CONTENTS. Advisory Board, Associate Editors, Reviewers and Editorial Board Members iii-v

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1 CONTENTS Advisory Board, Associate Editors, Reviewers and Editorial Board Members iii-v Information and Guideline for Authors Original Paper The Effect Of Depressive Disorders On Compliance Among Hypertensive Patients Undergoing Pharmacotherapy Norzila Zakaria... Azlin Baharudin... Rosdinom Razali... Designing A Culture, Language And Illness- Specific Self-Esteem Scale In Bahasa Malaysia Shamshunnisah Abu Bakar... Hasanah Che Ismail... Quality Of Life Among Preinvasive & Invasive Cervical Cancer In Malaysia Metabolic Syndrome In Psychiatric Patients With Primary Psychotic And Mood Disorders Sharifa Ezat Wan Puteh... Syed Mohamed Aljunid..., Paul Ng... Rushdan Mohd Nor... Metabolic Syndrome In Psychiatric Patients With Primary Psychotic And Mood Disorders Abdul Hamid Abdul Rahman... Holifa Saheera Asmara... Azlin Baharudin... Hatta Sidi vi Identifying Depression Among The Human Immunodeficiency Virus (HIV) Patients In University Malaya Medical Centre, Kuala Lumpur, Malaysia Tung Mun Yee... Mary Lee Hong Gee... Ng Chong Guan... John Tan Jin Teong... Adeeba Kamarulzaman Outpatient Drug Prescribing Pattern For Bipolar Disorder Patients In Southern Thailand Pichet Udomratn Verbal Memory Test Performance in Patients with Bipolar I Disorder Attending A Psychiatric Clinic of A University Hospital in Kuala Lumpur, Malaysia Normala Ibrahim... Abdul Hamid Abdul Rahman, Shamsul Azhar Shah..., Depression And Coping Strategies Among Sexually Abused Children In A Malay Community In Malaysia Rohayah Husain... Rosliwati Md Yusoff... Mohd Jamil Yaacob... Zaharah Sulaiman Short Report Patient Satisfaction with Psychiatric Case Management in Singapore Margaret Mary Hendricks Rathi Mahendran i

2 Carers As Teachers Raynuha Mahadevan Loh Sit Fong Aishvarya Sinniah Ruzanna Zamzam Marhani Midin Wan Salwina Wan Ismail Case Report Comorbid Charles Bonnet Syndrome In Tourette Disorder: A Case Report T..Maniam... AKanni Renganathan... Norzila Zakaria... Mohd Jamil Yaacob... Van Rostenberghe Hans Review Article Varenicline - A New Pharmacotherapy For Smoking Cessation: Implication For Smokers With Mental Health Problems Noor Zurani Md Haris Robson... Rusdi Abdul Rashid... Muhammad Muhsin Ahmad Zahari... Mohammad Hussain Habil Opinion The Effectiveness Of Paliperidone For Adolescents With Atypical Presentation Of Bipolar Disorder In Manic Phase: A Case Report Lessons To Be Learned: The Margaret Mead s Bali Experience Denny Thong ii

3 Advisory Board, Associate Editors, Reviewers and Editorial Board Members Advisory Board Mohamad Hussain Habil, MBBS. President of the ASEAN Federation for Psychiatry and Mental Health Felicitas Artiaga-Soriano, MD. President of the Philippines Psychiatric Association Hong Choon Chua, MBBS. Pichet Udomratn, MD. Syamsul Hadi, MD. Yen Teck Hoe, MD. President of the Singapore Psychiatric Association President of the Psychiatric Association of Thailand President of the Indonesian Psychiatric Association President of the Malaysian Psychiatric Association Chief Editor Hatta Sidi MBBS MMed DipSCH Co-Editor Marhani Midin, MBBS MMed Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Center Cheras, Kuala Lumpur, Malaysia Tel: ; Fax: Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Center Cheras, Kuala Lumpur, Malaysia Tel: ; Fax: Associate Editors Marhani Midin, MMed (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur ) Mohamad Hussein Habil, MPM Mohd Najib Alwi, MRCPsych (University Malaya Medical Center, Kuala Lumpur ) (Cyberjaya University College of Medical Sciences, Cyberjaya, Selangor) Rusdi Abd Rashid, MPM (University Malaya Medical Center, Kuala Lumpur ) NoorZuraida Zainal, MPM (University Malaya Medical Center, Kuala Lumpur ) Ruzanna Zam Zam, MMed (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur ) Salina Abdul Aziz, MMed (Ministry of Health, Kuala Lumpur, Malaysia) Tuti Iryani Daud, MMed (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur ) iii

4 Reviewers Marhani Midin, MMed Mohamad Hussein Habil, MPM Mohd Najib Alwi, MRCPsych Nik Ruzyanei Nik Jaafar, MMed NoorZuraida Zainal, MPM Ramli Musa, MMed Rusdi Abd Rashid, MPM Ruzanna Zam Zam, MMed Salina Abdul Aziz, MMed T Maniam, MPM Tuti Iryani Daud, MMed Wan Salwina Wan Ismail, MMed (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur) (University Malaya Medical Center, Kuala Lumpur) (Cyberjaya University College of Medical Sciences, Cyberjaya, Selangor) (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur) (University Malaya Medical Center, Kuala Lumpur) (International Islamic University of Malaysia, Kuantan, Pahang) (University Malaya Medical Center, Kuala Lumpur) (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur) (Ministry of Health, Kuala Lumpur, Malaysia) (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur) (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur) (Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur) Editorial Board Members Suwanna Arunpongpaisal, MD. Siow-Ann Chong, MBBS. Irmansyah, MD. Philip George Joseph, MMed Thawatchai Leelahanaj, MD. Manote Lotrakul, MD. Benchaluk Maneeton, MD. (Khon Khen University, Khon Khen, Thailand) (Institute of Mental Health, Singapore) (University of Indonesia, Jakarta, Indonesia) (International Medical University, Seremban, Malaysia) (Phramongkutklao Hospital, Bangkok, Thailand) (Ramathibodi Hospital, Mahidol University, Bangkok, Thailand) (Chiang Mai University, Chiang Mai, Thailand) Dinah Pacquing-Nadera, MD, MSc, (Philippine Psychiatric Association,, Quezon City, iv

5 DPBP. Wetid Pratoomsri, MD. Atapol Sughondhabirom, MD. Pramote Sukanich, MD. Tinakorn Wongpakaran, MD. Philippines) (Chachoengsao Hospital, Chachoengsao, Thailand) (Chulalongkorn University, Bangkok, Thailand) (Ramathibodi Hospital, Mahidol University, Bangkok, Thailand) (Chiang Mai University, Chiang Mai, Thailand) The ASEAN Journal of Psychiatry is a peer-reviewed psychiatric and mental health journal published twice a year by the ASEAN Federation for Psychiatry and Mental Health. The journal aims to provide psychiatrists and mental health professionals with continuing education in basic and clinical science to support informed clinical decisions. Its print version is sent to all members of the Psychiatric Associations of Indonesia, Malaysia, The Philippines, Singapore, and Thailand. Unless clearly specified, all articles published represent the opinions of the authors and do not reflect the official policy of the AFPMH. The publisher can not accept responsibility for the correctness or accuracy of the advertisers text and/or claims or opinions expressed. The appearance of the advertisement in this journal does not necessarily constitute an approval or endorsement by the AFPMH. Advertisements are accepted through the Editorial Committee and are subject to approval by the Editor. v

6 Information for Authors manuscript submissions to the Editor, The ASEAN Journal of Psychiatry at the following address: Hatta Sidi MBBS MMed DipSHC. Chief Editor, ASEAN Journal of Psychiatry ( ) Professor of Psychiatry, Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Center (UKMC) Cheras, Kuala Lumpur, Malaysia. ( vi

7 ORIGINAL ARTICLE THE EFFECT OF DEPRESSIVE DISORDERS ON COMPLIANCE AMONG HYPERTENSIVE PATIENTS UNDERGOING PHARMACOTHERAPY Norzila Zakaria*, Azlin Baharudin**, Rosdinom Razali** *Department of Psychiatry, Universiti Sains Malaysia (USM), Health Campus, Kubang Kerian, Kelantan ** Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur. Abstract Objective: To study the effect of depressive disorders, severity of depression and, sociodemographic factors on drug compliance among hypertensive patients at primary care clinics. Methods: A total of 201 hypertensive patients on treatment for at least 3 months who attended the HUKM Primary Care Clinic and Salak Polyclinic were selected for this study. Patients were screened for depressive disorders using the Hospital Anxiety Depression Scale (HADS) and those who scored 8 and more were further interviewed to establish a diagnosis using the Mini International Neuropsychiatric Interview (MINI). Patients who were diagnosed to have depressive disorders were further rated for the severity of the illness by using Hamilton Rating Scale for Depression (HAMD). Drug compliance was assessed during a 2 month follow up using the pill counting method (ratio considered as compliant). Results: The prevalence of non-compliance among hypertensive patients was 38.3%. There was no association between the diagnosis of depressive disorders and drug compliance. Among the 12 patients who had depressive disorders, severity of depression as rated by HAMD, showed significant association with drug compliance (Mann-Whitney test z = , p<0.05).conclusion: The results suggested that severity of depression has significant association with poor compliance to medical treatment. It is therefore very important to identify and treat depression to avoid poor drug compliance and further complications related to hypertension. ASEAN Journal of Psychiatry, Vol.10 (2): July Dec 2009: Keywords: depression, compliance, hypertensive patients 89

8 Introduction Hypertension is known to be the most important risk factor for cardiovascular morbidity. In Malaysia, hypertension is ranked as the first in the list of the 10 leading causes of hospitalization [1]. In contrast, compliance to treatment among hypertensive patient is poor. A local study on drug compliance in hypertensive patients using the pillcounting method showed that a prevalence of non-compliance with medication of 26% [2]. One of the known factors associated with poor compliance with antihypertensive medication was depression [3] and scientific studies have examined the relation between them [4]. However it has also been proposed that hypertension itself is a risk factor for depression [5-7]. In Malaysia, neurotic depression (3.31%) is the most common psychiatric diagnosis [8] and the prevalence of emotional disorders is 15.2% [9]. This indicates clearly that hypertensive patients who are suffering from depressive illness are at a higher risk to develop cardiovascular disease. All medical professionals should take extra caution to prevent lethal complication by treating hypertension and depression properly. The objective of this study is to examine the effects of depression on compliance among hypertensive patients undergoing pharmacotherapy and to look for any modifiable factors needed to deal with the compliance problems. Methods This study was part of an Intensified Research in Priorities Areas (IRPA) project entitled To identify the psychosocial factors of non-compliance among patients with hypertension undergoing pharmacotherapy. This study was conducted at 2 centers i.e: the Primary Care Clinic of HUKM in Bandar Tasik Selatan and Salak Polyclinic, in Sepang. The study was conducted from the beginning of June 2004 to the end of December 2004.This was a cross sectional study and study subject were selected using the universal sampling. The estimated sample size was calculated using the PS software (Dupont & Plummer, 1997), based on comparing two proportions to detect the difference of 24% in prevalence (P 1 -P 0 ) with 80% power and alpha A total of 196 subjects were needed for this study. Inclusion criteria includes patients aged 40 years and above who had been diagnosed to have Essential Hypertension, must be on antihypertensive medication for at least 3 months prior to the study, can read and write, and able to converse in English or the Malay language. Patients must give written informed consent for enrollment in this study. Exclusion criteria included pregnancy, secondary hypertension, renal impairment (serum creatinine > 125 mmol/l) within the last 6 months of recruitment date, impaired liver function tests (> 3 times the upper limit of normal range), concomitant medical diseases (diabetes mellitus, ischaemic heart disease, congestive cardiac failure, cerebrovascular accidents, bronchial asthma and chronic obstructive pulmonary disease) and blood pressure of 200/120 mmhg or more. This study embraced a two-stage caseidentification process in which a screening procedure was followed by a 90

9 diagnostic interview. All hypertensive patients who fulfilled the inclusion criteria were offered to join the study with written informed consent taken. The initial samples were screened for depression using the self rated Hospital Anxiety Depression Scale (HADS) [10] and only a sub-sample (those who had HADS score >8) received the full diagnostic interview using Mini International Neuropsychiatric Interview (M.I.N.I) [11]. The administration of M.I.N.I was done by two trained psychiatric doctors. Those with depression would further undergo severity rating using Hamilton Rating Scale for Depression (HAM-D) [12]. Flow chart of the study procedure All patients participated in IRPA project were given all questionnaires including HADS Score 8 or > on HADS Score <8 on HADS MINI DEPRESSIVE DISORDER HAM-D Compliance / non-compliance at 2 months follow up 91

10 Compliance to treatment was done based on the pill counting method, i.e: counting the left over medication during follow-up visits. For this purpose all the antihypertensive medications prescribed to the patient would be counted by the research assistant without the patient s knowledge to prevent bias. The medication was prescribed for 10 weeks but the appointment date was 8 weeks. During the subsequent follow up, the left over medication needed to be returned and counted. If the patient failed to turn up 7 days after the appointment date, phone call would be made to remind them about their appointment. The ratio of the used medication then calculated, for this study acceptable ratio was 0.8 to 1.2 [2,27]. If the patient forgot to bring the medication, they were allowed to bring it the next day, but if they failed to do so, they were considered as non compliant. Data analysis Analysis of the data was done by using the computer program, Statistical Package for Social Studies (SPSS) Version 11.5 and Stata Version 8.1. The basic descriptive statistics were calculated. Compliance to treatment was taken as the dependent variable. The independent variables were the HADS scores, HAM-D scores and the sociodemographic data. Logistic Regression was used for dichotomous dependent variable. Ethical consideration This research project was approved by the Research and Ethics Committee, Faculty of Medicine, Universiti Kebangsaan Malaysia. The purpose of the study was explained to the subjects before agreeing to participate in the major IRPA study. Those who were found to have depressive disorders were referred to the psychiatric clinic for further management. Results A total of 207 patients who attended the primary care clinic of HUKM in Bandar Tasik Selatan, Cheras, Kuala Lumpur and Salak Polyclinic (127 and 80 patients respectively) were invited to participate in the study. However, 2 refused to join the study, 1 was excluded due to newly diagnosed Diabetes Mellitus and another 4 patients were unable to complete the study because of inability to make time. Therefore, the response rate was 97% with a total of 201 subjects. 92

11 Table 1 Sociodemographic characteristics of the respondents Variables N (%) Mean (SD) Sites HUKM Primary Care Clinic Salak Polyclinic Age (years) (60.2) 80 (39.8) 72 (35.8) 87 (43.3) 33 (16.4) 8 (4.0) 1 (0.5) 53.7 (8.34) Gender Male Female Ethnic group Malay Chinese Indian Marital Status Single Married Widow/Divorced Education None Primary Secondary Tertiary Occupation Unemployed Housewife Pensioner None Employed Government Servant Private Sector Self Employed Total Monthly Household Income (RM) < 1,500 >1,500 Duration of Hypertension (months) < >120 Family History of Hypertension Yes No Number of Medication Prescribed (48.3) 104 (51.7) 142 (70.6) 50 (24.9) 9 (4.5) 4 (2.0) 186 (92.5) 11 (5.5) 8 (4) 53 (26.4) 115 (57.2) 25 (12.4) 55 (27.4) 35 (17.4) 9 (4.5) 24 (11.9) 43 (21.4) 35 (17.4) 118 (58.7) 83 (41.3) 128 (63.7) 38 (18.9) 35 (17.4) 149 (74.1) 52 (25.9) 132 (65.7) 56 (27.9) 3 12 (6.0) 79.8 (85.89) 93

12 Table 1 shows the sociodemographic characteristics of the respondents. Most of them were in the age group of years old, (79.1%). Distribution of the sex was almost equal: female 97 (48.3%) and male 104 (51.7%) and majority of the respondents were Malays 142 (70.6%). Most of the patients were married 186 (92.5%) and only 8 (4%) did not have any formal education. About quarter of the respondents (27.4%) were housewives. Half of the patients (50.7%) were employed and mostly were working in the private sectors (43.1%). More than half of the patients (58.7%) had a monthly family income of less than RM Majority of them,74.1% had a family history of hypertension and 65.7% were on only one type of antihypertensive medication. Table 2 Distribution of psychiatric diagnosis of the patients using MINI Diagnosis Total Cases Percentage (%) Major Depressive Disorder Dysthymia Major Depressive Disorder with lifetime panic disorder Total Table 2 shows the distribution of specific diagnosis of depressive disorders among the patients. Only 12 patients had depressive disorders (6%). Major Depressive Disorder is the most common (58.3%) type of mood disorder, followed by Dysthymia (33.4%). Only 1 patient had co-morbid Major Depressive Disorder and lifetime Panic Disorder (8.3%). The prevalence of non-compliance to drug treatment among hypertensive patients was 38.3% (77). Patients with depressive disorders have 0.78 times at risk to become non-compliant to treatment. 94

13 Table 3 Relationship between sociodemographic factors and drug compliance Variables OR (95% CI) LR test (df) p- value Age 0.91 (0.445,1.867) 0.06 (1) Gender 0.64 (0.365, 1.339) 2.34 (1) Ethnic group 0.89 (0.478, 1.640) 0.15 (1) Marital Status 1.01 (0.346, 2.963) 0.00 (1) Education Secondary Tertiary 1.15 (0.615, 2.171) 1.11 (0.432, 1.912) 0.20 (2) 0.20 (2) Occupation 1.01 (0.574, 1.77) 0.00 (1) Total Household Income 0.68 (0.383, 1.202) 1.76 (1) Duration of HPT 1.00 (0.998, 1.005) 0.88 (1) Family History of HPT 1.00 (0.528, 1.912) 0.00 (1) Number of Medications Prescribed (0.445, 1.533) 0.88 (0.265, 2.926) 0.31 (2) 0.31 (2) OR of education is compared to primary education, while OR for number of medications prescribed is compared to those on monotherapy. (OR = Odds Ratio, CI = Confidence Interval, LR = Logistic Regression, df = degree of freedom) Logistic regression was used and there was no significant association between drug compliance and sociodemographic factors (Table 3). However severity of depression has a significant association with drug compliance (z test = , p=0.037). Discussion This study is the first local study done to look into the association between depression and non-compliance in hypertensive patients taking medications. This study found that about 6% of hypertensive patients were depressed. This figure is low as compared to some of the earlier studies in Malaysia [9,13]. However, these studies were on emotional disorders, and not specific for depressive disorders. Findings in this study, however, were to some extent comparable to some of the international studies [14-16] where the prevalence of depression in primary care patients is about 6-10%. Depression is often cited as one of the factors for non-compliance to treatment. However this study failed to prove this 95

14 theory. On the other hand, severity of depression has a significant association with poor compliance. This is consistent with some overseas studies [3,17]. Botelho and Dudrak 1992 [18] in their studies to examine the effect of depression and anxiety on compliance also found that more severe depression was associated with lower drug compliance. Assessment of compliance to treatment is often difficult. Direct questioning of patients in interviews is a simple and rapid method but inadequate for evaluating medication compliance [19]. The only study done in Malaysia was done by Lim T.O et al 1992 [2] used the Pill Counting method to measure compliance with hypertensive treatment. However, patients who want to avoid showing that they had missed doses may not return unused medication. Therefore, pill counts only provide accurate compliance estimates for compliant patients and the accuracy diminishes among patients with lower compliance rates [21,22]. According to Sackett D.L 1977 [26], 80% compliance with medication is required to achieve a blood pressure reduction and thus a ratio of 0.8 (80%) or more is usually taken as a criterion for adequate drug compliance. There were a few studies done on the relationship between depression and anxiety with drug compliance. Most of the studies found that higher depression is associated with lower drug compliance in various medical conditions [18,23-25]. Due to the small number of patients who had depressive disorder (12 respondents), the significant association using non parametric Mann- Whitney test could be misleading. In conclusion, this work may support the idea that severity of depression affects compliance with medical treatment. Therefore, primary care doctors should equip themselves with basic psychiatric knowledge in order to detect depression. Referral to the psychiatrist is needed to ensure that patients receive proper treatment. On the other hand, medical officers in the Primary Care Clinics should be trained to detect psychiatric problems among patients and should update themselves with current management of psychiatric disorders. Psychiatric medications should be made available at all Primary Care Clinics with the involvement of Family Medicine Specialists to reduce patient load at tertiary referral centres. This study is not without its shortcomings. The urban (HUKM PCC) and rural (Salak Polyclinic) cohorts may not be representative of the general Malaysian population. Further studies are recommended to replicate these findings using a larger sample size. The scope of this result is also limited to patients who were literate in Malay and English languages only. Many patients could not be included in the study due to language barrier, although they fulfilled other inclusion criteria. Several sampling bias were identified in this study. Due to the author s limited time frame, the samples were followed up only once which was 2 months after they were first seen by the author. Ideally, if there was sufficient time, it would be good if compliance was assessed on at least three visits. In future studies, it is recommended that the questionnaires be translated into different local languages such as 96

15 Mandarin and Tamil to capture other ethnic groups. Another way would be to include the Chinese-speaking or Tamilspeaking researchers who are trained to use MINI. The author is also aware about the issue of side effects of antihypertensive drugs on compliance. However this issue was not studied. It was actually being addressed in the bigger multicenter national study of which relationship between the side effects and compliance is part of the main objectives. The effect of antihypertensive drugs on depression and anxiety was also not studied. Most of these drugs are recognized to cause or increase risk to cause depression such as beta blocker, diuretics, methyldopa, and calcium channel blocker. The low prevalence of depression in this population maybe due to the small sample size. A prospective study with a larger sample size and longer follow-up time is needed in future to establish more definitive link between depressive and anxiety symptoms, and compliance. References 1. Malaysia s Health 1996, Ministry of Health Appendix 17: Lim, T. O., Ngah, BA., Rahman, RA., Suppiah A., Ismail F., Chako P. et al. The Mentakab Hypertension Study Project. Part V Drug Compliance in Hypertensive Patients. Singapore Med J.1992; 33: Wang PS, Bohn RL, Knight E, Glynn RJ, Mogun H, Avorn J. Noncompliance with Antihypertensive Medications. The Impact of Depressive Symptoms and Psychosocial Factors. J Gen Intern Med. 2002; 17: Glassman, AH, Shapiro, PA. Depression and the Course of Coronary Artery Disease. American Journal of Psychiatry. 1998; 155: Musselmen, DL, Evans DL, Nemeroff CB. The relationship of Depression to Cardiovascular Disease: Epidemiology, Biology, and Treatment. Arch Gen Psychiatry. 1998; 55: Alexopoulos G, Meyers B, Young R. Vascular depression. Arch Gen Psychiatry. 1997; 54: Krishnan, R, Hays J, Blazer D. MRI-defined depression. Am J Psychiatry. 1997; 154: Ramli H, Kasmini K, Hassan S, krishnaswamy S. A Prevalence Survey of Psychiatric Morbidity in a Rural Malaysian Village. Asean Journal of Psychiatry. 1991;1: Fuziah P, Sherina MS, Nor Afiah MZ, Jefferelli SB. A Study on the Association of Emotional Disorders and Physical Symptoms Among Adult Patients Attending a Rural Primary Care Clinic. The Malaysian Journal of Psychiatry. 2004;12: Zigmond AS, Snaith RP The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983; 67: Sheehan, DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a 97

16 structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Psychiatry. 1998; 59(20): Snaith RP, Baugh SJ, Clayden AD, Husain A, Sipple MA. The Clinical Anxiety Scale: An Instrument Derived from The Hamilton Anxiety Scale. Br. J. Psychiatry. 1982; 141: Maniam T. Psychiatric Morbidity in an Urban General Practice. Medical Journal Malaysia 1994;49: Johnson J, Weissman MM. Klerman GL. Service Utilization and Social Morbidity Associated with Depressive Symptoms in The Community. JAMA. 1992; 267: Berardi D, Leggieri G, Ceroni GB, Rucci P, Pezzoli A, Paltrinieri E, et al Depression in Primary Care. A Nationwide Epidemiological Survey. Family Practice 2002;19: Nease DE, Malouin JM. Depression screening: a practical strategy- Applied evidence: research findings that are changing clinical practice. Journal of Family Medicine. 2003;52(2); Boutelle RC, Epstein S, Ruddy MC. The Relation of Essential Hypertension to feeling of Anxiety, depression and anger. Psychiatry. 1987; 50(3): Botelho RJ, Dudrak R. Home assessment of adherence to long term medication in the elderly. J Fam Pract. 1992; 35: Joyce A, Cramer BS, Rosenheck R. Compliance with Medication Regimens for Mental and Physical Disorders. Psychiatr Serv. 1998; 49: Lim, TO, Ngah, BA, Rahman, RA, Suppiah A, Ismail F, Chako P, et al. The Mentakab Hypertension Study Project. Part V, Drug Compliance in Hypertensive Patients. Singapore Med J. 1992; 33: Pullar T, Birtwell AJ, Wiles PG, Hay A, Feely MP. Use of a Pharmacologic Indicator to Compare Compliance with Tablets Prescribed to Be Taken Once, Twice or Three Times Daily. Clinical Pharmacology and Therapeutics. 1988; 44: Rudd P, Bynny RL, Zachary V, Lo Verde ME, Mitchell WD, Titus C, et al. Pill Count Measures of Compliance in a Drug Trial: Variability and Suitability. American Journal of Hypertension. 1988; 1: Taal E, Rasker JJ, Seydel ER, Weigman O. Health Status. Adherence with Health Recommendations, Self Efficacy and Social support in Patients with Rheumatoid Arthritis. Patient Educ Counsel. 1993; 20: Schneider MS, Friend R, Whitaker P, Wadhwa NK. Fluid Noncompliance and Symptomatology in End-stage Renal Disease: Cognitive and Emotional Variables. Health Psychol. 1991; 10: Blotcky AD, Cohen DG, Conaster C, Klopovich P. Psychosocial Characteristics of Adolescents who refuse cancer treatment. J Consult Clin 98

17 Psychol. 1985; 53: Sackett DL: Hypertension in the Real World: Public Reaction, Physician Response and Patient Compliance. In: Genest J.. Kevin E., Kechal P eds. Hypertension: Pathophysiology and Treatment, New York: McGraw-Hill; p Nuesh R, Schroeder K, Dieterle T, Martina B, Battegay E. Relation between insufficient response to antihypertensive treatment and poor compliance with treatment: a prospective case-control study. BMJ. 2001; 323: Correspondence Author: Norzila Zakaria, Department of Psychiatry, Universiti Sains Malaysia (USM), Health Campus, Kubang Kerian, Kelantan. drnorzila@yahoo.com Received: 1 February 2009 Accepted: 2 March

18 ORIGINAL ARTICLE DESIGNING A CULTURE, LANGUAGE AND ILLNESS-SPECIFIC SELF-ESTEEM SCALE IN BAHASA MALAYSIA Shamshunnisah Abu Bakar*, Hasanah Che Ismail** *Department of Psychiatry and Mental Health, Hospital Sultan Abdul Halim, Sungai Petani, Kedah 08000, Malaysia,**Department of Psychiatry,Universiti Sains Malaysia 16150, Kubang Kerian, Kelantan. Abstract Objective: Self-esteem is an important component of psychological health. In Malaysia, Rosenberg s self-esteem scale remained the single most popular utilized scale for studying global self-esteem. This study aims to design a language, culture and illness specific self-esteem questionnaire. Methods: The study consisted of 2 phases. The first phase was to generate items for the new self-esteem questionnaire (SSES) in Bahasa Malaysia. Literature review on the concept of selfesteem and its content was conducted. This was followed by expert opinion from professional care-givers. The items were qualitatively validated by healthy subjects and patients with schizophrenia from the same locality, culture and language. The second phase consists of quantitative validation of the items. Items in the new scale were analyzed based on the responses from 165 stable schizophrenia outpatients. The validated Malay version of Rosenberg Self-Esteem scale (RSES) was used concurrently as a comparison. Results: The SSES displayed good internal consistency for its two domains (Cronbach s alpha=0.88, 0.81) and test-retest reliability (ICC), ranged from 0.44 to Its construct validity was confirmed by confirmatory factor analysis. The concurrent validity of SSES and RSES using Pearson correlation was The Cronbach s alpha for the validated Malay version of RSES is Conclusion: This study presents a new self-esteem questionnaire (SSES) which has high concurrent validity with the standard RSES and confirms the reliability and validity of SSES in Malay patients with Schizophrenia. ASEAN Journal of Psychiatry, Vol.10, No.2, July Dec 2009: Keywords: Shamshunnisah Self-Esteem Scale (SSES), Rosenberg selfsteem scale (RSES), Brief Psychiatric Rating scale (BPRS), validation Introduction Self-esteem refers to an individual s sense of value or the extent to which a person appreciates himself [1]. Selfesteem is considered as the evaluative component of the self-concept, a broader representation of self that includes 100

19 cognitive, behavioral and affective components [2]. High self-esteem is characterized by tolerance and respect for others, self-motivated, capable of handling criticism and take control of their lives; whereas low self-esteem is characterized by people who wants to impress others, have doubts about their worth and acceptability, and expose themselves to failure [2,3]. Low selfesteem has been said to be a constant companion for people suffering from stigmatizing illnesses. Cross-cultural researches have suggested that self-concept varies greatly depending upon the culture one lives in, either independent self (individualist) or interdependent self (collectivist) [1, 4]. The Asian interdependent cultures consist of seeing oneself as part of an encompassing social relationship and realizing that one s behavior is determined and dependent on what one perceives to be the thoughts, feelings and actions of others in the relationships [1]. Malaysia is an Asian country, which in many ways can be considered as an interdependent culture. The Rosenberg's self-esteem theory relies on reflected appraisals and social comparisons. Rosenberg s Self-Esteem Scale (RSES) was developed to measure adolescents global feelings of selfworth, and is generally considered the standard one against which other measures of self-esteem are compared. The scale is one-dimensional in nature: one subjective experience of self-worth and was arranged in two factors structure: self-confidence and selfdepreciation. The scale test-retest correlations are typically in the range of.82 to.88 and Cronbach s alpha in the range of 0.77 to 0.88 [5]. Using the RSES cross-culturally creates two methodological concerns: (1) comprehension and/or the translation bias and (2) response bias. Statements, such as I feel that I'm a person of worth, at least on a level equal with others, have varied meanings depending on cultural norms. In some cultures, including Malaysians, modesty may be a highly valued trait, so one might disagree with the statement in order to appear humble. So far, there are no specific scales developed to measure self-esteem in the people with chronic mental illnesses. This indicates the lack of interest or effort in looking into the specific ways in which people with major mental illnesses perceived their self-worth or self-esteem. For the above reasons, an attempt is made to construct a new selfesteem scale, taking into consideration perception and views from patient with schizophrenia and their professional care-givers. The items for the new selfesteem scale were generated into the local Malay Language and pilot-tested on healthy volunteers and patients with schizophrenia in the same population. The study aims to develop a culturespecific questionnaire that would be considered important in defining the global self-value or self-worth of a person with schizophrenia. Methods Stage 1: Identifying domains, facet and items of global self-esteem. The process involved in the generation of the Shamshunnisah Self-Esteem Scale (SSES) consisted of gathering experts psychiatrists, sociologist and 101

20 psychologist opinion, focus group discussion and finally conducting a pilot study of the questionnaire. A draft of items concerning self-esteem was then generated. This draft underwent review and inputs from the immediate supervisor and then the draft was given to other 6 experts (2 psychiatrists, 2 sociologists and 2 psychologists) for comments. Subsequently a workshop was held inviting those experts and the draft was discussed and subjected to debate and further commentary. Two focus groups consisting of 10 healthy subjects and 10 stable schizophrenia patients were interviewed separately using the first draft questionnaire. The patients with schizophrenia were from those attending the psychiatric follow-up clinic. They were patients on treatment and in remission. A systematic method for obtaining information on the comprehensiveness and the evaluation of items for the questionnaire was conducted first with the healthy group, followed by the group with schizophrenia. The first draft of the SSES ( first DQ) consisted of 53 items and had two domains: self-worth and social relation or functioning (Table 1). The 53 items were each evaluated by degree of importance in defining selfesteem by a 5 points likert scale by the two focus groups. There are two ways of answering the questionnaire, that is by assessing the frequency:- 1.Tidak Pernah (Never); 2.Jarang Sekali (Rarely); 3.Kadang-kadang (Sometimes); 4.Agak Kerap (Frequently); 5.Sentiasa (Always). Total items in this mode: 20 items and the second style of answering is by assessing agreement: 1.Sangat Tidak Setuju (Strongly Disagree); 2. Tidak Setuju (Disagree); 3.Agak setuju (Somewhat agree); 4.Setuju (Agree); 5.Sangat setuju (Strongly Agree). Total items in this mode are 33 items. The questionnaire also has positively worded questionnaire (28 items) and negatively worded items (25 items). The expert s suggestion was to arrange the items randomly. This was carefully thought and suggested in order to reduce bias and to enhance the level of concentration when they were answering the questionnaire. The items were rephrased whenever appropriate, giving importance to the ease of comprehension by the patients with schizophrenia. During data analysis, the negatively worded items will be recoded and reversed on analysis. The score range will be discussed at the final stage of the questionnaire. Subsequently, a pilot study of the first stage DQ was completed using 50 stable patients with a diagnosis of Schizophrenia based on the DSM-IV classification of Mental Disorder and 100 normal subjects. Only patients with schizophrenia who experience symptoms that are relatively stable and if present at all, are almost always less severe than in acute phase. Patients can be asymptomatic and manifest nonpsychotic symptoms for example tension, anxiety, depression or insomnia or experiencing attenuated positive and negative symptoms of Schizophrenia [6]. Objective assessment to describe such patient would be those who score 0 or 1 in the BPRS psychotic symptom subscale [7]. Patients, who are cognitively intact, free from current severe concentration and attention problems, able to show coherent thinking and give relevant verbal and written responses. They should also be 102

21 able to give informed consent to take part in the study. The standardized validated Malay version of the Rosenberg self-esteem questionnaire (RSES) was also given to them at this setting [8]. (refer appendix B). The normal subjects represent a population that consisted of a good range of age, different level of education and socio-economic background and fairly equal gender. The age for normal subjects range from years old and for schizophrenia the age ranges from years old. For normal subjects: 20 were medical students, 5 were student nurses, 5 were doctors, 40 consisted of nurses and medical assistant, 30 were clinic attendants and cleaners in HUSM. To obtain test-retest reliability of the questionnaire, 50 normal subjects and 30 schizophrenic patients we asked to refill the questionnaire after one week of their initial interview. However, only 30 normal subjects and 20 schizophrenic patients returned their completed questionnaires. After the pilot study, an exploratory factor analysis was performed to determine the psychometric property of the first DQ and RSES. Refer table 1. Confirmatory factor analysis was done using the question scores of all questions. Principal component method (varimax rotation method) was used to extract 2 factors to support the theoretical assumption of the two major domains in the self-esteem questionnaire which were self-worth and social relation or functioning. The principal component matrix used has grouped the first DQ into two distinct groups: 15 items into factor 1 and 13 items into factor 2. The 23 items that could not fit into any factors were excluded. Factor 1 has 6 items with r more or equal to 0.60 and 9 items with r = 0.42 or more and less than The factor 2 has 5 items with r more or equal to 0.59 and 8 items with r = 0.41 or more and less than Refer Table 1. After careful analysis of the result and discussion, it was concluded that the factor 1 represent items that assessed self-worth and factor 2 represent items that assessed social relation or functioning. This support the original theoretical assumption made at the early stage of item generation. The eventual total items in domain self-worth were 15 and 10 items in domain social relation or functioning. Items that had high internal consistency and reliability were selected and form a new set of questionnaire. The new scale had been named as Shamshunnisah Self-Esteem Scale (SSES). 103

22 Basic flow of item generation methodology Review of literature and reading Input from experts Face validity and content validity of the questionnaire Focus groups A first draft of the questionnaire (first DQ) and Pilot Study of the first DQ Factor analysis: item s reliability and validity Generated new SSES 104

23 Table 1: Factor analysis: Construct Validity of First DQ (53 items) using principal components analysis with varimax rotation. N=150 Items a Domain 1: Self-worth A.14 I am special A.15 I am being loved by others B.17 I am capable of attracting my partner A.17 I am happy with the way I look A.13 I am a special person A.18 My life is meaningless B.22 I surely could make my partner happy B.23 I would not be able to have a good marital relationship A.3 I am proud of myself B.2 People usually like me B.19 I am not capable of getting married A.1 I love myself B.24 I am capable of having my own children B.18 I am not attractive A.19 My life is useless Domain 2 : Social relation or functioning B.6 I feel lonely B.5 I disappoint those who care about me A.2 I cannot accept the way I am A.10 I am proud of my work B.4 I am scared of not being accepted by my colleagues A.9 People look down on my work B.10 People would dislike my real self A.7 I am capable of completing my work successfully B.3 I need to pretend to make friends B.8 I am satisfied with my friendship A.24 Any impending problem would just vanished by ignoring it A.4 I don t love myself A.12 I have every right to be happy A.5 I respect myself A.6 I am a person with high self-esteem (general question on self-esteem) E 4.00E 8.21E E Factor loading Factor 1 Factor E E E Rest of the 23 items could not fit into any domain r< 0.04 r< 0.04 Stage 2: Quantitative study of selfesteem in stable outpatient Schizophrenia using SSES and RSES. The subjects were 165 stable patients with schizophrenia attending outpatient psychiatric clinics of Hospital Universiti Sains Malaysia (HUSM) and Hospital Kota Bharu, (HKB), Kelantan. The definition of the stable patient with schizophrenia was already stated in the stage 1 methodology. The study protocol was approved by the Research & Ethics Committee, School of Medical Science, Universiti Sains Malaysia. Written informed consent was obtained 105

24 from all participants after explaining the nature of the study. A single researcher, who was trained in psychiatric interview and examination, interviewed all the subjects individually. The patients were asked to fill up the form consists of 25 items of SSES and 10 items of the translated and validated Malay version of Rosenberg Self-Esteem Scale (RSES). This is a combination between an interview and questionnaire type where an interviewer is present in the same room as respondents but yet the respondents complete the questionnaire themselves. The collected data was entered and analyzed initially using the Statistical Program for Social Science (SPSS version 10) for descriptive and simple linear regression analysis (SLR). Comparison between the RSES and the SSES The SSES and the RSES are available in the appendix A and B respectively. The SSES measures one s self-worth (SW) and social relation and functioning (SF). As been mentioned early (methodology section), the SSES has 25 items in total and has 5 points Likert scale in the response. The scale ranges from , with 125 indicative of the highest score possible. The cut-off scores in SSES are: 25-74, low self-esteem; 75-99, moderate self-esteem; , high self-esteem. The SW domain has 15 items and the SF domain has 10 items. The maximum scores for the SW and the SF are 75 and 50 respectively and the minimum scores for the SW and the SF are 15 and 10 respectively.the RSES measures global self-esteem and personal worthlessness. It has 10 items and when 5 points Likert scale used, the maximum score would be 50 and the minimal score would be 10. Using the same frame of score range as SSES, the cut of scores for the RSES would be as follows: 10-29= low selfesteem; 30-39= moderate self-esteem; 40-50= high self-esteem. Result Psychometric Property of the SSES Internal consistency Cronbach s Alpha is a widely reported measure of internal consistency. Each attitude scale should have a value of about 0.6 or more [9]. The Cronbach alpha values of the domains of selfworth and social relationship and functioning are 0.88 and 0.81 respectively, reflecting a high internal consistency [9]. The Cronbach alpha for the validated Malay version of Rosenberg scale is This value is slightly better to the previous local study by Mahmood N.M et al (1999) who obtained Cronbach alpha of

25 Table 2: Reliability analysis of each domain of the SSES and the RSES (Malay version) Item Corrected item-total Correlation Internal consistency Domain self-worth A.1 A.3 A.5 A.6 A.11 B.2 A.13 A.15 A.18 A.17 A.14 B.18 B.17 B.22 B Domain social relation or functioning A.7 A.9 A.10 B.4 B.5 B.6 B.8 A.12 A.24 B.10 Rosenberg self-esteem scale items: Test-retest reliability of SSES Stable scale would produce score that has high test-retest correlation if the test is repeated after a period of time [9]. In this study, the agreement of the subjects ratings on the questions at the time point one and two, as reflected by intra-class correlation coefficient (ICC), ranged from 0.44 to 0.87, with 20 out of 25 items with ICC value below 0.75 were regarded as having fair test-retest agreement. The rest 5 items with ICC value equal to 0.75 or more were regarded to have good test-retest reliability. 107

26 Concurrent validity This requires a comparison between scores with the new questionnaire and a well established one. A high correlation between these two scales indicates concurrent validity [9]. In this study, the responses to the SSES and to the validated Malay version of Rosenberg (RSES), (Table 3) were analyzed to obtained concurrent validity. The highest correlation was found between RSES and the total SSES and the lowest in the SW. For further interest, the RSES score, SW domain score, SRF score, total SSES score were compared with the question 7of the SSES. The question 7 statement is Saya mempunyai harga diri yang tinggi. There were significant correlation between the scores of RSES, the SW, SRF domains, and the total SSES with the question 7. The correlation coefficients were found to be 0.46, 0.62, 0.40 and 0.60 respectively. Refer Table 3. Table 3: Correlation matrix (Person) of the RSES, self-worth (SW), social relation or functioning domains (SRF) and the total SSES (n=165). RSES SW SRF TOTAL SSES QUESTION 7 RSES 1.00 SW 0.64** 1.00 SRF 0.71** 0.55** 1.00 TOTAL SSES 0.77** 1.00 QUESTION ** 0.62** 0.40** 0.60** 1.00 **correlation is significant at the 0.01 level (2- tailed) Distribution of SSES and RSES scores in the schizophrenic patients The scores of SSES and RSES in patients with schizophrenia were normally distributed (Graph 1.1 and 1.2 respectively). The levels of self-esteem in patients with schizophrenia based on different tools, i.e. SSES and RSES are shown in Table

27 Graph 1.1 Distribution SSES score in the 165 schizophrenic patients Graph 1.2 Distribution of RSES score in the 163 schizophrenic patients 109

28 Table 4. Level of self-esteem in the schizophrenic patients as measured with the SSES and RSES SSES RSES Level of selfesteeesteem N=165 Level of self- N=163 Low (25-74) 15 (9.1%) Low (10-29) 15 (9.1%) Moderate (75-99) 84 (50.9%) Moderate (30-39) 105(64.4%) High ( ) 66 (40.0%) High (40-50) 43 (26.4%) N=frequency Discussion The psychometric performance of the SSES is quite impressive both in terms of reliability and validity. The internal consistencies for the domain self-worth and social functioning or relation were high (Cronbach s alpha values of and respectively). The internal consistency for the validated Malay version of the RSES was only These Cronbach s alpha values are obviously acceptable and comparable to the value obtained in Mahmood N.M et al (1999) where the value was However, in comparison to the SSES, it shows some weakness in the homogeneity among items in the scale when used in this sample. The original RSES has Cronbach s alpha in the range of 0.77 to 0.88 [5]. The test-retest reliability coefficient of SSES assessed after one week interval ranged from 0.44 to This demonstrates acceptable stability of the instrument to measure self-esteem over time. In contrast to the general assumption that mentally ill patients have low selfesteem, using SSES this study found that 50.9% of the sample studied has moderate level of self-esteem and 40.0% of them actually have high self-esteem. Thus, only 9.1% of the sample studied reported low level of self-esteem. Even though the percentage for the moderate and high self-esteem as measured by the SSES and RSES differed, where the RSES captured larger subjects with moderate level of self-esteem (64.4% versus 50.9%), the percentage of subjects with the low level of selfesteem were about the same (9.2% versus 9.1%). This could reflect that SSES with it two domains of self-worth and social relation or functioning was more sensitive in detecting the positive self-concept in this subjects than RSES. The validity of the SSES was also demonstrated through the significant positive correlation with the standardized validated Malay version of RSES. The highest correlation was between the RSES score and the total SSES score. Moreover, question 7 of the SSES which actually means I have a high self-esteem has stronger correlation to the total score of SSES than to the RSES (0.60 versus 0.47). This could possibly means that the SSES is more sensitive in measuring selfesteem in this sample. Findings from the confirmatory factor analysis indicate that the SSES has 2 factors and this relates very well with the proposed domains of 110