnout rates among residents, including psychiatry. There is a paucity of studies examining the relationship between burnout and learning context, stress levels, resilience, stigma in healthcare providers and coping methods concurrently within the same cohort. OBJECTIVE: We examined the rate of burnout among our psychiatry residents in a cross-sectional study and hypothesised that burnout is associated with poorer perception of learning environment, greater perceived stress, stigma levels, lower resilience and specific coping strategies during training. METHODS: Ninety-three out of 104 psychiatry residents (89.4%) within our National Psychiatry Residency Programme participated in the study from June 2016 to June 2018. Relevant scales were administered to assess the perception of learning environment, burnout, stress, resilience, stigma levels and coping methods, respectively. We performed comparisons of the above measures between groups (burnout vs no burnout) and within-group correlations for these same measures. RESULTS: Overall, 54.8% of the sample met criteria for burnout. Residents with burnout had poorer perception of the learning environment, greater stress levels (both p<0.001), were less willing to disclose/seek help and employed greater active-avoidance coping strategies. Within the burnout group, greater perceived stress was correlated with poorer perception of learning environment (rs=-0.549) and greater use of active-avoidance coping (rs=0.450) versus additional use of problem-focussed coping within the non-burnout group. CONCLUSIONS: Burnout was related to both environment and learner factors. These findings viewed within the transactional, sequential and imbalance models of burnout suggest the need to address stressors, beef up coping, provide continual support and develop resilience among our learners.

Network Meta-Analysis and Cost-Effectiveness Analysis of New Generation Antidepressants.

BACKGROUND: Major depressive disorder (MDD) impacts health, quality of life and workplace productivity. Antidepressant treatment is the primary therapeutic intervention. This study assessed the efficacy and tolerability of new generation antidepressants and their cost-effectiveness in the Singapore healthcare system. METHODS: We conducted a systematic search for head-to-head randomised controlled trials on ten antidepressants (agomelatine, duloxetine, escitalopram, fluvoxamine, fluoxetine, mirtazapine, paroxetine, sertraline, trazodone and venlafaxine) employed as monotherapy in acute MDD management. We performed a network meta-analysis to compare their relative efficacy. The outcome measures for efficacy were response and remission rate, and mean change in Hamilton Depression Rating Scale (HDRS) score; and for tolerability, study withdrawal rates due to adverse events. To evaluate their relative cost effectiveness, a decision tree simulating a cohort of MDD patients using antidepressant as monotherapy was constructed from a societal perspective over 6 months. We used effectiveness data from our network meta-analysis and local data on resource use for depression in Singapore. The incremental cost expected for each additional quality-adjusted life-year (QALY) gained was calculated and presented as the incremental cost-effectiveness ratio (ICER). RESULTS: We identified 76 relevant articles for the network meta-analysis. Of the ten agents included in the analysis, mirtazapine and agomelatine were most efficacious in achieving response and remission, respectively. Mirtazapine and duloxetine resulted in the greatest magnitude of change in the HDRS score. Agomelatine, escitalopram and sertraline were the best tolerated of the drugs analysed, while duloxetine was the least well tolerated drug. Using a composite outcome of efficacy (response and remission rates) and tolerability, agomelatine, escitalopram and mirtazapine were the favoured treatments. In the cost-effectiveness analysis, apart from agomelatine, all the treatments were dominated by mirtazapine. Against mirtazapine, agomelatine was not cost effective given that its ICER exceeded the threshold value. CONCLUSION: Agomelatine, escitalopram and mirtazapine had favourable balance between efficacy and tolerability. In addition, mirtazapine was a cost-effective option in the Singapore healthcare system.

Sexual assaults in Singapore: a comparative study of rapists and molesters.

Sexual assaults vary in terms of severity from molestation, which involves touching, stroking, fondling or grabbing of any part of the victim's body, to rape, where victims have been known to suffer severe emotional trauma. The aim of the study is to compare molesters with rapists using hypotheses that molesters and rapists commit their offences at different times of the day, at differing locations and with differing relationships with their victims. The influence of alcohol on both groups was also studied. Convicted molesters and rapists were given a semi-structured interview in prison. Demographic information and details of each offence were obtained from prison records. Comparisons were made of the demography, time, place, reasons for assault, relationship of offender to victims and the role of alcohol and drugs consumed by the perpetrators. Molesters and rapists were of similar age and ethnicity, but differed in that rapists had attained a lower educational level and were more likely to be single. Rapists were more likely to report having drunk alcohol, committing rape after midnight and in secluded places. Molesters struck in the afternoon hours and usually in crowded places. Victims of molesters tended to be relatives whereas victims of rapists were more likely to be ex-spouses or ex-lovers. Molesters tended to give other reasons for their offences. Differences between molesters and rapists could lead to intervention strategies chiefly targeting the issues of poor socialisation skills in molesters and alcohol counseling for rapists.

Case formulation in psychotherapy: revitalizing its usefulness as a clinical tool.

OBJECTIVE: Case formulation has been recognized to be a useful conceptual and clinical tool in psychotherapy as diagnosis itself does not focus on the underlying causes of a patient's problems. Case formulation can fill the gap between diagnosis and treatment, with the potential to provide insights into the integrative, explanatory, prescriptive, predictive, and therapist aspects of a case. Despite the acknowledgment that case formulation is a basic, necessary, and key clinical skill, it is still largely undertaught and underlearned. Some of the issues faced in the development of a case formulation include that of immediacy versus comprehensiveness, complexity versus simplicity, observation versus organization, and the need for cultural sensitivity toward each individual patient. METHODS: The authors propose five aspects of case formulation beneficial to therapists and residents in training. CONCLUSIONS: The authors argue that case formulation remains an important and indispensable integrative tool for therapists and residents in training who are involved in psychotherapeutic interventions.