Digital psychiatry in Nigeria: A scoping review

Background

Mental healthcare workforce shortage in Nigeria poses a major obstacle to mental health services scale-up. Digital psychiatry may provide a veritable platform to bridge treatment gaps.

Aim

To provide an overview of quantity and range of peer-reviewed publications on digital psychiatry in Nigeria.

Setting

A comprehensive literature search encompassed all original, peer-reviewed research articles on digital psychiatry in Nigeria. PubMed, Google Scholar, and a direct exploration of relevant journal article reference lists were utilised. Inclusion criteria covered peer-reviewed original articles conducted in Nigeria between January 2013 and January 2023, regardless of quality. Exclusions comprised case reports, reviews, dissertations, and abstracts.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines were adhered to, while methodological framework of Arksey and O'Malley was used to describe the review.

Results

Fourteen studies meeting inclusion criteria exhibited two primary research areas: implementation and intervention. Most studies focused on intervention strategies, showcasing efficacy of digital devices in enhancing outcomes in depression and clinic appointments. Implementation studies indicated favorable acceptance by both clients and healthcare practitioners.

Conclusion

Digital technology seems acceptable to Nigerian patients and clinicians. Policies to operationalise provision of digital healthcare services will have positive impact in addressing unmet mental health needs. Finally, the quality of the evidence from majority of studies has to be enhanced, and additional studies are required to uncover gaps in some regions of the country.

Contribution

This research demonstrates that, despite some drawbacks, digital methods of providing mental healthcare are practical in Nigeria.

Effect of dolutegravir-based drug combinations on the level of medication adherence and viral load among adolescents living with HIV in resource-limited setting: a pre-post design

OBJECTIVES

The use of antiretroviral drugs among HIV-infected adolescents has been challenged with poor medication adherence, leading to an unsuppressed viral load and ultimately to drug resistance. Recently, dolutegravir has been approved for use in adolescents with HIV, but the evidence on medication adherence and viral load suppression is limited. The study determined the effect of dolutegravir-based drug regimens on the level of medication adherence and viral load among treatment-experienced adolescents.

METHODS

A longitudinal pre-post design study was done among adolescents living with HIV at a paediatrics clinic in Nigeria. Assessment of medication adherence and viral load testing was done before and at six months of transitioning to dolutegravir-based regimens. McNemar-chi-square was used to determine the effectiveness of the drug on adherence and viral load suppression. Multivariate logistic regression analysis was performed to determine the predictors of drug adherence and viral suppression.

RESULTS

The mean age of the participants was 14.7 years (SD=3.2), and 53.3 % were males. The mean duration of ART use was 10.3 years (SD=3.2). Six months after transitioning to dolutegravir, there was a significant decrease in viral load (Z=-7.947, p<0.001) and an increase in medication adherence score (Z=-7.554, p<0.001), among the treatment-experienced adolescents. Viral suppression was 13 times higher among respondents with good medication adherence as compared to those with poor medication adherence (AOR=13.24, CI=3.25-53.90).

CONCLUSIONS

Dolutegravir is effective in improving medication adherence and viral suppression among Adolescents living with HIV. Thus, the need to transition eligible adolescents to dolutegravir to sustain better treatment outcomes.

Psychosocial aspects of Noma (Cancrum Oris) in sub-Saharan Africa: A scoping review

Noma is a neglected tropical disease of an underserved population. Our review describes the volume and scope of existing research evidence on psychosocial aspects of Noma in sub-Saharan Africa (SSA). Our literature search was conducted on all original peer-reviewed research articles on the psychosocial aspects of Noma in each country in SSA using PubMed, Google Scholar, and a direct search of reference list of pertinent journal articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines was used to describe the review. A total of six studies were found in four countries of the region. One in three persons with Noma has a mental health condition, indices of social disadvantage and belief in the supernatural causation of the disease are very common. However, despite evidence of enormous need, a huge gap still exists in the area of psychosocial alleviation.

Dimensional approach to gender dysphoria in Nigeria: Association with socio-demographic and psycho-sexual variables

Background

Recent changes across the world with respect to gender transitioning of children and adolescents have generated a bio-psycho-socio-cultural discourse among interest groups.

Aim

This study sought to examine gender dysphoric symptoms among adolescents and young persons in an African population, using a dimensional approach.

Method

A total of 747 primary/secondary school and university students aged 10-24 years were studied using the 27-item Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA). Participants were divided into early, mid- and late adolescents. The composite and domain scores were calculated using the criteria described by Deogracias, and comparison of the median scores was done using Mann-Whitney U-test and Kruskal-Wallis test as appropriate. Dunnett's post-hoc test was used for pairwise comparisons.

Results

The prevalence of self-identified transgender and self-reported non-heterosexuals was 0.9% (95%CI: 0.36-1.92) and 18.6% (15.85-21.59), respectively. The participants as a group scored 4.56 out of a possible 5 on the gender dysphoria scale, indicating less gender dysphoric symptoms in this cohort. However, participants in mid- and late adolescents had significantly lower scores when compared with early adolescents (P = 0.009). Self-reported transgender had significantly lower scores in the social (P = 0.001) and socio-legal (P < 0.001) indicators of the scale.

Conclusion

The findings of this study, although, preliminary demonstrated less gender dysphoric symptoms in this cohort of Nigerian adolescents and young adults compared to the Western population. Nevertheless, some degree of GD was noticed, revealing that this condition is existent in our society.

Longitudinal Factor Structure of the Brief Psychiatric Rating Scale Among Incident Cases of Schizophrenia Attending a Nigerian Hospital

Background

Schizophrenia, from its early conceptualization, has been described in distinct clinical subtypes. However, these categories were found not to be stable phenotypes over time, hence the dimensional option, whereas at cross-sectional level, the dimensions of psychopathology have been replicated across studies; there is dearth of data on the longitudinal stability of the factor structure of the symptoms of schizophrenia in African populations.

Aim

This study examined the longitudinal stability of the factor structure of the 18-item Brief Psychiatric Rating Scale (BPRS) across intervals of 16-week naturalistic treatment follow-up.

Patients and Methods

Consecutive incident cases that fulfilled the criteria for schizophrenia were recruited into the study. After a baseline assessment, 160 incident cases of schizophrenia were followed up 4 weekly for indicators of symptomatic outcome for 16 weeks. The Brief Psychiatric Rating Scale (BPRS) assessments were conducted in clinical interviews and with the Scale for Assessment of Negative Symptoms (SANS). Five BPRS assessments were made across the monthly intervals of follow-up. Exploratory factor analyses (EFA) using maximum likelihood extraction and varimax rotation with Kaiser normalization was used to extract the factors.

Results

A four-factor structure was found at baseline, namely negative, positive, depressive/anxiety, and manic symptom dimensions. From week 4, the manic and anxiety/depression dimensions remained invariant over time, while negative and positive symptoms merged into a psychosis dimension that was invariant.

Conclusion

The persistence of the mood dimensions supports the DSM-5 recommendation to include these dimensions in the assessment of schizophrenia psychopathology. The longitudinal emergence and invariance of the psychosis factor echo the idea of unitary psychosis and, along with the prominence of mood dimensions over time, reflect recent molecular genetic findings about the sharing of genes by schizophrenia and mood disorders.

Psychosocial aspects of adult cancer patients: A scoping review of sub-Saharan Africa

OBJECTIVE

Psychosocial aspects of adult cancer patients in sub-Saharan Africa (SSA) have been described in silos of research articles. Integrative analysis of regional evidence is lacking. This review aimed to describe the scope of existing research on mental health problems, identify research gaps and make informed research, policy and practice recommendations.

METHODS

Search was conducted for original peer-reviewed research articles, irrespective of their quality, on psychosocial aspects of cancer in all SSA countries using PubMed, Google Scholar, Google search, African Index Medicus and direct searches of reference list of pertinent journal articles. Publications in English or translated to English were included. Case reports, dissertations, abstracts, publications without primary focus on psychosocial issues, psychosocial issues in children and studies conducted with SSA populations living outside the sub-region were excluded. The methodological framework described by Arksey and O'Malley was used to synthesize and present the results. Inductive approach was used to arrive at the thematic areas. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guideline was used to describe the review.

RESULTS

Eighty-three studies conducted across 15 countries were identified. Six thematic areas emerged namely; psychosocial needs, psychiatric disorders, coping strategies, suicidality, psychometrics and psychosocial interventions. Fifteen of 46 countries had at least one study with the majority of articles emanating from Nigeria. Research articles on psychosocial needs, psychiatric morbidities and coping strategies appears adequate for systematic review in SSA region. Despite the overwhelming evidence of high unmet psychosocial needs, a huge gap exists regarding psychosocial interventions.

CONCLUSION

Further research is needed into identified gaps in the region and quality of evidence of these studies need to be improved upon. Comprehensive policies and action plan development are sin qua non for addressing psychosocial problems of adults with cancer in SSA.

Family, twin and adoption studies of severe mental disorders in sub-Saharan Africa: a scoping review

PURPOSE

The traditional genetic epidemiological studies are necessary to improve accurate risk communication to service users and their families. This scoping review aimed to describe the volume and scope of existing research evidence on family, twin and adoption studies of severe mental disorders (SMDs) in SSA. This is with a view to identifying gaps in the literature and the adequacy of data for a systematic review and meta-analysis.

METHODS

Literature search was done for all original peer-reviewed research articles on the topic in SSA using PubMed and MEDLINE. Publications included were peer-reviewed original articles, irrespective of their quality, carried out in the region from the 1970s till 9th March, 2022, which were available in English or translated to English. Case reports, abstracts, and studies among populations living outside the region were excluded.

RESULTS

A total of five studies that met the inclusion criteria across the 46 countries in the region were identified. Of the three thematic areas of focus, only family studies on SMDs had research work in SSA. These studies provided evidence of familial clustering of SMDs in SSA. There were no twin and adoption studies on SMDs in the region. However, the review noted the establishment of two twin registries in Guinea-Bissau and Nigeria. A huge gap exists in the area of twin and adoption studies on SMDs in SSA.

CONCLUSION

The volume of research evidence on traditional family genetic studies of SMDs is grossly inadequate to consider a systematic review in SSA. We have suggested studies to remedy the situation.

Health-Related Quality of Life Among HIV-Infected Children and Its Association With Socio-Demographic, Clinical and Nutritional Variables: A Comparative Approach

Background: The human immunodeficiency virus (HIV) infection and its treatment impact the child’s life as well as that of their caregivers. As therapeutic advances are made in the field, improved survival has shifted the focus from morbidity and mortality to quality of life. This study aims to compare the health-related quality of life (HRQoL) of children living with HIV in comparison with an HIV-negative control group and determine its relationship with socio-demographic, clinical, and nutritional variables.

Method: This was a multi-center cross-sectional comparative study involving 274 participants (137 per group) carried out in tertiary and secondary level healthcare facilities in Nigeria. Socio-demographic, clinical, and nutritional variables were obtained using a researcher-designed data collection sheet. HRQoL was measured using the Paediatrics Quality of Life Inventory (PedsQL 4.0), while caregivers’ burden was assessed using the Zarit-Burden Interview (ZBI). A comparison of the health-related quality of life of the cases and the control group was done using an independent t-test. The predictors of HRQoL among the cases were measured using multivariate stepwise linear regression analysis.

Result: The overall health-related quality of life of HIV-infected children and those of the HIV-negative control group were similar. However, there was a significant difference in the school and psychosocial functioning domains between the two groups with HIV-positive children scoring lower in these domains. For HIV-positive children, being from upper social class (p = 0.01, R² = 0.098), male gender (p = 0.005, R² = 0.063), higher scores in the caregiver burden scale (p = 0.009, R² = 0.150) and more disease severity (p < 0.001, R² = 0.321) were significant predictors of lower health-related quality of life.

Conclusion: The findings of this study show that the overall health-related quality of life of HIV-positive children was similar to that of age- and sex-matched HIV-negative control group. This finding gives clinicians some optimism that with adequate treatment, HIV-positive children will have better outcomes not only in mortality but in psychosocial variables such as quality of life. In addition, the finding on the relationship between caregiver burden and HRQoL underscores the need to focus on family-based interventions to improve the burden of caregiving on family members involved in the care of HIV-positive children.

The effect of structured psychoeducation on caregiver burden in carers of patients with schizophrenia in Nigeria: A 12-week follow-up investigation

Background

Despite robust evidence of the huge burden of caregiving amongst caregivers of patients with schizophrenia, there is a paucity of data in Africa on the interventions to address this enormous burden of caregiving.

Aim

This study aimed to determine the effect of structured psychoeducation intervention on the burden of caregiving in comparison with ‘care as usual’ in a Nigerian Psychiatric Hospital.

Setting

This study was done at the out-patient and in-patient units of the Federal Neuropsychiatric Hospital, Enugu, Nigeria.

Methods

Caregivers of inpatients who fulfilled the International Classification of Diseases (ICD-10) criteria for diagnosis of schizophrenia were recruited for the study. The caregivers were then allocated into two groups (Group A received structured psychoeducation intervention in addition to ‘care as usual’ whilst group B received only ‘care as usual’). After the baseline assessment, the caregivers were followed up every 4 weeks for a period of 12 weeks. At each interval of follow-up, caregivers were assessed for caregivers’ burden using the Zarit Burden Interview (ZBI). Repeated measures analysis of variance (mixed type) was used to determine the effects of the interventions on caregivers’ burden in the two arms of the study across the intervals of follow-up.

Results

The attrition rate at week 12 was 10.7%; leaving 130 for the assessment of outcome variable at the end of follow-up. Structured psychoeducation intervention was significantly better than ‘care as usual’ in ameliorating caregivers’ burden [F (1, 123) = 21.75, p < 0.001, Partial Eta Squared = 0.39].

Conclusion

These findings seem to suggest that caregivers who received structured psychoeducation intervention experienced a greater reduction in caregiver burden than those who received ‘care as usual’. Whilst the study addressed short-term effect, the findings of this study are in accord with other studies that have supported the impression that psychoeducational family-based intervention is useful with regard to caregiver burden.

Project OPUS: Development and evaluation of an electronic platform for pain management education of medical undergraduates in resource-limited settings

INTRODUCTION

Pain is a very frequent symptom that is reported by patients when they present to health professionals but remains undertreated or untreated, particularly in low-resource settings including Nigeria. Lack of training in pain management remains the most significant obstacle to pain treatment alongside an inadequate emphasis on pain education in undergraduate medical curricula, negatively impacting on subsequent care of patients. This study aimed to determine the effect of a 12-week structured e-Learning course on the knowledge of pain management among Nigerian undergraduate medical students.

METHODS

Prospective, multisite, pre-post study conducted across five medical colleges in Nigeria. Structured modules covering aspects of pain management were delivered on an e-Learning platform. Pre- and post-test self-assessments were carried out in the 12-week duration of the study. User experience questionnaires and qualitative interviews were conducted via instant messaging to evaluate user experiences of the platform. User experience data was analysed using the UEQ Data Analysis Tool and Framework Analysis.

RESULTS

A total of 216 of 659 eligible students completed all sections of the e-Learning course. Participant mean age was 23.52 years, with a slight female predominance (55.3%). Across all participants, an increase in median pre- and post-test scores occurred, from 40 to 60 (Z = 11.3, p<0.001, effect size = 1.3), suggestive of increased knowledge acquisition relating to pain management. Participants suggested e-Learning is a valuable approach to delivering pain education alongside identifying factors to address in future iterations.

CONCLUSION

e-Learning approaches to pain management education can enhance traditional learning methods and may increase students' knowledge. Future iterations of e-Learning approaches will need to consider facilitating the download of data and content for the platform to increase user uptake and engagement. The platform was piloted as an optional adjunct to existing curricula. Future efforts to advocate and support integration of e-Learning for pain education should be two-fold; both to include pain education in the curricula of medical colleges across Nigeria and the use of e-Learning approaches to enhance teaching where feasible.

Nutritional status of primary school children: Association with intelligence quotient and academic performance

BACKGROUND

Nutrition plays a pivotal role in brain development throughout life. Sub-optimal intellectual ability and poor school performance are said to be among the long term effects of malnutrition. The aim of this study was to determine the association between nutritional status of the participants, their intelligence quotient (IQ) and academic performance.

METHODS

Children aged 6-12 years who met the inclusion criteria were recruited from the public and private primary schools in the local government area using a proportionate multistage sampling technique. Weight and height were measured using standard protocols and interpreted as normal or abnormal using the World Health Organization AnthroPlus®. IQ was assessed using the Raven's Standard Progressive Matrices and was grouped into optimal and suboptimal. Academic performance was assessed using the past records of class assessment, and was classified into high, average and low academic performance. A semi-structured questionnaire was used to obtain data such as-age, gender, socioeconomic indices and family size of the study participants.

RESULTS

The prevalence of underweight, thinness (wasting), stunting, overweight and obesity were 2.0%, 3.6%, 2.1%, 6.7%, and 4.2%, respectively. Indices of over-nutrition were significantly associated with optimal IQ and good academic performance. There was a trend in the association between wasting and suboptimal intelligence [AOR (95%CI) = 1.5 (1.0-3.0), p = 0.06].

CONCLUSION

Acute and chronic under-nutrition did not adversely affect the IQ and academic performance of the study population. The relationship between over-nutrition, IQ and academic performance disappeared when socio-economic status was controlled for.

Double burden of malnutrition amongst patients with first-episode schizophrenia in a psychiatric hospital: A 1-year follow-up study

BACKGROUND

Despite the burgeoning data on the double burden of malnutrition (DBM) in sub-Saharan Africa, longitudinal studies to examine malnutrition amongst first-episode schizophrenia are uncommon in the modern literature.

AIM

To determine the extent of nutritional variations amongst persons with schizophrenia at intervals of 1-year treatment follow-up.

SETTING

This study was conducted at the Federal Neuropsychiatric Hospital, Enugu, Nigeria.

METHODS

Consecutive incident cases that fulfilled the criteria for schizophrenia were recruited into the study. After a baseline assessment, 206 incident cases of schizophrenia were followed up at 4th, 8th, 12th weeks, 6 months and 1 year for indicators of nutritional outcome. The body mass index (BMI) was used to measure the nutritional status amongst the study participants. Changes in the BMI across intervals of follow-up were examined using repeated measures analysis of variance, whereas the socio-demographic and clinical variables were evaluated as predictors of outcome using multiple regression analysis.

RESULTS

After 1 year of treatment with antipsychotics, the prevalence of underweight decreased from 19.9% (95% CI, 19.8% - 20.0%) at baseline to 16.0% (95% CI, 15.9% - 16.1%) at 1 year, but the prevalence of overweight/obesity increased from 29.1% (95% CI, 29.0% - 29.2%) at baseline to 43.2% (95% CI, 43.0% - 43.3%) at 1 year of follow-up. The predictors of BMI at 1 year were antipsychotic medication (32.7% variance), duration of vagrancy (24.0%) and age at onset (20.0%).

CONCLUSION

The finding of coexistence of undernutrition and overnutrition across the intervals of treatment follow-up underscores the need for comprehensive interventions to address both extremes of malnutrition amongst patients with schizophrenia.

Soil-transmitted helminthiasis: A neglected tropical disease among urban slum dwelling school-aged children of a sub-Saharan African city

Background

The need to generate a robust epidemiological data on the neglected tropical diseases is imperative, in order to encourage access to formal care, drive public policies and ensure the allocation of resources by policy-makers.

Objectives

The objective of this study was to determine the prevalence of soil-transmitted helminthiasis (STH) and its association with nutritional variables among primary school pupils living in urban slums in a South-Eastern sub-Saharan African city of Enugu, Nigeria.

Methods

The stool samples of school-aged children living in urban slums were analyzed for ova of the helminths using the Kato-Katz methods, whereas the nutritional assessment (weight and height) was obtained and analyzed to indicate acute or chronic malnutrition. Degrees of helminthic load were then classified. The socioeconomic status was determined while the prevalence of STH and the relationship between it and the nutritional stratus was assessed to ascertain any significance between being malnourished and having STH as this will inform policy decisions.

Results

There were a total of 371 analyzed stool samples from 228 females (61.5%) and 143 males (38.5%), with 285 (76.8%) from the lowest socioeconomic class. The prevalence of STH was 18.1%, while that of acute and chronic malnutrition were 3.3% and 7.5%, respectively. The intensity of infestation was, however, light, with the highest mean egg intensity of 74.4 ± 32.8 documented for ascariasis. There was no statistically significant association between the presence of STH and various indices of acute and chronic malnutrition (P > 0.05).

Conclusion

STHs prevalence is high among children living in urban slums. Nutritional status was, however, not adversely affected by helminthic infestation.

Feeding behaviors among incident cases of schizophrenia in a psychiatric hospital: Association with dimensions of psychopathology and social support

BACKGROUND

Despite early description by Eugen Bleuler of abnormal feeding behaviors among patients with schizophrenia, it has remained poorly studied and understood by clinicians. The present study sought to describe the various eating behaviors among incident cases of schizophrenia and its relationship with the dimensions of psychopathology and perceived social support.

METHODS

This study elicited information on the feeding behavior of 206 incident cases of schizophrenia being followed up for various nutritional outcomes. Feeding behavior, dimensions of psychopathology and perceived social support were measured using literature based researchers' constructed nutritional questions, Positive and Negative Symptoms Scale (PANSS), and Multi-dimensional Scale of Perceived Social Support (MSPSS), respectively. Relationship between food refusal and dimensions of psychopathology as well as perceived social support were tested using independent t-test.

RESULTS

Food refusal was seen in 56.5% of the patients, with 32.5% of it attributed to suspiciousness. Of the 13.2% with Inappropriate feeding behavior, 46.4% and 14.3% were related to abnormal food preparation and pica, respectively. Food refusal was significantly associated with positive symptoms dimension and general psychopathology (p < 0.05).

CONCLUSION

Our findings show that subtle feeding abnormalities occur among schizophrenia patients and this is related to positive symptoms dimension and poor perceived social support.

Morbid risk of schizophrenia amongst relatives of schizophrenia probands: A family-controlled study

Introduction

There is a dearth of data on heritability of schizophrenia in Africa. The few African studies that addressed familial psychiatric morbidity in schizophrenia involved relatively small sample sizes and addressed psychiatric morbidity only in first-degree relatives. The present study sought to improve upon the methodology of previous African studies, and widen the scope to second- and third-degree relatives with a view to enriching the field of genetic epidemiology in Africa.

Methods

This study elicited information on the morbid risk of schizophrenia amongst 5259 relatives of schizophrenia probands (n = 138) and 6734 relatives of healthy controls (n = 138) through direct interview of patients, available relatives of patients and controls. Diagnosis of probands was confirmed using Mini International Neuropsychiatric Interview. Through a direct interview of 138 patients and their available relatives, a family history approach using the Family Interview for Genetic Studies was utilised to obtain information on the morbid risk for all relatives that could be recalled. The same approach was utilised for the interview of the controls (aged 45 years and above) and their relatives. Morbid risk estimates were calculated using the Weinberg shorter method.

Results

Morbid risk for schizophrenia in the first-, second- and third-degree relatives of schizophrenia probands was 10.9% (95% confidence interval [CI] = 10.6-11.2), 4.2% (95% CI = 4.1-4.3) and 3.9% (95% CI = 3.6-4.2), respectively, compared with 2.6% (95% CI = 2.5-2.7), 1.6% (95% CI = 1.5-1.7) and 1.5% (95% CI = 1.4-1.6), respectively, of the healthy control group.

Conclusion

The findings support the widely noted impression that schizophrenia significantly aggregates in families of schizophrenia probands more than healthy controls.