Indian Journal of Social Psychiatry

: 2016  |  Volume : 32  |  Issue : 2  |  Page : 174--176

Workshop on management of “Difficult to Treat” serious mental illnesses using problem-based learning approach

Mamta Sood1, Nitin Gupta2,  
1 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Correspondence Address:
Dr. Mamta Sood
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029


The patients with “difficult to treat” serious mental illnesses (SMIs) pose a significant challenge for practitioners. A workshop was conducted during Annual National Conference of Indian Association for Social Psychiatry, Kolkata, November 2013 using “problem-based learning” approach focusing on the management of “difficult to treat” SMIs. The problem was presented in the form of paper-based case vignette. This format for the workshop was reported to be useful by the participants.

How to cite this article:
Sood M, Gupta N. Workshop on management of “Difficult to Treat” serious mental illnesses using problem-based learning approach.Indian J Soc Psychiatry 2016;32:174-176

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Sood M, Gupta N. Workshop on management of “Difficult to Treat” serious mental illnesses using problem-based learning approach. Indian J Soc Psychiatry [serial online] 2016 [cited 2022 May 26 ];32:174-176
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Serious mental illnesses (SMIs) affect 1–2% of the population.[1] There exists a sub-group amongst patients with SMIs who continue to have persistent dysfunction and psychopathology. These difficult to treat patients include not only the so-called resistant or refractory patients but also those who for some reasons fail to show the desired response to therapy.[2] Ruggeri et al.[3] defined these patients as having nonorganic psychosis with severe dysfunction and on treatment for 2 or more years; with 31–40% of patients with psychosis who fulfilled the criteria for “difficult to treat” SMI.

The management of patients with difficult to treat SMIs poses a significant challenge to the clinicians and number of evidence-based guidelines for pharmacological and psychosocial therapies exist.[4] The treatment with antipsychotics remains the backbone of the management; the comprehensive management plan should also address the environmental and sociocultural issues (arising out of evaluation) keeping in perspective the short-term goals of improved psychopathology and treatment of comorbidities and long-term goals of improved functioning and reduced disability.


The authors are both working as consultant psychiatrists with about two decades of professional experience. They both recognize that the SMI population is one of the main cohorts of patients which are treated by psychiatrists in either an academic and/or private setting. Although there is no robust research data from India, but extrapolating from the figures mentioned by Ruggeri et al. there would be a high percentage of “difficult to treat” SMI patients being encountered in practice. Keeping this in perspective, the authors felt the need to discuss this aspect of management of SMI patients in the form of a workshop.

The main principles for conducting the workshop were to promote sharing of information, have an interactive discussion, keep the content pragmatic, and the contents-cum-discussion could be easily translated (postworkshop) into clinical practice. The learning objectives of the workshop were how to formulate a comprehensive plan for evaluation and management of patients with difficult to treat SMIs in routine clinical practice in accordance with available evidence-based pharmacological and psychosocial treatments focusing on the patient as a whole. The workshop was conducted by the authors during the Annual National Conference of the Indian Association for Social Psychiatry for the delegates at Kolkata in November 2013 using the problem-based learning (PBL) approach [5] focusing on management of “difficult to treat” SMIs.

PBL is a small group teaching method, in which a problem is presented to the participants as stimulus for learning. Working on identified problem areas helps them to understand the relevance of the existing scientific knowledge and its application in clinical practice. Besides the acquisition of knowledge, learning in a group facilitates communication skills, teamwork, finding solutions to the problems, taking independent responsibility for learning, sharing information, and respect for others.[5]


The duration of the workshop was for 1½ h. At the beginning of the workshop, after informal introductions among the group members and authors, an overview of the workshop was presented which highlighted its structure and outlined the objectives. The workshop was divided into three parts: Part I - Brief power-point presentations of 5 min each by both authors in which important issues were highlighted. Part II - Participants were divided into three groups of 5–6 participants and given paper printed case vignette each (which were also displayed on the screen). They were asked, as a group, to work on the case vignette for 15 min. Each group was given a problem in the form of case vignette depicting patients with nonorganic nonaffective psychoses with significant disability and dysfunction despite treatment and having some specific issues encountered in routine clinical practice such as physical and substance use comorbidity, poor drug compliance, violence, attempted suicide, family coping and burden, etc. In the end of the vignette, six questions were asked about the case, i.e., to identify at least three important/key psychosocial and pharmacological considerations, and three short- and long-term goals of management for patient and family. To formulate answers to these open-ended questions, the participants had to tap into their knowledge of recommendations and guidelines for management of patients with SMIs/”difficult to treat SMIs” and/or their clinical experience. These questions were chosen to generate discussion in the group. Part III - A group leader, nominated by the group, presented their findings taking 10 min each. Each presentation was followed by discussion among the participants and coordinators. After the third part, the concluding session of the workshop involved the coordinators summing up the entire workshop highlighting important lessons learnt. In the end, the participants were requested to fill up the feedback form. It contained questions regarding content, time, organization, balance of theory and practical, use of the material learnt, and response of the coordinators on a Likert scale with responses from “strongly disagree” to “strongly agree.” In addition, it had two open-ended statements at the end asking respondents to list strengths and limitations of the workshop.

As mentioned earlier, to ensure active involvement of the participants in the present workshop, a PBL approach was used. Paper-based problem situations in the form of case vignette were chosen, to ensure that all the participants in a group were exposed to the same problem situations.


A total of 17 participants took part in the workshop. All of them were psychiatrists having clinical experience ranging from being postgraduate trainees to 33 years of clinical experience. They were in the age range of 26–59 years and were working in different settings, viz., office-based practices to medical colleges.

Feedback forms were provided by 16 participants; one participant did not consent. Among the 16 respondents, 10 were consultant/senior psychiatrists and six were postgraduate trainees [Table 1].{Table 1}


This workshop was conducted on the management of “difficult to treat” patients with SMIs using PBL approach. This method has been previously used in a program for the sensitization of medical officers about common mental disorders.[6] The format of the workshop was such that the participants were involved for the predominant duration of the workshop as the coordinators took <15% of the time. From the authors' perspective (in their role as facilitators of the workshop), the PBL approach kept the focus of discussion on the identified issues. In addition, it facilitated exchange of ideas, active participation and giving opportunity to voice opinion by all members of the group. The program was well received and it was observed that most participants were active in the discussion.

For all the respondents, the predominant response was – “strongly agree” for the items related to organization, content, and response of the presenters; “agree” for the items related to time and balance of theory and practical. They were equally split between “strongly agree” and “agree” for the last item of being able to implement in practice. “Disagree” responses were noted only for items of sufficient time, and balance of theory and practical; there being no “disagree/strongly disagree” responses for other four feedback items. Hence, it can be safely deduced that the overall feedback was positive, i.e., respondents principally agreed that the workshop (using a PBL approach) was well organized, had clear content, with the satisfactory involvement of the presenters, and was easy to implement into future clinical practice. However, it does need to be noted that 13% did not agree that there was a balance between theory and practical - an area for us authors to address for future workshops of such nature and content. Most striking was the lack of agreement by 38% of respondents (in which 25% actually disagreed) regarding “time being sufficient.” This feedback is interesting as the time devoted toward the workshop in the conference was 90 min (i.e., 1½ h) which is generally the time allotted in principle at various conferences. Since we had devoted <15% overall time for our presentations in the workshop, the feedback probably is an indication that the participants expressed a felt need for a longer duration beyond 90 min. In addition, the respondents listed strengths of the workshop as – being well organized, thought provoking, sustained the interest, clinically relevant realistic situations, interactive, and allowed for the high involvement of attendees. They listed limitations of the workshop as - time was less, lack of full case information, and more number of case vignettes would have been useful. Hence, on comparing this feedback with our observations, it can be seen that there was a reasonable degree of convergence between both which is a heartening aspect. In addition, on the basis of the positive feedback, we can also conclude that the objectives outlined for PBL were largely achieved.

We made an attempt to see if there was any difference in the feedback of respondents who were experienced clinicians versus those who were trainees [Table 1]. It may be clarified here that due to very small overall sample and subsequent smaller “N” in the sub-groups, quantitative analysis was not deemed appropriate and hence not carried out. The results so presented are purely observational. For the first three items, there was no gross difference between the two sub-groups. However, more trainees “disagreed” with “time was sufficient” on one hand, and “agreed” regarding “presence of balance between theory and practical content.” Finally, more trainees showed a tendency to “agree” less strongly than the experienced clinicians in being able to implement workshop into practice. This could be a reflection of still not having the complete knowledge of the subject, along with the subjective feeling of lack of competence due to being a trainee. However, this is conjectural and needs confirmation.


The patients with difficult to treat SMIs pose a significant challenge for practitioners. In this workshop, the format of PBL approach was used. It was reported to be useful by the participants of both long-standing clinical experience and trainees alike. Instead of dyadic methods of lecture, symposia or invited talks, PBL in a workshop format can be a useful teaching and/or presentation method in various continuing medical education programs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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