Clinician perceptions of common mental disorders before and after implementation of a consultation-liaison psychiatry service: a longitudinal qualitative study in government-operated primary care settings in Penang, Malaysia.

OBJECTIVES: To explore primary care clinician perceptions of barriers and facilitators in delivering care for common mental disorders (CMD) before and after implementation of a consultation-liaison psychiatry service (Psychiatry in Primary Care (PIPC)) in government-operated primary care clinics and to explore the clinicians' experience of the PIPC service itself. DESIGN: This longitudinal qualitative study was informed by the Normalisation Process Model and involved audiotaped semi-structured individual interviews with front-line clinicians before (Time 1) and after (Time 2) the PIPC intervention. The Framework Method was used in the thematic analysis of pre/post interview transcripts. SETTING: Two government-operated primary care clinics in Penang, Malaysia. PARTICIPANTS: 17 primary care medical, nursing and allied health staff recruited purposely to achieve a range of disciplines and a balanced representation from both clinics. INTERVENTION: Psychiatrists, accompanied by medical students in small numbers, provided one half-day consultation visit per week, to front-line clinicians in each clinic over an 8-month period. The service involved psychiatric assessment of patients with suspected CMDs, with face-to-face discussion with the referring clinician before and after the patient assessment. RESULTS: At Time 1 interviewees tended to equate CMDs with stress and embraced a holistic model of care while also reporting considerable autonomy in mental healthcare and positively appraising their current practices. At Time 2, post-intervention, participants demonstrated a shift towards greater understanding of CMDs as treatable conditions. They reported time pressures and the demands of key performance indicators in other areas as barriers to participation in PIPC. Yet they showed increased awareness of current service deficits and of their potential in delivering improved mental healthcare. CONCLUSIONS: Despite resource-related and structural barriers to implementation of national mental health policy in Malaysian primary care settings, our findings suggest that front-line clinicians are receptive to future interventions designed to improve the mental healthcare capacity.

Medical Student Perceptions of the Value of Learning Psychiatry in Primary Care Settings in Penang, Malaysia.

OBJECTIVE: The study's objective was to determine the educational value of participation in a consultation/liaison psychiatry service to primary care clinics, from the perspective of Malaysian medical undergraduates. METHODS: A mixed method design was used. Fourth-year medical students participated in a consultation/liaison psychiatry service to two government-operated primary care clinics. Each student attended two half-day consultations to the clinics during the psychiatry clinical clerkship. Students joined in discussions with primary care clinicians, performed supervised clinical assessments, and administered a depression screening instrument. The learning experience was evaluated through four focus groups, each with 9-10 participants, held throughout the academic year. An end-of-year, anonymous, online questionnaire survey was administered to the entire class. Thematic analysis of focus group transcripts was performed and quantitative statistics were calculated (Stata version 13). RESULTS: Focus group themes included the following: (a) active learning opportunities in primary care psychiatry consultation had perceived added educational value, (b) students benefited from contact with patients with previously undiagnosed common mental disorders, and (c) students' primary care experience raised their awareness of societal and professional responsibilities. Of the class of 113 students, 93 (82%) responded to the questionnaire. The survey responses reflected the qualitative themes, with 79 respondents (85%) stating that the learning experience met or exceeded their expectations. CONCLUSIONS: Academic psychiatry has been criticized for its overreliance on secondary care settings in undergraduate clinical teaching. Our findings suggest that supervised clinical placements in primary care are feasible and provide added educational value as a routine component of the undergraduate psychiatry clinical clerkship.

Changing undergraduate attitudes to mental illness.

BACKGROUND: Promoting positive experiences of patient contact during psychiatry clerkships may be important in influencing medical students' attitudes to people with mental illness. Here we report findings from a focus group study that explored the impact on undergraduate attitudes of participation in a novel social interaction programme for people with mental illness and their carers, provided by a non-governmental organisation (NGO). METHOD: An audio-taped focus group interview was undertaken with 14 medical students using a semi-structured interview guide. The recorded discussion was transcribed verbatim and thematic analysis was performed. RESULTS: Initial apprehension about interacting with patients lessened as the students engaged in shared activities. Students described their increased awareness of the normality and competence of psychiatric patients. As future doctors, they reported a greater understanding of the benefits of social inclusion for patients and carers alike. Promoting positive experiences of patient contact … may be important in influencing medical students' attitudes to people with mental illness DISCUSSION: Medical students' joint participation in a group activity programme for people with mental illness in non-hospital settings may have advantages in promoting positive attitudinal change. Clinical teachers could usefully incorporate this type of experience into the undergraduate psychiatry curriculum.

Improving metabolic monitoring in patients maintained on antipsychotics in Penang, Malaysia.

OBJECTIVES: To evaluate the monitoring of metabolic parameters among outpatients maintained on antipsychotic medications in a general hospital setting in Malaysia and to assess the impact of a local monitoring protocol. METHODS: By performing a baseline audit of files from a random sample of 300 patients prescribed antipsychotic medications for at least 1 year; we determined the frequency of metabolic monitoring. The findings informed the design of a new local protocol, on which clinical staff was briefed. We re-evaluated metabolic monitoring immediately after implementation, in a small sample of new referrals and current patients. We explored staff perceptions of the initiative with a follow-up focus group, 6 months post-implementation. RESULTS: The baseline audit revealed a sub-optimal frequency of metabolic parameter recording. Re-audit, following implementation of the new protocol, revealed improved monitoring but persisting deficits. Dialogue with the clinical staff led to further protocol modification, clearer definition of staff roles and use of a standard recording template. Focus group findings revealed positive perceptions of the initiative, but persisting implementation barriers, including cultural issues surrounding waist circumference measurement. CONCLUSIONS: Responding to challenges in achieving improved routine metabolic monitoring of patients maintained on antipsychotics required on-going dialogue with the clinical staff, in order to address both service pressures and cultural concerns.

Malaysian medical students' perceptions of a film to promote psychiatry as a career.

OBJECTIVE: We aimed to evaluate perceptions of a Royal College of Psychiatrists promotional film among Malaysian medical students. METHODS: Year 3 (n=108) and Year 5 (n=108) students completed separate standard measures of attitudes to psychiatry: the ATP 30 and Balon scales, respectively. A questionnaire was also administered recording students' socio-demographic information, career preferences, perceptions of the film's effectiveness and its influence on career choice. Quantitative and qualitative analyses of responses were performed. RESULTS: The overall response rate was 95.5%. Mean career preference ranking for psychiatry was higher for Year 5 than for Year 3 (p=0.025). For most Year 3 (64.8%) and Year 5 (58.3%) respondents the film conveyed a positive image of psychiatry. Fewer perceived it as influencing career choice: 31.4% for Year 3 and 27.2% for Year 5. Higher scores on both attitudinal scales correlated positively with increasing likelihood of students rating the film positively (Year 3: p=0.000; Year 5: p=0.003). Thematic content analysis suggested possible socio-cultural influences on students' perceptions. CONCLUSIONS: Despite conveying a positive image of psychiatry, promotional films may have limited impact in changing students' attitudes towards psychiatry and in increasing interest in psychiatry as a career.