BJPsych Journals podcast transcripts

Check out the transcripts for BJPsych, BJPsych Advances, BJPsych International, and BJPsych Open podcasts.

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Sachin: Welcome to the BJPsych International podcast. In this episode.

Balan Rathakrishnan: Many people are not aware, oh, this is my problem because of gambling. The psychosocial education for them, it's still lacking.

Sachin: Professor Balan Rathakrishnan joins us to discuss ‘Gambling in Malaysia: an overview’. Hi, my name is Sachin, and I am a psychiatrist based in London.

Hamilton: Hi, I'm Hamilton, and I'm a psychiatry trainee based in London.

Sachin: You can officially say you're a psychiatry trainee now because it's actually true, which is amazing. Also congratulations.

Hamilton: Thank you. I don't think I've been going around claiming to be one before being one, but now it's official. Now I have the legal documentation to prove it.

Sachin: You're growing up before our very eyes. It's like you're a young character on home and away who's still on home and away.

Hamilton: There's a very niche reference actually, but I'll take the compliment.

Sachin: Today we're going to talk about gambling in Malaysia as part of one of the issues of BJPsych International. Actually, I have an editorial here by Professor David Skuse, who talks about gambling and governmental responsibilities, because the issue covers gambling within Malaysia and Nigeria.

He says that we are basically, throughout history, species who tends towards taking risks for a reward, but sometimes these risks can outweigh the rewards. Gambling is one of these situations where, as you know, the house always wins, and yet we still, for some reason, are lured towards it, and we might give in to the temptation to win it or maybe lose it all.

As psychiatrists, David Skuse says, we are all aware that gambling can be potentially addictive. Neuroscientific research has shown that the neural processes involved are shared with other addictions such as those associated with substance misuse. We've seen as well that people with problem gambling issues are likelier to have a history of addiction issues within the family, not just related to gambling.

Hamilton: Because of the possible harms that can arise from gambling, and subsequent addiction to gambling, particularly to certain individuals such as children and adolescents, many societies in history have attempted to regulate it. Historically, there are some religions that actively do not allow gambling, but even in secular society, concerns about gambling have become focused on the age at which behaviour begins with a view to protecting children who are still developing their prefrontal cortex, and therefore don't have the exact same amount of executive function and self-control and inhibition that an adult would.

Sachin: Basically, it becomes a balance between protecting people's freedoms to do what they choose to do, and protecting vulnerable people who are more at risk of harm from certain activities.

Hamilton: Yes, and at risk of developing patterns of behaviour that they may carry on through the rest of their life.

Sachin: We talk about certain cultures regulating gambling. As we mentioned, this issue of BJPsych [International] talked about the cultures within Nigeria and Malaysia. Malaysia is an interesting one. Let's just talk about Malaysia for a second. It's a Southeast Asian country with a population of about 32.3 million people. It gained independence from the British Empire in 1963.

Islam is the predominant religion in Malaysia, with about 60% of people in Malaysia practicing Islam, and is followed by Buddhism with 20% of people, and Christianity with about 9% of people, and Hinduism, about 6% of people, and the rest practice traditional or Chinese religions. It's a very multicultural society, but with a strong influence of Muslim values within a large portion of the population.

As such, and as we'll find out, gambling is forbidden for the majority of Malaysians as it's forbidden under Islamic law. Most Muslims don't engage in legal gambling. Then Malaysia being a multi-ethnic population, you'll see that with Chinese population making up about 25% of the population, and people with Indian ancestry making up 12% of the population, those groups have access to gambling. It's not culturally forbidden through Sharia law for them, and so they're more likely to be taking part in gambling where it occurs. It's a very interesting situation in Malaysia with two sets of values applying to two different portions of the population.

Hamilton: Before we continue, because of course, this is a podcast that is largely listened to by psychiatrists, and is aimed to be for whoever wants to listen to it, but a large amount of the audience will be psychiatrists. I think it's important to mention that when one talks about gambling addiction, as the article mentions, the term gambling disorder sits alongside addictions of substance misuse in the DSM-5, but in the ICD-11 from the World Health Organization, the term gambling disorder has now replaced the term which was previously used, pathological gambling.

Sachin: Yes. ICD-10 lists F63.0, pathological gambling, which exists in the habit and impulse disorders category, which is itself within disorders of adult personality and behaviour. By the way, in that category, it has cousins such as pathological firesetting, pathological stealing, but then also things such as trichotillomania—hair pulling—and other habit disorders.

Meanwhile, in the ICD-11, it is now gambling disorder, as you say, category 6C50. Interesting. It's now in the category disorders due to addictive behaviours, which itself is in the category disorders due to substance use, or addictive behaviours. I think the shift really is in recognizing that gambling disorder has many shared neurological correlates with other disorders of addiction. Its cousin within this category, by the way, is gaming disorder, which is the interesting new disorder to the ICD-11, which is making a lot of news articles worldwide.

Hamilton: Very much the new kid on the block.

Sachin: Basically, yes. We may reference things such as pathological gambling, problematic gambling, gambling disorder, gambling addiction, all referring to what the ICD-11 will know as gambling disorder, basically.

Hamilton: The crux of it, if I'm not mistaken, can be quite simply boiled down to the disruptive impact that it has on the life of the individual and those around them, does it not?

Sachin: Yes. We are talking philosophically, that's where most disorders of the mind tend towards, is that you can't really think of them as a disease if they're not causing some kind of detrimental impact. Otherwise, it's just a variation of human behaviour, right? It still is a variation of human behaviour, but it becomes a disease when you think about, "What problems is it causing?"

In the ICD-11, the criteria is that you have a pattern of persistent or recurrent gambling behaviour, which may be online, which a lot of gambling is in Malaysia, as we'll find out; or offline, which is a lot more restricted in Malaysia, and manifested by an impaired control over gambling.

In terms of onset, frequency, intensity, duration, ending the gambling, where you gamble, losing control of all those sort of things; an increasing priority given to gambling to the extent that gambling takes over other life things that you want to get on with; and a continuation or escalation of gambling, despite negative consequences. That would be probably the most irrational part of it, is that even when it's causing you harm, you can't stop.

Obviously, there's other sort of criteria about how long it has to have been going on for, but you can see a general pattern in dependence syndromes, even to substances or to behavioural issues, is that it's about a lack of control, and it's about harm caused and continuing despite that harm.

Hamilton: So you're telling me that even if one were to lose a large amount of money over the course of a single week in Monte Carlo or Las Vegas, that wouldn't necessarily meet criteria for gambling disorder, because it needs to be a persistent pattern of behaviour and an impact on one's life in multiple areas?

Sachin: Right. It's important not to confuse harmful behaviour with dependent behaviour, or even just excessive behaviour with dependent behaviour. Even when it comes to excessive behaviour, context is key. For example, if I told you that a man lost a million dollars in Las Vegas last night, you might be like, "Oh, okay, that sounds bad," but if I told you that man's name was Jeff Bezos?

Hamilton: Well, he probably, while he was there in the casino, made twice that, if not more.

Sachin: Exactly. Yes, the context is key, clearly, and pattern, and again, detriment to life. That raises the question that David Skuse's editorial raises, which is, what should a country do about this? We'll find out what Malaysia is doing about it, but David Skuse says that a total ban on gambling seems unrealistic in any society, particularly, one, because it would be very difficult to enforce, and two, because that will drive the activity underground where it's then harder to regulate. But if gambling is permitted, he asks, how does one ensure that it does not cause harm?

Should governments encourage some forms of gambling, such as lotteries as a way of raising money for good courses? For example, there's a Malaysian lottery called Da Ma Cai. [chuckles] Maybe this is bad timing, I just went onto their website and it says they're seizing all operations.

Hamilton: Oh, well, I guess we can take that one off the list.

Sachin: Da Ma Cai will temporarily seize operations and no draws will be conducted during the total lockdown period. Oh, is that Covid thing.

Hamilton: Oh, I see, to discourage people going outside unnecessarily.

Sachin: Yes. Da Ma Cai is a Malaysian lottery, currently they got a jackpot of 35 million Ringgit.

Hamilton: How much is that worth in GBP, Sachin?

Sachin: Well, maybe you can Google it and tell me, and in the meantime.


Hamilton: I just expect you to be able to reel this off.

Sachin: In the meantime, I will tell you that the slogan is, "Support education, play with us," which sounds to me like they, just like our national lottery, have some community benefit too existing.

Hamilton: It turns out that 35 million Malaysian Ringgit is just over £6 million. That's not bad.

Sachin: Amazing.. Da Ma Cai says that funded predominantly from the profits of PMP, which is Pan Malaysian Pools, TCC, which is The Community Chest, funds the establishment, development and advancement of schools and learning institutions which are not for profit and which do not receive sufficient funding or aid from the government or from the community. Just like our national lottery and Malaysia has lotteries which support community goods. That sounds pretty cool, and that's one of the legal lotteries within Malaysia.

Back to the editorial, which questions maybe lotteries are a good way of raising money for good causes. Then questions, does permitted advertising of privately organized gambling activities such as casinos, horse racing, or sporting fixtures reflect an open society? Or does the encouragement of gambling of any sort lead to abuse, and for some individuals, the road to destitution? Both Nigeria and Malaysia are struggling with these challenging questions, as are we in the UK.

Hamilton: The first paragraph, after the brief introduction for the article, talks about the history of gambling in Malaysia, and references sources which suggest that gambling was likely brought to Malaysia by Chinese merchants in the 19th Century. The article goes on to mention how gambling, both in legal and non-legal forms, is quite popular in Malaysia and available in various forms with lotteries, casino games, and horse racing being legal, but in comparison, sports betting or online gambling being considered illegal.

Naturally, there's a very unique dynamic at play in Malaysia when it comes to gambling. Who better to tell us about the situation regarding gambling in Malaysia than one of the authors himself, and for that we have Sachin's interview with the first author of this article, associate professor Balan Rathakrishnan, who will very kindly tell us about his article ‘Gambling in Malaysia: an overview’.

Sachin: I'm here with Balan Rathakrishnan. Would you please introduce yourself? Let us know what you do and what is your interest in this topic?

Balan: Thank you so much, Dr. Sachin. My name is Balan Rathakrishnan. I was born in Malaysia, and currently I've been working in the Universiti Malaysia Sabah in the faculty of Psychology and Education. You know Universiti Malaysia Sabah, which is the Borneo side of Sabah, and its about my 17 years of experience in teaching. My focus of my research is usually based on deviant behaviour intervention for young adolescence, and also for those in high group risk youth.

Basically, I really lot of research concerning about these people, especially youth group related to their whatever given behaviour, for example, they've been involving in sexual behaviour, alcoholic, and antisocial behaviour problem in schools or in the university.

Sachin: Then how about gambling?

Balan: Gambling, I have done one or two research related to gambling. In Malay, we can it judi. Judi means gambling. In Malay we call it judi. It’s also under law of Malaysia because this is not in the norm. Which then we call this is a deviant behaviour, because it's not permitted by the law, and also the norm of people. The society itself not recognizing it's a good behaviour. We call it is a deviant behaviour.

Sachin: You say it’s deviant behaviour because it's not permitted by the law. But as I understand it in your paper, there's separate laws operating in Malaysia, is that right? What's the situation in Malaysia with the legal status of gambling?

Balan: When we look into the legal part, what I said just now, we have two different part that we need to look into. Number one is the law, whether the law is permitting exactly what is the gambling, or the second part is the society itself, the culture of people. Then as I said, both gambling, whether it's been legal or illegal, is still not been recognized by the society as okay now. I said about the law, is still there are Act which we have to follow, which we call Betting Act 1953, which they call legal because it's under the minister of finance.

Sachin: When we think about the demographics of Malaysia, Islam being the predominant religion with more than 60% of people are Muslim, do they have a separate code under which they operate?

Balan: Yes, because under the Malaysia, we call dual system of law, whereby for gambling. This is under Sharia partner. We've got Sharia, it is law, and that is the Act which we call 559 Act under the Sections of 18. Whereby this is only for Muslims, whereby if they've been caught for any illegal gambling, or they've been involved in gambling, they can be charged under the Act of 559 under Section of 18.

Whereby they are not being permitted any type of gambling, whether they can be inside the house, or even they can go to the legal gambling centre, for example, casino. Casino is a legal whereby it's been permitted by the minister of finance. Even then, Muslim are not being permitted to enter the premises because under the Sharia law, it is illegal for them.

If it's for non-Muslim, they've been permitted to this casino, whereby it's considered as legal, and if they go to that premises, they’ve been allowed. For non-Muslim, for example, Chinese, we have about 25% of Chinese in Malaysia, we have about 12% to 13% of Indian in Malaysia, and then other races, they've been permitted to go these premises, which is been legalized for gambling. We have one centre which is very popular in Malaysia, which we call Casino Genting Highlands, which is located in Pahang, Malaysia.

Sachin: This is the one land-based casino in Malaysia, isn't it?

Balan: Exactly. Only one land and property, and after that, no land and property is permitted for this gambling. There are many other illegal gambling and betting. They have like Magnum, Sports Toto, Da Ma Cai. This is like betting, sweepstakes, lotteries, gambling, mission games, and online games and all that. Which is illegal, but there are many practices being done by, especially these young generations on that, which is illegal. Da Ma Cai, Magnum, Sports Toto is been legalized because that is a lottery centre whereby it's acceptable, and you can go and buy. Muslims are not permitted to go there also.

Sachin: There's some legal avenues for gambling, but also illegal gambling goes on, and as I understand it, online gambling is an illegal form which people are engaging in, including international gambling sites which serve Malaysia.

Balan: Exactly, exactly. Like I said just now, lotteries, you can buy lotteries, you know, right? Lotteries?

Sachin: Yes.

Balan: That means they do gambling by buying lotteries whereby there are centers, which is been legalized, which I have said just now. Magnum, Sports Toto, and Da Ma Cai. These are the lottery centre, which is legalized in Malaysia. Even though that is a lottery centre which is legal, it's not been permitted for Muslims under the Sharia law.

Sachin: Wherever there is gambling illegal or not, there is the potential for pathological gambling.

Balan: Exactly.

Sachin: You have summarized in your paper, the research in Malaysia with regards to this. Can you tell me just broadly what you know about what factors are associated with higher gambling levels in people.

Balan: When we're talking about pathological problems, we must divide these components of gambling, because when we look into the issue of gambling, we can divide by three components. The first one is problem gamblers whereby they've been starting to gamble, and they're still in the mode of control, their attitude and their behaviour, and it's not really much into their psychopathological problem.

The second category we call moderate level of gambling, whereby they're involved with gambling and they have a lot of issues related to their psychologically, and they relate to other social-psychological problems like forexample, they have been using a substance, for example, alcohol drugs related to this gambling.

The last one is a psychopathological, which is they're related to their mental disorders problem and because it’s too much [unintelligible 00:21:55]. They cannot be brought themselves from the psychopathological gambling as their activity which then it causes a lot of psychopathological.

If you look into my paper, psychological issues, there are many, especially on how the involved in this gambling and how they relate with their daily life and psychological issues and related to their mental health problems.

Sachin: Yes, and in terms of the social issues, which are associated with higher levels of gambling, you've noted that younger people, Chinese demographic, lower education levels, and higher-income seemed to be associated. Then this was interesting to me. Another factor that you noted was associated with higher gambling, was being from paternal-headed families.

Balan: Now, when we look this non-Muslim, which is Chinese and Indian, when we look into the issue, go deeper into them, what the social demographic factor, especially this Chinese and Indian family have been doing, when we look into that, one of the main activity, it's because of the family background. Some of them are very poor family, poverty issues, and sometimes these Chinese also, maybe the parents have been doing it back. This is in the Chinese family because the parents have been doing it, so the children also follow.

The chances for them, these Chinese family, those are in very poor situation, or they have issues of low education level. They've been involving with this activity long, long time ago. It's for them become like an attitude which they can follow from the parents.

Sachin: I guess if there's anything I would ask further is about, why is it particularly the Chinese demographic who are at risk?

Balan: 25% of population in Malaysia are Chinese, and only about 12% are Indians, and the rest are 60% are Malays and Muslims. When you look into these Chinese, their background, the history, how they started with this gambling, it started very long, long time ago. Even you see in China, because these Chinese peoples, all of them are come from China, and some are the different type of world, but they've been migrated to Malaysia. They've been doing business in a really as a historical way, they've been doing it, this type of business many, many years ago.

When they come to Malaysia, they also have brought this type of culture whereby gambling become a business for them. That's how it started. To answer your questions why there are many people involved are Chinese compared to other races in Malaysia, because that business been brought many, many years when they come migrated to Malaysia.

Sachin: Now, what is the level of gambling among adolescents?

Balan: There are no specific statistics in Malaysia. There is no perfect, or there is no accurate data, related to this percentage, but there are many research have been done in Malaysia stating that there are young adults involving, starting from age of 13, and there are many cases of young adults involving when they're age of 15. We don't have real, exact, and accurate, and precise data related to these statistics. It could be our next research, which we should more focus on that in our related research on gambling.

Sachin: Your paper noted that a recent study looking at around 2,000 Malaysian adolescents found that around 30% of them had participated in some form of gambling over a 12-month period. They're certainly doing it, to what degree, it's not clear, but they're certainly doing it, and noting that certain factors associated with adolescents gambling include the parents gambling, being male, and other high-risk factors, which are closely associated with adolescence gambling. Do you have an estimate of what the prevalence is of problem gambling in Malaysia?

Balan: The prevalence statistics, if I look into Malaysia, we have about 4.4. That is the latest, I think there are research being done. The rate of prevalence in Malaysia, it's about 4.4. Especially in the state of Selangor, which a lot of people have been associated with this gambling.

Sachin: Why in that state?

Balan: To answer you that state, because the prevalence problem with gambling in Malaysia was determined using the largest state of Selangor, which the population itself is about 5.6 million. This is the data statistics from the department of statistic, Malaysia 2010. That sampling shows that because of the population itself in Selangor is the highest.

Sachin: Yes.

Balan: The chances for them to be involved to categorize as problem gamblers are quite high in Selangor compared to other state in Malaysia.

Sachin: Right. Since that's 4.4% of the general population in Malaysia's largest states are problem gamblers, and then beyond that, 10.2% are moderate-risk gamblers.

Balan: Exactly.

Sachin: That's quite lots of the general population, isn't it? 1 in 10 moderate risk.

Balan: Exactly. The truth. There are many people have been, and significantly they're related to their state because when we are looking to many states in Malaysia, because we have about 13 states in Malaysia, and Selangor is one of the richest and one of the broader of population. The chances people to be aware exposed is there is a tendency for them to involve with this type of gambling. Even you see, I see casino is in a state of Pahang, which is very closely to Selangor. The statistic shows Selangor has about 570,000s of people being involved with moderate-risk problem gamblers.

Sachin: Now, people who have pathological gambling, do they seek help, and where do they seek help?

Balan: Very good question, Sachin. If they have pathological issues, especially on this mental health, they cannot withdraw from this attitude and behaviour. Usually, there are many services we do, especially private counsellors whereby they can seek a lot of private counsellors, been professionals for this addictive behaviour, and one of that is gambling.

There are also services being given in the government hospital. Whereby if there are poor people, financially are poor, they can seek for these government hospitals whereby there are centres and programs to help them out in order for them to tackle these psychopathological issues. There are also private hospitals and private clinics doing it, this type of service, for those people who are really in need.

Sachin: As I understand it, although it's mainly anecdotal from your paper, it says that it's more likely for people to seek help once things have really hit the fan in terms of there starts to be legal issues regarding debt, bankruptcy, fraud, domestic violence, or other crimes. That's when people come to the attention of services rather than seeking help earlier on.

Balan: Exactly, exactly. That's why I said I have categorized them, like moderate, problem gambler, and psychopathological. Usually, the early stage, they don't really recognize, they don't identify. That is what I can say awareness, awareness on the earliest stage is not bad. Whereby when they're having a problem, moderate level and involving with the other antisocial behaviour, like drugs, even alcohol or other antisocial behaviour, then [unintelligible 00:30:35], then they know they also involved with gambling and so on.

I think many people are not aware, "Oh, this is my problem because of gambling," the psychosocial education for them, it's still lacking. That's why I say really, the culture, number one. I relate in the poverty, I relate in their social environment at least. That's why I relate with these issues of gambling. I relate with these issues of gender. I relate with issues of social cultural in Malaysia, and how psychologically they've been involved. That's why I say gender issues, because male they're more open, they can go out, they mix with friends, and they've been exposed with the situation of gambling compared to female and so on. I also relate with a social demographical factor, like for example where did you come from?

Maybe they are from a poor family, whether they come from rural area. Because chances for people from urban area is more easily to expose with these type of facilities and also chances for them to involve with gambling.

Sachin: I imagine, now we know that it's not legal under Sharia law, but if a Muslim person were to fall into pathological gambling, which is possible for anyone to do, whether it's legal or not, it must be very difficult for them to seek help because they by their culture shouldn't have been doing it in the first place, and so there's probably a lot of stigma attached to it.

Balan: Exactly.

Sachin: Now, the rest of your paper goes into what needs to be done regarding pathological gambling in Malaysia. It is noted that there's no structure to gambling treatment services in the public sector in Malaysia. What do you think needs to be done going forward with regards to pathological gambling?

Balan: Okay, thank you so much, Sachin. That’s a good question. First of all, I'm as a psychologist, I do believe that the number one is the awareness, especially for young generation. It's not time when they are in the moderate level of gambling. My focus of research shows young adults and young group of people, like for example, we can start this awareness problems in a school, which is more structured educational program to shows to the young generation gambling what are the pros and cons of their involving with that activity, whether like sports, even they do gambling, betting for sports and footballs.

Betting is very popular in Malaysia. A lot of young people, students especially involved with this betting. Betting especially for sports, football, for example. They bet to get money. We need to tell them, students, especially young generation, what are the advantages and disadvantages of this involvement of them? Awareness is number one. Second thing is we need to also have more structured counselling programs and counselling centres, whereby we giving them a chance for them to understand what this type of structure of counselling and program whereby those are moderate level and psychopathological people can go and easily they can get the solution from this type of centre.

Those things what I personally feel is that easy centres everywhere, whereby maybe even in many government hospitals are providing this type of services to easily people go and meet and there is no stigma regulations on them. When I go and meet the counsellors or meet the doctor or go to the centre, I'm not a problematic, but I'm seeking help. That type of attitude I think it's more appropriate, much needed for these young people in order for them to reduce with the psychopathological issue related to their gambling issue.

Sachin: How about in terms of research? Can you see areas in which further research is needed?

Balan: Thank you so much. I think that one research that I, number one, is about statistics. There is no exact research done on the level, number one is the statistics in Malaysia, especially, who are the different group of people involving with this gambling, number one. Number one is the statistics.

Number two, what are the problem associated with this gambling, especially maybe it could be problem associated, maybe they are anti-social behaviour associated problem or psychopathological problem which is related to them, number two.

Number three, what are the types of intervention that we can provide to this type of group of people? Maybe they're problem gamblers or moderate level or psychopathological. We need to have a different, different type of intervention, number three. That is number three.

Number four, what are the awareness program that the [unintelligible 00:35:34] of people can do? This type of awareness program, how we want to go about? These are the four part that we need to focus in for our future research, whereby this can become a very holistic type of research, whereby each and every component, psychological issues, education issues, economical issues, social cultural issues, and psychological issues, which we can cater for them, health issues. We catered all as a holistic in order to help those involving too much with this gambling.

Sachin: In terms of legislation, I know you say that a debate needs to be had because there's two ways it could go, I suppose. What do you see happening? Do you see Malaysia banning gambling outright, or do you see them legalizing more forms of gambling and regulating it?

Balan: Okay, now. Thank you for that question Sachin. I think in order for that, so far, what I can see, the gambling centre is only one land property, which is in a casino in [unintelligible 00:36:40]. Other than that, I think there is not much development on these centers, but there are many illegals gambling is going on, especially this online gambling games and all that. I think there must be a more legal on these illegals activities, which is going on because I think there are many agents which they can make a lot of money. They are recruiting many young generations in order for them to make money out of this.

I think there must be a legal, more legal operations, identifying those like these agents, and in order for them to reduce this problem, because we cannot avoid 100%, we cannot terminate these issues 100%. We cannot demolish these issues 100%, but what we can do, we try to educate people. What are the advantage? What are the problems when they're associating with this type of illegal gambling, especially lottery, they know illegal lottery, betting for game, online games and all that. We're educating people and if more issues of online illegal activity can be identified, I think many problems can be resolved, especially related to this young generation.

Sachin: We have a minute left, Balan. Would you like to add anything that you feel is important or hasn't been said yet?

Balan: I thank you so much for this wonderful opportunity. I think this is a great opportunity for me to elaborate more on this gambling. I hope there are many professional out there. Maybe internationally we can collaborate research related with gambling in Malaysia. I'm very happy to work and associating with whoever are interesting on these gambling issues, especially tackling on these young generations. What I feel that it's not about the problem, I'm not looking, it is a problem.

Now, what I'm looking is, what are the solutions that we can give? What are the interventions program? How this intervention program can be workable? What I believe is to help them out. There are many people out there needs our help, and I believe and I strongly see that as a psychologist, my contributions back to my society. My society needs my help. What are the intervention that I can do, especially this awareness program? What are the module that we can design create to help these people out there in order for them to educate them, number one, to manage them better and to help them out.

Sachin: Excellent. Well, thank you very much, Balan Rathakrishnan, for joining me.

Balan: Thank you so much, Sachin.

Hamilton: I still find it quite interesting and hard to believe that there is just one legal land-based casino in the country.

Sachin: Let's find out about this casino. The one and only casino in Malaysia, Casino De Genting, has got a five star in Trip Advisor.

Hamilton: Oh, wow. That bodes well.

Sachin: I mean, you're the only casino in town. You don't really have to be that good, but they incidentally are. Here's a review of Casino De Genting. "This big casino is the one and only casino in the whole of Malaysia. Lots of games are available, the most popular game is baccarat." There you go. Baccarat.

Hamilton: I mean, casinos themselves are fascinating environments if we look at the psychology of how casinos as are laid out in the architecture. Because most casinos they won't have windows or they'll have minimal windows and they'll have a degree of lighting that makes it difficult to know the time of day and often there won't be clocks around on the wall, which often makes it quite easy to lose track of time.

What's more, again, this is more for casinos in general. I don't know about the situation of Malaysia's one casino, especially given the fact that I don't know the differences in alcohol laws, but often in casinos, at least in the UK and America, alcohol would be provided at often lower prices than one would expect in other establishments, almost as if to encourage people to become slightly more disinhibited. This isn't, before big casino goes after me, this is all speculation of course, but it stands to reason that if alcohol is cheaper, then one is more likely to purchase alcohol and therefore experience the effects of its consumption prior to gambling in the same establishment.

Sachin: Well, a very broad answer to your question. Alcohol is generally prohibited for Muslim consumers in Malaysia. As again, Sharia law forbids Muslims from drinking alcohol. It's mostly banned for Muslims across the states of Kelantan and Terengganu.

Hamilton: Right, but these individuals won't be in the casino.

Sachin: Yes, and so the legal drinking age in Malaysia is 21 years old and above presumably for everyone else, and it used to be 18 back in 2017. Any vendors, restaurants, and retailers need a license to serve or sell tap or draft beers, liquors, and spirits in the country. Bottled and canned beers are exempted from such a licensed requirement, which is why it's common to find many vendors and coffee houses serving alcohol in the premises without a license throughout the country. That's the issue with alcohol. I've seen a nice picture of a supermarket with shelves stack with alcohol in a non-halal section. This one casino by the way looks really nice.

Hamilton: What was it called again?

Sachin: Casino De Genting.

Hamilton: Oh, it does look pretty.

Sachin: It looks lavish.

Hamilton: It looks like a casino.

Sachin: Seen one casino, seen them all.

Hamilton: I have only seen one casino.

Sachin: [laughs] I've seen the one casino.

Hamilton: It was also interesting because when I initially read the article, it mentioned how there aren't any structured gambling treatment facilities available in the public sector in Malaysia, with most facilities being available in the private sector, but it sounds like from your discussion with Balan, that actually there are some government-run facilities.

Sachin: Yes. From what it sounded like he was saying is that if you don't have the means to access private psychiatric help, then government centres do have programs running within them, but it doesn't strike me that there's anything, say, focused on gambling necessarily. It may be the case that these programs available in government centres are more based towards more broader psychological or psychiatric issues. He ultimately did make the call for more structured counselling centres within Malaysia to address the issue of gambling.

Hamilton: I see, so not specialized gambling treatment facilities, but rather more generic perhaps psychiatric or psychological therapy based centres.

Sachin: That seems to be the case. I guess it also seems to maybe match attitudes towards gambling as well, is that you'd expect maybe more of these structured counselling centres to pop up once the issue is less stigmatized, because if gambling itself is frowned upon culturally, then having gambling issues is probably quite taboo too.

Hamilton: Oh, absolutely. Whilst the research that Balan has gone through in the article, does report the epidemiology of gambling in the country as being predominantly non-Muslim members of Malaysian society. Imagine if one is a Muslim gambler in the country, there's even more stigma to seeking help and getting access to resources and the help one needs to break the cycle of addiction there.

Sachin: Yes. All the more reason, as Balan was saying, is that some research should be directed towards who encounters problem gambling and work out what these demographics are, so that culturally sensitive services can be developed, which are responsive to those needs.

Just to build on that, I was quite interested, as we mentioned about this being an issue, which is very attached to specific communities, and that usually when you hear that, you think that there's some underlying socioeconomic driver behind that. It's not necessarily that your ethnicity dictates how likely you are to encounter certain behaviours or disorders, but rather there might be an underlying socioeconomic driver.

But here, Balan is describing that maybe you are more likely to find the Chinese community involved within gambling in Malaysia. That is actually attached to historical roots of gambling within that community, including bringing gambling to the country. However, he does mention that while culture matters, family background matters and socioeconomic issues matter too.

Hamilton: In fact, that association that was reported in terms of the socio-demographic factors, including being young, a higher income, having no education levels, but also being of Chinese background was associated with high levels of gambling expenditure, not problem gambling behaviour, so to speak. As you've mentioned before, what counts as problem gambling for one individual or group of individuals may not be for others. Greater expenditure doesn't always equate to more of a problem or severe pathology, so to speak. I mean, one would think they can often be correlated, but it's not always necessarily the case.

Sachin: What struck me, although he mentions that there is more work to be done on truly assessing the prevalence of gambling issues in the country is this 4.4% prevalence of problem gambling and 10% prevalence of moderate risk gambling. As an estimate, that's a lot, one in 10 people of a moderate risk gambling behaviour.

Hamilton: According to the AusPsych website page on problem gambling, in the UK, problem gambling only affects about nine people in every thousand, but a further 70 people out of every thousand gamble at risky levels that may become a problem in the future. Which sounds a lot lower than what's been reported in Malaysia.

Sachin: Yes, because obviously that's a gulf between 70 out of a thousand re gambling at risky levels. Then 10% of people gambling at moderate risk. There's bound to be some definitional issue there, but it at least tells me that my spider sense about 1 in 10 people having risky gambling feels about right. That's not what you'd expect. That's like walking down the street and every few people you see has a moderate risking gambling. I think I'm fair in being incredulous at the idea of 1 in 10 people that you see out and about having high risk gambling behaviour.

Hamilton: Are you saying, Sachin, that you want to see them receipts?

Sachin: Yes, I want to see the gambling receipts. I guess the phrase for that is huge if true.

Hamilton: Absolutely.

Sachin: Huge if true, and then happening with very young people, and this is not like I'm saying it doesn't happen in the UK, but 13 years old, 15 years old, obviously we have similar issues of young people gambling in the UK and reporting that they've gambled online or more frequently through video games.

Hamilton: I mean, that figure alone, because obviously, to think that 10% of the general public would display moderate risk gambling behaviour and 4.4% demonstrating problem gambling behaviour. Then also the other study that's mentioned which found that 30% of Malaysian adolescents participate in some form of gambling over a 12-month period. 30%,that's, well, again, that's not problem gambling behaviour. That's just gambling in general. That's still not a small number, is it?

Sachin: Yes. It shows you how prevalent gambling might be within the culture. One of the points that Balan brought up was that you are more likely to be exposed to gambling, not only if you're male, because you are more likely to go out and socialize and be exposed to that thing within that culture. If you're from an urban environment, if you're from a city environment and that this issue might be less prevalent in rural places, but I don't imagine that that would remain the case much longer as online gambling becomes more prevalent. I know it's not legal within Malaysia, but that doesn't stop people from doing it. It's very difficult to enforce or regulate.

Offshore gambling would be even harder to regulate, right? Then, as with most countries, people are increasingly getting online through mobile devices and mobile internet that it wouldn't necessarily matter where you are. You have access to gambling.

Hamilton: There's other forms of gambling that often arise, which aren't originally intended for gambling. For example, there was a big problem with the online game Counter-Strike GO, where people were gambling on the outcome of matches for items and skins in the game which had monetary value. There was a large trading website set up for this purpose, which has since been shut down by Valve, the company that makes Counter-Strike GO.

For quite some time, there were many individuals gambling and losing quite a lot of money on this platform, even though the game itself doesn't have any gambling features in it. We know that attempts are being made to reduce exposure to gambling at a young age. They've changed how age-related classification for video games, for example, works now in this country where any gamer has a depiction of gambling, say, if it's possible to play blackjack in the game, that game would now receive a age rating classification of 18. That means games like Super Mario 64 DS which had a mini-game in which you could play blackjack with Luigi would now be age-rated 18, which I find somewhat amusing.

Sachin: That's not a legal age rating, is it, as PEGI.

Hamilton: Yes, it's recommended. It's not legally enforced.

Sachin: Well, in the UK, it's legally enforced, but the people making that decision would have been an independent ratings board. In parts of Europe, it's not enforced at all despite it being a European rating system. That's just to make a distinction that that's not the government saying that depiction of gambling is worthy of an 18 rating, but an independent ratings board saying that. I think, yes, your point is well taken.

If anyone listening wants to look up that form of gambling, it's called skins gambling or skin gambling. Yes, there's a lot of talk within the UK government about what aspects of video games may constitute gambling, particularly when it comes to loot boxes, for example, which are items you purchase which give you chance results, so there is a element of luck and risk involved in that which is currently being reviewed as, does that constitute gambling?

There are potential ways in which people are concerned that children are being exposed to gambling. Then literal gambling as well, through apps and things like that, which pose further concerns, but also just tells you that you're not going to get anywhere just by making gambling illegal, because people will find a way. Perhaps another consideration is bringing the issue out into the open, regulating it, and as Balan said, focusing more on educating the public about how to approach these behaviours in a safer, less risky manner.

Hamilton: Awareness is key.

Sachin: Yes.

Hamilton: Right, because we've improved awareness. It might be possible to pick up signs of problem gambling at an earlier stage, rather than what is the sad, common case where it only really becomes clear as a problem to others when someone has already racked up a large amount of debt and has entered quite a dark period in their life and potentially have had to take out loans in order to make up for the money that they've lost through gambling.

Sachin: Yes, there's a lot of issues wrapped up there about seeking help late until things have become worse. One is the awareness as you say. Another is really the stigma of having a gambling-related issue. Then not just how these issues affect the person, but how they're affecting mental health services, which is mental health services have to be equipped to handle these issues earlier, and to reach people more effectively before these gambling issues become issues of debt, of fraud, of criminal activity, of substance use, of other mental illness, they really want to reach these people before those significant further issues develop.

Hamilton: Yes, but before those life-destroying effects take place. That was really quite an interesting run-through of the gambling situation in Malaysia. Before reading this article and listening to the interview, it never occurred to me that the unique socio-cultural situation in Malaysia would have such a profound impact on social behaviour and such a huge impact on gambling in the country and the degrees to which individuals experience addiction to gambling.

I think as David Skuse mentioned in the editorial, gambling is both a human pastime with a profound amount of history, but also is a global universal pastime. Therefore, when gambling goes wrong, it's important that it isn't underestimated. As we've all heard, we know of the destructive effects it can have when one loses control over their ability to regulate their own gambling behaviour.

I'm quite glad that Associate Professor Balan Rathakrishnan and co-author Sanju George have been able to do this fantastic article, shedding some light on the gambling situation in Malaysia, and the potential future landscape of how best to improve the situation through increased awareness and education.

Sachin: Let me ask you, would you ban gambling outright?

Hamilton: One need only look at accounts of prohibition-era America, and I think it's the elephant in the room that we haven't really addressed as much. We briefly mentioned alcohol use, but just like gambling, alcohol use is a pastime with perhaps far more history with regards to use throughout human civilization. No, I wouldn't ban it, doesn't really work. Banning alcohol just leads to illegal underground alcohol use, and much the same happens with gambling.

I think certain types of gambling are illegal in Malaysia, such as online gambling, but it clearly happens anyway. The article itself mentions that the illegal lottery business in Malaysia generated about 60% more revenue than all of the six legal operators combined. Clearly, there's a lot of appetite for underground gambling.

Sachin: Clearly, people don't want to do lotteries which benefit education, apparently.

Hamilton: What is wrong with you?

Sachin: The six legal lotteries available to you and you play illegal ones? Why?

Hamilton: I would like to know the discrepancy in the prize amount, because it would be quite sad if the amount is the same or less. It's just like, if I play this lottery, I could feed hungry orphans, but if I play this lottery, I could win big bucks. I don't know. That's a terrible mental image. Who knows, Sachin, who knows? Would you ban gambling?

Sachin: No, but if you asked me the same question about other vices, I might say, yes. It's very difficult to come up with a consistent answer and know why I'm saying yes or no. To me, it just feels like gambling is a normal human behaviour, and that the harmful aspect affects a small enough proportion of society that there's no black and white about these issues, but I would veer more towards freedom in the case of gambling, simply because you don't want to pathologize a normal human behaviour.

For those in whom it does become pathological, you want to try and prevent and help, and that's best achieved by bringing these issues out into the light. I understand that there's also a moral overlay to this, and unsurprisingly, Malaysia is a very religious country, and so people have moral objections to gambling too. That is not a question I'm here to answer, that is a moral question for yourself to answer, you listening at home.

Hamilton: You, the listener.

Sachin: Yes, exactly. That's personal. Well, it doesn't matter what I think about morals or whether we should inflict morals on other people.

Hamilton: I think it matters a little, Sachin. You are a functioning member of society after all.

Sachin: If you want to get into it. [laughs] Anyway, thank you very much for joining us this episode. We will see you next time. If you want to check out that article, by the way, it is titled ‘Gambling in Malaysia: an overview’ by Balan Radhakrishnan and Sanju George, available in the BJPsych International Journal. This has been the BJPsych International podcast. Goodbye.

Hamilton: May the odds be ever in your favour.

Thank you for listening to this BJPsych International Podcast. For the latest updates, follow us on Twitter @TheBJPsych. To listen to more podcasts from the BJPsych Journal portfolio, visit us on SoundCloud or search for us online.

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Dr Oliver Gale-Grant: Hello, and welcome to another edition of the BJPsych Advances Podcast. My name's Oliver Gale-Grant. I'm joined today by Dr Peter Wilson who is a consultant psychiatrist and Trust Research Lead at Cheshire and Wirral NHS Trust. We're here today to discuss his new paper written with Clara Humpston and Rajan Nathan, ‘Innovations in the Psychopathology of Schizophrenia: A Primer for Busy Clinicians’, which is published in BJPsych Advances. Peter, thank you so much for joining us.

Dr Peter Wilson: Thank you for having me. Pleasure to be here.

Dr Gale-Grant: This is a paper that I think, at first glance, might look a little intimidating to some clinicians, because it covers essentially some neuroscience updates in schizophrenia and how the knowledge can be applied to the clinic. Tell us, what's the headline that we should take away?

Dr Wilson: The headline is, there's no need for any intimidation. I'm a full-time clinician, so the neuroscience element is more of a hobby for me than anything else. But the headline is that I think there's been a lot of developments in terms of the psychopathology of schizophrenia in the last 40 to 50 years that we don't tend to hear much about, whether that's at medical school or in postgraduate training. It was really just to give people a flavour that I seem to have come across these, thanks to some of my academic contacts, and it's really exciting, and really interesting things happen. I think that the time is about right that we can start introducing these developments into clinical practice.

Really, these developments are in the domains of phenomenology, so we've got a better and richer understanding of the experience of schizophrenia and psychosis, but also in processes in both the mind and the brain and the cognitive processes. Also, there's been the birth of computational psychiatry, which is about how we can start analysing all this information, and I wonder if that might be the key to how we can bring some of these advances into the clinic and into the inpatient wards. Really to say, it's a really exciting time, and I think that the time is right to bring these new advances, as I say, into clinical practice.

Dr Gale-Grant: I think something that most people could agree on is that advances in the clinical treatment of schizophrenia are somewhat overdue in the world of psychiatry, and as I guess most people in psychiatry know that management hasn't changed a great deal in the last 50 years. What are the changes in understanding that you're trying to get across here? Should we maybe talk through the different sections of the paper one by one a little bit?

Dr Wilson: Yes, great. That'd be great. I'll just give you an update. We've sort of split them into a few categories really, which of course is artificial, because they all meld into one. One of the most useful things that I've been introduced to is looking at a level of analysis concept. For a long time, there have been debates about, was schizophrenia a brain disorder or a psychological disorder? The answer is, of course, that it's both. It just depends at which point or level of analysis you look at.

For example, there are treatment options for all the levels. One is, if you look at it very basically, you can start with genetics, and then the neurochemistry, and then the cognitive approaches, going up to the mind-based approaches, going up then to the psychological presentations into society. We broke the paper down looking at developments in each of those. The first thing to say really, is we began by looking at phenomenology, and what really is the clinical presentation of schizophrenia. We thought that for a long time, particularly at medical school and postgraduate courses, we're taught a very old system of psychopathology based on the mid-19th century really, of Kraepelin, and Schneider, and that sort of thing.

It was just to say that since then, there have been people doing a lot of work about the experience of schizophrenia, and I think we've got a bit more of a more nuanced understanding now. I would just take you through, perhaps start some of those— Just start there. Then perhaps if we look at some of the mind-based models, and particularly ipseity, then some of the cognitive models, perhaps aberrant salience and source-monitoring defects, before looking at how the computational and predictive processing models might be able to gel it all together perhaps and link all the levels.

If we start at what we think schizophrenia is now, there's been some really, really interesting work done in terms of instruments. Now, these can be categorized into the BSABS, the EASE, and the EAWE. That's all a bit of a mouthful, but the BSABS stands for the Bonn Scale of Basic Symptoms, and what that talks about really, it just gives us a sort of introduction about the notions of schizophrenia. I think one thing a lady called Nancy Andreasen talked about a while ago was the death of phenomenology in the United States. What she was saying was that we've become very focused on symptom checklists, the DSM and ICD checklists.

I think what the Bonn Scale does looking the basic symptom concept, is to widen our lens a little bit. It talks about— Obviously, people with schizophrenia tend to have a hypersensitivity to sound, and also experience symptoms of what could be termed as metachromasia, which is a change in perception of colour, or even dysmegalopsia. We found out when we read the Bonn Scale and the BSABS that these are things that we'd heard patients saying, but we didn't necessarily know they were part of the schizophrenia concept. We just thought that it was something they were saying.

The EASE, that's The Examination of Anomalous Self-Experience developed by Josef Parnas around about 2005. That focuses on a disturbance of self-awareness, looking at the concept of schizophrenia as a disorder of the self, or the ipseity model as we call it. What it does, again, it just gives us that richer understanding of what our patients are experiencing. Things that resonated with me in particular on the EASE were things about spatialization of experience. That's where a patient reports that their thoughts are located to a particular part of their head or their brain. I'd heard patients talking about that, but I didn't know it was a thing so to speak, until I read the EASE which, again, is just a long list of questions, but it gives you that richness to understanding the patient experience.

I had a patient tell me that his own thoughts were at the back of his head, and the thoughts not under his agency were in a circle in the middle, and I think that is what Josef Parnas was getting at in his EASE. The EASE also talks about the notion of mirror-related phenomena, where patients with schizophrenia can sometimes spend a long time examining themselves in the mirror, and that's looking for facial change. I'd seen it on the wards, but I'd not picked it up as being part of a syndrome necessarily.

Then the final scale we talk about in the paper that clinicians might not be particularly familiar with, is the EAWE. That's the Examination of Anomalous World Experience developed by Louis Sass and colleagues. That's similar to the EASE, and it can be used in partnership, but it focuses on the lived world and has a more world-facing view. Items on that that really interested me were things that— It talks about the notion in schizophrenia of movements or events being sped up or slowed down. Again, that was something I'd heard patients say, but you won't find it in the diagnostic manuals necessarily. I just found it gave us a much broader view of things, really.

The first section of the paper just deals with that really, the difficulties in where we got to with traditional psychopathological frameworks, and that there is alerting the listener to] that there are these now new frameworks which just give us a much broader and more detailed understanding of our patients.

Dr Gale-Grant: What do you recommend for a psychiatrist wanting to improve their schizophrenia clinical practice? Would you recommend that they're implementing one of these, or multiple of these, or all of these into each time that they meet a new patient?

Dr Wilson: That's a really good question. The answer is no. We all know working in NHS, everyone is pushed for time, and clinical encounters are no different. What I think though is just having an awareness of these instruments, even just having a read-through once just allows the clinician to be aware of some of the things that patients might be experiencing. They're often quite private thoughts, and something that patients often don't reveal unless we specifically ask. Also, I think that if you have an awareness of these instruments, you can get to a diagnosis more quickly.

If you constrain yourself as we all tend to do, including myself, when we're pushed for time about asking for the positive symptoms of delusions and hallucinations, you miss a lot of that patient experience. I think that the real advantage of these instruments is that it allows you to get alongside the patient, and it gives them confidence that you understand an experience for them that's quite often frightening or mystifying. When a patient sees that you recognize that, it gives them a little bit of comfort.

As well as being able to diagnose a bit quicker and get to the essence of things, it allows you to say get alongside, and that helps with all sorts of things. It relieves fear in the patient, and it allows their family to recognize that you understand this process, and that it's not new to you. I think that's really important in how we see things. The last thing too about these scales is, wellas I say, I certainly recommend going through them for every encounter to just have an awareness of things that are in them, is that I think in the next— I hope in the next decade or so, they're going to act as a sort of centre point to the focus of more neurobiological research.

One of the difficulties we've had is that a lot of research obviously focuses on the DSM-5 and ICD definitions, and there's a bit of concern that if we haven't got those right as being at the essence of schizophrenia, then we're unlikely to get the research on neurobiological correlates completely right.

Dr Gale-Grant: That is a universal problem in psychiatric research, isn't it? Is that, obviously, the diagnoses themselves are to a certain degree moving targets. They're not stable from one decade to the next decade, they're not stable from one country to the other country, or one manual to the other manual, so. Yes, it is attractive to move to a symptom-based classification for clinical research work. The recommendation is that a psychiatrist listening to this reads one of these scales and tries to get a bit of a grasp of the different symptom domains that are contained within. In the next part of the paper, you're discussing this next idea that might be helpful to clinicians, which is thinking about cognitive-process-based models, of which the first one, the aberrant salience hypothesis, I guess people may have heard of, but just talk us through this section a little bit.

Dr Wilson: Yes, this is probably— The cognitive-based process models and the predictive processing framework are probably my favourite parts of the paper, because I think that— What a lot of people said to me when they read the paper was that, when we go to medical school, people are put off psychiatry because it seems like a sort of [unintelligible 00:10:36] translation. Whereas actually, the advantage of these systems is that we can let psychiatrists and patients know that we now have a better understanding of why you're having these experiences, rather than just translating them into technical terminology.

The two things that I really liked, particularly with aberrant salience is because it gives a process to a symptom. Aberrant salience is a process that's critical in explaining delusional mood, it's one virtually all clinicians will be familiar with—

Dr Gale-Grant: Just to interrupt you, aberrant salience, just for the benefit of any psychiatrist that hasn't got the medical school [crosstalk]— Okay, go on.

Dr Wilson: Yes, that's what I was coming to. It's a deficit in the way we normally filter out the mundane. If you think about the amount of information we're getting visually or auditory, it's absolutely huge, but most of it isn't relevant to that immediate decision-making that we've got to make. If we have a problem filtering out the mundane, or a problem with the filter, and therefore, we give salience to the things that don't need it, that tends to lead to a general sense of inexplicable significance, and that's what we mean by delusional mood. We think linked to that is dopamine chemistry, and there is very good evidence about that.

Perhaps if I just go into that link with dopamine then, I think we know that drugs that increase [unintelligible] dopamine release such as amphetamines cause psychosis. We know that drugs that block D2 and D2 receptors help with psychosis, but the key question is then, if we think we've got this process where we give importance to events which shouldn't have them, or the mundane, can we link that to dopamine as we have linked [unintelligible] schizophrenia to dopamine in the past for many years?

I think there's some really good studies. An early one was done by Jon Roiser and colleagues at UCL. They asked patients who are at ultra-high risk of psychosis, so people who didn't have a frank psychosis yet, but were considered very high-risk, to do salience attribution tests. Then they did functional MRI and PET scans, and what they found out was that they were able to say that aberrant salience, this notion of giving importance to events which don't need them, were indeed involved in psychosis. Not only that, but that disturbances in subcortical dopamine were at the root of the aberrant salience experience.

I think when I came to get alongside the patient, I was saying in my paper that I think if we can start using the term "aberrant salience" in the case notes rather than delusional mood, we've got one step closer to solving the problem so to speak. I don't know if it's a big step or not, but it's an important step. I think what I've been trying to do, and some of my colleagues have is, when you start using that sort of term, a process term in your explanations with patients and families, I think it really seems to resonate with them.

Their families know that they have a delusional mood, but they're picking up connections and mystifications where there aren't any, so if you tell the family that, you haven't really told them anything new. If you can tell them about aberrant salience and how it's linked to dopamine, they can't filter out all the mundane information, that gives them a sense that we have got an understanding of this. Again, it gives them a sense that we're able to sort of rationalize frightening and quite strange experiences of both the patient and the family. That I think is the value in a cognitive process term.

Dr Gale-Grant: I can see, that could be quite comforting from a psychoeducational perspective to a patient to say that, look, there is some sort of understanding of why this is happening. I guess the criticism of this would be that, how strong really is our understanding that that's what's going on in schizophrenia? I mean, just about any part of the brain that you can name, any connection between any two areas and any neurotransmitter has been associated with schizophrenia in dozens of papers. It's a bit sort of a— I guess, a sort of controversial and cloudy area to pick your way through, isn't it?

Dr Wilson: It is. I think the benefit of the paper is that it is aimed at people like myself who are full-time clinicians. It's aimed at that level because that's the level I can give, but I think there's enough information suggesting that these things are-- We know that dopamine is involved in aberrant salience, and I think what's given us the real clarification in more recent times with advent of the predictive processing network, which I think, as I say, links these levels, and I think it's the connections between symptoms or the phenomenology and the experience, and the neurochemistry and the brain pathways which is going to give us the real advances.

Perhaps if I just use this time to go through the predictive processing network, which of course involves dopamine chemistry. This notion has come along perhaps the last 10 to 15 years, and it's underpinned by Bayes’ theorem, which is quite simply that incoming information is interpreted in the light of our prior expectations and beliefs.

Incoming information, you think about the visual information, the information you hear, it's not just a case of seeing something and believing it. It's a case of seeing something, and then that gets weighed up by your brain who tells you whether to believe it or not, so it's not quite as simple as we first thought. A good example though is Mooney images. If you have a distorted image in black and white, it can be quite difficult to see anything in that image, but if someone tells you what to look for, the image becomes much clearer. That's an example of our sensory information being interpreted in the light of our prior expectation or a prior belief.

Really, the brain is constantly making predictions, and our brain also has an internal model of the world. Now, if our sensory data from our eyes and ears don't match the world model and are unexpected, this generates a prediction error signal, and our brain's model of the world needs to be updated. If the delicate balance of this prediction system goes awry, it can result in faulty predictions, leading to false beliefs, delusions, and false perceptions, hallucinations.

Our beliefs and our perception emerge from a very complex and delicate balance of interaction between bottom-up and top-down processes. Now, just going into it very briefly because that's all I can, bottom-up refers to a signal from sensory information, the eyes and the ears. Top-down refers to signals driven by cognition and prediction. We think that that balance is mediated by dopamine, and so this notion of the brain being a predictive organ and a processing organ just gives a bit more weight to the notion that— Just saying alone that schizophrenia is a disorder of dopamine, which as you say, we've been saying for a long time, this gives a bit more nuance, a bit more detail, and makes it into a process rather than just a link of "this causes that," which we know is a greater simplification.

Dr Gale-Grant: Yes. I suppose that's the thing, isn't it? In the field of schizophrenia research or any sort of brain chemistry research, it's very complicated, so there is a need, I suppose— If you're going to try and bring something into at least the mind of a clinician, there's a need to have a way of simplifying and thinking about it. I think thinking about this top-down bottom-up imbalance is quite a reasonable one that most people could probably get along with.

Now, I suppose the overarching mantra of this paper is that patients should think more about neuroscience. Obviously, what you've said in the paper could reasonably be implemented. I suppose the question is really, is this going to actually bring about help and change to patients? If I was a patient, would it be better for it to be thought about in maybe a more nuanced way, or would it actually make a difference if someone ran out a diagnostic manual and prescribing the first drug on the list? I suppose that's what I can't quite see in my mind.

Dr Wilson: Yes. That's the key question, isn't it? That is the crux of the question. The answer is, I think this sort of approach looking at more detailed phenomenology in trying to use terms like source-monitoring deficits and aberrant salience in clinic is important. The reason I think that is, as I touched on before, I think it allows you to demystify frightening concepts and frightening experiences for relatives too.

As clinicians, we're quite used to these presentations of delusions and hallucinations, but if you've got a relative who's experiencing these, and you're not from a medical background, it's really frightening and really unusual. I think to be able to give patients and families an explanation based on process, rather than just saying it's dopamine, or anything else, I think that's a significant step forward. I also think it has all sorts of advantages we find having been trying to do that for about a year now in my own ward, it gets patients next to you. They're much more willing to try medications or work with you if they feel they've got confidence that you know a little bit more about what's going on.

The other thing to say is, I think I do push for a bit of connection between university neuroscience and the clinic, because I also think that sort of approach has an innate advantage of driving up clinical standards. Aside from anything else it achieves, I think it does improve clinical standards. The other advantage I would say of trying to use that approach, while I do think it has some direct benefits in terms of understanding, I also think the more clinicians we get thinking that way, if we do get a closer alliance, and I hope we do, between university departments and their local psychiatry units, because I think we have lost that in recent years, especially when talking to more experienced colleagues, I think that we can pave the way for a manner of thinking. I'm hoping that with the advances we're seeing in computational psychiatry, we might start to see some real fruit being borne from that in the next 10, 20 years, and I think importantly, collaborations between clinicians and academics, because I do think there's a role for clinicians who have a really good feeling for mental illness, being able to have some role in directing research.

Clearly, we're not going to understand the stats, or the mechanisms quite as well, that's not our role, but I do think there is an advantage in an exchange of ideas happening on a regular basis. We've got the ability to do that online now that we didn't have a while ago, but I think that exchange, as I say, drives up clinical standards, and can help shape the direction for future research if we get it right, as well as being, I will say, motivating and enjoyable for clinicians. As I say, I think for lots of people who were trained in a very traditional way, looking at the sort of first-rank symptoms, and that sort of thing, this will really be a pleasurable way to open their eyes, I think. This really [unintelligible] me over when I saw these concepts, and it's quite exciting to be involved in. Yes.

Dr Gale-Grant: Well, I think there's a lot of things there that no clinician would disagree with. There is a need for schizophrenia treatments, in particular, to be updated, and you're right, that the chasm between the clinical and research world in mental health is just growing by the day, so thank you very much for attempting to narrow it, and thank you for joining us on the podcast. That was Dr Peter Wilson, a consultant psychiatrist and Trust Research Lead at Cheshire and Wirral NHS Trust. We were discussing his new paper in BJPsych Advances, ‘Innovations in the Psychopathology of Schizophrenia: A Primer for Busy Clinicians’. Pete, thank you so much.

Dr Wilson: Thanks, Oliver. Absolute pleasure.

Thank you for listening to this BJPsych Advances Podcast. For the latest updates, follow us on Twitter @TheBJPsych. To listen to more podcasts from the BJPsych Journal portfolio, visit us on SoundCloud or search for us online.

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Dr Sachin Shah: Welcome to the BJPsych International Podcast. In this episode:

Dr Yugesh Rai: In Nepal, family plays a very predominant role in taking the care of people with mental illness, and the decision is quite collective. The family gets actively involved in the decision making.

Sachin: Dr Kamal Gautam and Dr Yugesh Rai discuss ‘Insight and challenges: mental health services in Nepal’.

Hamilton Morrin: Hi, I'm Hamilton, and I'm a junior doctor based in London. Well, actually, now, I should say the Tunbridge Wells area. And I'm joined by Sachin, a psychiatrist working in London, and today we're going to be talking about an article in the BJPsych International titled, ‘Insight and challenges: mental health services in Nepal’. We're also going to be listening to two of the authors of this paper, Dr Yugesh Rai and Dr Kamal Gautam.

Sachin: What's the article about, Hammy?

Hamilton: The article is broadly about the current state of psychiatry and mental health services in Nepal. Mentioning the fact that psychiatry is relatively new in the country having only developed over the past 50 years. Also, addressing some of the gaps in psychiatric services in the country, including a lack of old age psychiatrists and forensic psychiatrists.

The authors go on to outline mental health policy in the country, and they list a number of potential approaches that can be seen as a way forward for mental health services in Nepal. Before we listen to the interview, Sachin, the authors of the article mentioned the World Health Organization, mhGAP, can you tell us a bit about what that is?

Sachin: The World Health Organization have this program called the mhGAP, the Mental Health Gap Action Programme, and it's basically designed to help scale up care for mental health conditions, but also neurological conditions and substance use disorders worldwide, because they've identified that these conditions, they're highly prevalent and burdensome worldwide. I'm going from the mhGAP document here.

The World Health Organization recognized the fact that the resources that are provided to tackle this illness burden are not sufficient, they're not equally distributed, and they're not sufficiently used, which results in a lot of people with mental health disorders, and substance use disorders, and neurological disorders not getting the treatment they need worldwide. The World Health Organization says the gap between what is urgently needed and what is available to reduce the burden is still very wide, and so they have the Mental Health Gap Action Programme, which reflects their commitment to reducing that gap, hence, mhGAP.

Now, the mhGAP has a whole plan about how to address this, but what I wanted to focus on was their stance on integration of mental health services into primary care, because that's obviously as will be identified in the interview coming up, a major part of getting mental health services out to communities where psychiatric services are not well established, and not entirely unknown. In the UK, for example, where GPs are increasingly handling mental health services.

This is from the WHO document on mhGAP. Again, where it says that “mhGAP calls for mental health to be integrated into primary health care. Management and treatment of mental health disorders, neurological disorders, and substance use disorders in primary care should enable the largest number of people to get easier and faster access to services. Integration of mental health into primary health care not only gives better care; it also cuts wastage resulting from unnecessary investigations and from inappropriate and non-specific treatments.”

That's the ethos there, and one of the important things is having mental health services at the primary care level. As you'll hear in this interview, Nepal's psychiatric services understand that need, but the resources need to be there to implement it.

Hamilton: Could you give us some examples of how primary care providers might be able to handle mental health services?

Sachin: Wow, Hammy, I thought you were going to let me get away with being vague. Let me have a look at the document for some concrete examples. The World Health Organization has a table with evidence-based interventions to address priority conditions. Depression, for example, they suggest that treatment with older or new antidepressants by trained primary health care professionals is an intervention.

For schizophrenia and other psychotic disorders, they suggest that treatment with older antipsychotics by trained primary health care professionals within the community setting is appropriate. For dementia, they recommend basic education about dementia and specific training on management of problem behaviours by trained primary health care professionals.

For alcohol use disorders, they recommend screening and brief interventions by trained primary health care professionals, and early identification and treatment of alcohol use disorders in primary health care. For drug use disorders, they recommend early identification and then provision of preventative and treatment interventions by trained primary health care professionals. Even in children, they recommend identification and initial care in primary health care settings.

Hamilton: How about we take a listen to the interview, Sachin?

Sachin: Sounds good.

Thank you both for joining me. I wonder if you could please start by introducing yourselves?

Yugesh: Hello, I'm Yugesh Rai. I'm currently a psychiatric trainee working at Essex Partnership University Trust in Colchester. Basically, I finished my psychiatric training in Nepal as well, and I came to UK on The Medical Training Initiative Scheme by the Royal College. Now, I'm working here as a trainee.

Dr Kamal Gautam: Hi, this is me Dr Kamal Gautam. I'm an adult psychiatrist. I did my Masters degree in Psychiatry from Tribhuvan University Kathmandu, Nepal. Thereafter, I have been affiliated with a non-government organization called Transcultural Psychosocial Organization Nepal. Recently, I am serving in the position of Executive Manager, and I have also been involved in a number of research activities, as well as a clinician at TPO Nepal. I'm also a practicing psychiatrist at Karuna Hospital Budhanilkantha, Nepal.

Sachin: What is the structure of health care in Nepal?

Kamal: Basically, the health care delivery system of Nepal constitute of the primary health centres, specifically known as the health post, primary health care centres, primary hospitals, secondary hospitals, and tertiary hospitals. These have been distributed across various geographical regions of the country, and are taken care of by the Ministry of Health and Population, Nepal.

These services have been tried to made accessible to the general population and free of cost, but at the same time, the services delivered by these health facilities are not adequate, and most of the times, the health services are out of pocket expenditure, and have to be incurred by the people themselves. Starting from the community where the people can access the health post according to the need and demand, also the level of care, people can go and access primary, secondary, and tertiary hospitals.

Most of the time, these health facilities are inadequately staffed, and pharmaceutical supply chain management is also not smooth, thereby, causing difficulty in delivery of the health services to people and making it accessible to all. Most of the times, though the health care delivery system exists within the government and the Ministry of Health and Population, most of the times, the service and the human resource is inadequate.

People usually tend to visit the private hospitals and medical colleges teaching hospitals situated in the urban areas of the country, where they have to pay from their pocket themselves. These are private hospitals, most of the times, it is out of pocket expenditure. When they happen to visit the government hospitals, most of the times, the services are free of cost, except for a few tests and a few procedures.

Sachin: Nepal's first psychiatric outpatient service was established in 1962, and the first inpatient service in 1964. How have mental health services developed since then?

Yugesh: In regards to the mental health services in Nepal, it started in general hospital setting. Unlike in most countries, the mental health service started with asylums. In comparison with the UK, I find mental health services works closely with other in general hospital setting, rather I find here that the mental health trust and AQ trust or other medical facilities are run by different organizations.

We only have one mental hospital established in 1984. It is now in Lalitpur, Lagankhel. The capacity is around 50 beds. This is the only mental hospital in Nepal. Most of the mental health services are provided by medical colleges in Nepal. Mostly, these are located in the urban areas and also, there are regional government hospitals at the province level. They do provide mental health services as well. There are also a few private hospitals who we specifically provide mental health services.

Kamal: Additionally, since we have been working in the field of mental health in Nepal for quite a long time, we find a huge treatment gap in Nepal. TPO Nepal, we conducted a research under the program for improving mental health care in Chiton, district of Nepal. We found that almost 90% of the people with alcohol use disorder and depression did not receive any care for the last one year.

It emphasizes on the need to fill in the treatment gap and make the mental health services accessible to the general population. Since most of the mental health services are centred around the cities and urban areas, and the people residing in the most rural areas of the country in diverse geographical setting are often deprived of mental health care. This is the scenario and a number of non-government organizations like Transcultural Psychosocial Organization Nepal, CMC Nepal and [unintelligible 00:11:35], these organizations had been working on the principles of community mental health care and especially TPO Nepal, we had been advocating for integration of mental health care into the primary health care setting, where we [unintelligible 00:11:49] an extensive evidence on the feasibility, acceptability, and appropriateness of the services delivered by the primary health care providers who were trained on WHO Mental Health Gap Action Programme.

Over the last few years, the government and the Ministry of Health and Population has been trying to integrate the mental health services into the primary health care setting. It is supposed to reduce the treatment gap and make the services accessible, but at the same time, and due to COVID-19 and ongoing various types of disasters and the limitation of resources and funding, these had not been scaled-up throughout various regions of the country. There is still additional treatment gap and the burden of the disease.

Sachin: You mentioned, in terms of non-governmental organizations, their role was particularly important.

Kamal: Yes. Especially the community mental health services started in Nepal in 1984 where the [unintelligible 00:12:50] to Nepal, they started the primary health care clinic. Then there was a set of services from the Tribhuvan University Teaching Hospital. Thereafter, with other non-government organizations coming into existence, they have been working on training various carers of [unintelligible 00:13:08] like the community psychosocial counsellors, the community psychosocial workers, who are trained on training raging from the seven days to six months duration. These [unintelligible 00:13:19] of service providers, they provide basic psychosocial support and there's some focus psychosocial support, especially depending on the behavioural activation component of depression and also the motivation enhancement therapy for alcohol use disorder.

These counselling support services had been rendered in the community by these organizations. At the same time, we try to refer the cases who have mental health problems from the community to the health facilities, so that the government health workers are then trained and after the capacity building, or especially on training on mhGAP, these primary health care providers, they do the assessment, and then they provide the medication and the follow-up services through the primary health care centres under the health care delivery system of Nepal government.

This has been presently progressive over the last few years. The government has been able to scale-up this community mental health program to various regions of the country and a community mental health care package was developed in 2018. Thereafter, based on this community health care package, the community mental health programs are designed, developed, and then implemented to make the mental health care and psychosocial support services available to the general population across various regions of the country.

Sachin: Dr Gautam, would you care to describe your specific role with the Transcultural Psychosocial Organization Nepal?

Kamal: Basically, Transcultural Psychosocial Organization Nepal is a non-government organization, working on the delivery of mental health care in Nepal. TPO Nepal works in four main teams, the capacity building, service delivery, research, and advocacy with the government. I have been affiliated with this organization for the past four and a half years where I joined as a consultant psychiatrist.

Then, I gradually took over as a program manager, a deputy executive manager, and then I have been serving in the position of executive manager for the last one and a half years. I am also being involved actively in the researches, especially with the children and adolescents. Also, the biological research and also, randomized controlled trials in Nepal.

I also work directly with the Ministry of Health and Population in drafting the training curriculum, in revising the national mental health policy, formulation of national mental health strategy and action plan and then arranging the training and then supporting the government directly in all technical programmatic development and advocacy for integrating mental health into primary health care setting in Nepal.

Sachin: We covered the payment system for health care in general, in Nepal. That typically, publicly-funded health care will be understaffed and people will tend to pay out of pocket. With mental health disorders, is it the case that there are certain mental health disorders, which are expected to be free of charge for treatment?

Kamal: Actually, the government has developed a basic health service package, which basically means that for those [unintelligible 00:16:37], which have been included in the basic health package, would be provided free of cost to every native citizens. This is how the government has been providing the services to people.

Contrastingly, mental health disorders were not included in the basic health service package before last one year. Most of the time, people had to pay for getting mental health services and there was no trained human resources, especially the psychiatrists and psychologists being sent out in urban areas. The lack of trained human resources in the areas, people had difficulty getting them into the services.

Last year, the government of Nepal Ministry of Health and Population revised the basic health service package including depression, psychosis, alcohol use disorder, and epilepsy in the basic health service packages. This means, in the days to come, this is a legal provision. In the days to come, the government is planning to provide all the mental health services free of cost.

Basically, this four disorders, the treatment, and support for these illnesses would be provided free of cost. This is the provision but practically, with regarding to the logistics and availability of human resources, still there is some gap with the availability of these services in all the regions of the country.

Yugesh: I'd like to add, regarding the epilepsy, often like in low and middle income countries, it falls under the remit of psychiatrist as we don't have access to specialist like a neurologist. This epilepsy often are tend to be managed by the psychiatrist. We can see on the list, what medication do we use in the management of epilepsy, it's often phenobarbitone and phenytoin. Often, when we manage epilepsy in community settings, we see patients on these medications.

Sachin: This refers to the list of medications covered in the basic health service package. In addition to covering those mental health conditions treatment free of cost, these medications will also be covered free of cost. You list that the medications covered include diazepam, amitriptyline, chlorpromazine, trihexyphenidyl, phenobarbitone, carbamazepine, sodium valproate, risperidone, and thiamine, which is an interesting set of medications and certainly, a few anti-epileptics in there. Certainly, fewer second generation anti-psychotics and SSRIs.

Kamal: Yes. Well, you noticed that most of these medications, especially phenytoin and phenobarbitone, these are very old and as ananti-epileptic often causing various side effects to people, including the cognitive decline. Organizations like TPO Nepal, we have been advocating for incorporating other psychotropic medications, which would be safer and also more cost-effective and also had lesser side effects.

Based on continuous lobby and advocacy with the government, finally, sodium valproate and carbamazepine were added into this list. Some of these drugs have been procured and have been supplied to a few of the regions of the country with mental health programs. Still, there is no continuous supply of these medications. This is one of the gaps that has been existing in the mental health in Nepal.

Sachin: Now, what do we know about the prevalence of mental health disorders in Nepal?

Kamal: Initially, most of the studies were reliant on the non-governmental organizations in Nepal conducting the researches. Recently, we had a national mental health survey, which was planned in 2017. The data collection was done over one year duration between then 2019 to then 2020 and the results have been published. Which showed the prevalence of mental disorders around 12.9%. That the prevalence of suicidality was also quite high.

It was almost 7.4%.

It also has highlighted that the mental disorders are quite prevalent in the community, including the children and adolescents. Most of the mental disorders seem to highly prevalent in province number two, which has lower human development index. Has porous borders with India and also gender-based violence, dowry system stigma, and other traditional practices being more common in this region of the country.

However, during the disasters and human development context, the prevalence of these disorders and anxiety, depression, and other various forms of psychological distress, seem to be increasing in context like post-earthquake and COVID. In TPO Nepal, we also conducted an online survey immediately after the onset of COVID-19 epidemic and the lockdown in Nepal. Where we tried to analyse four of the constructs of psychological disorder.

It showed that almost 50% of the people attending the survey had at least one symptom of psychological distress. 32%of the people had two or more symptoms of psychological distress. This article has been accepted in BMC Psychology and are getting published soon. We seem to have an increment in the mental health problems with the onset of humanitarian context, emergencies, and disaster.

Sachin: You were telling me, Dr Gautam, before the interview, about the impact of COVID-19 in Nepal, what has happened with COVID-19? How the country has been managing it?

Kamal: Sure. The country actually witnessed few cases during the month of March and on March 24th, the nationwide lockdown was announced. Initially, we had very few cases and the lockdown was announced quite early. After lockdown, people were forced to stay in quarantine at home and that the special connection was lost.

Many people lost their job and were unemployed. With ongoing economic recession, people seem to have problems with managing their daily livelihood and sustaining their families. We also conducted one study on the prevalence of suicidal behaviour during the COVID-19 epidemic in Nepal. Where we saw that the rate of increase in suicides and suicidal behaviour was quite higher this year, especially following the epidemic.

During the last four months, following the lockdown, rate of increase in suicide was 19.4% as compared to the previous year. We would see that the suicidal behaviour had increased. Also, we could see a lot of people presenting with mental health problems. Also, practically, like I am performing as a tele-psychiatrist as well. TPO Nepal, we provide a telemental health services to people free of cost, where we run a helpline. We have been receiving a large number of calls to this helpline as well.

The number of people seeking care is increasing. Most of the times, their stress seems to be precipitated by the economic problems, financial constraints, loss of employment, and difficulties sustaining their family. Also, the number of people suffering from gender-based violence has been increasingly reported in Nepal. Also, the number of people attempting self-harm seem to have increased.

Overall, we can say that the mental health problems have been increasing. The need for mental health services has been emerging further in these days.

Sachin: How about access to mental health services aside from the telemental health services, which are provided? Has that been maintained or has COVID-19 posed difficulties with providing mental health services?

Kamal: One of the gap that we saw was, since there was lockdown for almost more than six months and people who has been previously diagnosed, who had pre-existing psychiatric illness and who were previously under psychotropic medications could not make up their follow-up visits to psychiatrist and psychologist in urban areas. Their treatment continuity was hampered, one thing.

At the same time, while the mental health problem seemed to be increasing and that there were incidents of more people with mental health problems, they also had difficulty visiting the psychiatrist for appointment and also continuing, starting their services. There seems to be increase in the mental health problems but at the same time, there was a barrier with the linkage to the available services and the resources.

This would have resulted total increment in the mental problem and disruption of psychotropic medication and services, relapse of illness. That that was also quite illustrated in one of the other studies that we conducted during this COVID-19 lockdown. As these gaps existed in the continuity of services in Nepal, what we did was at TPO Nepal we expanded the time. Many of the organizations, they also started the helpline and hotline services for providing the mental health services and telemental health services.

Sachin: This is a new barrier to accessing mental health services throughout the world in fact, but one existing barrier that you already mentioned in your paper is that of how mental illness is viewed within Nepal and the stigma towards mental illness. Can you tell me more about that and how it interferes with accessing mental health services?

Kamal: In countries like Nepal, there's a lot of stigma associated with mental health. Here, the previous research showed that almost 52% of the people with mental health problems, they seem to visit the traditional faith healers. There's a lack of awareness, one thing. The other thing is that there's associated stigma and people tend to hide their problems. They do not know that it is a mental health problem most of the time and tend to visit their traditional faith healers, especially the [unintelligible] and others. That's how the pathway to care is when there's a psychiatrist or a specialist, it's delayed most of the time.

Since there's a barrier to accessing care and mental health services are not accessible in the rural regions of the country, most of the time, people seem to get to a psychiatrist after a very long time, after the onset of illness. When we try to say that it's a mental health problem and we try to [unintelligible 00:27:26] patients with mental health problems, they seem to be more reluctant in accepting that it's a mental health problem.

What we find more as a practitioner is when we see it as a heart-mind problem or we say in Nepali [Nepali language], it seems to be more acceptable, rather than saying it as a mental health problem.

The care for the community mental health psychiatrist like especially work on the community mental health programs, we tend to explain it as a heart-mind problem, rather than a mental health problem so that it's more acceptable and people tend to visit the psychiatrist and then to talk and they're more open to the communication. That's how the services can be continued.

Yugesh: I'd like to add from the findings from the pilot study of National Mental Health Survey, we saw that people with any form of mental disorder, only around 18% received treatment in the last 12 months. The major barrier identified for the under-treatment was related to the knowledge and the attitudes of the patients and their family members. About 80% of the participants in that pilot study of National Mental Health Survey, they said that they did not want to receive treatment because they want to sort problems on their own. Or they have the feeling that the problem would get better by itself.

This is related a lot to the stigma of the mental illness, as well as the culture of perception. Like mental illness could be the person might have done something bad in their previous life or this could be some evil spirit or some cultural explanation, so it's related to that as well.

Sachin: What is the relationship like between faith healers and psychiatrists in Nepal? Is there any interface there?

Kamal: Actually, in Nepal, the traditional faith healers, most of the time, they seem to provide various health related services including mental health services in the country. Whenever people have some physical illness or if they have some mental illness, they seem to visit the traditional faith healers because these traditional faith healers are quite available in larger number. They're locally accessible. People have faith in them. They believe that they have been haunted by a spirit or it is due to their misdeeds in previous lives.

If they go to the traditional faith healer, they believe that he will perform some ritual and he or she will be free of all illness. That's how they believe. They perform the rituals regularly when they fall ill. These traditional faith healers, most of the time, they are illiterate or maybe less educated. They seem to be more of their practice and the profession. They seem to be reluctant in referring them to a psychiatrist or service provider because if they refer to the psychiatrist or service provider, their profession and their service is hampered.

They believe that their patients are also lost. Most of the time, they are reluctant in referring them. At the same time, what I believe as a community mental health practitioner is, if we enrol them as a part of mental health program in the community, saying that, "Yes, you do your own ritual. At the same time, this is a sort of mental health problem and only your ritual performance would not really be solve the problem. If you refer them to a community mental health practitioner, then they will get well and there will be a more compliance to your treatment. What you can do is you do your ritual and then perform them and refer them to the mental health practitioner, so that they can get treatment on time. At the same time, you can continue your services.

That's how a few of our organizations, we have been trying to incorporate them into the community mental health care practice. Many of the times, it's difficult because they are more traditionally deep rooted, and they more believe it as mysteries from previous lives. They can perform some sort of magical, traditional healing practices, which will relieve them of mental health problems.

This is sometimes challenging, but at the same time, attempts have been made to train them, to sensitize them on mental health. At the same time, linking the patients from the community to the mental health care within the community and then the urban areas where psychiatric services are available.

Sachin: Yugesh, you mentioned that part of the barrier is mental health knowledge with the patient themselves, but also with family. What is the family role in caring for someone with mental illness or managing their illness?

Yugesh: In Nepal, family plays a very predominant role in taking the care of people with mental illness. Unlike UK, people are quite autonomous. Patient often make their own decisions and this is quite contrasting in Nepal. Autonomy is limited and the decision is quite collective. The family gets actively involved in the decision making.

Even if the patient wants something, ultimately, the final decision depends on the senior family members. This decision is taken into account while we are delivering care to an individual patient. Lots of things are involved here in terms of providing financial support for the care. The family usually funds the care out of their pocket.

Also, for example, if a patient has to get admitted in the mental health unit, the patient on their own is very difficult for them to get admitted. There has to be at least a family member or friend accompanying them in their inpatient admission as well. In terms of admission, logistic support is needed to provide to the patient. For example, taking care of the patient, bringing them food, and also procuring medications. Also, if we have to do some tests, payment of the bills, and also to get the test reports and things like that.

Family members are extremely involved in the care and it is very important. Otherwise, often, people who don't have family members, it's very hard for them to access mental health care.

Sachin: Now, can we talk about the psychiatric training in Nepal as part of medical training? What is that like and how does that contribute to the workforce? What is the size of the psychiatric workforce in Nepal?

Yugesh: Currently, the rough estimate is that, there are about 200 psychiatrist in the country. The training program for psychiatry is called MD Psychiatry. It's a three-years postgraduate training program. We don't have any subspecialty training or higher training in psychiatry.

It started in 1997 and is now available in 16 different centres. Each of the training programme is quite different.

The duration is for three years but the curriculum, there are five different training programmes or different training curriculums. This is not uniform. Also, one of the difference is that the evaluation process or the examination process differs from one training programme to the other training programme. The rough estimate is that there are about 35 psychiatric trainees are currently training in the training programme.

The good thing is that since in 2008, the number of psychiatrists was only 40 but now, roughly in 12 years, it has almost become 200. The number of training places or training institute have increased. Also, the number of people who want to make a career in psychiatry. Lots of trainees have shown interest in psychiatry as well during this years.

Sachin: One thing that strikes me from the layout of workforce that you've provided, is that and you mentioned, there's not much subspecialty training is that there's at present, only three registered child psychiatrists and no registered old age psychiatrists. Also worth mentioning is that, there's 50 registered psychiatric nurses. There's fewer nurses than there are psychiatrists?

Yugesh: There are fewer psychiatric nurses. Often the nursing services are provided by the nurses who are trained in medical specialties. There are fewer nurses specifically trained in psychiatry, but the rest of the support is given by medically trained nurses.

Kamal: What I would like to add is, though we have 50 psychiatric nurses, most of these nurses have not been practicing as a psychiatric nurse but rather, they have been posted in academic departments. Also, they have been working in Medicine Department and other departments, rather than the psychiatry unit to of the hospitals.

The concept of psychiatric nursing is also quite in infancy. At the same time, we do not have a specialized addiction psychotherapist or geriatric psychiatrist or forensic psychiatrist here in Nepal. Most of the times, adult psychiatrist seem to be providing various service facility services to people in the country.

Sachin: I think there was something else to mention about specific child and adolescent psychiatry, which I believe was that there's only one full-time outpatient clinic for children in Nepal. There's no dedicated inpatient unit for children.

Yugesh: The full-time outpatient clinic for children is at Kathmandu at Kanti Children's Hospital. There is a Child and Adolescent Psychiatry unit. Often, the child mental health services are also provided by some Child Guidance Clinic at different departments of psychiatry in medical colleges.

The sad thing is that there is no inpatient unit for children. If a child needs to get admitted in the mental health unit, they are often admitted in the general ward. This can be quite difficult, I think, for the child to be in the general adult ward.

Sachin: Now, National Mental Health Policy, to move on to policy, was formulated in 1996. What has been the progress since then?

Kamal: Though the National Mental Health Policy was formulated almost two decades back, the Mental Health Act was never drafted and it never came into existence. Effective implementation of the National Mental Health Policy was not done. Due to this, the rolling out of the mental health services to the country, making the mental health services accessible to the most rural community and building the human resources in the country, especially. Also, protecting the rights and privileges of people with mental health problems was quite challenging.

Under this scenario, there were few attempts to promulgate and then implement the National Mental Health Act, but his was always challenging, and it never came into existence. In the meantime, the government formed a different department called the Epidemiology and Disease Control Division, which was established in 2018. After designation of this department as a focal unit for mental health and non-communicable diseases, there has been a good momentum in establishing the mental health care system in Nepal.

Currently, the government has drafted the National Mental Health Strategy and Action Plan. It's a five-year plan and you can define studies, strategies, quite well. This also divides the role of local government, the provincial government, and the federal government on rolling out the community mental health services based on the national community mental health care package.

This is supposed to be endorsed by the Ministry of Health and Population over the next few months. Once this comes into existence, I anticipate that the community mental health programs will be more effectively implemented, and the services will be more accessible to the rural communities in the country.

Sachin: The strategies you mentioned are part of attempts to revise the mental health policy and is awaiting endorsement by the Ministry of Health and Population. The strategies contained within this draft are one, to ensure the availability and accessibility of optimal mental health services for all the population of Nepal. Two, to ensure management of essential human and other resources to deliver mental health and psychosocial services. Three, to raise awareness on mental health to demystify mental illness and to reduce associated stigma and promote mental health. Four, to protect fundamental rights of people with psychosocial disability and mental illness. Five, to promote and manage Mental Health Information Systems and research in mental health programs.

Kamal: Yes. This has been listed out in the recently drafted National Mental Health Strategy and Action Plan and TPO Nepal and myself, where I have been involved as one of the technical expert in drafting, and then revising, and then conducting formal consultations with the provincial and local government in different regions of the country. I hope this will be endorsed by the Ministry of Health and Population soon.

Sachin: Can you please tell me about the Psychiatric Association of Nepal?

Yugesh: Psychiatric Association of Nepal was established in 1990. It is currently affiliated with World Psychiatric Association, World Association of Social Psychiatry, and SAARC, that is South Asian Psychiatric Federation. It regularly organizes annual meetings and also continuing medical education programs and seminars not only in Kathmandu, but also in different regions of Nepal.

It also publishes a peer-reviewed journal that is called Journal of Psychiatrists' Association of Nepal. This is published twice in a year. The recent activities of Psychiatrist's Association of Nepal are, it has been quite active in the national mental health programs. Raising awareness about mental health on the media, and also, in policy reforms and advocacy.

Sachin: You finished the article with seven different areas you have identified for development and growth of mental health services in Nepal. Shall we just have a look at those points? The first area which you identify is a need to increase the mental health care budget.

Kamal: The budget allotted for mental health in Nepal is still not adequate. It is said that the budget allotted for mental health should be around 10%. Most of the times, it's less than 1% of the total health budget allotted every fiscal year. We see that with this funding and resources, the demand for scaling-out mental health care is quite challenging.

Sachin: You then identify the need to increase mental health awareness and fight stigma?

Kamal: As we talked before, most of the times, people do not know about the mental health problems. They seem to go to traditional faith healer and they seem to hide their mental health problems. We need to conduct a massive awareness and sensitization campaigns.

At the same time, stigma associated with mental health care among other health care providers, as well as people with mental health problems and their families, is quite high. Conducting anti-stigma campaigns and maybe often mobilizing the service users has been found quite promising in few of the research evidences from TPO Nepal. I believe we need to conduct awareness programs and anti-stigma campaigns.

Sachin: Then the need to increase recruitment of psychiatrists but also to create positions for other aspects of the mental health care workforce?

Yugesh: The positive thing is that the number of psychiatrists has increased as well as clinical psychologists and also community based psychosocial workers and psychosocial counsellors. Now, it's high time the government starts creating vacancies in the government hospitals and in government settings for recruitment of this manpower, so that it could be utilized in a better way. Also, they could go to every corner of the country and serve the people residing all over Nepal.

Sachin: Then the need to expand subspecialties within psychiatry?

Yugesh: This is I think, another emerging need. With time, we do need a subspecialties in psychiatry and this could be initiated at the medical colleges and the universities. One important thing that is happening in the country is the development of subspecialty program in Child and Adolescent Psychiatry by the gap unit in Kanti Hospital in Kathmandu. Similarly, several programs need to be developed in old age psychiatry, addiction, and forensic psychiatry as well.

Sachin: Then you identify the need for a suicide registry and the need for a suicide prevention strategy?

Kamal: In Nepal, we see that there is no formal suicide registry. Most of the times, the cases of suicide happen to be reported by the Nepal police. Only the cases who have attempted suicide are reported. The people committing suicide outside the country are never reported. Most of the times, when they are brought for forensic examination or autopsy, this is reported.

In the most rural regions of the country, when people commit suicide, they are often unnoticed. People cannot come and report to the police due to geographical inaccessibility. I believe that the number of suicide cases that has been reported is false. At the same time, we do not know the data of suicidal behaviour, especially the deliberate self-harm and other attempts, so we need a formal registry.

At the same time, there is no national suicide prevention strategy. The suicide has been emerging quite largely over the last few years. We need to have a formal suicide prevention program and package as well. Most of the programmes on suicide prevention have been initiated and implemented by a few nongovernmental organizations. The country at large, that's the best suicide prevention programs in the community. This needs to be developed and also implemented over the coming years.

Sachin: Then the need for the government to prioritize mental health research. You mentioned the government because mental health research currently is reliant on NGOs?

Kamal: Most of the time, when you look into the literature, most of the articles and publications belong to the non-government organizations. We do have medical colleges. We do have the psychiatry departments, and also, the national Nepal Health Research Council.

We do not have a larger trial and also evidence on the prevalence of mental health problems. Also, different interventions done on the part of the universities, academic universities, teaching hospitals, and psychiatrist. I believe, as a part of academia, research needs to be extended, and needs to be gradually taken up by the government institutions so that we have formal funding and also we have continued research activities, generating sufficient evidence on the prevalence as well as impact of interventions and how to scale up these programs.

This also needs to be scaled up. We have tried to highlight this bullet in the National Mental Health Strategy and Action Plan that has been drafted recently.

Sachin: Finally, this gets into what you were telling me about previously, Dr Gautam, about the need to implement psychiatric services within primary care settings. That this is only possible and can only be scaled up if there is appropriate clinical supervision of the trained non-specialist service providers and if there's a regular supply of psychotropic medications?

Kamal: The government has been trying to rule out the community mental health program based on the national community mental health care package, which was drafted a few years back. It illustrates and it defines how the capacity building activities should be done, how frequently the clinical supervision should be done? There has been a challenge with the supervision post training. Once the health care providers are trained on mental health, it's not that once they're training on mhGAP will make them adequate to deliver with expertise, so that they can give our mental health services in the community.

We need to supervise them clinically, periodically. What we say or what we have been practicing in Nepal is called as a psychiatrist case conference. If we supervise them in the community and we build their capacities to periodic supervision, the quality of services being delivered can also be assured.

At the same time, we can enhance the skills and expertise of the non-specialist service providers, so that the people can get the maximum benefit and quality services within their local community and from the health workers, who exist within the health care delivery system of the Ministry of Health and Population.

Sachin: Well, I'd like to thank you both for taking me through this paper and for guiding me on the states of mental health care in Nepal as it stands. How it's progressed from the '60s to the '80s, '90s and onwards, and steps forward for future progression. Is there anything that either of you want to add or want listeners to take a look at?

Kamal: First of all, I'd like to thank you for granting us an opportunity to share our insights and experiences from mental health in Nepal. I like to thank you first. At the same time, I would like to plead all the audience that mental health is an emerging problem. We being residing in the low income country like Nepal, we do not have adequate resources to scale up mental services in Nepal, and that we expect support from all concerned exports and also all the agencies who can support the Nepal government in making the services accessible to most of the communities in Nepal. Thank you.

Yugesh: I'd like to thank Sachin for providing this opportunity to talk about our article, about the challenges of providing mental health services in Nepal. Lastly, I'd also like to thank all my colleagues in Nepal, who are working in the field of mental health. I think they are providing excellent service in terms of limited resources they have and the constraints that they are facing. I hope the future of mental service in Nepal is bright. Then, also, I hope that we can provide services to all the people living all over Nepal.

Sachin: The article is ‘Insight and Challenges: Mental Health Services in Nepal’, in the BJPsych International. Dr Kamal Gautam, Dr Yugesh Rai, thank you for joining me.

Yugesh: Okay. Thank you very much.

Kamal: Thank you.

Hamilton: Sachin, I always find these articles on mental health services in other countries, as well as the interviews with their respective authors quite enlightening. As to be perfectly honest, there's a lot that I personally don't know about mental health services in other countries, and I find it really useful to hear about the unique challenges faced in different countries, as well as the strategies that psychiatrists in those countries think might be the best approach for dealing with any potential limitations that they encounter.

Sachin: I agree. It's really lucky. I feel blessed that I'm able to speak to people from around the world, particularly in low-income and middle-income developing countries about how psychiatry operates in low-resource conditions.

Hamilton: It was interesting to hear that currently, in a poll, there are about 200 psychiatrists working, which perhaps if you compare it to the UK may seem like a smaller number, but the fact that this is an increase from 40 psychiatrists back in the year 2008, that's quite a substantial improvement that was made over a fairly short period of time. It sounds like the post-graduate training scheme, which started in 1997 for psychiatry has been fairly successful in Nepal.

Sachin: Not only have they upped the number of psychiatrists, but the subspecialties are beginning to flourish. It's the very small beginnings, but from having no child and adolescent psychiatrists to having, is it three?

Hamilton: I believe it's three, yes.

Sachin: That is no small thing to introduce an entire subspecialty. Can you imagine being one of the three child and adolescent psychiatrists in Nepal?

Hamilton: To be honest, I can't even begin imagine it. It's only outpatient services, no inpatient facilities whatsoever.

Sachin: That does make me think though because obviously, they mentioned that in the case where children may need to be admitted to an inpatient facility, they typically get admitted to adult wards, but that just reminded me that the UK has had its own scandals of children being admitted to inappropriate places because there aren't enough child and adolescent inpatient spaces available for them.

Hamilton: No, absolutely.

Sachin: It hits home like thinking that the UK, when it comes to CAMHS is definitely resource-deprived. We sometimes talk about lower resource countries, but it's not like we are sufficiently resourced here in the UK. Then just imagine how things are in countries, where there are no child and adolescent inpatient facilities.

Hamilton: I did like your question, Sachin, about if there's any interaction or collaboration between local faith healers and psychiatry in Nepal. It seems the answer was, unfortunately, a sad one in that it sounds like there may be occasions where faith healers dissuade individuals from seeking psychiatric help and services because it would serve to undermine their very profession.

Sachin: We have spoken before to people who talk about how psychiatry is interfacing with local faith healers in their own countries. That seems like a reasonable path forward, especially the way Dr Gautam even mentioned that in Nepal, it doesn't seem to be through lack of trying on psychiatrist part.

He said that they were trying to say, "Look, you refer your patients on to us. We will treat them and you can continue doing what you're doing." We know, well, we say because like it's a very sort of ivory tower position to say, "We don't think what you're doing is working, right. We don't think what you're doing is working. Send them to psychiatry where we think what we'll do may help and you can continue doing what you're doing. Between us, we can keep on doing what we're doing."

It makes sense to me, especially because if you continue having only faith healers involved and there's no recovery—

Hamilton: Then you alienate the patient?

Sachin: Yes, that could end up alienating the individual from seeking help from anyone. It seems like a win-win to me because no one is trying to shut faith healers out of the system and it would be a very arrogant position to do so, but psychiatry wants to be involved.

Hamilton: It all comes back to the bio-psycho-social approach. If faith healers are a prominent part of one's community and society, then certainly, if individuals would like to have them involved in their care should be part of the dialogue.

Sachin: I think so much of this is not just about interfacing with faith healers, but as our authors have identified, it's about increasing mental health literacy as well and fighting mental health stigma. This whole idea, for example, that mental illness could be what we sort of worry about here is that it's some moral failing.

Our authors identified that it could be seen as to do with something that you have done. The roots of it is always that you're responsible for your mental state. We try to get away from that because we see the biological side of things that we see it like an illness, which does, of course, have a social component, but not a moral component.

Quite rightly, they identify that one of the seven steps forwards for improving mental health care in Nepal is to increase mental health awareness and fight stigma, which I think is a global battle.

Hamilton: Yes, it's all the more why we stand to learn so much from each other. I will say one more thing in the list of points for what the way forward may be for psychiatric services in Nepal. I do like that one of the points addresses concerns regarding suicide rate in Nepal and the presence, absence, or lack of a national suicide registry or suicide prevention strategy. There's no doubts that having a suicide prevention strategy and appropriate recording of suicides is a very important step to take in the prevention of suicides in any country really.

Sachin: Well, you can take it to its extreme because we've got an episode coming soon, which is about mental health in Pakistan, which notes that Pakistan do not report suicide rates at all. If you attend hospital having attempted suicide, then that gets reported to the police. Think about what that does in terms of stigma and in terms of recognizing it as a problem, which is not immoral in nature.

To take Pakistan's example is like an extreme, but we can say that definitely, a society's attitude towards suicide will impact how that issue is viewed and it's important to talk about suicide and be open about it, but also then registering it, getting more accurate numbers, and opening people's eyes about the fact that this is a problem that exists, and researching it. Understanding what are the underlying factors involved here.

Hamilton: Thank you for joining us for another BJPsych International podcast. I've been Hamilton.

Sachin: I've been Sachin.

Hamilton: We look forward to having you join us for another podcast soon.

Thank you for listening to this BJPsych International Podcast. For the latest updates, follow us on Twitter @TheBJPsych. To listen to more podcasts from the BJPsych Journal portfolio, visit us on SoundCloud or search for us online.

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Oliver Gale-Grant: Hello, and welcome to another edition of the BJPsych Advances podcast. My name is Oliver Gale-Grant, and I'm joined today by Professor Harry Kennedy, who is a professor of forensic psychiatry at Trinity College Dublin, and also Executive Clinical Director of the National Forensic Mental Health Service in Ireland. We're here to discuss his new paper, which is being published in BJPsych Advances called ‘Models of Care in Forensic Psychiatry’. Harry, thank you very, very much for joining us.

Harry Kennedy: Good morning, Oliver. It's pleasure to be here.

Oliver: Your paper discusses essentially a way of planning an entire model of care in the context of forensic psychiatry. This is, I suppose, something some psychiatrists won’t have thought about. Perhaps we'll start by just talking through exactly what it is that's proposed. As far as I see, you've got a four-element model of care in which you have a written constitution describing how you're going to plan your entire service. Is that broadly correct?

Harry: Yes, Oliver. This derives from our having for more years than I like to remember, been involved in the planning and construction of a new forensic hospital for a population of 5 million here in Ireland. Most people will know that Central Mental Hospital in Dundrum, opened in 1850, 11 years before Broadmoor, we were a trial run for Broadmoor, and we are now replacing a very old building, a building that's beautiful from the outside, not very useful from the inside.

When you set out to do that, architects start off by saying to you, "What is your model of care?" Actually, that was the starting point for having to think about a model of care. Myself and my colleagues over at this stage, more than a decade, have been evolving this idea. In the middle of designing a hospital and then constructing it, and planning the manpower, we realized that the building, of course, is just a shell, and architects say, "We do everything for you,", you have to imagine a sort of doll's douse pick it up, turn it upside down rattle it, "We'll do the bits that don't fall out, you have to do the rest."

Of course, they then get interested in person flows - where do people come in? Where do they go out? How many people work here during the day? How much space do we need for all of this? Then fundamentally, we the clinicians have to start asking ourselves, "Well, actually, what are we at here?" Because the hospital is just forensic practice, the hospital is the large middle bit of a comprehensive pathway, which starts in the community, of course, but spends a huge amount of our activities in prison inreach, in court diversion schemes, and in community aftercare.

Putting that all together requires you to describe the whole system so that you can work out what the hospital does in the middle, and of course, the hospital is far more than the architecture. It's really about the treatment and the safe environment in which to deliver treatment. Then you begin to frame all of this.

In almost doubling the size of our service, as we move from the old hospital to the new hospital, we bring in lots and lots of new colleagues, new nurses, new allied health professionals, we have to recruit and train highly-specialised doctors. You have to think, "Well, how do we explain to our new colleagues what it is that we're doing, and why we're doing it? How will we know, five years on from now, that the enormous expenditure, the huge amount of activity, was worth it? What are we actually trying to achieve?" All of this hangs together in this concept of a model of care.

Oliver: In your paper, essentially, you break that very complicated concept down into four principles, which you've called goals, pathways and processes, treatments, evaluation and logic models. Maybe we just talk through those very quickly. I suppose it starts with what the goal is of your model. You've given some examples in the context of forensic psychiatry here of what could be reasonable goals.

Harry: Yes. Well, of course, the reason we're interested in goals because mostly when you ask other people, what are their goals, what's the guiding principle, they'll give you a lot of pieties and platitudes about making everything better. The trouble with that, of course, is that it's very difficult to apply it in practical terms. Goals are quite important. What we're trying to achieve, of course, is to vindicate people's rights. Their rights to health, their rights to being in the least restrictive place, but in order to do that, we fundamentally have to provide a safe environment, so that we can treat people who are a danger to themselves and others.

Actually, providing a therapeutically safe and secure environment is the next goal in an ordered hierarchy of goals after vindicating rights. After that, again, what we're really there to do, having provided a rights-based setting in which it is safe to treat, is to actually provide treatments. One of the terrible truths in all of psychiatry, is how little good modern evidence we have for what works. Concentrating on that becomes very important and that brings you to the fourth most important goal, and the fourth element of a model of care, and that's evaluation.

There's this terrific saying from Chris Webster, the founding author of the HCR 20, modern risk assessment, that if you can't count something, you can't see it, and actually, if it's something that you think cannot be counted, it's probably not real. There is a real obligation on us, particularly senior clinicians, service leaders, to evaluate and keep a long perspective. One of the things that we're very concerned with, one of those goals, is to be sustainable.

Mostly, new services open in a blaze of glory, everything's shiny and new and well-resourced and operates very well and meets a lot of those initial performance goals. You admit more people than you used to admit, hopefully, you discharge more people than you used to admit. The real test is, will this be sustainable? Will we still be performing as well as we wanted to perform in five years time?

Oliver: You've got some suggestions here for ways you can actually measure this performance, ways you're going to evaluate these goals in a box in your paper here. Now, some of these, I suppose, are things that are actually fairly standard measures that are probably used across certainly the NHS and lots of other health care services. They're things like how many people you're going to admit per 100,000 population a year, how many you're going to discharge, which direction they're going to be moving in as an LP because you're moving from, I suppose, more restrictive to less-restrictive settings.

Now, there's question I had is, are these things that you can be in control of even in the relatively, I suppose, constrained environment of forensic psychiatry? There is a great deal of outside pressure on your model, if you see what I mean. If there's a delay in another part of the service that you have no control over, say in the forensic context there might be a prison is full, and you can't send someone there then. How do you deal with those sort of external pressures on your system?

Harry: Fundamentally, by evaluating to see what is happening. If you don't realize that you are nested within larger systems, you will be the victim of circumstance, and your patients will be the victims of those circumstances. You're absolutely right there. Maintaining that awareness through evaluating, is a way that you can at least have your voice heard on behalf of your patients, advocate for the right pathways, the right services. There are ways you can influence this sort of thing.

Fundamentally, by delivering treatments, and the logic model is very important part of that, it's the relationship between resources in, to the health gains out. Now, again, you need to be thinking very hard about what counts as a health gain. Moving from a very secure place to a less secure place is an obvious example.

These outcome measurements that you evaluate, divided, I think into two halves. There are population-based and organizational-based measures of how well you're doing as a service,. And then there are patient level measures as well, which, of course, for us as clinicians are the fundamental goals, but the organizations we work within will quite rightly want to know what we're doing with the resources they provide us with.

For instance, if there are legally binding powers in courts to send patients to us, we need to show that we are meeting those obligations, and if we need to influence conditioners about resources, we need to be able to show what it is that we need and why it is that we need it. Yes, admissions per 100,000 per year, about 0.7 per 100,000 in a lot of countries, discharges per 100 beds, or perhaps per 100 staff per year.

Violence and restrictive practices per 100 admissions or per 100 beds, or perhaps per 100 staff, episodes of absconding. Positive drug screens. Again, if we want to be a safe and therapeutic environment, we need to be drug-free as well as violence-free. Then at the individual level, what we have called the four recoveries.

Recovery theory at the moment is one of those wonderful things which is above and beyond criticism, and rightly so. It's like mother love and apple pie, but there are four types of recovery, which in a sustainable evaluated service, we have a responsibility to be aware of. Forensic recovery, moving people from highly restrictive, highly secure settings to less secure settings, taking the person who lacks the capacity to consent to their treatment and restoring that capacity. That's a responsibility.

Symptomatic recovery simply because it reduces suffering. Highly symptomatic people are suffering. Symptomatic severity is related to suicide and to violence. But then of course in modern times, functional recovery, and this brings us back to good evidence about what treatments work, restoring somebody as near as you can, to autonomy, to independent functioning or providing the supports they need to at least fulfil their sense of self-actualization, self-transcendence people talk about.

Then, of course, personal recovery, which people often think of as all of recovery, but that’s engaging the patient co-production hope. Those vital things that motivate people to achieve their own best level of health and independence. If we're not measuring those things, we can't see them. If we say they aren't measurable, we're probably a bit diluted. I'm very into quantitative things as you might gather.

Oliver: Yes, and I sensed that from this paper. I sensed that very much. I suppose that's the two halves of the model, the staff and the model of care which is your goals and then your outcomes that we've discussed. I suppose the tricky part in some ways is how you're going to go from the goal to the outcome and that's these two elements of the model, the pathways and processes, and then the treatments.

There's some very nice diagrams, I should say, if anyone is listening to this in this paper and in the supplementary material of different sorts of models of eventually pathway flow throughout a system included in this paper. How can you know if your pathways or if your treatments are responsible for your final outcome? As I suppose, how would you know if you say, oh, well, the number of people are discharging for 100,000 beds is decreasing. How can you identify what you may be able to do to change that?

Harry: Well, this goes back to Austin Bradford Hill and how we know anything in epidemiology or population-based studies. A dose-response curve would be one way of looking at it. Do those who have more hours of face-to-face therapies do better than those who don't? Now, there's a cause and effect loop there, which can be quite interesting because someone who is unable to engage in treatment or unwilling to engage in treatment will have less hours of face-to-face time and will make less progress.

We have to provide the treatment. We also then have a responsibility to engage and motivate so that people use the treatment and while all the best evidence for effectiveness is about biological treatments, medications. We've been pretty stagnant in that field for the last 40 odd years. It's a long time since we had a new, very effective medication, maybe new biologicals will change that, but in the meantime, we do actually provide a wide range of psychological and occupational, and family-based therapies for which there is very little evidence.

Working on that is a huge responsibility. There are very, very few randomized controlled trials of complex interventions in forensic psychiatry. We need to do a lot more of that. For that, we need to be networking. Again, in the same way, that a model of care describes one service, a pathway here, for instance, I'm interested in a population of 5 million, but that's never going to be enough to do very large systematic, randomized controlled trials of how to make things better. For that, we need to be working cooperatively internationally, in the same way that oncologists work.

If heaven forbid one of us was diagnosed with leukemia or a lymphoma tomorrow, the oncologist that we would be referred to would almost certainly offer us enrolment in an international multicentre randomized control trial of treatment as usual versus treatment plus. It's really disappointing and perhaps a little bit shocking that hasn't happened in psychiatry yet. It's about time it did. I think that can only happen in forensic psychiatry services because this is where we see relatively newly diagnosed, very severely ill people, and this is where we can control the conditions to actually know what it is we're delivering.

Oliver: Yes. It's as you said, I suppose one reason that doesn't happen in psychiatry is because assessing the impact of all of the, as you say, relatively un-evidenced things like the therapeutic environment, like the relationship with members of the care team, other patients, it's very, very difficult, which [unintelligible 00:15:46] I suppose is as you say, the forensic psychiatry setting is arguably more controlled for that than some other parts of psychiatry. Obviously, your paper is about forensic psychiatry, it is considering making a model of care for a forensic setting.

To what extent do you think this thing is applicable to any part of psychiatry or indeed any clinical setting? Do you think another service director looking to start their own service in say a different branch of psychiatry could apply the same sort of model that you have here?

Harry: Not only can they, I think they should. I think this is a universal, it's not unique to psychiatry either. This is old hat. If you were a cardiologist, a metabolic physician, old age services, of course, have had these broad multidisciplinary multi agency models for years. What is fascinating is that most of the models of care that we all train in as medical students and then as trainees are implicit or tacit, and it's when you have to start and think about making it explicit that it becomes quite interesting and actually a hugely uniting thing. This is how you bind colleagues and patients and their families and communities into a joint enterprise.

One of the things that people say about a model of care is that it's a bit like the constitution. Most countries have a constitution and all the laws, all the judgments, all the statutory instruments have to be compatible with that constitution and they are implicit within that constitution.

The same is true here. If, for instance, you were a new consultant appointed to manage a community mental health team or adolescent service, for example. You would have your part of larger service, neighbouring services, either side of you, social services, education services, and so forth. You would have to start thinking, "Well, how are we currently operating? What is my predecessor doing here? Do I want to keep doing what they were doing? What about my neighbours? Should I be doing stuff with them or do I want to do things slightly differently?"

At the very least you can write a standard operating policy for your own bit of it, but that will have to fit somehow in some larger system and if no one has written that larger system down, you can start nudging your colleagues to put one together.

Oliver: That is a key recommendation of your paper, isn't it? Is that once you've made your model of care where you're setting one up, you have to write it down and then as far as I understand it, to show it so at least the new staff members, so people are aware of what's going on.

Harry: Yes. We're in the process of almost doubling the size of our services. We move into the new hospital, a huge recruitment exercise of people who are completely new to the forensic practice and the HR managers all honestly believe as an act faith that all these new people are going to read all the policies. This is nonsense. Heaven helped their poor souls. They believe this sort of thing. We have 40 core policies. Each of them runs for about 20 odd pages. Nobody's going to read those.

The most you can hope for is that you can give them a model of care. Ours is 13,000 words. It's a real thing. It's a document of 20 or 30 pages, 13,000 words and it is possible to sit down with a cup of coffee and read it. We hope everybody will do. Obviously, they're all going to end up signing those policies. Yes. I've read this policy on how to do one thing or another and I'm sure they've looked at them, but I do want people to read the model of care.

Oliver: Yes, I suppose that leads too nicely to perhaps a couple of cynics' questions to finish with. Obviously, in in the NHS in psychiatry, the pressure on services is normally high, I don't know if same is true in Ireland but I imagine it is. I suppose one question is how does the model of care idea mesh with the reality that occurs in health services which is that the best laid plans are very quickly scuppered.

One quote that I must pick up in your paper is to say is that a key part of model care keep things flowing as your better occupancy should be 85%. As I'm sure you know better occupancy numbers that are not in three figures are often a cause of great red rag to a bull anger to people that have worked in the NHS for a long time. How can this planning mesh with a reality in which sudden acute events are almost commonplace and plans are changed at a moment's notice by higher powers?

Harry: That figure of 85% better occupancy comes from a brilliant, brilliant very senior colleague Peter Millard who was an old age physician in St. George's when I worked in London in the 1990s. Peter Millard was a mathematician fundamentally who built on the work of a physiologist called Ludwig von Bertalanffy to mathematically model how hospital care worked, mostly in old age medicine in his case though also in in psychiatry.

It's quite important to hold onto that just as an explanation to commissioners and indeed patients on your waiting list for why it is that we're stuck with the waiting list. Here's how we might manage better. That notion that you can mathematically model reality is always, of course, simplification, but also always a way of conceptually working out what really matters. As clinicians we are scientific about the patient in front of us, the individual person with whom we have a therapeutic relationship.

As clinical managers we have a responsibility to be often the only scientists in the room, the only ones who understand the mathematical modelling that actually does shape what happens subsequently. It's extraordinary how little knowledge there is more widely about how these things work and yet they do work. Length of stay for instance shouldn't be expressed as a mean figure. It should be expressed as a half-life or a median. Relatively few people are interested in this.

I hope the article might raise awareness. It's a bookend for a piece I wrote also in Advances in 2002 which was just defining therapeutic security, and of course, I didn't invent physical relational and procedural security. Other people had written about it beforehand. What you often find yourself doing particularly for such a terrific journal as Advances, I'm flattering you guys here, what you do is you speak the culture, you write down what you learned in your own training so that it makes sense to other people.

That piece in Advances it still has some value, I referred back to it in this piece, but if you like this new article is 18 years later, 19 years later what more did I wish I knew 20 years ago when I wrote that first one. This is the answer to that question. 85% occupancy, I hope so.

Oliver: Me too. Well, Harry thank you very, very much for joining us. It's been an extremely thought provoking discussion of a very interesting article. That was Professor Harry Kennedy who is a professor of forensic psychiatry at Trinity College Dublin and executive clinical director of the National Forensic Mental Health Service. We've discussing his new article models of care in forensic psychiatry in BJPsych Advances. Harry, thank you so much for joining us

Harry: Thank you very much, Oliver.

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Romayne Gadelrab: Hello, and welcome to another edition of the BJPsych Open Podcast. My name is Dr Romayne Gadelrab and I'm one of the two digital content editors of the BJPsych Open along with Dr Piyush Pushkar. Today I'm really excited to be joined by professors Richard Williams and Kenneth Kaufman, authors of the ‘Narrative Review of the COVID-19 Healthcare and Healthcarers Thematic Series’ here at the BJPsych Open. It goes without saying that this is a really important theme for the BJPsych Open to have covered. It's one of many important learnings which we're soon going to get into.

Before I delve into the issue, can I formally introduce my guests? We have Professor Richard Williams who's a professor emeritus of mental health strategy at The Welsh Institute for Health and Social Care, and the presidential lead for COVID-19 emergency preparedness and mental health to the Royal College of Psychiatrists, as well as the director of psychosocial and mental health programme for the faculty of pre-hospital care at the Royal College of Surgeons of Edinburg.

Then we have Professor Kenneth Kaufman. He's a professor of psychiatry, neurology, and anaesthesiology at Rutgers Robert Wood Johnson Medical School, and a visiting professor at the department of psychological medicine at the Institute of Psychiatry, Psychology, and Neuroscience, King's College, London, and is, of course, the Editor-in-Chief of the BJPsych Open. That was quite a lot there. Thank you so much to both of you for joining us today.

Richard Williams: Pleasure.

Kenneth Kaufman: It's a pleasure.

Romayne: As we're all very aware, the coronavirus pandemic has and continues to have a huge impact on us individually and to our society. However, it also completely disrupted the field of research and some areas excelled, such as the creation of the vaccine, and others suffered. For example, some of the research I've been working on has been put back about two years behind where it should be and lots of mental health research has been cancelled altogether.

I read recently that even by the end of just 2020, that there were maybe over 200,000 coronavirus-related academic papers and preprints published. I wanted to know how it was curating this theme from a no doubt huge array of submissions and what might have been like to be an Editor-in-Chief during this time.

Kenneth Kaufman: Romayne, to answer this, I must put it in perspective. As a senior academic psychiatrist, as well as the Editor-in-Chief of BJPsych Open, I first considered the need for global psychiatric response in March of 2020, and with Eva Petkova, Kam Bhui, and Thomas Schulze published an editorial in the British Journal of Psychiatry entitled ‘A global needs assessment in times of a global crisis: world psychiatry response to the COVID-19 pandemic.’

We consider the key challenges for psychiatry that require urgent attention to ensure the mental health and well-being for all, COVID-19 patients, healthcare professionals, first responders, people with psychiatric disorders, and the general population. Prior to any publications regarding the psychiatric psychosocial aspects of COVID-19, we emphasised that mental healthcare should be an integral component of healthcare policy and practice towards COVID-19. We noted that this must be regarded as a major public health imperative. In essence, any official response to a pandemic like COVID-19 without a safety component would violate a government's prime duty to ensure the health and safety of society.

There are multiple core themes that needed and still need to be addressed. Dissemination of knowledge, clinical care, appreciation of both our patients' and healthcare providers' perspectives, and the long-term effects on the psyche in general population. While Richard has been a key academic during prior pandemics and disasters, my approach to COVID-19 remained much more personal. How and why? I view this pandemic as a global health disaster and compared this to the disaster for which I was a psychiatric responder.

I recall being in the ER on the evening of 9/11 into the wee hours of the next morning, arriving home after 4:00 AM, being notified by my wife that my neighbour needed to speak with me immediately. I learned that he was away from the World Trade Centre towers for a Central Manhattan meeting and witnessed trapped tower workers jumping to their death. For greater than 20 years, I have cared for 9/11 survivors and first responders. Acute distress, depression, and anxiety symptoms have blossomed to chronic PTSD, major depression, and anxiety disorders.

Though over extended time there's decline in severity for the general population, a recent longitudinal study noted increasing prevalence of PTSD amongst rescue recovery workers. This, of course, when you consider it in light of what will happen to healthcare workers over the ensuing 20 years from COVID-19. Which brings us to COVID-19. My first goal is to publish initial snapshots of early mental health responses to COVID-19. Though initial cross-sectional studies have methodological weaknesses with lack of generalisability, they can enlighten us of acute current symptoms, not diagnoses, pretend what might come, and through discussions of limitations and strengths lead to improved longitudinal research.

As the EIC, I've dealt with many COVID submissions impacting mental health of the general population, healthcare staff, and specific populations. I found this an important editorial and scientific educational process, which has led the journal towards a more critical review process as the pandemic now enters its third year. As both Editor-in-Chief and clinician, I recognise the need for population studies, but mirroring 9/11, I also recognize the need to address the effects on healthcare workers and healthcare systems. I view this thematic series as just the beginning. Thank you.

Romayne: Thank you, Ken. I think that's really, really interesting.

Richard: Let me just add to that and say, Ken, I think we learned a huge amount, didn't we, from 9/11? It's a very different type of disaster, catastrophe even, because it all happened on one day—except that it didn't. The events took place on one day, but the aftermath for people has gone on ever since. It really is quite staggering, but what that has introduced us to is just how long and sometimes delayed are the mental health and psychiatric impacts on people.

When you look at a disaster of the nature of a pandemic, which is ongoing, continuous, lasts many, many days, and when I first got involved, I thought this is an event that has the prospect of going on for years. How sorry I am that I was right. How do humans cope with that kind of continuing disaster? Is it the same or is it different? The advice that we gave to the authorities was based on the best we could muster from discontinuous disasters and that served us well, but we still have to answer the question, what will be the cumulative impacts?

Romayne: From your experience of— Richard, as you mentioned before, that this isn't your first pandemic that you've experienced and you were saying to me before we started recording. I'm thinking what is that timeframe where you think we'll really understand the mental health impacts? Could you gauge that from previous pandemics you've experienced?

Richard: Yes. One of the things I've done over the years is to read what was in the public domain. There's a seminal book called Pale Rider written by a specialist medical journalist, which is a seminal piece of work and really is a really impactful introduction because it talks about the Spanish flu, a misnomer if ever there was one, but that arguably killed 50 million people, possibly more. Of course, in those days we didn't even know that that was flu and it was caused by a virus. The basic public health measures are written down in the history of that event.

We could see that there was a propensity for things to go through three or more phases, waves, and that large numbers of members of the public would be affected. The last one I was involved in was the flu pandemic, the H1N1 flu pandemic of 2010 when I was directly involved in advising the Department of Health about conduct of interventions for that. It struck me then just how much we need to look back at that and say, "We were lucky that time, we were well prepared." A lot of those preparations weren't wholly necessary, this time I sense we were under-prepared and a lot of the preparations we might have made were thin.

Each pandemic is different, but I think the impacts only time will tell us what they are. There are clearly ways in which people react to the immediate events that take place. For most of us, that was being curtailed in our own houses, having our liberty restricted, which is quite a devastating things for people. Those of us in psychiatry know that only too well from the ways in which our patients cope with being detained. That's a very different quality than whole echelons of society being restricted in their movements. Clearly, there were a lot of people who were very distressed by that.

This distress wasn't evenly distributed across the population, but perhaps we'll come back to that. I think there are a number of phases and it's only now that I think we're beginning to think we need to prepare everybody, the country, the services, everything else, for what I think will be a much bigger impact at the psychological, psychosocial, and psychiatric levels of this pandemic, which is of course still ongoing. In most other countries of the world, it remains a very big problem. Though we feel that we might be at the junction point in the UK, that itself is not clear. Let me stop there.

Romayne: That was great, Richard. Thank you so much. Actually, I think that's quite a good start into delving into some of the themes that were emerging from the whole series. I think that comparison with how our patients might feel when they're being detained to large amounts of society having to experience that isolation and being detained in their own house and fear I think was huge.

I think that was one of the big themes that came out, that you were saying the impact on the public of having to lock down and also having to adhere to these precautionary measures that we’ve never had to take before. Could you maybe, either of you, tell us a little bit more about the findings that came out through the papers?

Richard: Yes. I think some of the papers are quite interesting in that regard. I made a comment earlier that the effects of lockdown, et cetera, weren't distributed evenly across the population. This brings us to what we know of the social causes of mental ill health. [inaudible] has been going on about that for a long time, the social causes of ill health. This has been shown in huge terms during this pandemic that is one thing to lock people down but coping with that— Of course, we're in a position now to cope with it much better than we might have done before because of the joys of modern electronics.

We've only had access to conferencing facilities, so my work continued substantially unabated, but that wasn't true for everybody. What was it like for families with children who couldn't go to school, who were locked down in small premises of inadequate housing, and who didn't have funds that they could buy electronic devices and couldn't afford to connect themselves to the internet? That's where I think the polarization of our society has been shown up by this event in no uncertain terms. I think those impacts, this is what I call this socioeconomic trajectory of impact has become so noticeable. That's perhaps one of the— I hesitate to say good things, but if you understand what I mean.

There is a side to this pandemic which has brought us face to face with some of the realities. We've had to face the different circumstances that people from ethnic minority backgrounds have faced, children from more deprived families have faced. It really is a huge, huge learning point that we can't eclipse. In one sense, I think we've learned so much, but we've also seen huge goodness from people.

In my own area in Bristol where I live, we've watched people rally around charities. Individual people who've collected materials together—used computers—refurbished them, provided free of charge access to the internet. What we've also seen, a really grand side to some people. I don't think we should forget that, we need to put the whole thing in perspective, in my view. People are more good than bad in my experience. By that, I mean that people are more altruistic and giving and supporting of each other than they are necessarily selfish. That's a quality that we've got to learn to exploit and develop, it seems to me, in modern society.

Kenneth: Richard, when you comment on the social trajectory, the issue that comes to mind is the fact that we're really dealing with policy issues over time.

Richard: Yes.

Kenneth: It's critical that you raise this issue. Unfortunately, it's too obvious that it's there, but this actually makes us ask the basic question, what policies will change over time both quickly and over an extended period of time? Are we willing to do that?

Richard: Yes. I think we as psychiatrists probably bump as much as any other specialties, possibly and arguably more than some specialties, into the small politics of healthcare, of society, and all these things. It's something we can't ignore, it's there. We have an important responsibility to speak out about some of these matters, which is why I was very keen that we included these social trajectory issues in the narrative review. I think if we only just underline what so many other people have researched, we are acting as a potent source of dissemination of that knowledge, but maybe we need to go further than that. It's the dilemma that faces psychiatrists in all sorts of arenas of their work, is it not?

I've spent a lot of my time during the pandemic working with the people at the front line, people in intensive care units, and people who can't say no. They are in the accident and emergency departments, they're in pre-hospital specialist medical care.

Although it's thought of as glamorous of turning up in a fast car or a helicopter or something, it's not that glamorous when you get down to what you face. Helping those people to cope with the ghastly situations we've faced of stacking ambulances at the doors of hospitals and things like that I've seen as an important part of the ethic that I've taken on here. I think there's a social side to a lot of what we do, there's a policy side, and I don't think we should be too scared of recognising those things.

Romayne: Sorry if this question's going a bit off piste, but to many of the psychiatrists, psychologists, and other people listening to this podcast, what are things they can maybe do to speak out like you were saying or to be heard? It can feel difficult sometimes when you are seeing this and you're experiencing this and you're reading about it to work out what you can do to maybe influence policy.

Richard: You're 100% right. It was recognising that years and years ago when the facilities in Bristol, the psychiatric facilities for young people, particularly adolescents, were so poor that we felt or I felt I had to export myself to a place of greater influence. It's why I got involved with the Royal College of Psychiatrists in the first place because I thought that there might be a platform from which you could speak on a broader base and with greater authority from which people could not disqualify you, or they could but perhaps with more difficulty than if you were just a lone voice.

Maybe people need to think about what really matters to them, what it is that they've learned from their patients or from their work that they might want to speak out about and find vehicles for doing that in a way in which their colleagues can support and join with them. It's important, I think, the group aspect of this of having a social group to support you with some of these things is critical. Going it alone is much, much more difficult.

Romayne: Thank you. Obviously, Ken, I appreciate you're across the water from us. Is there anything that's maybe different happening over in the US that you'd advise?

Kenneth: Unfortunately, we're probably not following the playbook that we had written years before in our pandemic books. They did exist, but we didn't use them. I guess that's the issue. The best phrase would be we're regretting it now. We've witnessed over time too many cases, too many deaths that has occurred in England and other countries, significant disruption in our lives. At the same time, it shouldn't be forgotten, regardless of the issue of social trajectory and problems with those who have deprivation, some individuals have found personal growth during the pandemic. I think one of the papers that we published address such.

There are types of silver linings that can come all sorts of tragic issues. Hopefully, we're going to learn from this and do better in the future. We're going to find that over time because as Richard clearly stated, this is not going away overnight. Talked about different variants, there may yet be further variants to come. People need to be aware of that. [inaudible 00:21:39] before, Romayne, about adherence.

We need to understand what is important for us for basically society-- [inaudible 00:21:49] Talk about policy before— there’s both clinical ethics, there's public health ethics, but there's also political ethics. They don't always match, but we have to do the best we can to try to get things out there so people understand what is occurring, what might be best for society on a long-term basis. There are fortunately different institutions which have set up large ongoing longitudinal research programs. Hopefully from that, we'll learn a lot more, but I think this will take place over time.

Romayne: Of course.

Kenneth: As Richard commented about the advantages of speaking from the Royal College of Psychiatrists, I would also comment that in being involved with the journal, I get the ability to be able to see articles and try to get them disseminated assuming the quality is appropriate. Out of that, hopefully, we'll do better things over time. I guess as we're going to go through the rest of this podcast, we're going to realise the limitations on the original research, what needs to be done in the future.

Romayne: Of course. Yes, I would love to talk about that maybe a little bit further on. I think that's such a strength of this thematic issue, like you're saying, is the issue does explore things like potential mental health difficulties, shall we say, that people had due to the COVID-19 pandemic. Post-traumatic stress disorder, some papers talking about increased levels of adjustment disorder, depression.

Like you were just both alluding to, it's a term that I wasn't really familiar with thinking about this post-traumatic growth where some people actually had positives. Obviously, that wasn't for everyone but in one study, particularly a high number of people, I think it was in Portugal, said that they experienced things like improved relationships. I don't know if you have—

Richard: I've heard people saying that they have got good things out of being corralled with their family.

Romayne: Maybe not everybody. [laughs]

Richard: Not everybody. [chuckles] You can have too much of a good thing perhaps. I'm not trying to be jesting about this, but the intensity of relationships I think is an interesting feature in this. Often our relationships are not intense enough and therefore not satisfying, but equally, they can be over demanding of us. It'd be interesting to revisit those families again several years on to see whether they would still claim post-traumatic growth. The interesting thing from my looking at post-traumatic growth over the years, and it first really flowered in my imagination in discussions with a Spanish colleague back in—oh, about 2010, I had a lengthy conversation with a man I'm thinking of. It seems to me that, A, we've underestimated this as an occurrence, but it's not independent of the suffering that people have. That the more stimulated people are by distress, by symptoms of possible mental disorders, you need that stimulation to get the growth out of it, it occurs to me, and the two are often intertwined. If you are too provoked by symptoms, then that post-traumatic growth doesn't occur in my experience, but equally being non-stimulated by the circumstances doesn't provoke you to growth either. It's a complex phenomenon that we still ill understand, is what I'd say.

Roymane: Thank you. Obviously, I think I was jesting a bit in the beginning, but of course, we're all too aware of very hard difficulties like domestic violence and things like that-

Richard: Indeed.

Romayne: -been happening. Obviously, I want to mention that.

Richard: Do you know we've known this for some time and it's not often talked of, is that difficulties in domestic relationships and violence between close people are recorded after single incident disasters, just as they are after a very different kind of disaster that a pandemic represents. There is quite a lot of research showing that after 9/11, for instance. It's something when I teach on courses, I'd always draw to people's attention is if you get too focused on what happened and how people cope with that, you might miss out on some other important findings that may be as detrimental, if not more, in some instances.

Romayne: Thank you. I guess the next theme I wanted to delve into was thinking a bit more about the effects and the impacts of the pandemic on the healthcare services and their staff because a large number of the papers obviously focus on that. Do you want to tell us little bit more about the key findings?

Richard: I think the first thing to appreciate is just how serious the pressure is that our health services in the UK have been under. Those people who've been in it know that only too well. But a lot of people don't understand that. It really has taken many of our staff to the edge of their tolerance, is my sense of things. We coped reasonably well though under huge pressure with the first wave. As it came to a close, that solidarity and that mobilisation of support, which came about almost spontaneously, remember the days when we'd stand on our doorsteps on a Thursday night and clap, they disappeared in June in 2020 and they haven't returned.

Of course, we know about this, what we call the support mobilisation and the support deterioration phase we know about in relationship to other types of event, single incident disasters, and major incidents. We didn't know what would happen in this pandemic. I didn't know whether that would turn out to be a wave thing or whether it would be a one-off and it's turned out to be a one-off because as each wave has come, we've not seen a recrudescence of the support mobilisation. In fact, feels to me like an accumulated downhill trek for a lot of staff. The time we got to the end of the second wave, I think a lot of the staff, particularly the nursing staff, were cleaned out by their experiences.

As we say in the paper, you could almost feel the fatigue. It was a fatigue of a strange kind really. It's not just tiredness, it's gone haywire. It's different to that. It's qualitatively quite different. You think of the privations. I've had nurses talking to me about when the PPE was short in supply, the altruism they showed, particularly in that first wave, was truly enormous. Some of them said to me, "Do you know I didn't take my break this morning, so I've been in this PPE for 9 or 10 hours now because I didn't like to, because I thought I'd have to throw it away and put on a new set. If it's in short supply, maybe there wouldn't be enough for tomorrow."

You think that people voluntarily do those kind of things and put themselves at risk. I said, "Haven't you actually been to the toilet then?" "No, I've restricted my intake, so I didn't need to." People think about these things. They've gone to enormous lengths. I take my hat off to people who really go beyond. That's the thing that was coming through loud and strong as we got into beginning to write this paper and it hasn't gone away, but we find the reluctance in people to go back and do it again. As people said to me at the beginning of the second wave, we didn't want to go again or we found it hard to, but they did.

A nurse said in a television interview only the other night on the news, "There may be another variant and we may have to go through this again. I don't want to do that, but I suppose I should have to." People feel the pressure of their profession. That’s a shame that people feel in that sense. Some people have opted out and said, ‘’No, I’m leaving.’’ Some people have gone sick in between.

That’s another series of reasons as to why healthcare services are under truly enormous and staggering pressure. I think we need to talk about these things because, A, we need politicians and managers to understand just what it’s like to be involved, but we also need the public to understand and to forgive us for our shortcomings, which aren't really shortcomings at all in my review. They're the consequences of being overtasked.

Kenneth: Richard, you're commenting on important themes because it's not just the UK but also US and other countries where nurses have been overwhelmed, frustrated, and sadly quitting the profession, or that some of them, they can't handle any longer or they're supported adequately. The Murray paper, it addressed the ongoing healthcare, I should say, crisis that's been going on in England prior to this pandemic. It has not yet been adequately addressed.

Richard: That's another thing of critical importance I think you've brought up there, Ken. Imagining that we went into this pandemic, and I think in most countries, this would be the case, with a beautifully resourced and settled healthcare service is wrong. That was plainly the case in my vision of things in the UK. We went into this from a place of huge staff disgruntlement and ill feeling about the lack of resources, et cetera, et cetera. I won't go on at length about that because we do so in our other podcast.

A lot of these issues have made coping so much more difficult, and yet those—what I call secondary stresses, these circumstantial things—have turned up as being critical to a lot of the staff. But they're still there and we have still to face them. Imagining the health service is somehow being cured by its exposure to the pandemic is incorrect too. We have got to get people to take seriously the under-resourcing and the over-commitments of staff if we are to have a good quality health service to emerge into. Those are some of the looser findings. They aren't necessarily what the published papers show, of course, because so many of the published papers focus on symptoms rather than social and professional processes.

That's not to say there's inherently something wrong with them. It was a starting point. A lot of the papers we have reviewed in this narrative are from the first year of the pandemic, and we hope we could see a greater diversity of research methodology subsequently. I think both Ken and I want to add to this series of papers as we become more sophisticated and understand some of these really quite difficult questions better. People who hear this podcast, who read the paper, look at the series must not think that somehow that's it, this is the last word. No, as Kenneth said, this is the first word. I think we need to monitor this and see how we learn the lessons and what we do with them into the future.

I don't know if that's helpful, but people can read the paper and our narrative review, and they can look at the papers that are summarised in it and glean their own findings. I think that's probably better. I think another feature that I'd like to draw attention to is just those couple of papers near to the end of our narrative review in which we look at the impact on people who endeavour to support their colleagues. That is not without its cost either as those papers are beginning to suggest.

One of the papers, I think really quite a good one, looks at the advice that healthcare staff were given as the pandemic started. It shows that our attuning of that advice to what the healthcare staff wanted by advice was not wholly accurate. It just reminds me that the whole business is a job of co-creation and collaboration. I think that's another lesson we've learned.

We also need to protect people who volunteer themselves to work with their colleagues and to ensure they're supported as well. Who cares for the carers I think is a very important question that comes out of this. Maybe that's something that ought to have been there all along, but certainly, this pandemic allows us to focus on that a bit more than perhaps we might otherwise. Do you have thoughts about that, Ken?

Kenneth: The issue about caring for the carers is really critical. Especially for psychiatrists caring for individuals who are having issues dealing with the pandemic, meaning the healthcare providers, because that's actually lacking in the United States, at least in my viewpoint. At some level, it's being done but I don't think as much as should be. I know that some of the colleagues I've spoken to have spent a lot of time, a lot of effort in trying to help others, and at end of the day, they feel somehow that nobody's thinking about them. It's sad when you hear somebody say that if that's there.

There’s another point to mention that we don’t have papers about but ought to be considered and that is in the process of this pandemic, we’ve put off healthcare for many of our normal services. By so doing, we’ve disrupted the morbidity mortality from those illnesses, and because of such, this will impact the mental, being perhaps psychic status, of individuals and the families. I hope that over time, this is looked at and appropriate research is done.

Romayne: Yes, I think that's a really, really important point. Thank you. Ken, I wanted to ask you more about some of the limitations to the research because we do have these fabulous 22 papers that delve into so many different things around this theme of COVID-19. What do you think some of the limitations might be at this stage?

Kenneth: For me, especially as an editor, this is perhaps one of the most important topics to consider for what scientific journals publish informs not simply the scientific community but the public, and they also have influence on policy. Thus it's important to compare the methodologic rigor of our initial publications and compare this against what we desire as a gold standard. As noted in our narrative review for this series, there are multiple limitations which are being addressed as this journal moves forward with regards to how it views future submissions. It's important to appreciate that we have gone through many phases associated with the pandemic with more yet to come.

We've talked about already but the initial lockdown, primary and secondary stressors, lack of PPE, high mortality rates. Then consider easing restrictions multiple ways, further variants with the current restrictions. It keeps on going. Clearly, there's a time course to these events and associated impact on both general and healthcare provider, mental health as well as healthcare system itself. Yet the quickly published findings, as occurred with the original papers in the first year, all the submissions had inherent limitations. Many of our initial submissions were online cross-sectional surveys. This involved convenience as opposed to cohort sampling and bias.

These studies and even some studies that go on for a bit have lacked control groups. Psychometric scales not necessarily intended for specific diagnosis were utilized, and others inferred diagnosis when they were really referring to symptoms. Some scales were not yet validated for specific countries, cultures, and languages impacting responses. Since participants completed surveys blindly, we have no answer as to their state of mind or other environmental factors that might have impacted why they might answer in a particular way. As such, Richard, I believe you would comment that there's greater noise due to greater variability,

Richard: That's right. I think we don't know anything much about the people who took part in many of these surveys. Most of them haven't been allowed to speak freely and to say what were things that bothered them most. The discourse is being controlled, if you like, by the questions asked. I can imagine a circumstance in which somebody is very distressed and is keen to get that over. They find in a questionnaire something that approximates to how they feel. This to me is a possible reason as to why questionnaire-based research tends to yield more substantial suggestions of diagnoses or possible diagnoses than does clinical research.

We’ve been completing some work only this week on the Manchester bombings, very interesting pieces of work, where we were very keen to allow the people who used the services to describe themselves. This either narrative or qualitative research I think is also important. I'm very keen to see people embrace mixed methods approaches much more keenly. We've got a couple of papers in this narrative series which attempt to do that.

Kenneth: We do.

Richard: It's quite interesting to see how the survey findings and the narrative findings don't necessarily concur.

Kenneth: They don't.

Richard: If you look at the narrative findings, you'd think people are doing quite well. If you look at the survey, they seem to doing less well than you thought. I think we always need to be thinking about providing a mechanism for allowing the subjects of research, our participants who give so much to enable it to happen, to actually speak for themselves, which I think is interesting,

Kenneth: To get back to what I was trying to say regarding limitations, all these limitations lead to a lack of generalisability, as well as impact and ability to establish causality. We don't really have causality from our papers. However, these limitations do not mean that the articles presented lack meaning. They gave us a necessary early snapshot, allowing us to consider what future research should address.

Be it mental health and wellbeing, psychiatric symptoms versus diagnoses, which are very different, suicide rates, impact of sociodemographic factors, we need to consider our most vulnerable populations, primary and secondary stressors, adherence to behavioural mitigation, moral injury, stigma, and the impact of psychic medications and COVID among other things.

These initial papers point to greater appreciation of our research limitations. We now can better address these limitations with the following. Longitudinal studies with appropriate sampling and control groups, focused research questions, sensitive and validated instruments. Further, and this is a point that Richard made, these papers highlight the lack of mixed methods research that can be so rich to our better understanding of COVID-19. Quantitative data is essential, but perhaps the most meaningful is qualitative data for the latter puts it all into context, and the context is critical.

Romayne: Thank you so much, Ken. Thank you. With 22 papers as part of the theme, I think I could probably talk to you both for the rest of the afternoon [chuckle] slash into the evening. We probably can't do that. I guess I just wanted to give you both a final opportunity to maybe give our listeners what the take-home message is or something that you particularly want the listeners to remember with regard to this special issue.

Richard: The thing I'd like to focus on is the importance of people's relationships. What has become clear to me very powerfully during the course of the pandemic in talking to lots and lots of people on the frontline and who've done enormously important work, and by and large coped rather well with it, not always and not for everyone, but is just how powerful is the social support they get from peers from the teams. Having a cohesive team is so important, I think, to the quality of the work done, the safety of our patients, and the safety of our practitioners. I can't stress that enough.

Similarly, we need to think widely about what a team is. For instance, I was talking to a facilities manager whose job was to keep the ICU going at the peak of the pandemic when we didn't have enough ICU beds to get patients into. Keeping the plumbing going was a critical feature. The plumber who came into the unit to sort things out was a key member of that team as were the ward clerks. It's not just the clinicians. I think we need to think about teams, about corporate support or collective support, meaning the kind of support we get from groups. We need to think about how we can research that too. That's my take-home point.

Romayne: Thank you. Ken.

Kenneth: I guess my take-home point is that we're only at the beginning. You do not yet have a necessary later larger-scale studies to override the initial snapshots. Not necessarily that some of these snapshot findings are wrong, but they probably are incomplete. What we really need are the longitudinal studies. Now we can better comment on what was initially published, what truly is accurate. We need to appreciate that we will be dealing with the psychiatric, psychosocial, economic effects of this for many years to come. Be very supportive of each other.

Romayne: Thank you. Thank you so much to both of you for giving up your time today to speak to us about this really important thematic issue. Just as a reminder to our listeners, you can read Ken and Richard's narrative review. It's called ‘Narrative Review of the COVID-19 Healthcare and Healthcarers Thematic Series’ which gives a really great summary of these 22 papers, which you can all read in the BJPsych Open.

Thank you for listening to this BJPsych Open Podcast. For the latest updates, follow us on Twitter @TheBJPsych. To listen to more podcasts from the BJPsych Journal portfolio, visit us on SoundCloud or search for us online. Thank you to everybody who's been listening. Thank you so much for taking part today. I really appreciate it.

Kenneth: Romayne, thank you very much.

Richard: Thank you.

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Hamilton Morrin: Hi, everyone. Welcome to another episode of the BJPsych International podcast. My name is Hamilton, and I am a psychiatry core trainee working in London. I am joined by--

Sachin Shah: Hi, my name is Sachin, and I'm a psychiatrist working in London also. [chuckles]

Hamilton: Yes, and today we're going to be discussing an article published in the BJPsych International in December 2020, titled ‘Pattern of psychiatric in-patient admissions in Al Ain, United Arab Emirates’, which was offered by Dr Karim Abdel Aziz, et al.

Sachin: We'll be speaking to Dr Karim about the article later on.

Hamilton: Sachin, is this our first article on mental health services in the United Arab Emirates? I think it might be.

Sachin: It's certainly the first UAE article we've covered on the podcast. Shall we talk about the country first? I've got up this article from the BJPsych International as it happens, ‘Country Profile on the United Arab Emirates’, from April 2008 of the journal.

Hamilton: Sure.

Sachin: Hopefully, things have not changed too much since then, but we know, from our current article, that the UAE, in 2017, had an estimate population of 9.3 million people. It's actually interesting that the gender division in UAE is slanted. That, at least in 2008, and I'm sure this has not changed, males constituted 67.6% of the population and females 32.4%. As we'll see, a large percentage of the UAE is actually made up of foreign expatriates. As of 2008, and again, I'm hoping things have not changed too much, only 21.9% of the residents of the countries are Emiratis, so, UAE citizens.

The remainder comprise of expatriates from nearly 120 countries, coming to look for work in this, I'm quoting the article, "oil-rich country." The largest ethnic group amongst resident population is Asian, with the majority from the Indian subcontinent. The official language is Arabic, and the official religion is Islam.

Hamilton: The actual United Arab Emirates Federation was formed in 1972 and consists of seven different emirates, which are Abu Dhabi, Dubai, Sharjah, Ajman, Umm Al Quwain, Fujairah, and Ras Al Khaimah. The UAE is a high-income country, apparently, as of 2008, so it may have changed somewhat. At the time, the proportion of gross domestic product spent on healthcare was 3.5%. Now, the country profile mentions that tradition and religion are both considered highly important in the UAE, and as a result, there can often be the notion that supernatural forces are the cause of mental illness.

In addition, self-blame and guilt can arise in those who are mentally unwell, as there can be a belief that mental health symptoms are a punishment for one's sins. What's more, subsequently, given this belief behind the potential causes of mental illness, often the first stop for seeking help may be traditional healers, which, of course, is something we know isn't exclusive to the UAE. In fact, in a previous study of the help-seeking preference for mental health problems in children by Eapen and Ghubash, it was found that only 37% preferred to consult a mental health specialist.

It is proposed that perceptions of mental health and attitudes towards mental illness have improved with improvement in education, employment, and social opportunities. However, there still remains a large degree of stigma associated with mental illness that often prevents individuals from seeking appropriate care.

Sachin: What is the article we're looking at today?

Hamilton: The article we're looking at today is titled ‘Pattern of psychiatric in-patient admissions in Al Ain, United Arab Emirates’. Essentially, the article is a retrospective study of data on all patients admitted to a regional psychiatric inpatient unit over the course of a three-year period. They reflect on the breakdown of different presentations—psychopathology present—as well as the nationality of patients, and identifying and comparing trends in presentations between UAE nationals and expats. They go on to postulate the causes behind these discrepancies, and they make suggestions for the future of psychiatric care in the UAE.

Sachin: Who better to tell us about these findings and what it means for UAE than the first author of the paper, Dr Karim Abdel Aziz.

Hamilton: Cool.

Dr Karim Abdel Aziz: My name is Karim Abdel Aziz. I am currently an assistant professor at the United Arab Emirates University in Al Ain, in the eastern region of Abu Dhabi, in the United Arab Emirates. I moved to the United Arab Emirates from the UK about seven years ago, 2014. It's obviously a different work experience than what it would be in the UK, and I was actually very interested in terms of the makeup of the population, in terms of the general population, and also in terms of the psychiatric population.

My interest in writing this paper came from the fact that, from using very detailed electronic medical records, we found that we had a huge pool of data regarding inpatient admissions to the psychiatric inpatient facility in Al Ain, which is where I'm based at the moment, and where I do my clinical work. It's called Al Ain Hospital. We retrospectively looked at three-year data from 2012 to 2015, looking at the pattern of psychiatric inpatient admissions in that hospital. Now, just to put that into some context, Al Ain, or the east region of Abu Dhabi caters to about a third of the psychiatric inpatient population.

There's about maybe 33 inpatient beds there, of something approaching nearly 100 beds or 105 beds for the whole of the UAE. It is, in some ways, quite representative of what the general inpatient psychiatric population for the country might be. It represents maybe a third of that. It was fascinating because the UAE, in terms of its population makeup, is overwhelmingly a population of expats and migrant workers if I can put it that way. That was bound to reflect on the psychiatric population and the inpatient psychiatric population, more specifically.

When we retrospectively looked at the data, the very interesting thing is that, in addition obviously to the local Emirati population, which made up, I believe, about 59% of the inpatient population, we had about over 40 other nationalities admitted in just that one facility. These are people ranging from Europe, North America, but overwhelmingly from the Asian subcontinent, from the neighbouring country of Oman, and interestingly from Ethiopia, amongst many other countries. That's in terms of its makeup.

In terms of the actual patterns of diagnosis, it was interesting in the sense that the primary diagnosis for inpatient admission for the whole population or for that whole sample, were psychotic disorders followed by bipolar disorders. Then substance use disorders, then major depressive disorders, acute stress disorders, adjustment disorders. Then when we broke that down by nationality, or we broke it down into Emiratis versus expats, we found that the primary or the major diagnosis in both obviously was psychotic disorders.

There was a statistically significant difference in terms of more Emiratis being admitted with substance use disorders, and significantly more expats being admitted with adjustment and acute stress disorders. Those were the main findings of the paper. Its implications are in terms of planning for future services within Al Ain, and maybe the wider country of the UAE.

Sachin: Could you give me a sense of what it is like at Al Ain Hospital? This is a hospital, as you say, which carries 30% or a third of the country's bed capacity. How does that work over there?

Dr Aziz: Yes, it's certainly a busy hospital. There's a high turnover of inpatients. It is the only inpatient psychiatric facility in the eastern region of Abu Dhabi. It caters to Al Ain City, so, the main city of Al Ain itself, and a wider catchment area that covers the other smaller towns in the eastern region of Abu Dhabi. That covers approximately a diameter of 150 kilometres if you take Al Ain as the central point of that. It serves a population of around 770,000 people, so it's quite considerable in terms of the size of the population it serves, the unit itself is always busy. There's usually an overflow of patients. There's a recent move now to expand that 33-bed capacity to try and include maybe an additional further 20 beds.

Sachin: The one thing you noted beyond the disorders ranked as most admitted, so, psychotic disorders and bipolar, they also accounted for the longest duration of stay, psychotic disorders, and bipolar disorders, so there seems to be a lot of inpatient demand for these conditions. How is that matched by out-patient care?

Dr Aziz: Yes, the outpatient service in Al Ain is quite well developed. It works differently than it would in the UK. It's a hospital-based outpatient service, so it's actually based within the hospital campus, not obviously within the department. It usually consists of maybe five clinics or six clinics running simultaneously, 8:00 to 4:00 every day or 8:00 to 5:00 every day. It's made up of consultants, specialists, and residents so these are the, what we would call SHOs in the UK or STs, ST1s to ST3s. We have got six clinics running five days a week, so quite intensive and service again, well developed. It usually runs as a general psychiatry service.

Even with specialised or subspecialties like old age, it's usually fit within the umbrella of the general adult service. There is a move to try and develop more specialised clinics, but that still hasn't formally taken off so it's all done under the umbrella of general adult psychiatry.

Sachin: The other breakdown, as you mentioned, was the breakdown between ex-pats and local Emiratis. 41% of admissions over those three years were local Emiratis, but that seems disproportionate to the fact that Emiratis make up 20% of the country's population.

Dr Aziz: Yes.

Sachin: What would describe this disproportionate admission rate?

Dr Aziz: Excellent question. I think it comes primarily from, if we take the starting point is that even prior to coming into the country, expats usually undergo some kind of health screening, physical and, and mental health, but prior to starting employment, so it's less likely that more of the severe end of the spectrum of illnesses, which are usually disabling and affect people's ability to work. There's less likely to be expats with those kind of disorders that require admission.

In addition, the city of Al Ain has the highest concentration of Emiratis for the major cities in the UAE, so although we said around 20% for the whole country, Al Ain, it's probably much higher than that. I don't have an exact figure, but certainly, in terms of Emiratis, Al Ain has the highest concentration of Emiratis for a major city. The other point that it could be of issue is the insurance health coverage that many expats receive. There's different levels of insurance in the UAE, so, Emiratis are covered for all diseases and disorders, including mental health, so, receiving treatment or access to treatment is not an issue at all.

That's true for both government facilities and for private mental healthcare providers. It's different for many of the expats. There are challenges in terms of seeking mental healthcare. Obviously, if it's a psychiatric emergency, exemptions can be made, but for many of the expats, especially those requiring longer-term follow-up, many have had to either pay out of their own pockets or seek exemptions from payment, with many of them actually opting to seek treatment back home in their own countries, with all the challenges that that entails.

Sachin: The other breakdown between Emiratis and expats was that the average age of admitted local Emiratis was three years older than the average age of expats admitted. What do you make of this difference between the age of admission?

Dr Aziz: Could be a number of reasons for that. It could partly be due to the fact that Emiratis may delay in seeking healthcare as there's still a stigma surrounding mental health issues, as there are in many other parts of the world. That could be one reason. Another reason is that in many of the older population, the mental health population, so, for example, patients with dementia, are overwhelmingly made up of Emiratis. As expats, once they reach a retirement age or even earlier, most of them will no longer stay in the country, so this might skew the mean age towards older Emiratis I suppose.

Sachin: The other factor I think that was mentioned was that local Emiratis may seek treatment elsewhere. Is there a faith-healing treatment option that is used within the UAE?

Dr Aziz: Oh, very much so. I hesitate to use these words, but it's a big industry here. Very frequently Emiratis will use and often seek traditional healers as their first port of call even before seeking a medical professional for a mental health issue. That is extremely common, and I suppose it goes back to the model that, again, exists in many other countries in terms of things like possession by evil spirits, or what we call the evil eye in this part of the world, so there is usually a cultural explanation before people veer towards the medical model.

Sachin: When we think about the different pressures that Emiratis and expats may be under, it might be borne out in the difference in rates of the conditions that they are admitted with. The statistically different rates that your study found was that local Emiratis are more likely to be admitted with substance use disorders. That's 23% versus 5.4% in expats. Meanwhile, expats are more likely to be admitted with adjustment disorders and more likely to be admitted with acute stress disorders. What does this tell you about these populations?

Dr Aziz: Yes, in my opinion, expats probably experience more of the acute stress disorder, adjustment type disorders mainly related to these stress of migration. That's a big factor. Many of these patients who are admitted with these disorders are young, single, semi, or unskilled workers living without their families, often working in demanding jobs, with their families back home relying on them for financial support, and a certain degree of uncertainty with regards to their job stability. All these are pressures and factors that could be at work here for these patients.

In terms of the substance use disorders, why is it more amongst Emiratis? I suppose it has something to do with the legal and financial implications for expats using substances. Obviously, there are, but I suppose it has something to do with the affordability of drugs, if you like, the ease of access to it. For example, the drug most seen, particularly in inpatient facilities for substance misuse is crystal meth. That's the number one drug that patients seek treatment for. It is extremely expensive drug, so it'll probably make more sense that Emiratis can more easily afford this drug.

Again, the other thing is the general lack of availability of easy treatment facilities for expats. I suppose also the legal implications, so obviously, if an expat were to face legal consequences, they could be very dire indeed, including prison, but also they'd lose their financial livelihood. They'd probably be deported from the country. Whereas Emiratis maybe the implications are not as dire in terms of things like deportation.

Sachin: Substance use disorder was the primary diagnosis for 12.6% of all the admissions seen over those three years. What is the country's situation with regards to substance use, the attitude towards it, and the legislation surrounding it? Is it particularly unique to the UAE, or is this something that's reasonably noticed?

Dr Aziz: I would say in terms of rates of substance misuse, it's probably comparable to other countries in the region. In terms of awareness of it, recently, in the last maybe 10 years, there have been two major treatment facilities developed specifically for substance use disorders. One in Abu Dhabi called the National Rehabilitation Centre, and one in Dubai called Erada Centre. These work very closely with the police and the criminal justice system.

For example, individuals charged with possession or are found to be using drugs, for example, the criminal justice system offers them a route into treatment as opposed to them serving time in prison, so, that interdisciplinary collaboration is certainly much needed and is a very positive step. It provides high-level care for these patients. Again, at the moment, it's still something that is exclusively available to Emiratis. It's available to expats, but at a cost. Again, it would be one of the challenges in terms of expats accessing care with ease, and which might also explain why we don't see as many of these ex-pats coming for treatment to government facilities.

I suppose what we would like to see in terms of substance misuse disorder is more Emirati doctors working within these types of services because, at the moment, it almost exclusively relies on expats and the reason being that obviously, Emiratis would have more awareness of local cultural issues. They'd probably be easier to retain as there does tend to be a large turnover in the expat workforce. I believe that would be one of the goals to aim for in terms of these disorders.

Sachin: Now, something I noticed of interest was that psychotic disorders was the most common presentation for expats, but when you break it down by nationality, the largest expat group, the largest non-Emirati group, Ethiopians most commonly presented, not with psychosis, but instead with acute stress reaction, which was 29% of the cases that Ethiopians presented with, considering that acute stress disorders otherwise has a low incidence amongst expats.

Dr Aziz: We're actually conducting a separate study on that very issue at the moment, so we're looking at the question of Ethiopian inpatients because, as you said, what we did notice from the study, they make up about 10% of the inpatient population, the whole inpatient population of the study, even though within the general population, they're probably represented by less than 1%, so there's an overrepresentation in psychiatric inpatients, and as you very kindly pointed out, there's an excess of acute stress diagnoses. What we notice so far from the data that we have is that the Ethiopian inpatients who were more likely to develop acute stress disorders tended to fit a certain profile.

Overwhelmingly, these tended to be females, young. Either in their late teens or early 20s, single. Usually working in unskilled or semi-skilled jobs, so, majority were housemaids. Most had no language skills, not even English, so there was a huge language barrier. Many had recently just arrived into the country, so it may be a matter of days or even weeks from the arrival to their admission to the psychiatric inpatient unit, and many were outside their homes for the first time.

Sachin: Let's talk about how the UAE is equipped to deal with the demand for psychiatric services. Now, your paper tries to address working out what this demand is, or what might be needed in terms of services. It notes that currently, there's 1.6 psychiatrists 0.76 psychologists, 4.37 nurses per 100,000 population in the UAE. What is your impression of the current psychiatric workforce in its ability to deal with the mental health burden in the UAE?

Dr Aziz: Yes, the demand is there, it's increasing. Unfortunately, because of the recent COVID situation, restrictions on people going in and out of the country, recruitment has probably not kept up with the demand as well as it could have. In the last few years, we've noticed that more patients are presenting to mental health services. There's also a steady increase in the number of private mental health care facilities, although these only offer outpatient services so far. The medical schools have increased both in number and in the number of students they take on.

We've noticed more students, in recent years, opting for careers in psychiatry. There's also been very concerted efforts on the part of the healthcare leadership to enhance both the quality and quantity of services through international collaborations with major institutes or institutions from Europe and North America, both for accreditation of training programs and accreditation of services. There's also been recent efforts to integrate mental health more into primary care. I suppose part of the reason for that could be reducing the stigma that's seen as part of primary care more.

Regarding the issue of mental health for expats, the main challenge would be facilitation of access to mental health care. I think the way to do that is basically to provide insurance coverage that covers mental health as part of the standard package of care.

Sachin: What further research or what next steps do you feel need to be taken?

Dr Aziz: As I mentioned at the start of our conversation, I work at the university, so research is very much a part of what I do. I would say, in terms of what we can do, there's a huge database of electronic records, untapped data, that we're only starting to look into. The medical records are extremely well documented. It's all computerized. With a click of a button, you can access a lot of information not just regarding diagnosis but even regarding things like auditing, the various monitoring policies for, say, for example, antipsychotics.

This can generate a wealth of data both for research purposes and for service planning. I see that as the way forward because obviously, the development of mental health services in this part of the world needs to be in line with what is actually happening on the ground. Hopefully, this paper has been a positive step in that direction.

Sachin: One thing that you made me wonder when you were talking about more medical training posts opening up and more medical trainees looking towards mental health, within the medical training scheme, and within medicine in UAE, how is psychiatry viewed as a specialty?

Dr Aziz: It's a very interesting question. A very good question. What I've noticed is that more and more Emiratis are going into psychiatry. Not something that we saw a lot of in previous years. I work at a medical school, so the medical students have to pass through us as part of their undergraduate rotation. Hopefully, we are giving a good account of ourselves. I've had many students approach me wondering what it would be like to have a career in psychiatry. Many of them are interested in it, but for whatever reasons again related maybe to stigma, they don't find their parents being particularly supportive of it.

I don't know. Again, maybe it's going back to this idea that maybe psychiatry is separate from mainstream medicine just because of the uniqueness of what we do and the facilities that we have, which tend to be separated from the general hospital. It's almost looked like as maybe something different from mainstream medicine, but again, that's slowly beginning to change. Attitudes are beginning to change. There are still challenges, obviously, in terms of changing both students' and the wider population's perception of psychiatry, but certainly, in the few years that I've been here, I've certainly seen a change hopefully towards the better.

Sachin: It's been very interesting talking to you about this paper, and it just shows how just auditing and seeing the pattern of data emerge over what's going on within acute psychiatric care can tell such a story about what's going on socially, and the social determinants of mental health within any country really, but in the UAE specifically for this study. I do hope that people take an interest in this study, and people within the UAE and the region continue to contribute towards research of this kind and to the development of mental health services within the UAE.

Dr Aziz: Indeed. Thank you for having me, and thank you for your very interesting and deep questions.

Hamilton: I like how straightforward it is, and I do like the breakdown and exploration of reasons why certain presentations might be more common in UAE nationals as opposed to expats with a lot of it just being, or at least in the discussion that you had with Dr Karim, a lot of it does seem to be logic. Like, the idea that everyone is screened in terms of their physical health and mental health on arrival, so it makes sense that, in expats, say most of the psychotic disorder diagnoses might be screened against like schizophrenia or whatnot.

Sachin: Yes, and I said it in the interview as well. It's just very satisfying and logical how it fits together like a puzzle solution where you've got the data and you can see what kind of story it tells.

Hamilton: As I was reading the article and listening to the interview, I was thinking about what I've seen on the psychiatric wards here in terms of how many patients are on the ward of psychotic disorder or bipolar disorder, and it made me realizs, I don't know about you, but at no point, do I— It's not that I don't think about it, but it's not at the forefront of my mind if someone is a UK national or not. Obviously, there'll be some aspects at play in terms of each person's individual circumstances and what's going on in their life, but I've never, in my mind, thought, or it's, I've had no reason to believe, "Ah, yes, acute stress disorder, I'm seeing more often in expatriates as opposed to UK nationals."

Sachin: Well, you might without realizing it. For example, if you get patients who are from countries where there is civil unrest or conflict, you might wonder about trauma.

Hamilton: Sure, PTSD and whatnot.

Sachin: Yes.

Hamilton: That is a good point. I guess when you put it like that, that might be a more common trend that you'd expect. We also do know from research around the psychosis and schizophrenia that it is more common in those who've immigrated to another country. I guess one would hypothesize as related to the stress of upheaval and moving location and finding work in a new place.

Sachin: Yes, and certainly, when you talk about thinking about the patients, and where they've come from, and what they've been through, that just makes me remember my first consultant in psychiatry who stressed to me that I should present patients with the personal history first to make things clear in terms of—

Hamilton: The journey that they've come along to get to here, to this point.

Sachin: Exactly, and to be really clear about it. Like, they grew up in this decade, they were this years old at this time and were in this part of London, or this part of the country, or this part of the world, but to give a real, clear picture of the culture that they were experiencing as they grew up because it's very different for— I don't need to break it down granular, but everyone has a different story which will influence their lives in terms of adversity.

Hamilton: Of course. That's interesting actually. Obviously, there are reasons why, generally, we start with presenting a complaint partly because of the SBAR format and for the sake of time, having everything in a neat structure. At the same time, sometimes I have always wondered when I present patients like that, not just in psychiatry, but in medicine in general, am I creating a form of confirmation bias in the listener? If I say what my impression is right at the start, and then tell the story, are they then retrospectively seeing those links and connections there, when, otherwise, if I just told them the story of the patient and who they are, and their life, would they have come to a different conclusion?

Sachin: Exactly. That also came up, not just with my first consultant, but with the consultants I had in forensic psychiatry, who, again, didn't want to hear the presenting complaint first, or didn't want to hear the offense first. They wanted to hear the person's story, what led them up to this point because, again, you could really prejudice the view of someone by starting with, "Here's the psychiatric illness," or, "Here's the—"

Hamilton: Index offense, or?

Sachin: The index offense exactly, or here's their involvement in the criminal justice system, when you really want to foster empathy with the patient. That's not to say that knowing their psychiatric illness would make you less empathetic, but you want to see them as a person before you see them as a diagnosis.

Hamilton: Of course, absolutely. Otherwise, how on earth are you going to form any sort of therapeutic connection in relation with them in the pursuit of making them better? There has to be that recognition of the individual that they are and the journey that they've had to get to this point.

Sachin: Yes. To bring it to the UAE, this wasn't in an interview, but it is in the article, it sounds obvious, but just about what expatriates go through, the article says that many expatriates originate from countries affected by political unrest, poverty, ethnic, and racial discrimination, and military conflicts. Plus, added stressors such as isolation and societal differences after moving to the UAE can also occur more frequently, explaining the higher occurrence of stress-related diagnoses in expatriates. We have the idea that the immigration process, and that's both pre-immigration, during immigration, and post-immigration, can have a load of stressful effects, but those are some specifics.

We can look at the list of countries that these people come from actually. Of the total of 570 patients, about 60% were expatriates from 42 different countries. The most common, as mentioned in the interview, was Ethiopians, around 10%, followed by Pakistanis 7.4%, Omanis 5.6%, Indians 5.4%, and Bengalis 5.3%. The data tells the tale really of additional stress-related mental illness within those populations.

Hamilton: It's also quite nice and interesting seeing the term expatriates being used here in this paper because, in the UK, I feel like it's one that is used unequally in that, just anecdotally, you'll hear about British expatriate, British expats overseas, but then if someone is living here, they're not an expat, but they're seen rather as, the more loaded term, immigrant or immigrant worker, will be used instead.

Sachin: Yes. I admit I had to switch my thinking around when reading this paper, although we understand the situation of UAE, that it's got a lot of workers from overseas. You read the word expatriates, and I think, especially in this country, naturally associate that with Brits in Spain, for example, who would—

Hamilton: [unintelligible]

Sachin: Exactly. They'd have the financial means to be able to do that, and so then when you read that expatriates have a high degree of stress-related mental health conditions, or that you hear from Dr Karim, that they may not be able to afford mental healthcare in the UAE, you have to flick that switch that, okay, expatriates is a broader term than that, and rightly so.

Hamilton: To come back to the trend specifically of high numbers of patients from Ethiopia with acute stress reaction, as you mentioned, many of the countries listed are countries that have conflict ongoing within their borders. Of course, there is a civil war taking place in Ethiopia at present. Yes, it'd be interesting just to go through that list and just confirm the current social, economic, and political situations in each of those countries.

Sachin: Because, again, we broadly said, oh, the risk of schizophrenia, for example, is higher in people who migrate from one country to another, but then does that granulate into what kind of—

Hamilton: Situation?

Sachin: Yes, what kind of situation is the country from which you're migrating?

Hamilton: Yes, that's interesting because I guess, on these kind of questionnaires, when you assess a patient, you'll assess their symptomatology, and often, in research, that's like the scoring on different criteria checklists. Like, "To what extent did you have depressive symptoms, symptoms of anxiety, and PTSD symptoms," but what checklists are there for like degree of social unrest, or economic situation, or within one's home country, and how relevant is it in each different individual?

Sachin: Yes, that is, of course, only one stressful part of the migration process, which is the pre-migration, the civil unrest, the social factors. The oppression that might cause someone to leave a country or even flee a country, but then there is the migration process itself, which can be perilous. It can be—

Hamilton: Oh, life-threatening.

Sachin: Life-threatening, yes. Then there's the experience in the new country where you may be a minority, where you may be persecuted.

Hamilton: Of course, there'll be knock-on effects of the situation back home as an individual is still in contact with family and friends, and they can continue to be distressed at the situation at home. There's pre, during, and after, but then also, at the same time, you do get the shockwaves and ramifications from the situation beforehand, or if the journey itself was traumatising and induces PTSD-like symptoms, then, yes, it's almost like some sort of Venn diagram, or I feel like one could make a flow model to depict this, or maybe perhaps someone has.

Sachin: Yes, I imagine they have. Al Ain hospital in itself sounds very interesting, taking up a third of the beds in the country, which really sounds like it's going to be busy [chuckles] is the best way to say. Another titbit from the article is that there is rehab facilities because a lot of this article gets into--

Hamilton: Substance use disorders?

Sachin: Exactly. A lot of this article gets into substance use disorders, and as Dr Karim mentioned, there is a move towards having specialised services for substance use. There's a national rehabilitation centre in Abu Dhabi city. However, it's located far from Al Ain Hospital, so people end up getting admitted to Al Ain Hospital with substance use disorders anyway. That would explain a lot of the admissions to Al Ain Hospital, although there are specialised services in the country.

Hamilton: Whenever substance use disorder, where we have facilities pop up in conversation, always, it makes me realise and think about, of course, our own situation in terms of the availability of public facilities, as opposed to private rehabilitation facilities. It just made me realise actually, do forgive me, I think this has come up often in these discussions, but it seems that healthcare currently is free only for United Arab Emirates citizens. Interestingly, apparently, Dubai and Abu Dhabi are the second and third most popular medical tourism destinations in the region.

Popular with medical tourists. I'd be curious about the breakdown for mental healthcare, but it looks like expats do need insurance to be able to access the healthcare.

Sachin: Yes. That again brings us to how Emiratis are, in terms of population size, overrepresented in mental health institutions. That they have more admission percentage than they are a percentage of the population. Again, this was explained by the fact that expatriates have health screening for entry to the country, and again, affordability issues, and expatriates may be going back to their own country to get healthcare, meaning that Emiratis make more use of services. Also, Emiratis are more concentrated within the big cities.

Again, that will make up for some of the disproportionality.

Hamilton: Yes.

Sachin: Just to tie up the substance use because we were asking how does UAE stack up against the region for drug use, and the article does, in fact, reference—

Hamilton: What? The United Nations World Drug Report?

Sachin: Yes. The United Nations World Drug Report 2019, if we bring that up, we get some prevalences of drug use in various countries. We can look at cannabis, for example, the annual prevalence of use as a percentage of the adult population, 5.35% for cannabis in the United Arab Emirates. That would compare to— That's pretty high in terms of countries in the Middle East or near the Middle East. The only ones which are higher are Lebanon 6.4%, and Israel 27%, apparently, depending on source. A more comparable country might be Afghanistan 4.28%.

I think we should always compare to United Kingdom, so, 2018, 7.6%. Cannabis, just a bit lower than the United Kingdom. Cocaine, no data for the United Arab Emirates. Amphetamines, no data for the United Arab Emirates. Ecstasy, I can take a guess on that one.

Hamilton: Wait, no data for amphetamines?

Sachin: Yes.

Hamilton: What?

Sachin: Am I missing it? Amphetamines, Afghanistan, Iran, Israel, Kuwait, Pakistan, Saudi and that's it. God, the lack of data on this table is making me think I shouldn't have brought it up to begin with. Opioids, nothing for the UAE. Opiates, it's almost doesn't bear mentioning. The United Arab Emirates percentage is 0.02%. Also includes problem opiate users. That can't be. There's not much data in the UN World Drug Report 2019 about the United Emirates, but it is significant in the region in general.

Hamilton: So “the United Arab Emirates is one of the few nations in the world that can impose even a death penalty for drug abuse”.

Sachin: Oh, that might explain things. Clearly, there is a need to address legislation as well as mental health services because, as Dr Karim mentioned, there's a stigma issue, but clearly, it's not just about attitudes. It's about actual fear of prosecution. You don't want to make yourself known as a drug user if that's the penalty, especially if you are an expatriate.

Hamilton: Yes, you could lose your job, position in society. It sounds like, in terms of possession, presence of illegal drugs detected in blood or urine tests is also counted as possession, for which you can be prosecuted, fined, and possibly imprisoned.

Sachin: What's your source?

Hamilton: The source I'm using is World Nomads travel safety website, and The Legal 500. The website that breaks down the different schedules of penalties for use, possession of narcotics, and illegal substances in the UAE. Yes, clearly, that might be something that prevents people from getting in contact with healthcare services. Also, I wonder if as a clinician, your focus is on your patient, and treating, and taking care of them, but perhaps one might be worried for your patient's wellbeing regarding if you, I guess it's tricky, but the extent to which you record their drug use.

Not record it, but who knows who has access to that information and what it could be used for, and the impact it could have on someone's future willingness to engage with healthcare services.

Sachin: Yes. Dr Karim did mention that there is collaboration or co-working between mental health services and the justice system to maybe help people who are within the justice system for drug use to be diverted to mental health care, which sounds like a positive. I hope that that also involves trying to medicalise the issue rather than criminalise the issue. I guess all that's left, I don't know if you want to talk about the workforce.

Hamilton: The workforce?

Sachin: Yes. Basically, there's only like 1.6 psychiatrists per 100,000 population.

Hamilton: It's a trend we see often, low number of psychiatrists per capita, but of course, mental health services aren't just purely delivered by psychiatrists. There was also the mention of the way forward potentially being following the World Psychiatric Association's Guidance on community mental health care. I know, in the article and in the interview, Dr Karim mentioned how outpatient services were provided at the same hospital. That's where the inpatient services were provided, which sounded quite interesting. Obviously, there are benefits to having clinics and facilities more local in the community for individuals perhaps with a different level of needs and requirements, but as a good buffer before they become unwell enough to require admission.

Sachin: Just in terms of trying to increase the workforce, the other aspect of that is wanting to increase the number of local Emiratis joining the workforce because, as Dr Karim said, it's a bit of a expat-heavy sector.

Hamilton: I guess to do that, there needs to be an evaluation of the medical education provided nationally. Then it's not just that, but how many are choosing to do psychiatry? It sounded like, just briefly from towards the end of the interview, Dr Karim mentioned that there still is stigma amongst, I guess medical students, applicants, with regards to psychiatry being seen as something separate, and of course, that's not exclusive to the UAE.

Sachin: Yes. I was just going to say that's no surprise, is it? Here, in the UK, we've got the Choose Psychiatry program for a reason, which is to encourage recruitment into psychiatry. This just makes you realise that it probably should be more of a global program if anything. I wonder who would spearhead something like that.

Hamilton: Just from Twitter engagement, I think the whole Choose Psychiatry campaign has made waves not just nationally but has been seen internationally as a successful example of how to boost recruitment. We know that numbers of people applying for psychiatry training in the UK have gone up. We've had years where every post was full, which was something that was previously unheard of. It's sad to think that a spin is needed or a good engagement campaign is needed, but I guess the numbers can't be ignored. It worked for psychiatry training in this country, and I hope it continues to work for psych training in this country.

Maybe we need more #ChoosePsychiatry offshoots in other countries, and maybe other specialties need their own #ChooseGP, or I've seen #ChoosePediatrics pop up on my timeline even. Obviously, I'm reducing a massive campaign with lots of varied facets, through a simple hashtag, but it's the best way to sum it up really. Funnily enough, my in-laws actually met working in the United Arab Emirates. My father-in-law is a Sudanese doctor, but he was working there, and he met his wife who, at the time, was working as a nurse. She's from the Philippines. Just anecdotally from speaking to them, there is this quite big culture of there being at least expat doctors and expat nurses.

I guess I'm curious what it would be like to work there, but I guess the focus, of course, in this interview was more on the patient experience, but I'd be interested in reading figures on the workforce breakdown as well.

Sachin: That was the article ‘Pattern of psychiatric in-patient admissions in Al Ain, United Arab Emirates’ by Dr Karim Abdel Aziz, et al. We’ll leave you with the implications of the paper, which says that "There is a great need to improve knowledge about mental illness in the UAE, and to develop ways of increasing access to mental health services. Our analysis provides clinical information that can contribute to promoting knowledge and help reduce stigma by improving the perception of mental illness.

It is likely that a screening program based in primary care might facilitate earlier detection of mental illness in the community, while a proactive education program in schools and in the community might prove useful to improve knowledge about mental disorders and how to access services at the earliest convenience. Future service planning would also benefit from creating specialised substance misuse services locally to serve the needs of the community." That's it. I've been Sachin.

Hamilton: I have been Hamilton.

Sachin: Thanks for joining us. See you next time.

Hamilton: Farewell.

Thank you for listening to this BJPsych International Podcast. For the latest updates, follow us on Twitter @TheBJPsych. To listen to more podcasts from the BJPsych Journal portfolio, visit us on SoundCloud or search for us online.

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Oliver Gale-Grant: Hello, and welcome to another edition of the BJPsych Advances podcast. My name is Oliver Gale-Grant and I'm joined today by Martin Curtis, who is an old-age psychiatrist in Warwick, and who holds a Master's Degree in Mental Health Law. Today, we're going to be discussing his new paper in BJPsych Advances, which is called ‘The Court of Protection: expert witness and professional reports’. Martin, thank you very much for joining us.

Martin Curtis: Good morning.

Oliver: Your paper discusses a case in the Court of Protection and some of the ramifications of the legal judgment handed down. Maybe you could just start by giving us a really brief summary of the case.

Martin: I have an interest in mental health law, and looking for cases that are quite unique, such that I can try as best I can almost translate or make aware of the judgment to a clinician. That's what I always try and do. I've had a series of papers like this. I try and bridge the gap between pure legalese and clinical stuff. I'm always looking for unique papers. This one's unique because the judge in the case gave quite explicit advice and guidance for clinicians who were preparing expert reports. I always look for a unique selling point of a paper, and that was what it was for me, and it had guidance around clinicians preparing reports for the Court of Protection. That was the key thing.

The case itself was about an older person in a care home who had a variety of capacity-based decisions to be made, which is not unusual at the Court of Protection. The case in itself wasn't remarkable, but there was issues around the expert witness and how they presented their evidence in writing to the court, which eventually wasn't satisfactory. They had to redo the case with bringing in a second expert witness. That was the key thing for the case.

Oliver: Basically, as you say, this case was a 68-year-old-woman who was in a care home. Basically, correct me if I've misunderstood this. The local authority had wanted to determine that she lacked capacity so they could continue to make decisions about her placement.

Martin: Yes, there was a variety of things. When Court of Protection cases go to court, it's usual to have a variety of capacity-based decisions to be assessed. In this case, I'm just quickly looking at the case here. In this case, there is issues around whether she could litigate in court her place of resident care, and support contact with other people because she developed a relationship with another resident, management for property affairs, engagement in sexual relations, and whether she intended to marry.

All of those individual decisions would've been individually looked at to see and assess whether she had capacity to consent to those specific decisions. I think it was born out of a variety of issues, and I suspect it was possibly the relationship she'd developed with the other gentleman that might have been the final trigger. I don't know.

Oliver: Maybe something that would be useful for a general psychiatrist is obviously almost every psychiatrist will be aware of the Court of Protection, but many people might not be clear as to exactly how a case ends up in the Court of Protection. What is it that specifically has brought this case to the attention of a judge? Is it just that the person spent a lot of time in the care home or is it that there's been some dispute or what's caused this to come to court?

Martin: The applicant, you're right is the local authority. I guess there was just a variety of issues that they felt that they couldn't decide locally just, that there was probably some disagreement possibly around the capacity for these individual things. I think that's what prompted them to bring it to court so they would've made the application to the Court of Protection to make these decisions.

Oliver: What makes this case interesting from our perspective is that once the case was in court, all sides together decided to ask an expert witness who is referred to in your paper as Dr X who's a consultant forensic psychiatrist. They asked this expert witness to prepare a report. That is really what interests us if I'm not mistaken.

Martin: That was the key. In these Court of Protection cases, it's usual to instruct an expert that's agreed by— The parties can be obviously the applicant in this local authority and then the other people involved. The general way they approach it is to ask one independent expert witness with specialism in this area to become involved. It's unusual, I think I've alluded to it, or I've mentioned in the paper that it's unlikely to get a second expert witness. Although they did in this case because they felt the evidence produced by the expert witness in this case which caused "disquiet" amongst everybody, including the expert witness to be fair, meant that the judge felt that they couldn't make decisions on the evidence produced in this case. That's why a second expert witness was requested.

Oliver: Then what really, I suppose has got you to write this paper, is that the expert witness Dr X produced a written report and basically, to cut a long story short, the judge wasn't convinced by the written report for various reasons.

Martin: There was various written reports throughout the process. I think he wrote four in total. The key thing is that the court instructs the expert witness with a variety of specific questions. I think in this case, he reviewed the person three or four times. The disquiet came from the fact that there was a lack of explanation. He changed his view laterally, but there was no obvious explanation or reasoning behind that. It reached a head in that prior to the actual court case that the parties and all those involved hadn't really had time to ask for more reports.

It came out through verbal evidence that there was some essential mismatch or lack of explanation of his views really, and how it tied in specifically to the principles and the sections of the Mental Capacity Act. I think that was the thing in the end that he didn't quite answer the specific questions to the satisfaction of the court and the parties involved, and also his view changed, which is absolutely fine. Obviously, you can change your view, but it was felt that there wasn't a satisfactory reasoning or explanation of that change, although they accept that opinions can change.

The key thing is, and I think the legal team for the people involved said, "We don't think one of the first principles of the Mental Capacity Act, i.e. everybody is presumed to have capacity until proven otherwise,” they felt that in this case, that the presumption of capacity hadn't been disproved or they used the word rebutted. That was one of the key things was that they felt the evidence produced wasn't satisfactory enough to rebut this presumption of capacity in the patient for these various decisions.

Oliver: You've put this box in the paper, box two which basically goes over the problems that the judge had with the expert evidence, which as you say, is essentially that it was not decision-specific enough and that basically, Dr X wasn't really explaining exactly what he’d said to the person, and what they said back and how that had led to his views. Is that a fair summary of the problem with the evidence?

Martin: Yes. They used the word— The expert evidence, I don't think the judge in the case was overly critical in the sense that the expert witness was very experienced, et cetera. It was probably just a culmination of contextual issues in the case, I guess. Then there was an issue that they tackled about whether the person involved, how well they did or didn't engage in any interviews. There's a comment about how the expert felt he’d hit a brick wall in his attempts to have a final interview with her. The judge actually makes helpful in his advice and guidance.

He says that's fine people can hit these brick walls, but you need to show what you did to try and overcome that. It may be insurmountable, but there are other ways around possibly for some people using various methods or different communication strategies, or seeing somebody at a different time or whatever. Again, I think the expert witness probably did hit a brick wall as it was called, but the judge wanted just a bit more information about that, how the expert witness tried to overcome it, I think.

Oliver: I think that's a very interesting point because this actually will probably be a situation that many psychiatrists have been in when attempting to assess somebody's capacity. Is that you feel that simply you can't engage the person well enough to actually make a decision. You can't necessarily get them to give you answers to questions that you want. That is an interesting point. In this case, what's happened, and this is in box three of your paper, is basically that the judge has actually released some guidance as to what their views are about what you should do.

This is specific to the Court of Protection, but what you should do when preparing a report. Maybe we just talk about those briefly so there's lots of interesting points being made here, but the basic summary, as far as I've understood, is that number one, you have to make sure that what you say is lined up with the Mental Capacity Act, number two you have you have to be specific, and then number three, which is point H here, there are some points about what to do if the person doesn't engage.

Martin: Yes. I'm just reading that box now and it's all contextual in the sense of how urgent these assessments are. I think this was a less urgent assessment as it were, and I think that the judge is again saying to quote part of that point H the expert might consider what further bespoke educational support can be given to promote their capacity or engagement in the decisions that may have to be taken on their behalf. Failure to this, again, is a “Failure to take steps to assist the person to engage or support indecision making would be contrary to the fundamental principles of the Mental Capacity Act.” That's section one, three, and section three, two.

You may end up concluding you can't get sufficient information from the patient, but again, it's about showing you're working out really, and so you might arrive at that conclusion, but it's just showing you're working out. I'm relatively old and I did A level maths back in the day, and I never truly looking back really understood what pure maths was all about, but I knew if I did the process and showed my workings out, I'd get 18 out of 20. I might have got the answer wrong by many millions but I knew if I did the process, I think that's all the judge is really saying here is show your workings out.

I think that was something that was picked up on there's an accompanying commentary to this paper. I think that was showing your workings out was commented on that, I think as well. I haven't read the full paper. I've only seen its like abstract, but I think that was something that they've picked up on as well.

Oliver: I suppose obviously any psychiatrist who's going to provide a report for the Court of Protection, this box is going to be extremely important for them to read and to take on board. How much of this advice do you think is generalisable to more day-to-day capacity assessments that a jobbing psychiatrist might be doing around the country?

Martin: Well, the Mental Capacity Act has been around for quite a while, about 2007 or so, that was when it came into play full time as it were. Part of the problem with the Mental Capacity Act is that people are doing this probably in old age psychiatry and many of the psychiatry jobs potentially on an hourly basis, but of course the Mental Capacity Act doesn't come with regular forms, as you would find in the Mental Health Act. I was only talking to my junior doctor yesterday about how can you give COVID medication in the community, and where you get your legal authority from etcetera, etcetera, and again it's the Mental Capacity Act.

I think do people write down section one principles applied, section two, section three, section four best interests, do they write it down, I doubt it. I try and I often write in my notes, U/R/U/W, understand, retain, use, and weigh, and communicate. I try and use that when I do my clinical notes, just to say, this is how I thought about it and it's connected to the mental disorder, because those are key things you have to have— you may lack capacity, but it has to be linked to a mental disorder, obviously. I think there are clear basics from applying the Mental Capacity Act, which come out of this paper, trying to think of things a bit more sequentially when you're doing it but whether— the emphasis was clearly on report writing.

Which again, interestingly, the second expert witness produced the report clearly took the guidance from the previous case, and they noted that his report, or his or her report, was very clearly set out, referred to detailed instructions, which you have to answer what they ask you. Recorded the fundamental principles of the MCA, demonstrated capacity was decision specific, etcetera, and applying specifically making it obvious what bits of the section three Mental Capacity Act, the understand, retain, use, weigh, etcetera.

The other thing that came out, it's good to illustrate some of your decision making by quoting what the patient or the person said to demonstrate and reinforce an opinion that you arrive at. They're not expecting a transcript of your whole interview. I think those things are very useful. They're useful for any report writing really, especially if it's about being structured and answering the question. The key learning points are definitely generalizable into regular daily practice, but I think the basics around report writing is also useful really.

Oliver: As you've said, I think there is a lot of generalizable stuff, but in terms of the specific case, as you said, what happened is basically that, so the judge said they needed to have a delay and they’re going to get an expert report, which you explained was deemed by the judge to be of a better quality. Something that interests me is that actually the way this ended up, is that at the time of the first hearing, this person was basically being treated as though they were incapacious about every single one of these decisions.

Actually, at the end of this whole process, I found it very interesting that the court decided that the person did have capacity to make decisions about a couple of things in there, which was engagement with other people and sexual relations. Actually, that's quite interesting to me that once this— I don't know if you know maybe the person's capacity was fluctuating, who knows what the clinical reality was given that this person had frontal temporal dementia and there was several years, I think, during which this process was carried out. It seems unlikely that clinical case would've improved all that much.

Martin: Probably several months or possibly a year or so.

Oliver: The first one was a couple of years before the second.

Martin: Well, then maybe yes, but I think it's capacities decision specific, isn't it? That's the classic thing just because you cannot make assumptions on how anybody looks or their diagnosis. The starting point is whatever that person has or is or whatever, the starting point is they have capacity to make that decision, and it's on the authority to prove otherwise. The interesting thing was that she lacked capacity to the second ones felt she lacked capacity to consent to marriage, but she did have capacity to make decisions around contact with others which was this other chap, and also to engage in sexual relations.

During this time, the sexual relations thing is completely another podcast or ten in itself because there's been a glut of case law refining the test of capacity for sexual relations. As they allude to in this case, there was another key, a key case came out, which adjusted the issue around capacity consent to sexual relations which I can't off the top of my head recall all the intricate detail. That was one of the triggers for asking for another report in this case was the test of capacity to consent to sexual relations been updated through another case and so they reapplied that to this case.

Then this case is a good case about how previous case law continues to influence future case law and that's how things evolve. Yes, and I thought the interesting thing in this case at the end it was like they wanted to try and enable this relationship between this lady and her male friend to the point that they could even live together. I think it was a good outcome for the person involved really.

Oliver: Yes, absolutely that is a positive outcome. Listen, Martin, thank you very much for joining us on the podcast. I think this is all we have time for today. I think this paper will be very worth our reading for any psychiatrist who's performing capacity assessments, which is just about any psychiatrist.

Martin: It reads as a slightly niche market with when I was writing it I appreciated it was a bit of a niche market for expert witnesses, but that one of the other things I brought out was Section 49 reports which are increasingly troublesome in terms of just completing them, etcetera. That's where this paper might be very helpful for clinicians having to do these Section 49 reports that are requested by the Court of Protection. Although it's a bit niche for the expert witnesses, it's actually more equally applicable as the judgment says for these Section 49 reports that are increasingly requested by the Court of Protection. That's where general jobbing psychiatrists may well find the advice in this paper helpful.

Oliver: Absolutely. Thank you very much for joining us. That was Dr Martin Curtis, and we were discussing his new paper, ‘The Court of Protection: expert witness and professional reports’, which is published in BJPsych Advances. Martin, thank you very much.

Martin: Thank you very much.

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Oliver Gale Grant: Hello, and welcome to another edition of the BJPsych Advances podcast. My name's Oliver Gale-Grant, and I'm joined today by Dr Mariana Pinto da Costa who is a consultant psychiatrist at South London and Maudsley Foundation Trust, and a senior lecturer at King's College, London. We're here to discuss her new paper in BJPsych Advances, ‘To triage, or not to triage? The history and evidence for this model of care in psychiatry’, which she's written with her colleagues Dhanya Salimkumar and James Gary Chivers. Mariana, thank you very much for joining us.

Mariana Pinto da Costa: Thanks for inviting me, Oliver.

Oliver: Your paper talks about the triage ward system of inpatient care and gives an overview of the history of this model, and then a discussion of some of the evidence of its pros and cons. Give us a brief summary of the main points of the paper.

Mariana: Yes, sure. Basically, this article reviews the history of triage wards, and also the principles and the evidence for this model. Which basically is that with relation to the length of stay, there is a shorter mean and median in the triage model, but this is not statistically significant. Then with relation to readmission rates, there was no difference in one year readmissions. Then finally with what concerns staff and patient satisfaction, we didn't find any difference in terms of patient satisfaction. That actually staff satisfaction in the locality wards where there was a triage system in place, the satisfaction was lower.

Oliver: That's interesting, so the staff satisfaction actually in the locality wards, so the downstream wards, I guess, where somebody would go from the triage ward was actually lower with the triage system?

Mariana: Basically, this paper is a overview of different other articles that have been published in this system. What we know is that actually there is little evidence comparing the triage model of care with the traditional inpatient model of care, and equally, the evidence that does exist hasn't been synthesized. I have been working in different triage wards in different parts of London together with two other colleagues, Dhanya Salimkumar and James Gary Chivers, we've put together this article in the expectation to also summarize the evidence that exists.

With relation to staff satisfaction, it's quite interesting, because the results are mixed. What we know is that in previous articles, it was found a worse burnout in the traditional model of care, but equally in the traditional model of care, there was better staff satisfaction. This is a bit unclear to unpick, why is this the case? Because you have worse burnout, but equally the satisfaction was better.

Oliver: It's a confusing result that doesn't seem to make sense. I guess we should have probably started before we jumped into talking about this with just giving a little overview of the triage model. I imagine that this is familiar to most psychiatrists. Basically what most people are talking about w#

hen they say a triage ward is a ward to which 100% of new admissions will go initially. Is there any other features that you think define a triage ward?

Mariana: Yes, so basically the term triage, in itself, it illustrates that the patients are assessed and prioritized according to needs. Triage wards were introduced as a new model in 2004 in Lewisham and then they were expanded to other parts of the country. They were created at a time that there were a lot of concerns with traditional inpatient care. Basically concerns about the quality of care, with patient satisfaction, a number of serious incidents, but equally staff burnout and high turnover of staff. There was, at that time, high rates of bed occupancy which led to delays in patient admission. This was the country around early 2000s.

It was also at that time that the NHS planned and mandated the rollout of more than 300 home treatment teams across the UK. This attempt to reduce hospital admissions and facilitate earlier discharges. It was under this context that the triage model was created. The idea was that patients were admitted for assessment, and then depending on the assessment, they were discharged to primary care, or to community mental health team, or to home treatment team, or if they required a longer admission, then they would be admitted to a locality ward. Normally the length of stay was, at this time, in the early 2000s, up to seven days, after which the patient was transferred.

The idea was that there would be a management plan started early on in patients' admission to reduce length of stay. The findings that we have was that actually, this was able to happen. The rates of occupancy were more optimal. They reduced to 70%, which means that then beds were more readily available to patients that needed to be admitted, either from emergency services that sometimes-- I can relate, people waiting for an admission when they are acutely unwell, but also from the community. That was the rationale when it was created. Then in 2014, this triage model was expanded at SLaM to three boroughs, so not only Lewisham where it started, but also Croydon, and Lambeth.

Oliver: You have obviously a feature of the triage ward which is that it's where people are coming to you first and that the goal is that you're going to triage the patient. You're to try and put them into the most appropriate follow-on service. Now, the other thing about the triage ward that you note here is that there was higher level of consultant availability on the triage ward than the locality wards. The idea was basically that they'd get to see a consultant when you arrive very quickly and that would speed up the time to take a decision about clinical care. Is that the main practical difference between how care is carried out on a triage ward to a traditional locality ward, or are there any other differences to how the actual model of inpatient care works on a triage ward?

Mariana: Yes. Well, first of all, let me go back to the early 2000s [laughs] because, I guess, there were a number of principles that were quite revolutionizing at that time, which included, for example, the use of information technology. In Lewisham in the early 2000s, there was a large screen where information about the patients was displayed everyday in MDT meetings. Everyone would have detailed access and information to the patient that was being discussed. Of course, now we're in 2022, so technology is used in clinical care. It's not that innovative and transformative as it was in the early 2000s, but that was something that was also a principle then.

One of the things that you were mentioning like a senior review after 24 hours of admission, was one of the core principles in the psychiatric triage model, which even included that there were two part-time consultants working at that time. This included a consultant review on Saturdays. This meant that decisions wouldn't be delayed, and equally at that time there was always a philosophy of an MDT approach with the involvement of social workers, but also of dual diagnosis professionals in the assessments. For example, if someone who was admitted in hospital who had a substance use disorder, then there was more rapidly the involvement of dual diagnosis professionals to screen out the aim of that admission to hospital and to facilitate discharge.

The other thing was there was a view that from day one of the admission, there was a discharge planning discussion, which meant that in some admissions, from very early on it was possible to map out a plan that that patient required a longer admission. Therefore it was clear from early on that the patient would need to be referred to a locality ward. Equally, some patients don't require long admissions, and sometimes admissions might be quite short and might be as a response to crises, in which case it was easier to assess them, but also to facilitate safe discharge early on.

Then the other thing which was still in the principles of a triage ward was the close involvement, but also the early involvement of care coordinators and community mental health teams so that patients could be rapidly, safely discharged back to the community. Finally, I guess, what I've mentioned earlier, the earlier involvement of home treatment team to facilitate early discharge from hospital because early treatment team officially is still within what we call acute care, but by allowing the patients go back to the community and sleep there, they have the support from the home treatment teams in terms of monitoring their mental health status or adherence to medication but they're not in hospital 24 hours. I think these were the core principles at that time, which were quite innovative and made that these type of service was implemented in other areas across the country and it still exists today in different parts.

Oliver: I think a lot of those things have probably now become fairly commonplace on every psychiatric ward. Ideas like early involvement of the community team, ideas like starting discharge planning on day one of admission. I think this is probably things that have spread to most inpatient models, I guess. I think most wards probably incorporate some of those things. I guess the next part of your paper is discussing the actual evidence for whether this triage model is more efficacious than traditional inpatient care. As you say, the research results here from preexisting studies are somewhat mixed.

Mariana: Yes. I guess in healthcare health services research, we do research on the efficacy of different services, but then why and how and when services are implemented in a certain way and there are several decisions that are down to decision-makers and policy makers and sometimes they are taken also to respond to pressure that exists. I think there has been a time that there were questions around the effectiveness of the triage model of care, but equally what we found in the summary is that the research that was conducted on this type of services show that it's at least as good, if not better, than the traditional model.

Of course, this require resources. One of the things that was described in this triage model was that there was a senior review within 24 hours of admission and even these days, there's a lot of discussions around what happens over the weekends and what type of professionals can work over the weekends and whether if you would hire more staff to work over the weekends whether that would make any change in terms of length of stay and discharges.

These are discussions that are happening today and they are behind this paper, but what we have done having worked the three of us, the three co-authors, in this type of service as a triage model was basically to summarize and synthesize the evidence that exists of other researchers and clinicians that have worked and have studied this model of care and to show and to remind people that the evidence that exist is that triage wards are at least as good if not better than the traditional model.

For example, I think there are two parts that I think these days is important while highlight, which was triage models enable higher rates of rapid discharge with a greater proportion of acute care than performed in the community with the support of home treatment teams. I really want to emphasize how important home treatment teams are to have these services operating, but equally the triage model has enabled to a lower bed occupancy, which I think these days is very, very important because we see in the news there are many patients in A&E and many people waiting for psychiatry bed.

There have been a number of articles in the media reporting this and triage model did allow a lower bed occupancy by more rapidly screening patients that would require longer admission and might be treatment resistant. By seeing their story, trying to signpost the best pathway and the best care plan, but equally those patients that do not require a hospital admission to safely engage them to resources and community services that can continue to support them in the community. By doing that, by allowing another bed for a patient that requires other type of admission. Finally, also to avoid that patient just stay a lot of time in A&E unwell waiting for a bed.

Oliver: I suppose the patient outcomes are as you say, at least not worse and possibly they're better. The other angle, of course, is the staff experience. You go over in your paper a little bit here that basically you have some changes in staff experience in the whole system when you triage model which basically is actually staff satisfaction reduces in the downstream wards, in the locality wards. I find that's quite an interesting observation that's maybe different to my own personal experience. What do you think about that?

Mariana: I guess that's an interesting point. I can only speculate, but I guess one potential explanation would be that then patients that might require more support from social services, for example, or might be treatment resistant, then stay for longer periods in the locality wards. Then they might even delay further the discharge of these patients that for a number of reasons, their admission might be more complicated. That could be a reason to explain why staff then become more demoralised.

Oliver: I suppose, yes. It’s obvious, isn’t it really that if you have a triage model in place, you’re going to have the most acutely unwell patients probably going to be on the triage ward. Therefore people that come to the other wards as you say, are going to have a lower level of acuity, but you may then collect patients that for some reason can’t be discharged.

I suppose something that I’ve observed and I guess a lot of people listening would’ve observed is that when you work in a hospital that has a triage ward on the way in, it does change the character of the other wards to be people who have, as you say, a low level of acuity but maybe some other need, but, of course, it also just change the character of the triage wards that’s going to have a higher level of acuity. I think you can see that in some of the staff statistics you quote here. I think you get a higher rates of sickness amongst staff on the triage ward. Is that correct?

Mariana: Yes. First of all, one of the things that we say that more research is needed is actually around the number and difference on serious incidents between triage wards and locality wards. However, there was a paper by Hayes et al. in 2012 and they reviewed the data from admissions on active assessments in North London and they found no significant differences in incidents of verbal or physical aggression in comparison with data gathered previously in psychiatric wards in the city,128 studies.

Of course, this is only one example and more research is needed also because there is these reports from staff and people that might be listening to us that have worked in the past in triage wards. Everyone is aware that there are a number of patients that might be acutely unwell and when they are together, that can lead to a number of potential challenges in managing situations. Equally, the research that has been done looking at least on the differences in incidents in terms of verbal and physical aggression, didn’t find any difference.

Oliver: Actually, maybe as you say, it’s not really the case that you necessarily have a worse experience of adverse events on the triage ward. You finish your paper with this question of to triage or not to triage and you go over the pros and cons there. If you were to start a new psychiatric hospital tomorrow, would you start it with a triage ward or without one?

Mariana: That’s a very good question. I guess there are pros and cons. I personally think that services that have the principles of the triage they’re good to both avoid admissions, but equally to support patients that might not require an admission, but they still need support because when we say to avoid admissions, I think it captures a lot of things. It might be that also different hospitals and different services and different teams have different thresholds or even sometimes criteria of admission.

That does not mean that these people that go to any or that go to services or sometimes our services are alerted about them need support. I think we really need to provide support to people that have mental illness or are acutely unwell and are sent to services. Now, there are a number of services that can be available in the community and I think the more resources that we have in the community from assertive outreach teams or services that are sometimes 24/7 available to respond to patients needs in the community. They might also help to diminish this need for inpatient admission because inpatient admissions is always linked with what are the services available.

Sometimes if there are less services available in the community, then this forces that more patients are sent and referred to hospital to be admitted. I think it’s important to have triages that help out to differentiate how we can best support that person. In some cases, it might be through a long admission, for a number of things like changing medication that can be done in the community or providing a safe space when patients are presenting high risk to self and others or from others.

Equally, to triage the situations that we can safely discharge patients rapidly to the best service that can support them in the community. I think triage services should exist, but equally more services in the community that can support patients to be better included in the community.

Oliver: Well, I think most people would definitely agree with you on that final point. Mariana, thank you so much for joining us. That was Dr Mariana Pinto da Costa. We were discussing her new paper, ‘To triage or not to triage? The history and evidence for this model of care in psychiatry’, which is published in BJPsych Advances with her colleagues Dhanya Salimkumar and James Gary Chivers. Mariana, thank you very much.

Thank you for listening to this BJPsych Advances Podcast. For the latest updates, follow us on Twitter @TheBJPsych. To listen to more podcasts from the BJPsych Journal portfolio, visit us on SoundCloud or search for us online.

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Oliver Gale-Grant: Hello, and welcome to another edition of the BJPsych Advances Podcast. My name is Oliver Gale-Grant. Today I'm joined by Dr Hemant Bhargav, an assistant professor of yoga in the Department of Integrative Medicine at the National Institute of Mental Health and Neurosciences (NIMHANS) in India, and Dr Shivarama Varambally, who is a professor of psychiatry and head of the Department of Integrative Medicine at the National Institute of Mental Health and Neuroscience in India.

We're here to discuss their new paper in BJPsych Advances, ‘Yoga and mental health: what every psychiatrist needs to know’, which is also written with their colleague Dr Sanju George. Hemant and Shivarama thank you so much for joining me.

Dr Shivarama Varambally: Thank you for inviting us here.

Oliver: This is a fascinating article that covers the topic that I think most people in the UK will be aware of but will have very little knowledge about, which is yoga, and specifically yoga as a mental health intervention. Give us a quick summary of what the paper covers.

Dr Shivarama: This paper is trying to put maybe the work of the last 10 years at the NIMHANS Integrated Centre for Yoga together. Although NIMHANS is an institute that really has three major departments that is psychiatry, neurology and neurosurgery, much of the yoga work has been done in psychiatry. After 10 years, we feel we have reasonable understanding of what yoga can offer the various patients suffering from various psychiatric disorders.

We thought we put it together in a paper, which is easy to understand by most clinical psychiatrists because if you do a meta-analysis of something, for example, many times it loses the meaning when you look up 20 articles and put it together. We thought we'll put it together, and Hemant here, he's not a psychiatrist. He's a doctor with a specialization in yoga. He has been working in the last maybe seven or eight years with us looking at what are the different yoga practices, which may be good, and some, which may not be good in particular psychiatric disorder.

This paper essentially aims at putting this knowledge together, so a psychiatrist sitting in a community clinic or a city centre, for example, is faced with the patient, what yoga could offer that patient.

Dr Hemant Bhargav: Considering that yoga in the evidence base, you will see that the papers in the field yoga and psychiatry, each paper you see that a yoga intervention is different. There is a need for standardization of the intervention for specific conditions. With our clinical experience of over a decade now, we have come to a kind understanding. Basically, we followed a procedure through which we scientifically developed and then validated these yoga modules in specific clinical populations.

Then a one-hour module was developed. When we applied this in our OPD and IPD setup, we found that specific yoga practices could be more emphasising a particular disorder, and some yoga practices may be detrimental for the patients. Based on this clinical evidence and around 50-60 papers that we have published in this area, we could come up with this article. That is very handy for a psychiatrist. If a psychiatrist just reads this article, in his clinics, he will get accustomed to some useful yoga practices that he can prescribe to patients suffering from specific psychiatric conditions.

Oliver: It's a very interesting topic, which as you say, this paper gives a great overview. Now, I think an average psychiatrist in England is probably quite unaware of yoga beyond the idea of yoga as a form maybe of exercise. I certainly think that probably no one in England would've prescribed yoga to a psychiatric patient. Maybe we can go over quickly some of the evidence base because it actually seems quite strong. Maybe we start with depression. It looks like yoga is actually quite an effective intervention for depression.

Dr Shivarama: Yes. It's interesting you said that, Oliver, because if you look at guidelines around the world, one of the few guidelines which has added yoga in the treatment of, for example, Schizophrenia is the NICE guidelines in the UK. Even in Indian guidelines, it's still not there, but in the UK it's already there. The NICE guidelines for Schizophrenia in 2014 added yoga as one of the complementary interventions alongside exercise and other physical interventions based primarily, [00:04:52 Dr Bhargav: we have quoted this in the paper also], primarily based on two research studies from NIMHANS. Right now, as you pointed out, the best evidence possibly is in depression.

There are multiple studies of yoga initially as an add-on treatment, and recently as a sole treatment. There are almost to now three or four studies where yoga has been used by itself without medication as a treatment. Of course keep in mind the ethical concerns it would be done usually in mild-moderate cases, not very severe depression. Again, the first two studies to do that are both from outside of India. I think both are from the US, which are published. One is done on what we call Iyengar yoga. Another one has used some other form of yoga.

As Hemant was saying, one of the biggest problems in yoga research is what does yoga mean? When you say “yoga is good for depression”, what does it mean? Is all yoga good for depression? Definitely not. This is unlike medicine where we say, "Okay, Escitalopram in 10mg or 20mg is good for depression." Yoga, there is no such standardisation, and that's some of the things that we pointed out in this paper. Also, that when you say yoga, even papers which are published say, "Okay, yoga help patients with depression." Now, what is it yoga? We don't know. In fact, the earlier studies did not publish the yoga itself. They said, "Okay, we have done some yoga."

Now we have come to a stage where we have to say, "What is it that we're doing? How long were we doing it for? How often do we do it in a week? How long does the patient have to do it to get any useful benefits?" That's what we tried to cover. You, Hemant has been working in the area of substance abuse. For example, opioid addiction is something again that yoga has shown some benefit. I don't know the yoga well that much in this paper, maybe you could say something on that Hemant.

Dr Hemant Bhargav: Yes. I have been working in the area of opioid use disorder and application of yoga. Here at NIMHANS, we have a dedicated Centre for Addiction Medicine. Our department of Integrative Medicine works in collaboration with that. In this particular paper, we have looked at only the systematic reviews and meta-analysis as the evidence. Recently, we have published a couple of case series in this area of yoga and opioid use disorder. There are two papers. One is a randomised controlled trial that shows that six-month of yoga improves the quality of life that was published from Centre for Addiction Medicine.

I have published in this same paper where we actually describe the whole process of developing yoga module for this condition and then testing its feasibility on some 10 subjects. We also measured endorphin levels in these subjects, and we could demonstrate that regular yoga practice in a period of one month was able to enhance their endorphin levels. It means that you may know that opioids are exogenous opioids and the endorphins are endogenous opioids. What is happening is that with yoga, there is something happening in the immune system. The brain is able to generate more endogenous opioids, so the dependence on exogenous opioids is coming down.

That paper is under review where we have found that yoga actually in [unintelligible 00:08:32] reduce their pain and enhance the quality of life, and enhance endorphin levels. To answer your original question, if you ask me where are the places in which yoga would be applicable right now with the current evidence? Depression is definitely at the top. Schizophrenia as an add-on treatment. There's fairly reasonably good level of evidence. Anxiety disorders, again, quite good evidence. Cognitive decline in the elderly. There's quite a lot of good evidence to show that six months or more of yoga can really produce cognitive improvement and even produce physical changes in the brain, particularly the meditative techniques. Depression, Schizophrenia, cognitive problems in the elderly, somatisation problems, and substance use would be the five disorders that I would fairly confidently say that yoga has a good role.

Oliver: The evidence you're talking about here is actually mostly randomised controlled trials, isn't it?

Dr Hemant: Yes. Of course, in the last five years that is before that, they tended to be case series because the people who really were doing the yoga research, were not really aware of the research methodology in that degree of detail. Now, happily, around the world, there are a lot of people who are very good at research methodology doing work on yoga.

Oliver: Something that we should come on to speak about is what you mentioned at the start, Hemant, which is this idea that obviously yoga is a very broad field and that you need to do specific things for specific treatments. Just tell me, how do you go about deciding what the right form of yoga is for a certain condition or patient group?

Dr Shivarama: Oliver, this is a very interesting question and we have been trying to search answer to this question through systematic research in the last decade. So far, our understanding shows that there is a definite biological basis through which various yogi practices work. For example, if you look at the work in the area of neurophysiology, it now has been demonstrated very well that selective nostril breathing through each side, right nostril breathing, or left nostril breathing has differential effects on the neurophysiology.

For example, the number of trials have demonstrated that if you breathe in and out only through the right nostril, there is activation of the sympathetic nervous system. Whereas when you do that with the left, there is a parasympathetic activation. This has been applied systematically by Shannahoff-Khalsa in his researches on OCD patients also, where he could suggest some connection of the nostril breathing with the activation of specific areas in the brain.

Through SNRI studies also, it has been observed that selective nostril breathing has activating effect on the PFC of the contralateral hemisphere or the cerebral rhythms are correlating with the nasal rhythms so based on these kinds of mechanisms. Now, in the ancient yogic texts also, there has been a mentioned that right nostril breathing is called as the sun channel breathing, whereas the left nostril breathing is called as the moon channel breathing.

We did not know what it means scientifically, but when we did research, we understood that sun-channel breathing actually means sympathetic system activity in breathing, whereas the moon channel breathing means parasympathetic system activity in breathing. In this way, therefore, with the anxiety-related issues where there is sympathetic overactivation, selective left nostril breathing will have a cooling and calming effect.

Therefore, in OCD module and in the anxiety module, you see that this kind of left nostril breathing practices are emphasized. Similarly, the humming breath has a calming and relaxing effect on the brain. It internalizes the consciousness. We have also done a research where om chanting produce limbic deactivation. Limbic deactivation is a procedure that is used to treat depression also.

You stimulate the auricular branch of the agus nerve by electrical stimulation through the ears. This is used for treating depression. In our research, we found similar effect could be produced by chanting the sound om, the Vedic sound om. Therefore, it can be used as a non-invasive neuro-modulation technique. This is the approach. I have given you an example. This is a very interesting thing the om chanting or the humming breathing because we have been able to really nicely show that the blood flow in the brain changes quite dramatically.

It need not be om, because om, many people think is a Hindu religious symbol or whatever. The important point is the sound mmm. It could be amen. It could be amin. It doesn't really matter. What seems to happen is that when you do that, the blood flow to what we call as the limbic region of the brain, which is the most primitive region, which controls a lot of our negative emotional responses, like anger, greed, and that kind of thing, the blood flow comes down. That's very interesting. It has been done in perfectly normal people. I am not talking about patients here.

In response to your question, how do we go about selecting? What we do is we, let's take depression as an example. We look at examples which look like depression in the yogic texts. For example, what is called Vishada. Vishada essentially means depression in Sanskrit. There are some of the ancient texts like the Bhagavad Gita, for example, or other yogic texts talk about what are the characteristics of Vishada, what happens? The person bends down. The person looking down. Person is crying. These are all given there.

They say for this, what is the yoga that should be done. Then we pick up some of the yoga things. We make it into some kind of a practical module. Then we go to experts who are actually using this every day in their practice to treat patients. We say, "Look, is this module you think okay? Is this fine?" Then they say a few suggestions, at least 10 or 20 experts, we take suggestions. We refine the module, and then we come up with the practical 45-minute package if you want to call it that , which we then proceed to test in a randomised clinical trial. This is the methodology we have followed, and we have now developed such, what we call as validated modules for around eight disorders in neuropsychiatry.

Oliver: Are these validated modules publicly accessible? Can anyone look at these?

Dr Shivarama: Oh, yes. Most of them are published and the publications are available in the— Our website also has all these papers, actually. Many of them are published in the Indian Journal of Psychiatry, which is the national Psychiatry journal of India. Say, for example, we did that for depression, Schizophrenia, cognitive problems in the elderly, obsessive-compulsive disorder, somatization disorder, epilepsy, opioid use disorder. Anybody around the world who has a basic yoga training should be able to teach this yoga.

Oliver: This is the next question I was going to ask, which is that, I'm sure actually lots of psychiatrists in England when they listen to this podcast and read your paper. I'm sure they'd love their patients to do yoga. Of course, the difficulty is that there's not many people in England working in the mental health field that have any yoga experience. To what extent do you think an individual suffering from one of these conditions would be able to self-guide? Do you need a yoga expert to teach these modules or are these things you could do by yourself?

Dr Shivarama: Very unlikely. We wouldn't recommend it because the central part of yoga actually is breathing. When to breathe in and when to breathe out while doing the various practices is the core of yoga. That is what, unfortunately, many of the yoga studios, it's become like a cardio workout. You're doing yoga very fast or in a manner, which maybe helps the body but it really doesn't take care of the mind. Mindfulness component and the breathing linking component is not being given, but in fact, that's the core of you.

In fact, there's a very interesting paper that we have published, I think, in 2016, in the International Review of Psychiatry, which compares yoga and physical exercise. That's a very, very interesting paper, which talks about, what are the differences. A lot of the physiological changes are actually quite the opposite when you do yoga. I would recommend that the first, maybe five, six sessions if you can find a yoga therapist, after that, you should be able to do it yourself.

Oliver: I suppose you do, as you say, need to have someone that has the experience to teach those first [crosstalk].

Dr Shivaram: I think so. Although to qualify that statement, the yoga practices that we recommend for most psychiatric disorders are fairly similar. You could hang online and start to teach you the practice. It's still okay.

Oliver: I was going to ask about the potential of using it online, because I don't know how it's been in India, but in England, still a lot of psychiatric care is taking place online. Have you had any success with doing yoga teaching online?

Dr Shivarama: Oh, yes. During the COVID-19 pandemic, our clinical services we have to experiment this. This is a positive thing that has come out of the pandemic. Most of our sessions, they are usually the routine was that a new patient is referred to our yoga services. Then our trained yoga therapists teach them seven sessions, which are supervised. After that, we share a video of that practice with them and tell them to continue practicing at home. This was our usual routine.

Then during the pandemic, patients could not come to our yoga centre for these supervised sessions. Therefore, what we did was when they were coming to our centre, just the one session; we taught them in a supervised way and told them about the practices. Then from the next session onwards, we shifted them on Zoom platform. We started almost all other sessions, Schizophrenia, depression, substance use, everything was going on an online mode throughout the pandemic.

To our surprise, we expected that people would find it very difficult and there will be a lot of dropout, but fairly large number of people were able to adhere to those yoga practices. In fact, one of the barriers in one of our study, we found that to maintain yoga for a long time, one of the barrier was to travel a distance between the centre and the residence of the patient. That barrier we were able to overcome.

In fact, in many of our researches after that, we wrote an amendment to Ethics Committee and added tele-yoga component because we found that it has enhanced the adherence to yoga services. In fact, we are running a online yoga course for the public for the last, almost more than two years now, every day. There are 50, 60 people every day come. These are sessions for stress management and well-being. Anybody can log in, is our website where all our publications and Zoom ID for these sessions are available.

Oliver: That's fantastic. Just before we finish, talk to me briefly about your service because you are running a very large tertiary yoga service, as you say. Just talk us through a little bit how that service has come about.

Dr Shivarama: NIMHANS as some people would know is a tertiary psychiatry and neurology institute. Yoga research has been going on here since the 1970s, but it was purely research. In 2007, we started the first clinical yoga service and the NIMHANS Integrated Center for Yoga was set up with a grant from the Ayush Ministry, which is a ministry in the government of India which looks after what are called the complementary systems of medicine, Ayurveda, yoga, Unani, Siddha, homeopathy, and all these things. We ran it for five years in a project mode.

Then you are able to show enough evidence to convince the government to set up a proper yoga centre as a part of NIMHANS. From 2014, we have been running it as a part of the Institute. In 2019, the Department of Integrative Medicine of set, which integrates yoga, Ayurveda, and modern biomedicine together. We now have a 30-bed hospital where we admit patients for Ayurveda and yoga interventions. We also have outpatient three days a week. It's now a properly integrated centre. Say, for example, a patient comes with depression. They would come to NIMHANS and they would see, "Okay, I can go to the psychiatric department. I can go for counselling to the psychology department.

I can also go to the integrative medicine department for Ayurveda and yoga." Then they would come and see Hemant or one of the other people. They can take all the treatments or one of the treatments as they choose. Oliver, here, one important point is that in this Department of Integrative Medicine, all the three consultants, a consultant from the field of yoga, from the field of Ayurveda, and from the field of psychiatry sit together in one chamber and they see a patient together.

When the patient enters, all the three doctors see the patient together. This is one of a model that we have developed in this institute. Usually, in India what happens is if you have to meet a psychiatrist, you take a separate appointment even in the same hospital. You have to meet with a physician, and then you have to go to a yoga physician. Then what happens is that there is no communication between those physicians between each other. Sometimes the advice they give is also contradicting, the patient gets confused. It is also time consuming for the patient. They also paid three times.


Dr Shivarama: In this way, there is a crosstalk between the modern and the traditional systems of medicine that we are encouraging. We see that patient satisfaction also has improved with that. We hope that in the future, just like you have a nurse, you have a physiotherapist, you have occupational therapist in most psychiatric hospitals anywhere in the world, you would ultimately have one yoga-trained person in all psychiatric hospitals. It's already become a reality in many hospitals in India. Even private, I'm not even talking about government. I also know that there are similar systems in Japan, for example. The big psychiatric hospitals all have a yoga therapist appointed as part of the hospital staff.

I hope this will become a reality because the research has gone in the reverse direction. Usually, what it does, we start with the most severe cases. Yoga actually would be most useful to the milder cases to prevent them becoming psychiatric patients. If that has to happen, then it has to get into the community setup. In India, I think it's on the way. The government is setting up what I've called us wellness centres throughout the country. I hope this would be a model that can be followed throughout the world.

Oliver: I think the evidence it presented in your paper is very good, is very robust. I think there's always a desire psychiatrist worldwide to have non-drug options available, especially things that can be delivered with minimal intervention, with a small number of interventions from an expert followed by a lot of self-led care. I think this is something that's going to interest a lot of people.

I was joined today by Dr Hemant Bhargav and Dr Shivarama Varambally. We've been discussing their new paper, ‘Yoga and mental health: what every psychiatrist needs to know’, co-authored with their colleague Dr Sanju George, published in BJPsych Advances. Hemant and Shivarama, thank you very much for joining me.



Thank you for listening to this BJPsych Advances Podcast. For the latest updates, follow us on Twitter @TheBJPsych. To listen to more podcasts from the BJPsych Journal portfolio, visit us on SoundCloud or search for us online.

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