Initiative to improve handover notes in a tertiary psychiatric hospital.

Clinical handover is an important process in hospital settings, but it is often carried out inadequately, posing potentially serious consequences for the patients. This project aimed to increase the effectiveness of handover notes when patients were transferred between a general psychiatric ward and other wards in a tertiary psychiatric hospital. Effective handover notes in this project were defined to have the following five components: brief psychiatric history, reason for the patient to be transferred, significant risk issues, reason for psychotropic medication change and active medical issues. Baseline measurement obtained from audits revealed that the completion rate of effective handover notes was only 27.27%, which could potentially compromise patient safety and staff work efficiency. To address this problem, a series of plan-do-study-act (PDSA) cycles was implemented to improve the handover process. The interventions included education to junior doctors, reminders to complete effective handover notes and implementation of a handover template. Following each PDSA cycle, data were gathered to assess whether an effect had been achieved and to identify ways to enhance interventions to maximise impact. After the final PDSA cycle, the percentage of effective handover notes among all transfer cases reached 90.50%. Postintervention feedback from inpatient team indicated that effective communication between different teams was ensured, and staff satisfaction and time savings were improved. This study highlights the importance of employing PDSA cycles to assess and refine interventions and the usefulness of structuring the content of key components of handover notes to obtain measurable improvements.

From Unipolar to Bipolar: The Diagnostic Evolution in an Elderly Man.

A pivotal concept in the field of mood disorders is the dichotomy between unipolar depression and bipolar disorder. Due to the unique treatment in older age bipolar disorder and the scarcity of research in this area, it is clinically important to raise the awareness of the diagnostic conversion of unipolar depression to bipolar disorder in the elderly population. We present a case of a 71-year-old Chinese man whose diagnosis was revised to bipolar disorder after 9 years of treatment for unipolar depression. Organic workup, including blood tests and brain imaging, was performed to rule out organic causes. This patient eventually responded well to the combined treatment of an antipsychotic and a mood stabilizer. This case report adds to the growing literature of challenges in identifying and managing bipolar disorder in the elderly. As unipolar depression and bipolar disorder have different disease courses and different treatment strategies, it is essential for clinicians to be aware of diagnostic conversion. Further research is needed to delineate bipolar disorder from unipolar depression in the elderly population.

The development of clinical reasoning throughout the training and career of psychiatrists in Singapore.

Objectives: The current study sought to explain how different professional experiences led Singaporean psychiatrists to alter their clinical reasoning processes as their careers evolved from psychiatry residents to senior consultant psychiatrists. Methods: The current qualitative study interviewed 26 clinicians at various stages of their psychiatric career, spanning residents to senior psychiatrists.  The authors used a constructivist grounded theory approach to structure the collection and analysis of data. Analyses produced a dense theoretical explanation rooted in the experiences of participants. Results: Several differences emerged between the way psychiatry residents and senior psychiatrists explained their reasoning process and the experiences on which they based their preference. Residents preferred using deductive logic-driven frameworks that were diagnosis-centric, because of the pressures they experienced during their training and assessments. Senior psychiatrists emphasized a more holistic and problem-centric approach. Participants attributed the changes that occurred over time to practical experiences, such as their greater clinical responsibility and independence, and individual experiences, such as growing sensitivity to the clinical reasoning process or their growing propensity for professional reflectiveness. These changes manifest as an increase in repertoire and flexibility in deployment of different clinical reasoning strategies. Conclusions: It is important for trainees to be aware of the deductive and inductive modes of clinical reasoning during supervision and to be comfortable with shifting clinical focus from diagnoses to specific individual problems. Training programs should provide and plan adequate longitudinal clinical exposure to develop clinical reasoning abilities in a way that allows consequences of decisions to be explored. Continued faculty development to ease the diversification of clinical reasoning skills should be encouraged, as should reflectivity in the learners during clinical supervision.

Misdiagnosis of Psychosis and Obsessive-Compulsive Disorder in a Young Patient with Autism Spectrum Disorder.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social interaction and the presence of restricted and repetitive patterns of behavior. Making a first diagnosis of ASD in adults has certain difficulties, including inaccurate recall of developmental history and overlapping behaviors with other psychiatric conditions. This case study presents a young man who was assessed to have no major mental illness during his first visit to emergency services in a psychiatric hospital. During his second visit, he was initially assessed to have first episode psychosis, due to his possible delusional beliefs related to the insurance payout, social withdrawal, and strange behaviors, and then later he was assessed to have obsessive-compulsive disorder (OCD) instead of psychosis, because of his recurrent and intrusive thoughts. Eventually, his diagnosis was revised to ASD during outpatient follow-up after more comprehensive assessment. It is not easy to differentiate ASD from psychosis among some adult patients, even for expert psychiatrists. Cognitive rigidity in ASD may be similar to delusions in psychosis. Unusual behaviors in ASD can be confused with disorganized behaviors in psychosis. Differentiating ASD from OCD can be a complicated task as well, due to similarities between ASD and OCD. Restricted interests and repetitive behaviors in ASD may be perceived as obsessions and compulsions in OCD. Overall, diagnosis of ASD in adults requires comprehensive evaluation. Distinguishing symptoms of OCD and psychosis from autistic traits is critical for accurate diagnosis and optimal treatment. Although research in adult ASD has expanded alongside increased prevalence statistics over the past few years, more efforts to enhance the diagnostic processes in adult ASD are needed to reduce the challenges in this field.

Intellectual disability and COVID-19: A bibliometric review.

Background: During the COVID-19 pandemic, the vulnerabilities of certain groups of people have been highlighted, such as people with intellectual disability (ID). Although related research on ID has developed rapidly during the COVID-19 pandemic, the quantitative analysis of those research results has not been systematically performed through bibliometric analysis. Bibliometric analysis is a useful and rigorous method to explore large volumes of research data, and it allows researchers to extract quantitative information on distribution by author, time, country, and journal. Aim: The aim of the present study is to comprehensively analyze the current status and developing trends in publications on ID research related to and conducted during the COVID-19 pandemic. Methods: A bibliometric analysis was performed using the Web of Science database. Biblioshiny software was used to analyze and visualize the following information: main information of dataset, annual scientific production, journals which published the most relevant sources, most-cited authors, most-cited countries, most-cited global documents, word-cloud of keywords authors have used, and both the co-occurrence and co-citation networks. Results: A total of 450 publications were included. The average number of citations per document was 5.104. Among the top three journals, Journal of Applied Research in Intellectual Disabilities published 32 articles, Journal of Intellectual Disability Research published 29 articles, and British Journal of Learning Disabilities published 17 articles. The article with the title COVID-19 and People with Intellectual Disability: Impact of a Pandemic was the most cited with total 144 citations The United Kingdom had the most publications and had strong cooperative relationships with the United States, Canada, and Australia. The most popular keywords included mental health, autism, developmental disability, and lockdown. Thematic map analysis identified several possible clusters, including telemedicine, physical activities, and mental health. Conclusion: The present study provides a better understanding in this research field and may help clinicians, researchers and stakeholders to obtain more comprehensive view of ID and COVID-19. The insights gained from this analysis could inform future research.

Clarifying Self-Report Measures of Social Anxiety and Obsessive-Compulsive Disorder to Improve Reporting for Autistic Adults.

Background: Phenotypic similarities exist between autism-related experiences and anxiety (especially social anxiety and obsessive-compulsive disorder [OCD]), making it difficult for autistic people to self-report their experiences using existing measures developed for nonautistic adults. We examined whether clarifications aiming to tease out autism-related experiences from social anxiety or OCD in self-report questionnaires would influence autistic and nonautistic participants' ratings. Methods: Two autistic consultants and two experienced clinicians were consulted to develop item clarifications aiming to disentangle autistic from anxiety experiences for two questionnaires: the Social Anxiety Questionnaire (SAQ) and the Padua Inventory (PI) for OCD. Autistic adults (n = 50) and nonautistic university students with higher (n = 81) and lower autistic traits (ATs; n = 104) completed the original questionnaire followed by the clarified questionnaire items online. Results: For social anxiety, there were few significant differences between the original and clarified item and total SAQ scores. For OCD, participants reported significantly lower scores for the OCD-clarified PI items than for the original items and the autism-clarified items. Larger original-clarified PI mean item differences were noted in items describing repetitive behaviors, "obsessional" thoughts, and contamination fears. Similar patterns of differences were found in autistic and nonautistic participants with higher and lower ATs, but differences were often larger in the autistic group. Conclusion: The SAQ in its original form appears to be an appropriate measure for autistic people to self-report social anxiety. However, autistic people appeared to complete the original PI items to reflect, to some extent, their autism-related experiences, rather than the originally intended OCD symptoms. Thus, the original OCD self-report ratings were inflated using the PI. Professionals should therefore clarify the intended meanings of different items of the PI to ensure more accurate and relevant ratings of OCD symptoms in autistic people. Lay summary: Why was this study done?: Autistic people and people with higher autistic traits (ATs) often experience higher rates of anxiety. Anxiety measures developed for the general population may not be appropriate or accurate for measuring anxiety in autistic people. We investigated whether clarifying items in existing self-report questionnaires to tease out anxiety from autistic experiences would influence the way autistic adults self-report their social anxiety and obsessive-compulsive disorder (OCD) symptoms, and if so in what ways. We also wanted to know whether providing these item clarifications would affect the ratings of nonautistic individuals with varying rates of ATs to the same extent.What did the researchers do?: We initially consulted two autistic adults and two clinicians with experience working with autistic adults and co-occurring mental health difficulties. We selected two measures: the Social Anxiety Questionnaire (SAQ) for social anxiety symptoms and the Padua Inventory for OCD symptoms. The consultants identified social anxiety and OCD items that could be interpreted or experienced differently by autistic people and proposed ways to clarify them to make their meaning clearer.Next, 50 autistic people and 185 nonautistic university students participated in our online study. The nonautistic participants were grouped into those with higher or lower ATs. Participants completed the original social anxiety and OCD questionnaires first, followed by the clarified versions of the two questionnaires.What were the results of the study?: For social anxiety, we only found small differences in ratings when participants used measures with or without clarifications. This was true in both autistic and nonautistic participants. For OCD symptoms, autistic people's OCD ratings were significantly lower for many items after we provided clarifications, especially for items describing repetitive behaviors, "obsessional" thoughts, and contamination fears. This finding suggests that in the original questionnaire, autistic people may have also been rating their autism-related experiences, not just the OCD experiences or symptoms the questionnaire was trying to measure. We found similar differences between the original and clarified item ratings in nonautistic participants with higher and lower ATs. However, the differences were more common and pronounced with the autistic participants.What do these findings add to what was already known?: These findings suggest that original self-report measures of anxiety may need to be clarified so that autistic adults can better capture and rate their anxiety, rather than their autism-related experiences.What are potential weaknesses in the study?: We used only two anxiety questionnaires, so these findings may or may not be applicable to other OCD or social anxiety questionnaires available. Also, the clarifications we provided may not be representative of all autistic people's experiences, and it is possible that there are other and better ways to clarify the items. We also conducted many item comparisons in this study, so there is a possibility that some findings were due to chance.How will these findings help autistic adults now or in the future?: Our findings can help improve clinical interviews and use of anxiety questionnaires by making them more accurate. They can also help clinicians appreciate the importance of asking clarifying questions to ensure they better capture autistic adults' anxiety experiences.

Autistic traits in first-episode psychosis: Rates and association with 1-year recovery outcomes.

AIM: There is a growing appreciation that subthreshold but clinically elevated levels of autistic traits are clinically relevant. This study examined autistic traits in Singaporean patients with first-episode psychosis and their association with 1-year psychosis recovery. METHODS: The relationship between baseline patient characteristics, autistic traits (measured with autism screening questionnaires) and psychosis recovery outcomes at 1-year were examined in 180 adults in the Early Intervention Psychosis Programme in Singapore. RESULTS: Out of 180 participants, 50 (27.8%) had clinically elevated above screening-cut off levels of autistic traits on the self-reported 10-item Autism Spectrum Quotient and 8 (4.4%) on the staff-rated Autism Spectrum Disorder in Adults Screening Questionnaire. At baseline, those with more autistic traits were more likely to be unemployed, economically inactive (ie, students or homemakers); and to have diagnoses of mood disorder with psychotic features, brief psychotic disorder or psychotic disorder not otherwise specified as compared to schizophrenia spectrum and delusional disorder diagnoses. Although most participants showed improvements in their clinical outcomes at 1-year, those with higher autistic traits improved less in the Positive and Negative Syndrome Scale general psychopathology scale and in Global Assessment of Functioning symptomatology. CONCLUSIONS: Autistic traits are common in those with first-episode psychosis and may be associated with poorer clinical outcomes. Validated screening tools should be developed in this population to support earlier reporting.

Selection of New Psychiatry Residents Within a National Program: a Qualitative Study of Faculty Perspectives on Competencies and Attributes.

OBJECTIVE: Admission committees use multiple sources of information to select residents. However, the way in which faculty members use each data source remains unclear and highly context-specific. The present study seeks to understand how faculty members use various sources of information about candidates to make admission decisions to a National Psychiatry Residency Program. METHODS: The theory of core competencies was used as a foundation for this qualitative study. Framework analysis was used to structure the project and data presentation. Twenty key informants from the faculty were purposefully sampled in accordance with the initial theory. Open-ended semi-structured interviews were conducted to obtain their views about the essential competencies of psychiatrists and the ways in which these competencies could be reliably gauged. RESULTS: Participants described numerous competencies that they believed were essential to becoming competent psychiatrists. These competencies fell within the six core competencies of the Accreditation Council for Graduate Medical Education framework. However, several non-competency attributes (such as perseverance, empathy, and compassion) were also relevant in the selection process. To reduce the impact of self-presentation bias, to which these attributes were vulnerable, the faculty relied heavily on sources of information obtained from third parties, such as feedback from co-workers with first-hand experience of the candidate during their clinical placements. CONCLUSION: Faculty members place importance on informal informant-derived information about a candidate's non-competency attributes in addition to core competencies when deciding whether or not to select a candidate for admission into a residency training program.

Adult neurodevelopmental services in Singapore: A sociodemographic and clinical profile at a tertiary psychiatric hospital.

INTRODUCTION: The Adult Neurodevelopmental Service in Singapore is the first service of its kind in South-East Asia for adults with intellectual disability (ID) and/or autism spectrum disorder (ASD). However, few studies have documented and compared the sociodemographic characteristics and clinical needs of this subpopulation group. METHODS: Initial assessments conducted from 1 January 2015 to 31 December 2016 were retrospectively reviewed for this descriptive study. RESULTS: A total of 272 patients were included in the study (mean age 28.3 ± 11.5; 200 males, 72 females). Adults with ID comprised the largest percentage (52.9%), followed by those with ASD (30.2%), and then those with co-occurring ASD and ID (16.9%). The ASD subgroup had the highest proportion of individuals with employment, postsecondary school education, functional capabilities, and a psychiatric disorder. In comparison, adults with only ID and adults with co-occurring ASD and ID shared similar lower levels of education and employment, and had a higher proportion of individuals with epilepsy and aggressive behavior. DISCUSSION: In this study, adults with ASD had a unique social profile with different clinical needs compared to adults with only ID or to adults with co-occurring ASD and ID. Adults with only ID and those with co-occurring ASD shared many of the same social characteristics and high clinical needs. The analysis of these profiles will be useful in developing services that better meet the needs of this complex group.

Psychiatric Advance Directives and their relevance to improving psychiatric care in Asian countries.

People with mental illness may be unable to provide critical input about the care they wish to receive during a psychiatric crisis because of altered mental states. It is therefore imperative that clinicians seek to understand service users' wishes for care while they are well and able to provide meaningful input into the discussion. Achieving such an end may be done by discussing and completing a psychiatric advance directive. However, very few Asian countries have legislation that supports such advance directives. The present article seeks to give physicians more information about advance psychiatric directives and the potential role they could play to improve the healthcare provided in Asia to people at risk of losing capacity due to a mental illness. The degree to which mental health legislation supports psychiatric advance directives is documented for each country of South East Asia and Eastern Asia.

Adoption and correlates of the Dundee Ready Educational Environment Measure (DREEM) in the evaluation of undergraduate learning environments - a systematic review.

BACKGROUND: The Dundee Ready Educational Environment Measure (DREEM) was specifically designed to measure the undergraduate medical educational environment. This study seeks to review the adoption of DREEM internationally, and its association with different learning contexts and learner factors in order to better support our learners and facilitate future applications and research. METHOD: A systematic literature review was conducted on all articles that adopted and reported data using the DREEM from 1997 to April 2017. RESULTS: Overall, the majority of 106 included studies from over 30 countries were conducted in Asia and Europe (76.4% of studies) within medical, dental, and nursing programs (86.8% of studies). Seventy-nine out of 98 studies (80.6%) which reported DREEM scores observed a mean total DREEM score within the range of "more positive than negative" (101-150 out of maximum 200 points). Higher DREEM scores were associated with better past academic achievement, quality of life, resilience, positive attitudes towards course, mindfulness, preparedness for practice, less psychological distress, and greater peer support. CONCLUSIONS: Future studies may want to examine other correlates of DREEM such as coping styles, personality profiles, burnout level, and DREEM scores can be incorporated into reviews of learning environments to ascertain longitudinal changes following educational interventions.

The nosological significance of Folie à Deux: a review of the literature.

BACKGROUND: Folie à Deux is a rare syndrome that has attracted much clinical attention. There is increasing doubt over the essence of the condition and the validity of the original description, such that it remains an elusive entity difficult to define. METHOD: We conducted a systematic review of the literature of all cases reporting the phenomenon of Folie à Deux, from the years 1993-2005. RESULTS: 64 cases were identified of which 42 met the inclusion criteria. The diagnoses in the primary and secondary were more heterogeneous than current diagnostic criteria suggest. There exists a high degree of similarity between the primary and secondary in terms of susceptibility to psychiatric illness, family and past psychiatric history, than previously thought. CONCLUSION: Folie à Deux can occur in many situations outside the confines of the current classification systems and is not as rare as believed, and should alert the clinician to unrecognized psychiatric problems in the secondary.