Model answers to the Spring 1999 Essay paper

This is the actual guide given to examiners by the Royal College when marking the essay paper. It is supposed to be sent back to the College afterwards, but as you can see some copies still remain in circulation.

Marking

In order to ensure consistency in marking, Examiners are asked to adhere as closely as possible to the following procedures:

1. To assist you when marking, the Essay Panel have incorporated defined criteria in the Notes for Guidance. The criteria are as follows:

   1. Introduction for examiners: An introduction is provided to set the scene, so Examiners will have an understanding of what to expect from the candidate.
   2. Content: At least three core points of content required for a candidate to pass and a further three subsidiary points that the candidate should mention in order to obtain a good pass are provided.
   3. Logic of argument: In order for the candidate to pass, it should be an absolute requirement that the candidate demonstrates the ability to present a case for or against a specific argument or point of view stated or implied in the question asked. The salient points should be presented in order of importance. The candidate should also be expected to back up the research findings by giving reference to the literature.
   4. Literacy: The standard of grammar and spelling should be of an acceptable level.

    

   Penalties:

   1. The Notes for Guidance may incorporate a reminder about errors or if a candidate omits any important information/ facts relevant to the topic concerned (with an indication of the degree or penalty appropriate to each).
   2. Candidates should not be credited for giving irrelevant or inappropriate information.
   3. Your overall mark is a mark out of twenty and will be an aggregate of these two essay marks.

    

   The following can be considered as a guide for marking:-

   Score	Grade
   10, 9 or 8	Excellent
   7 or 6	Good
   5	Pass
   4 or 3	Borderline fail
   2, 1 or 0	Clear fail

Section A - General Psychiatry

QUESTION A1

INTRODUCTION

By way of an introduction the candidate might refer to epidemiological data, eg, variation in suicide rates between different countries and an increasing prevalence of suicide in young males. The candidate should also separate those suicide risk factors upon which psychiatrists have no influence (eg, male sex) from those on which the psychiatrist may exert an influence (eg, psychiatric disorder.

The evidence base for demographic and clinical variables associated with suicide is strong, but it is weak for the efficacy of interventions designed to reduce the suicide rate.

Comments from the Chief Examiner: There needs to be mention of diagnoses of suicide victims and this should be mentioned as either affective illness, alcoholism or schizophrenia in order for the candidate to pass.

Factors associated with suicide

In those who commit suicide a psychiatric disorder has been found in excess of 90% of cases. However, there might be a bias in the accuracy of suicide statistics, that those who have a psychiatric disorder are more likely to attract a coroner's verdict of suicide. Affective illness is the most prevalent psychiatric disorder; one estimate is that 15% of those with affective disorder end their lives by suicide which is a thirtyfold excess risk compared to the general population. About 15% of alcoholics eventually commit suicide and the majority of these individuals also suffer from depression. About 10% of schizophrenics die by suicide. There is an increased suicide risk in those with neurotic disorder, personality disorder, chronic physical disorder, comorbidity, a family history of suicide and a recent bereavement, particularly death of a spouse. There is an undoubted statistical association between unemployment and suicide, especially in men.

The Prevention of Suicide

A fundamental problem is the difficulty of predicting rare events. For example, if the risk of suicide during the year following a suicide attempt is about 1% then if our ability to detect those who kill themselves has a sensitivity of 80% and a specificity of 90%, of a 1000 attempters, 8 out of the 10 who might be expected to die by suicide within a year will be correctly identified. However, in doing so, a further 99 individuals will be incorrectly identified as being a suicide risk, ie, of 107 positive predictions there will be 99 false positives and 8 true positives identified. This false positive rate may be too high for predictions to be useful in targeting preventative efforts on such relatively high risk groups as young men, those who attempt suicide and those with a psychiatric disorder.

Again, at least one of these methods should be selected by the candidate in order to achieve a pass mark.

The candidate should mention the possibility of rapid access to staff in mental health centres, the provision of community outreach teams and crisis telephone line availability, but there is a dearth of studies indicating any impact of these on suicide rates. With regard to suicide prevention organisations, in the UK there is uncertainty about the impact of the Samaritans on suicide rates.

Since the majority of people who kill themselves have visited doctors during the months before their death, it is natural to focus on those contacts to see whether patients at risk can be better identified and managed. In the well known study by Barraclough and colleagues, of a hundred suicides only a minority of patients with depressive disorders were receiving antidepressant drugs at the time of their deaths, in spite of being in contact with medical agencies. Of those receiving medication, some were receiving inappropriate classes of drugs, eg, anxiolytic sedatives, and subtherapeutic doses were often used.

While the older antidepressant drugs are undoubtedly more toxic in overdose, only a small minority (6% in one study) of suicide cases have toxic antidepressant blood levels and some recent studies have found that some of the newer antidepressants are associated with a significantly higher overall standardised mortality ratio for suicide when all causes of suicide (not just toxic overdose) are considered. Isacsson has commented that the problem in preventing suicide is not of choosing a particular class of antidepressant, but that some depressed patients receive no antidepressant, some receive it in too low a dose, and some stop it too soon. Continuation and maintenance drug treatments are of obvious importance and Barraclough has suggested that lithium may have an important prophylactic role with recurrent affective disorder in the prevention of suicide. The candidate must mention the use of hospital admission, if necessary under a section of the Mental Health Act, as a preventative measure; there should be mention of appropriate use of ECT and the need to treat psychotic depression with both antipsychotic and antidepressant drugs.

There is a considerable body of opinion that some suicides will be prevented if obvious methods of suicide cease to be available. Thus the introduction of non-toxic North Sea gas in the UK may be an example and it has been suggested that in the USA a reduction in gun ownership may achieve the same effect. The psychiatris might ensure that a relative would look after the supply of medication to remove the risk of an impulsive overdose; patients may be given small quantities of medication at a time, thus allowing therapeutic effects to occur in a safe environment. Ways of reducing the availability and toxicity of medicines such as the provision of blister packs, the idea of combining a small dose of an emetic with drugs commonly used for self poisoning and the keeping of minimum supplies of medication in the home, require testing in controlled studies.

Bagley, Bancroft, Barraclough, Beck, Buglass, Catalan, Greer, Hawton, Holding, Isacsson, Isometsa, Jick, Kessel, Kreitman, Morgan, Robins (the famous American Study of 134 suicides), Roy, Sainsbury, Shepherd, and Weissman. An overview is provided by Hawton (1992) is his chapter "Suicide and Attempted Suicide" in Handbook of Affective Disorders (Editor: E Paykel) Second Edition. Churchill Livingstone: London.

Section A - General Psychiatry

QUESTION A2

ANSWER

This question should give the candidate the opportunity to display a breadth of knowledge of contemporary theory concerning the causation of panic and the implications of this theoretical knowledge for treatment.

CONTENT

The candidate must be able to describe biological theories of causation, psychological theories of causation, and treatment strategies.

1. This should include an exposition of the postulated relationship between serotonin and panic. The good candidate will also mention other systems which have also been implicated, including noradrenergic, cholecytokinin, adenosine, and benzodiazepine systems.

2. Psychological Theory

   In the sphere of psychological theory the candidate must be able to explain the basis of cognitive and/ or cognitive behavioural therapy. The better candidates may be able to describe the catastrophic misinterpretation hypothesis.

3. Treatment Strategies

   Drug treatments must be mentioned, including anti-depressants, particularly those acting upon serotonergic systems and short acting benzodiazepines. The advantages and disadvantages of these treatment strategies should be laid out, including particular problems such as benzodiazepine dependency, or, in respect of antidepressants, the effect of initial prescription which may give a possible increase in anxiety and which may, in turn, give rise to poor compliance.

   In discussing psychological treatments, there must be a description of behavioural, cognitive behavioural, and cognitive methodologies. The particular focus of treatments for panic should include mention of applied relaxation, respiratory control, interoceptive exposure and cognitive therapy.

LOGIC OF ARGUMENT

In discussing the case for an individual patient, the candidate may mention multi-centre trials, such as the CNCP study but, essentially, should be able to present an argument for and against pharmacological or psychological therapy for an individual patient depending upon that patient's circumstances and a precise assessment of the patient's need.

References

A number of key authors may be referred to including Nutt, McNally, Deaking, Klerman, Marks, Clark, Salkovskis, Beck, Cowan, and Tyrer.

Section B - Psychiatric Specialties

QUESTION B1

INTRODUCTION

The question has two components, the relative value of day hospitals in the care of patients with dementia and a discussion of prognosis. These two issues may be addressed together but each must be tackled for the candidate to pass. With increasing emphasis on cost effectiveness and evidence based practice, it is important to question the organisation of services. The candidate needs to be aware of the benefits that day care may provide while commenting about different ways that services may be organised. It should be acknowledged that there can be difficulties in measuring some of the benefits which are believed to occur in different settings. There is information on the relative costs but not the relative benefits of services provided in different ways. The advocates of day hospitals see them as part of a comprehensive district service alongside other hospital and community components (Howard). At best day hospitals provide a holistic assessment and management including support to patients and informal carers.

CONTENT

Prognosis

The case for day hospitals

These two main points in favour of day hospital care need to be made to achieve a pass mark. Further subsidiary points should be mentioned to obtain a good pass.

Problems with day hospitals and discussion of alternatives

These two points need to be made to achieve a pass mark with subsidiary points to achieve a good pass.

All forms of day care may be bedevilled by transport difficulties. Some units now use their own staff and transport. In geographically large catchment areas there has been some development of "travelling day hospitals".

LOGIC OF ARGUMENT

In order for the candidate to pass, they must present a case for and against day hospitals, to have some discussion of prognosis and to come to a credible and coherent conclusion on the basis of their preceding paragraphs.

Possible references include:

Ballinger B. 1984. The effects of opening a geriatric psychiatry day hospital. ACTA Psychiatry Scand, 70, 400-403.
Blessed G. and Wilson, I.D. 1982. The contemporary natural history of mental disorder in old age. British Journal of Psychiatry, 141, 59-67.
Creed et al. 1990. Randomised controlled trial of day patient versus inpatient psychiatric treatment. BMJ, 300, 1033-1037.
Diesfeldt H. 1992. Psychogeriatric day care outcome: a five year follow up. International Journal of Geriatric Psychiatry, 9, 519-523.
Fasey C. 1994. The day hospital in old age psychiatry: the case against. International Journal of Geriatric Psychiatry, 9, 519-523.
Gerard K. 1988. An appraisal of the cost effectiveness of alternative day care settings for frail elderly people. Age Ageing, 17, 311-328.
Gilleard C. 1987. Influence of emotional distress among supporters on the outcome of psychogeriatric day care. British Journal of Psychiatry, 150, 219-233.
Howard R. 1994. Day hospitals: the cases in favour. International Journal of Geriatric Psychiatry, 9, 525-529.
MacDonald et al, 1982. An attempt to determine the impact of four types of care upon the elderly in London by the study of matched groups. Psychol Med 12, 193-200.
Murphy E. 1994. Editorial: the day hospital debate. International Journal of Geriatric Psychiatry, 9, 517-518.
Roth M, 1955. The natural history of mental disorder in old age. Journal of Mental Science, 101, 281-301.
Woods J.P. and Phanjoo A.L. 1991. Follow up study of psychogeriatric day hospital patients with demenia. International Journal of Geriatric Psychiatry, 6, 183-188.

Section B - Psychiatric Specialties

QUESTION B2

INTRODUCTION

There are three components to this question:
1. Research methodology and issues of testability in general;
2. Methodological issues regarding psychotherapy;
3. Awareness of the research literature.
Candidates may focus more on one area than another if they wish but all areas must be covered to some degree for a pass mark.

CONTENT

Testability and general research methodology:

Candidates should show awareness of the underlying principles of research design, including hypothesis testing, randomisation, control groups, measurement of change, analysis of data, sources of bias, length of follow-up, generalisability. Candidates should show awareness that all research involves a "trade-off" between "internal validity" and "external validity" - the efficacy 'v' effectiveness problem.

In relation to psychotherapy good candidates will know about the debate between an approach using normal empiracal methods and an attempt to investigate "meaning". However, the two approaches are not mutually exclusive and candidates should focus on the issue of "testability". One paradigm has been called the "drug metaphor" i.e. the research question is essentially comparable to psychopharmacology in developing "pure" interventions delivered in a measurable form for specific problems with defined outcomes. The research summarised below demonstrates that this approach has been fruitful.
However, this concept of testability is limited and good candidates will bring in the need to test an underlying theory or mechanism by investigating process. Attempts have been made, but they are less developed than the "effectiveness and efficacy" paradigms.

Particular problems in psychotherapy research

At least one of these points must be mentioned to gain a pass mark

Awareness of research literature

Candidates should show some awareness of the available literature as summarised in several reviews, particularly Roth & Fonagy 1996 "What works for whom?"

N.B. Candidates should know that much of the evidence on efficacy comes from CBT, but they should be aware that there is now evidence of efficacy from RCTs for other modalities including psychodynamic and interpersonal psychotherapy, and for systemic therapies.

Good candidates will draw attention to the few comparative studies and the difficulty interpreting the results, e.g. the NIMH Treatment of Depression, Collaborative Research Programme (TDRCP). Meta- analyses of outcomes have shown relatively few advantages for any specific treatments, although there are slight advantages to CBT.

LOGIC OF ARGUMENT

The essay should have an introduction outlining the forthcoming argument. Logically the essay should discuss research methodology in general, apply it to psychotherapy research, and illustrate the points with some research examples.

OVERALL COMMENTS

A pass mark requires:

References

Aveline, M and Shapiro, D (eds) (1995) Research foundations for psychotherapy practice. Wiley: Chicester.

Elkin, I, Shea, MT, Watkins, JT et al (1989) National Institute of Mental Health Treatment of Depression Collaborative Program: General effectiveness of treatments. Archives of General Psychiatry 46, 971-982.

Roth, A and Fonagy, P (1996) What works for whom? A critical review of psychotherapy research. Guildford: New York.

Shapiro, D, Barkham, M, Ress, A, et al (1994) Effects of treatment duration and severity of depression on the effectiveness of cognitive/ behavioural and psychodynamic/ interpersonal psychotherapy. Journal of Consulting and Clinical Psychology, 62, 422-534.