Healthcare practitioners' views of self-harm management practices in older adults in Ireland: A qualitative study.

OBJECTIVES: To explore healthcare practitioners' views on management practices of self-harm in older adults. METHODS: Semi-structured interviews were conducted with healthcare practitioners, including consultant psychiatrists, general practitioners, clinical psychologists, psychotherapists, clinical nurse specialists and social workers. Purposeful sampling was used to recruit participants in the Republic of Ireland ensuring diverse perspectives of healthcare practitioners were included. Healthcare practitioners were recruited advertising via professional and clinical research networks, social media, and snowballing methods. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis. RESULTS: We conducted interviews with 20 healthcare practitioners from April to July 2023. Three main themes were generated: first, a perceived greater risk of suicide, and increased awareness of complexity in older adults' self-harm presentations. Second, integrated care as an avenue for improving the management of self-harm in older adults. Third, the importance of safety planning in risk assessments of older adults. CONCLUSIONS: Healthcare practitioners viewed self-harm in older adults as complex, challenging, and associated with high suicide risk, approaching patients with care and caution. The need for integrated support and improved collaboration between relevant healthcare practitioners was identified. Suggestions were made for primary care having a lead role in identifying and managing older adults after self-harm. Increased mental health promotion and awareness of mental health and self-harm in this age group would help address current stigma and shame.

Systematic epidemiological and clinical comparisons across all 12 DSM-IV psychotic diagnoses in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS).

BACKGROUND: Research on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses. METHODS: The Cavan-Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life. RESULTS: Among 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct. CONCLUSIONS: There are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.

'Challenges in experiential learning during transition to clinical practice: A comparative analysis of reflective writing assignments during general practice, paediatrics and psychiatry clerkships'.

INTRODUCTION: This study explored the reflective writing (RW) of senior medical students across a co-ordinated reflection education programme in General Practice, Paediatrics and Psychiatry clerkships during their transition to clinical clerkships. The study compared RW themes from within and across three clerkships in order to understand the influence clerkships had on experiential learning and developing professional identity. METHODS: All medical students in their penultimate year were invited to participate in the study. 135 reflection assignments were analysed. A qualitative thematic analysis of students' RW was performed. An inductive approach was used and data saturation was achieved. RESULTS: Clerkship specific themes were the intimacy of the experience in General Practice, the powerlessness students felt and the challenge of delivering family centred care in Paediatrics and the sense of perceived risk in Psychiatry. Common themes across the three clerkships were of emotional struggles in developing a professional identity. CONCLUSION: There is an educational need for developmental space for students during General Practice, greater focus on preparing students for relationship building during Paediatrics and addressing stigma and personal safety issues in students during the Psychiatry clerkships. Across clerkships there is a need for better use of evidence based pedagogies to support emotional development.

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.

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.

A qualitative study into the development of a physical activity legacy from the London 2012 Olympic Games.

Olympic Games have sometimes been considered as public health interventions capable of improving population health by encouraging increased physical activity levels. However, the evidence base does not appear to support this and is of poor quality, focussing on population level outcomes, usually related only to participation in organised sports. A new approach to research into the effects of such events is required focussing on the processes and mechanisms by which population physical activity levels might be increased enabling more effective use of such events in the future. Two separate processes, the 'demonstration effect' and 'festival effect,' have been proposed in Government guidance and are explored using qualitative methods in eight inactive people and four physical activity promotion specialists in Brighton & Hove. The findings appear to support the idea that watching elite athletes compete is unlikely to inspire participation among inactive people and may even discourage it by reducing self-efficacy as a result of the perceived competence gap. Despite this, positive attitudes towards the London Olympics were observed among inactive members of the public and a desire to become actively involved in the event. Examples of intention to continue participating in community events and physical activities as a result of positive experiences of Olympic related events were also observed.

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.

Profile and activities of a rural home-based psychiatric treatment service in Ireland.

OBJECTIVES: This study described the profile, activities and patient-related outcomes of a long-established home-based treatment (HBT) service in Ireland. METHODS: A retrospective descriptive study design was adopted to review and describe the activities of the Cavan HBT team over a 5-year period. Data including demographics, referral details, duration of admissions and outcome/disposal were retrospectively collected from the home treatment team mental health register of admissions between 2006 and 2010. Data were analysed using SPSS version 15 for windows. RESULTS: A total of 783 patients were referred to the team over the study period, of which 722 were admitted for home treatment. Most referrals (51%) were from General Practitioners and the commonest reason for referral/admission for home treatment was low mood (26%). While 10% required stepped-up care to the psychiatric inpatient unit, 77% were successfully discharged to the out-patient clinic for routine follow-up care. CONCLUSIONS: Common psychiatric illnesses can be safely and effectively managed with HBT within the context of a spectrum of therapeutic options in a community psychiatric service.

Duration of the psychosis prodrome and its relationship to duration of untreated psychosis across all 12 DSM-IV psychotic diagnoses: Evidence for a trans-diagnostic process associated with resilience.

While duration of the psychosis prodrome (DPP) attracts attention in relation to the developmental trajectory of psychotic illness and service models, fundamental issues endure in the context of dimensional-spectrum models of psychosis. Among 205 epidemiologically representative subjects in the Cavan-Monaghan First Episode Psychosis Study, DPP was systematically quantified and compared, for the first time, across all 12 DSM-IV psychotic diagnoses. DPP was also compared with duration of untreated psychosis (DUP) and each was then analysed in relation to premorbid features across three age ranges: <12, 12-15 and 16-18 years. For each diagnosis, medians for both DPP and DUP were shorter than means, indicating common right-skewed distributions. Rank orders for both DPP and DUP were longest for schizophrenia, intermediate for other schizophrenia-spectrum psychoses, psychotic depression and psychotic disorder not otherwise specified, and shortest for brief psychotic disorder, bipolar disorder and substance-induced psychotic disorder, though with overlapping right-skewed distributions. DPP was longer than DUP for all diagnoses except substance-induced psychotic disorder. Across functional psychotic diagnoses, longer DPP was predicted by higher premorbid intelligence and better premorbid adjustment during age 16-18 years. These findings indicate that, trans-diagnostically, DPP and DUP share right-skewed continuities, in accordance with a dimensional-spectrum model of psychotic illness, and may reflect a unitary process that has been dichotomized at a subjective threshold along its trajectory. Better premorbid functioning during age 16-18 years appears to confer resilience by delaying progression to overt psychotic symptoms and may constitute a particular target period for psychosocial interventions.

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm.

BACKGROUND: Presentation to the emergency department (ED) with self-harm provides an important opportunity for intervention. AIMS: To investigate characteristics and self-harm repetition risk of those discharged from the ED without a referral for mental health-related aftercare. METHOD: Data on consecutive self-harm presentations to EDs for the years 2013-2019 (n = 55,770) were obtained from the National Self-Harm Registry Ireland. Multilevel Poisson and Cox regression models were estimated. RESULTS: Half of the self-harm presenters were discharged from the ED (49.8%) and almost half of them did not receive a mental health-related referral (46.8%). Receipt of a psychosocial assessment was associated with a 50% reduced risk of non-referral (IRR 0.54; 95% CI 0.51-0.57). Non-referral was also less likely for young people (< 18 years), presentations involving attempted hanging, persons with previous self-harm presentations, and in the latter half of the study period (2017-2019 vs. 2013-2016), but was more likely for those brought by ambulance, presenting outside 9 am-5 pm and admitted to an ED medical assessment unit. Of those not referred, 19.3% had a repeat presentation within 12 months, compared to 22.4% of those referred. No difference in repetition risk between these two groups was evident in adjusted analyses. Self-harm history had the strongest association with repetition, with highest risk among individuals with four or more previous presentations (HR 9.30, 95% CI 8.14-10.62). CONCLUSIONS: The findings underline the importance of assessing all individuals who present with self-harm and highlight the need for comprehensively resourced 24hr services providing mental health care in the ED.

Home-based treatment and psychiatric admission rates: experience of an adult community mental health service in Ireland.

OBJECTIVES: This study assessed the impact of the introduction of a Home-Based Treatment (HBT) Service on hospital admission rates from two adjacent sectors within a mental health service. METHODS: This study used a naturalistic design to compare admissions into the acute inpatient psychiatric unit of Cavan General Hospital from two differently configured sectors - East and West Cavan Psychiatric sectors (East was a community-based and oriented service while the West was a more hospital-based service) prior to and following the introduction of a shared home-based treatment team. Data including demographics, date of admission, diagnosis at admission and sector of admission were retrospectively collected from a mental health register of hospital admissions between 1995 and 2002. Data was analysed using SPSS version 13 for windows. RESULTS: There was a 50% reduction in admission to the inpatient unit in the first two years of the introduction of HBT. This drop was more marked in the West sector compared to the East. CONCLUSIONS: The introduction of HBT resulted in a marked reduction in overall hospital admission rates and this reduction was also evident in the sector where other elements of a modern community mental health service already existed.

Mixed-effects models reveal prediction of long-term outcome by duration of untreated psychosis (DUP) and illness (DUI) varies with quantile gradation but is invariant with time across 7 years in the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS).

While associations between duration of untreated psychosis (DUP) and outcome have been widely reported, how long these relationships endure following initiation of treatment and how such associations are distributed across the range of DUP values encountered remain unclear. This study investigates prospectively (i) whether prediction of outcome by DUP and by duration of untreated illness (DUI) diminishes, remains stable or increases in the long term after initiating treatment, and (ii) whether these relationships for differing indices of outcome vary across gradations of DUP-DUI values. Sixty-two subjects were evaluated prospectively for DUP, DUI, premorbid features, psychopathology and quality of life at both first episode psychosis (FEP) and at 7-year follow-up; functionality and service engagement were assessed at follow-up. Data were analysed using mixed-effects models for DUP and DUI quantiles. Prediction by longer DUP and DUI of greater psychopathology, particularly negative symptoms, and lower quality of life remained stable between FEP and follow-up; longer DUP and DUI also predicted lower functionality and service engagement at follow-up. While most associations were confined to the longest DUP-DUI quartile, those between DUP-DUI and negative symptoms and quality of life were distributed in a graded manner across DUP-DUI quartiles. Material confounding with premorbid features, including lead-time bias, was not supported. These findings suggest that benefits of reducing DUP-DUI may endure for at least a decade beyond FEP and that even modest reductions in DUP-DUI may confer particular advantage in the more debilitating and intransigent domain of impairment.

Can precision medicine advance psychiatry?

Precision medicine is a new approach that considers differences in genes, environment, and lifestyle in an attempt to tailor treatments for individual patients. Psychiatry, as a discipline, has historically relied on clinical judgement and phenomenology-based diagnostic guidelines and has yet to take full advantage. This editorial provides an insight into the expanding role of precision medicine in psychiatry, both in research and clinical practice. It discusses the application of genetics and subgroup stratification in increasing response rates to therapeutic interventions, mainly focusing on major depressive disorder and schizophrenia. It presents an overview of machine learning techniques and how they are being integrated with traditional research methods within the field. In the context of these developments, while emphasizing the considerable potential for moving toward precision psychiatry, we also acknowledge the inherent challenges.

Atypical neuroleptic malignant syndrome and non-alcoholic Wernicke's encephalopathy.

We report the case of a middle-aged woman with a history of bipolar disorder, in the absence of alcohol or substance misuse. The patient had been maintained on fluphenazine decanoate depot and now presented acutely with cognitive dysfunction and rigidity. Laboratory tests revealed elevated creatine kinase, acute kidney injury with metabolic acidosis and transaminitis, leading to a provisional diagnosis of neuroleptic malignant syndrome (NMS). Neuroleptics were withheld; dialysis was commenced; and blood biochemistry parameters improved in tandem. However, mental status changes persisted, and re-evaluation revealed multidirectional nystagmus with bilateral past-pointing. MRI confirmed the diagnosis of Wernicke's encephalopathy (WE). Prompt recovery followed treatment with high-dose intravenous thiamine. We discuss the co-occurrence of NMS and non-alcoholic WE-highlighting the need for a high index of suspicion for these relatively rare neuropsychiatric diagnoses which are often missed in those with atypical presentations.

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.

Systematic comparison of duration of untreated illness versus duration of untreated psychosis in relation to psychopathology and dysfunction in the Cavan-Monaghan first episode psychosis study (CAMFEPS).

This study systematically compared duration of untreated illness (DUI) with duration of untreated psychosis (DUP) in prediction of impairment at first-episode psychosis and investigated the extent to which these relationships are influenced by premorbid features. The Cavan-Monaghan First Episode Psychosis Study ascertained cases of first-episode psychosis in rural Ireland via all routes to care with limited variations in socioeconomic milieu. Cases were evaluated for DUI and DUP and assessed clinically for psychopathology, neuropsychology, neurology, insight and quality of life, together with premorbid features. Analyses then determined prediction of clinical assessments by DUI versus DUP. The study population consisted of 163 cases of first episode psychosis, among which 74 had a schizophrenia spectrum disorder. Shorter DUI but not DUP predicted less severe positive and general symptoms, while shorter DUP and particularly DUI predicted less severe negative symptoms; neither shorter DUP nor shorter DUI predicted less severe cognitive impairment or fewer neurological soft signs; shorter DUP and DUI predicted increased quality of life; shorter DUI but not DUP predicted greater insight. Only prediction of quality of life was weakened by consideration of premorbid features. Results were generally similar across the two diagnostic groupings. The present findings systematically delineate associations with DUI versus DUP across domains of impairment in first episode psychosis. They suggest that DUI may reflect a more insidious process than DUP and that reduction in DUI may be associated with more consistent and broader diminutions in impairment than for DUP.

Educational environments in Asian medical schools: A cross-national comparison between Malaysia, Singapore, and China.

INTRODUCTION: Perceptions of the educational environment (EE) represent an important source of information on medical students' learning experience. Understanding and addressing these perceptions can help inform initiatives designed to improve the learning experience and educational outcomes, while comparison of student perceptions across medical schools can provide an added perspective. The aim of the study was to compare the EEs of three Asian medical schools: Royal College of Surgeons in Ireland and University College Dublin Malaysia Campus, Yong Loo Lin School of Medicine, Singapore and Xiangya School of Medicine, China. METHODS: Medical students in the clinical years (N = 1063) participated in a cross-sectional study using the Dundee Ready Educational Environment Measure (DREEM). Data were analyzed using SPSS version 22. RESULTS: There were significant differences between the three medical schools in the total DREEM scores (F [2, 1059] = 38.29, p < .001), but all were in the category "more positive than negative" (mean score 135.42, range 128.97-142.44). Highest DREEM scores were noted in year 5 at RUMC (139.79 ± 79), year 3 at YLL (145.93 ± 14.52), and year 4 at XSM (138.56 ± 18.91). Variations in total and subscale DREEM scores were also found between clinical years in each medical school. DISCUSSION: Total DREEM scores at the three medical schools are similar to those reported from other undergraduate settings. However, significant variations occurred in perceptions of the EE, as students progressed through the clinical years. Greater attention to the learning environment and the curriculum may improve students' educational experience.

The social identity of hospital consultants as managers.

PURPOSE: This paper aims to explore hospital consultants' social identification, in terms of perceptions of their position in society, the salient targets for their social identification and how this appears to influence their perceptions of management activities and change. DESIGN/METHODOLOGY/APPROACH: A purposeful sample of 15 hospital consultants from a wide range of specialities and work locations in Ireland were recruited. Semi-structured, in-depth interviews were undertaken and thematic analysis was used to interpret the interview data. FINDINGS: The paper finds that all interviewees perceived public attitudes towards hospital consultants, as a group, to be negative. Twelve interviewees derived most sense of belonging from group membership within their immediate work area. These groups seemed to represent sources of validation and esteem and enabled consultants to exercise control over their work. Many consultants, however, described a sense of detachment from their employing health boards. Management, as a salient target for social group identification, was perceived as associated with powerlessness and lack of respect. Interviewees generally viewed involvement in management with little enthusiasm and considerable caution. PRACTICAL IMPLICATIONS: This paper shows that management approaches to hospital consultants could benefit from awareness that their social identity may already be under threat. Assaults on core professional values in the communication surrounding change are likely to provoke resistance. Existing work groups, with which consultants identify, could serve as a less threatening means to engage them with issues of cost and quality than externally imposed structures. ORIGINALITY/VALUE: This paper informs ways in which hospital consultants could be more successfully involved in health service management.

Undergraduate learning in psychiatry: can we prepare our future medical graduates better?

Irish medical schools attract an increasingly diverse student population and produce graduates who will practise in many parts of the world. There are particular implications in this for the planning and delivery of the undergraduate psychiatry curriculum. In all countries, mental health services struggle for equitable resourcing, and mental health care within general medical services remains relatively neglected. The traditional undergraduate psychiatry offering has been justifiably criticised for being excessively oriented towards secondary care when the vast majority of medical graduates will pursue careers in primary care or in specialties other than psychiatry. Recently published articles in the Irish Journal of Psychological Medicine address the current challenges and opportunities in providing an undergraduate experience that better prepares students for the mental health aspects of medical practice in a global context. We summarise and discuss these contributions and the recent Royal College of Psychiatrists publication Choose Psychiatry: Guidance for Medical Schools.

Changing attitudes to psychiatry and interest in the specialty as a career choice during clinical undergraduate years at a medical school in Penang, Malaysia.

BACKGROUND: Studies have suggested that the undergraduate clinical clerkship improves medical students' attitudes to psychiatry and career interest in the specialty, but few studies have explored the sustainability of these changes. AIMS: To explore changes in students' attitudes to psychiatry and career preference for psychiatry during the course of their senior clinical years at RCSI & UCD Malaysia Campus (RUMC). METHODS: All year 3 students (n = 111) at RUMC were invited to complete the Attitudes towards Psychiatry questionnaire (ATP-30) and a separate questionnaire seeking opinions on career preferences. The questionnaires were administered at 3 points in time: in year 3 before the 8-week psychiatry posting, following completion of the posting in year 4, and at the end of year 5. Quantitative data analysis was performed using SPSS version 18, and free-text responses were thematically analysed. RESULTS: One hundred completed questionnaires (90.1%) were returned. There was a significant improvement in students' ATP scores after their psychiatry rotation and this was sustained into year 5. Psychiatry as a career choice had highest preference levels following completion of the clerkship but declined in year 5 to below pre-clerkship preference levels. Qualitative analysis of factors influencing a career in psychiatry revealed themes of job satisfaction, lifestyle factors, perceived image of psychiatry, and self-appraisal. CONCLUSIONS: Our findings suggest that an enriched undergraduate clinical clerkship experience can help to sustain improved attitudes to psychiatry into the final medical year. However, declining interest in the specialty a career choice prior to graduation presents an enduring challenge.