Clinical characteristics of people presenting with first episode psychosis pre- and during the COVID-19 pandemic in KwaZulu-Natal Province, South Africa

BACKGROUND

The COVID-19 pandemic and the lockdown experience may have not only precipitated or exacerbated mental illness but also influenced access to care and the nature and content of the psychotic symptomatology of people with psychosis.

AIM

This study aimed to evaluate the association of the COVID-19 pandemic and lockdown experience on clinical presentation and quality of life of people (QOL) with first episode psychosis (FEP).

METHOD

Two first episode psychosis cohorts from the same epidemiological area collected prior to, and during the COVID-19 pandemic and lockdown were compared in terms of clinical symptomatology, substance use and QOL. All adult in- and outpatients with FEP at five clinical units in KwaZulu-Natal, South Africa, aged between 18 and 45 years, were assessed with the MINI interview for psychosis, Positive and Negative Symptoms Scale, WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the WHO QOL scales.

RESULTS

Eighty-eight FEP participants were recruited between 2019 and 2020 (cohort 1) before the pandemic. Study recruitment was suspended in March 2020 due to the pandemic. On study resumption from November 2020 to November 2022, 95 new participants (cohort 2) were recruited. There were no sociodemographic differences between the two cohorts, except unemployment status (57% vs. 65%) and household income. The cohort presenting post-COVID-19 pandemic onset had significantly more positive psychotic symptoms (21.9 vs. 23.7), lower PANSS domain depressive score, more lifetime use of tobacco, cannabis and alcohol. However, they reported improved QOL (196 vs. 239).

CONCLUSION

Following the pandemic and lockdown experience participants presented with more severe psychotic symptoms and concomitant substance use but improved perceived QOL. This suggests the need to explore individual and social factors that may influence the clinical presentation.

Water, sanitation and depression in rural communities: evidence from nationally representative study data in South Africa

Clean water and sanitation provisions are essential for good hygiene and health, with rural South Africa facing a simultaneous access crisis of both, the direct health effect of restricted access to both on mental health remaining scarce and largely overlooked. This study investigated the association between access to clean water and sanitation on depression in rural South Africa utilizing the most recent data (year 2017) from the South African National Income Dynamics Study. Our study outcome was depression, based on the 10-item abridged version of the Center for Epidemiologic Studies Depression Scale (data available in SA-NIDS), the main exposures being access to clean water and adequate sanitation facilities (i.e. flushing toilets). Two types of analyses were conducted: first, adjusted logistic regression models were fitted to assess the relationship between lack of access to clean water and adequate sanitation to depression. Second, we conducted mediation analysis to investigate whether access to clean water mediated the relationship between lack of access to toilets and depression. A high proportion of rural participants lacked access to clean water (n = 6,188, 47.6%) and adequate toilets (n = 9,797, 81.6%). The regression analyses indicated that lack of access to both clean water (OR = 1.21, 95% CI: 1.06-1.39) and adequate sanitation (OR = 1.36, 95% CI: 1.10-1.69) were significantly associated with greater odds of depression. The mediation analysis indicated that access to clean water partially mediated the relationship between lack of access to adequate sanitation and depression, the total mediated effect being 18.2% (95% CI: 11.0%-51.0%). Most rural communities in South Africa lack access to basic services that are essential for human dignity and a decent quality of life, leading to opportunities for poor mental health, with its various consequences for socio-economic development and personal wellbeing, including avoidable depression.

Developing and testing unconditional cash transfer strategies among young adults with first-episode psychosis in South Africa: a study protocol for a pilot randomised control trial (PRS-FEP trial)

INTRODUCTION

Access to mental health services is a challenge, especially for young people who are over-represented in the unemployment and poverty index in South Africa. Therefore, continuing care is a problem after hospital discharge for young people with first-episode psychosis (FEP) due to a lack of clinical engagement and follow-up, for which they need support, including financial, to improve their outcomes. This pilot randomised control trial (RCT) aims to assess the feasibility and acceptability of financial support, in the form of an unconditional cash transfer (UCT), among young patients with FEP to prevent relapse.

METHODS AND ANALYSIS

This study will use a 1:1 ratio two-arm open-label pilot RCT of 60 young participants (18-29 years) with FEP in remission, who will be recruited from specialised psychiatric facilities in KwaZulu-Natal Province, South Africa. This study will implement an UCT and assess its feasibility, acceptability and preliminary clinical outcomes (ie, medication adherence, relapse, quality of life, personal and social function). The follow-up time will be 3 months, the outcomes being measured at baseline, months 1 and 3. Descriptive and conventional content analysis will be done for quantitative and qualitative data, respectively.

ETHICS AND DISSEMINATION

The study obtained provisional approval from the Biomedical Research Ethics Committee at the University of KwaZulu-Natal(#BREC/00004117/2022). Also is registered on the South African National clinical trial registry (#DOH-27-092022-5894) and approved by the KwaZulu-Natal department of health (#NHRD Ref: KZ_2002209_033). The results from this investigation will be actively disseminated through peer-reviewed journal publications, conference presentations and stakeholder engagement.

TRIAL REGISTRATION NUMBER

DOH-27-092022-5894.

Community disaster exposure and first onset of depression: A panel analysis of nationally representative South African data, 2008-2017

Sub-Saharan Africa faces unprecedented disasters, with climate change expected to exacerbate the frequency and severity of unpredictable and stressful catastrophic events. Unlike developed nations, reconstruction in developing nations is hindered by resource constraints, with certain communities potentially experiencing multiple and enduring effects of disasters. Despite the potential danger of such cumulative community disaster exposure on mental health (e.g. depression), large-scale population-level evidence for the region is limited. We investigated the association between exposure to cumulative disaster and the first onset of depression in a nationally representative survey in South Africa. We used panel data from the South African National Income Dynamics Study (SA-NIDS) from 2008-2017, consisting of 17,255 adult study participants who were depression free at baseline. Risk of first depression onset between individuals exposed and unexposed to community disaster was measured, accounting for multiple disaster exposure over time by fitting generalized estimating equation (GEE) regression models. Data on the geographic location of disasters were obtained from the South African government gazette, and mapped with the government delineated SA-NIDS households' locations. Of the sampled individuals, 2,986 were exposed to disaster during the study duration (17.3%). Increased cumulative community disaster was significantly associated with the likelihood of depression onset (adjusted relative risk [aRR] = 1.20, p<0.01, 95% CI: 1.09-1.33), even after controlling for socio-demographic factors. In sub-group analyses, greater likelihood of depression onset was found among females [but not in men] (aRR = 1.23, p<0.01, 95% CI: 1.09-1.38), Black African [but not in other population group] (aRR = 1.21, p<0.01, 95% CI: 1.09-1.36), lower education attainment group [but not in tertiary and above educational attainment group] (aRR = 1.20, p<0.01, 95% CI: 1.08-1.33), and lower income attainment group [but not in the top income quartile group] (aRR = 1.24, p<0.01, 95% CI: 1.11-1.38), due to cumulative community disaster. Although cumulative community disaster exposure was significantly associated with the first onset of depression, its negative impact may be more pronounced among individuals considered chronically socially vulnerable (i.e. the groups above) in South Africa. Given that many individuals in South Africa rely on social, food parcel relief, and health services from government/public sector, timely access to community-based supportive intervention is needed for disaster survivors, prioritizing socially vulnerable groups to help mitigate problems associated with mental health challenges.

Course of psychotic experiences and disorders among apprentice traditional health practitioners in rural South Africa: 3-year follow-up study

BACKGROUND

Culture is inevitably linked with the experience, interpretation and course of what modern biomedicine understands to be psychotic symptoms. However, data on psychoses in low- and middle-income countries are sparse. Our previous study showed that psychotic and mood-related experiences, symptoms and disorders are common among individuals who had received the ancestral calling to become a traditional health practitioner (THP) in rural KwaZulu-Natal, South Africa. Our related ethnographic study suggested that ukuthwasa (the training to become a THP) may positively moderate these calling-related symptoms. As far as we know, no research has been conducted into the course of psychiatric symptoms among apprentice THPs.

OBJECTIVE

We studied the course of psychotic experiences, symptoms and disorders among apprentice THPs. We also assessed their level of functioning and expanded our knowledge on ukuthwasa.

MATERIALS AND METHODS

We performed a 3-year follow-up of a baseline sample of apprentice THPs (n = 48). Psychiatric assessments (CAPE, SCAN), assessment of functioning (WHODAS) and a semi-structured qualitative questionnaire were completed for 42 individuals.

RESULTS

At 3-year follow-up, psychotic experiences were associated with significantly less distress and there was a reduction in frequency of psychotic symptoms compared to baseline. The number of participants with psychotic disorders had decreased from 7 (17%) to 4 (10%). Six out of seven participants (86%) with a psychotic disorder at baseline no longer had a psychiatric diagnosis at follow-up. Although the mean level of disability among the (apprentice) THPs corresponded with the 78th percentile found in the general population, 37 participants (88%) reported no or mild disability. Forty-one participants (98%) reported that ukuthwasa had positively influenced their psychiatric symptoms.

CONCLUSION

In rural KwaZulu-Natal, psychotic experiences, symptoms and disorders have a benign course in most individuals who are undergoing the process of becoming a THP. Ukuthwasa may be an effective, culturally sanctioned, healing intervention for some selected individuals, potentially because it reframes distressing experiences into positive and highly valued experiences, reduces stigma, and enhances social empowerment and identity construction. This implies that cultural and spiritual interventions can have a positive influence on the course of psychosis.

Ancestral calling, traditional health practitioner training and mental illness: An ethnographic study from rural KwaZulu-Natal, South Africa

This qualitative ethnographic study complements an epidemiological study on first episode psychosis in Vulindlela, a rural area in KwaZulu-Natal, South Africa. It focuses on two themes that emerged from our data: (1) the calling of the ancestors to become a traditional health practitioner and (2) ukuthwasa, the training to become a traditional health practitioner. The purpose of this study is to describe the ancestral calling, and to explore whether ukuthwasa may help with the management of mental disturbances, including unusual perceptual experiences. We also provide a discussion of the changing sociopolitical context of healing in KwaZulu-Natal, as a background to our study. In-depth interviews were conducted with 20 (apprentice) traditional health practitioners, formal health practitioners, patients and relatives recruited through local traditional health practitioners and a health care clinic. Our results show that the ancestral calling might announce itself with symptoms of mental illness including unusual perceptual experiences, for which some participants consider ukuthwasa as the only effective cure. We found indications that in some individuals successful completion of ukuthwasa might promote recovery from their illness and lead to a profession in which the unusual perceptual experiences become a legitimate and positively valued aspect. We suggest that - in this particular community today, which has been subject to several sociopolitical changes - ukuthwasa may be a culturally sanctioned healing process which moderates experiences that a Western psychiatric system might characterize as psychotic symptoms, providing some individuals with a lucrative and respected role in society.

Psychopathology among apprentice traditional health practitioners: A quantitative study from rural KwaZulu-Natal, South Africa

Sociocultural context seems to influence the epidemiology, phenotype, treatment, and course of psychosis. However, data from low- and middle-income countries is sparse. This research is part of a multidisciplinary and multimethod study on possible mental disturbances, including hallucinations, among (apprentice) traditional health practitioners (THPs) who have experienced the "ancestral calling to become a THP" in rural KwaZulu-Natal, South Africa. The aim of the current article is to examine whether the calling-related experiences can be assessed according to a psychiatric taxonomy. We included individuals who were identified with the calling and who were undergoing training to become a THP (ukuthwasa). IsiZulu-speaking formal mental health practitioners conducted thorough psychiatric interviews that measured psychological experiences with and without distress using the Community Assessment of Psychic Experiences, and psychiatric symptoms and disorders using the Schedule for Clinical Assessment in Neuropsychiatry. Of the 48 individuals who participated, 92% had psychotic experiences (PE), causing distress in 75%; and 23% met DSM-5 criteria for an unspecified psychotic disorder (15%) or mood disorder (8%). In conclusion, in rural KwaZulu-Natal, the ancestral calling may resemble phenomena that psychiatry would understand in the context of psychosis, ranging from subclinical PE to clinical psychotic disorder. Ukuthwasa might have a beneficial influence on the course of psychotic symptoms in some individuals, potentially because it reduces stigma and promotes recovery. Further multidisciplinary research is needed to investigate the psychopathology of the apprentice THPs and the underlying processes of ukuthwasa.

Major Depression and Stigma among Individuals with Multidrug-Resistant Tuberculosis in South Africa

Stigma is an important social determinant of health-seeking behavior; however, the nature and extent of its association with depression among people living with multidrug-resistant tuberculosis (MDR-TB) are not well-understood. We enrolled 200 microbiologically confirmed MDR-TB inpatients at a TB specialist hospital in KwaZulu-Natal Province, an area considered the epicenter for MDR-TB coinfection in South Africa. Four aspects of stigma and their association with major depression were assessed through individual interviews: 1) community and 2) patient perspectives toward TB, and 3) community and 4) patient perspectives toward HIV. A major depressive episode (MDE), HIV coinfection, and low income were significantly associated with greater stigma subscales. Based on an adjusted regression model, the MDE was the only factor independently associated with (all aspects of) stigma. These results indicate the potential utility of addressing stigma associated with the MDE as an important step in improving health-seeking behavior to promote adherence and retention in care.

Spatial clustering of food insecurity and its association with depression: a geospatial analysis of nationally representative South African data, 2008-2015

While food insecurity is a persistent public health challenge, its long-term association with depression at a national level is unknown. We investigated the spatial heterogeneity of food insecurity and its association with depression in South Africa (SA), using nationally-representative panel data from the South African National Income Dynamics Study (years 2008-2015). Geographical clusters ("hotpots") of food insecurity were identified using Kulldorff spatial scan statistic in SaTScan. Regression models were fitted to assess association between residing in food insecure hotspot communities and depression. Surprisingly, we found food insecurity hotspots (p < 0.001) in high-suitability agricultural crop and livestock production areas with reliable rainfall and fertile soils. At baseline (N = 15,630), we found greater likelihood of depression in individuals residing in food insecure hotspot communities [adjusted relative risk (aRR) = 1.13, 95% CI:1.01-1.27] using a generalized linear regression model. When the panel analysis was limited to 8,801 participants who were depression free at baseline, residing in a food insecure hotspot community was significantly associated with higher subsequent incidence of depression (aRR = 1.11, 95% CI:1.01-1.22) using a generalized estimating equation regression model. The association persisted even after controlling for multiple socioeconomic factors and household food insecurity. We identified spatial heterogeneity of food insecurity at a national scale in SA, with a demonstrated greater risk of incident depression in hotspots. More importantly, our finding points to the "Food Security Paradox", food insecurity in areas with high food-producing potential. There is a need for place-based policy interventions that target communities vulnerable to food insecurity, to reduce the burden of depression.

Neurocognitive functioning in MDR-TB patients with and without HIV in KwaZulu-Natal, South Africa

OBJECTIVES

Optimising medication adherence is one of the essential factors in reversing the tide of a TB-HIV syndemic in sub-Saharan Africa, especially South Africa. Impairment in key neurocognitive domains may impair patients' ability to maintain adherence to treatment, but the level of cognition and its relationship to HIV status has not been examined in individuals with drug-resistant TB. We therefore investigated performance on several key neurocognitive domains in relationship to HIV status in a multidrug-resistant tuberculosis patients (MDR-TB) sample.

METHODS

We enrolled microbiologically confirmed MDR-TB inpatients at a TB-specialist referral hospital in KwaZulu-Natal province, South Africa. We collected cross-sectional data on sociodemographic, clinical and neurocognitive function (e.g. attention, memory, executive functioning, language fluency, visual-spatial, eye-hand coordination). For the primary analysis, we excluded participants with major depressive episode/substance use disorder (MDE/SUD). We fitted adjusted Poisson regression models to explore the association between HIV and neurocognitive function.

RESULTS

We enrolled 200 people with MDR-TB; 33 had MDE/SUD, and data of 167 were analysed (151 HIV+, 16 HIV-). The mean age of participants was 34.2 years; the majority were female (83%), and 53% had not completed secondary school. There was evidence of impaired neurocognitive functioning across all domains in both HIV+/- study participants. Based on the regression analyses, individuals with co-infection (MDR-TB/HIV+), as well as those who had longer duration of hospital stays experienced significantly lower cognitive performance in several domains. Poor cognitive performance was significantly related to older age and lower educational attainment. The presence of major depression or substance use disorders did not influence the significance of the findings.

CONCLUSIONS

Adults with MDR-TB have significant neurocognitive impairment, especially if HIV positive. An integrated approach is necessary in the management of MDR-TB as cognitive health influences the ability to adhere to chronic treatment, clinical outcomes and functionality.

Exposure to waste sites and their impact on health: a panel and geospatial analysis of nationally representative data from South Africa, 2008-2015

BACKGROUND

Rapid population growth, urbanisation, and economic development have led to an unprecedented number of waste sites in developing countries. This challenge has become a contentious international relations issue, with an unsustainable amount of waste and its health consequences often being borne by developing countries. However, little national-level evidence is available in sub-Saharan Africa to quantify the association between exposure to waste sites and health.

METHODS

We used panel data from the South African National Income Dynamics Study (SA-NIDS) to investigate the association between exposure to waste sites and asthma, tuberculosis, diabetes, and depression. The SA-NIDS is a panel survey of a nationally representative sample in South Africa, which includes data reporting the health status of 32 255 individuals between 2008 and 2015. The study exposure was distance of households, in km, to the nearest waste site, derived from waste site geospatial locations from the South Africa Waste Information System.

FINDINGS

We observed a substantial increase in exposure of households to waste sites between 2008 and 2015. The median distance between study households and waste sites decreased from 68·3 km (IQR 31·1-111·7) to 8·5 km (3·0-23·7). Residing within 5 km of a waste site was significantly associated with asthma (adjusted relative risk 1·41; 95% CI 1·20-1·64), tuberculosis (1·18; 1·02-1·36), diabetes (1·25; 1·05-1·49), and depression (1·08; 1·03-1·14). The association persisted even after controlling for multiple socioeconomic factors.

INTERPRETATION

We identified multiple adverse health outcomes in individuals living close to waste sites at a national level in South Africa, suggesting the need to reduce the number and size of waste sites to diminish harmful effects on health and wellbeing for communities living in close proximity to such sites.

FUNDING

South African Medical Research Council, South African National Treasury, and Wellcome Trust.

Predictors of quality of life among community psychiatric patients in a peri-urban district of Gauteng Province, South Africa

BACKGROUND

Few studies on quality of life (QoL) among people with mental illness have been conducted in South Africa, and none in community dwelling individuals. However, a greater understanding of subjective QoL may inform community-based medical, psychotherapeutic, or social interventions. This study examined the QoL, clinical and sociodemographic characteristics of psychiatric patients attending community mental health clinics in the Gauteng Province of South Africa.

METHODS

A cross sectional interview-based study was conducted with 121 adult patients attending community psychiatric clinics. To reduce the impact of acute psychiatric symptoms on subjective QoL, only clinically stable patients were included. Sociodemographic details and clinical characteristics were recorded. Subjective QoL was assessed using the World Health Organization QOL-Bref scale (WHOQOL-Bref), and severity of psychiatric illness measured with the Brief Psychiatric Rating Scale, expanded version 4.0 (BPRS-E).

RESULTS

Just over half of the sample rated their overall QoL as good or very good. Residual psychiatric symptomatology was the strongest predictor of a poor QoL in all four domains of the WHOQOL-Bref. The most severe BPRS scores were for the symptoms of depression, anxiety and somatic concern. Perceived social support significantly predicted a better QoL in the psychological, social relationships and environmental domains.

CONCLUSION

This study highlights the negative impact of residual psychiatric symptoms on subjective QoL and the importance of social support in enhancing QoL.

Neurocognitive Impairment Risk Among Individuals With Multiple Drug-Resistant Tuberculosis and Human Immunodeficiency Virus Coinfection: Implications for Systematic Linkage to and Retention of Care in Tuberculosis/Human Immunodeficiency Virus Treatment

Although neurocognitive impairment (NCI) is a well-recognized challenge in human immunodeficiency virus (HIV), there is little evidence regarding it among individuals with multiple drug-resistant tuberculosis (MDR-TB) within HIV endemic sub-Saharan Africa. The extent of NCI risk, particularly HIV-associated neurocognitive disorders (HAND) risk, was investigated in 200 microbiologically confirmed inpatients with MDR-TB at a TB-specialist hospital in KwaZulu-Natal Province, South Africa. Within this population, the prevalence of HIV coinfection, major depressive episode, and substance use disorder was 89.50%, 10.50%, and 7.00%, respectively. After excluding individuals with major depressive episode/substance use disorder and monoinfection (i.e., MDR-TB without HIV), the prevalence of HAND risk was 43.5%. Older and low-income individuals had significantly greater odds of HAND risk, whereas those with family members/relatives who work(ed) in the health services had lower odds. The role of timely linkage to and retention of care in TB/HIV treatment to offset cognitive decline in MDR-TB/HIV coinfected individuals needs to be investigated further.

Major depression and household food insecurity among individuals with multidrug-resistant tuberculosis (MDR-TB) in South Africa

PURPOSE

Household food insecurity in South Africa is a pervasive public health challenge. Although its link to chronic health conditions is well established, its relationship to mental illness, particularly major depression, is not well-understood. Despite KwaZulu-Natal Province being the epicenter of the drug-resistant tuberculosis (MDR-TB) epidemic, and having the largest share of poverty in South Africa, this relationship remains unexamined. This study investigated the association between major depressive episode (MDE) and household food insecurity among individuals with MDR-TB.

METHODS

We enrolled and interviewed 141 newly admitted microbiologically confirmed MDR-TB inpatients at a specialized TB hospital in KwaZulu-Natal Province, South Africa. Logistic regression models were fitted to assess the relationship between MDE and household food insecurity, while accounting for socio-demographic status (e.g., age, gender, education, marital status, social grant status, income, and preference for living in one's community).

RESULTS

The prevalence of MDE and household food insecurity was 11.35% and 21.01%, respectively. MDE was significantly associated with household food insecurity (aOR 4.63, 95% CI 1.17-18.38). Individuals who are female (aOR 6.29, 95% CI 1.13-35.03), young (aOR 8.86, 95% CI 1.69-46.34), have low educational attainment (aOR 6.19, 95% CI 1.70-22.59) and receive social grants (aOR 7.60, 95% CI 2.36-24.48) were most at risk of household food insecurity.

CONCLUSIONS

MDE in individuals with MDR-TB was significantly associated with household food insecurity, independent of socio-economic status. Although MDR-TB is not exclusively a disease of the poor, individuals from socio-economically disadvantaged backgrounds (e.g., female, young adults, low education, and social grant recipients) were more likely to experience household food insecurity. Our study underscores the need to address the co-occurring cycles of food insecurity and untreated MDE in South Africa.

Identification of patients with recent-onset psychosis in KwaZulu Natal, South Africa: a pilot study with traditional health practitioners and diagnostic instruments

PURPOSE

There is considerable variation in epidemiology and clinical course of psychotic disorders across social and geographical contexts. To date, very little data are available from low- and middle-income countries. In sub-Saharan Africa, most people with psychoses remain undetected and untreated, partly due to lack of formal health care services. This study in rural South Africa aimed to investigate if it is possible to identify individuals with recent-onset psychosis in collaboration with traditional health practitioners (THPs).

METHODS

We developed a strategy to engage with THPs. Fifty THPs agreed to collaborate and were asked to refer help-seeking clients with recent-onset psychosis to the study. At referral, the THPs rated probability of psychosis ("maybe disturbed" or "disturbed"). A two-step diagnostic procedure was conducted, including the self-report Community Assessment of Psychic Experiences (CAPE) as screening instrument, and a semi-structured interview using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Accuracy of THP referrals, and test characteristics of the THP rating and the CAPE were calculated.

RESULTS

149 help-seeking clients were referred by THPs, of which 44 (29.5%) received a SCAN DSM-IV diagnosis of psychotic disorder. The positive predictive value of a THP "disturbed" rating was 53.8%. Test characteristics of the CAPE were poor.

CONCLUSION

THPs were open to identifying and referring individuals with possible psychosis. They recognized "being disturbed" as a condition for which collaboration with formal psychiatric services might be beneficial. By contrast, the CAPE performed poorly as a screening instrument. Collaboration with THPs is a promising approach to improve detection of individuals with recent-onset psychosis in rural South Africa.

Metabolic syndrome in antipsychotic naive African patients with severe mental illness in usual care

BACKGROUND

To determine the prevalence and incidence of metabolic syndrome in individuals with a first episode of severe mental illness from South Africa.

METHODS

Antipsychotic naïve study subjects with a first episode of severe mental illness and control subjects were recruited at baseline for a prospective study. Individuals without metabolic syndrome at baseline were followed up for 12 months after antipsychotic medication was initiated. Metabolic syndrome was determined at baseline and at the 12-month follow-up using the Joint Interim Statement criteria.

RESULTS

At baseline, the 67 study (M:F; 48:19) and 67 control subjects (M:F; 48:19) had a mean age of 22.8 (±3.7) and 23.3 (±2.6) years (P = .4), respectively. The majority were of black African ethnicity (97%) and 82% were diagnosed with schizophrenia. There was no difference in the prevalence of metabolic syndrome (4.5%) or any of the individual components between the study and control group prior to the initiation of antipsychotics. Of the 64 study subjects without metabolic syndrome at baseline, only 36 (M:F; 25:11) completed the 12-month follow-up (response rate 56.3%) and 2 subjects developed metabolic syndrome .The incidence of metabolic syndrome was 5.5% with a significant increase in the elevated waist circumference criterion after 1 year of antipsychotic treatment (P = .02).

CONCLUSIONS

There was a low prevalence and incidence of metabolic syndrome in this group of patients with a first episode of severe mental illness.

Sexual trauma and post-traumatic stress among African female refugees and migrants in South Africa

Background

While there is considerable research in developed countries on the nature and extent of post-traumatic stress among refugees and migrants, few report on female Africans migrating within Africa.

Aim

The aim of this study was to investigate the association between exposure to traumatic life events and post-traumatic stress disorder risk in refugees and migrants in Durban, South Africa, with specific focus on sexual trauma events among women.

Methods

Interviews were conducted on 157 consenting non-South African adults using a sociodemographic questionnaire, Life Events Checklist (documenting traumatic events experienced) and the Harvard Trauma Questionnaire (measuring post-traumatic symptomatology). Associations between total number of traumatic events and post-traumatic stress were explored using adjusted regression models.

Results

The results of one model indicated that greater numbers of traumatic life events experienced by women were associated with raised odds of post-traumatic stress disorder risk (β = 1.48; p < 0.001). Another model indicated that exposure to sexual trauma events were associated with greater odds of post-traumatic stress disorder risk (β = 4.09; p = 0.02).

Conclusion

Our findings highlight the critical importance of mental health service for females with history of sexual traumatic events for this vulnerable population.

Sexual trauma and post-traumatic stress among African female refugees and migrants in South Africa

Background

While there is considerable research in developed countries on the nature and extent of post-traumatic stress among refugees and migrants, few report on female Africans migrating within Africa.

Aim

The aim of this study was to investigate the association between exposure to traumatic life events and post-traumatic stress disorder risk in refugees and migrants in Durban, South Africa, with specific focus on sexual trauma events among women.

Methods

Interviews were conducted on 157 consenting non-South African adults using a sociodemographic questionnaire, Life Events Checklist (documenting traumatic events experienced) and the Harvard Trauma Questionnaire (measuring post-traumatic symptomatology). Associations between total number of traumatic events and post-traumatic stress were explored using adjusted regression models.

Results

The results of one model indicated that greater numbers of traumatic life events experienced by women were associated with raised odds of post-traumatic stress disorder risk (β = 1.48; p < 0.001). Another model indicated that exposure to sexual trauma events were associated with greater odds of post-traumatic stress disorder risk (β = 4.09; p = 0.02).

Conclusion

Our findings highlight the critical importance of mental health service for females with history of sexual traumatic events for this vulnerable population.

Psychosocial and behavioural interventions towards HIV risk reduction for serodiscordant couples in Africa: A systematic review

BACKGROUND

Sexual transmission of HIV frequently occurs in the context of a primary relationship between two partners; however, HIV prevention interventions generally focus on individuals at risk, rather than specifying couples as a unit of change and analysis, neglecting the crucial role that partners may play in sexual behaviour. This article reviews published scientific literature addressing couple-oriented HIV counselling and testing and other behavioural interventions using an online search for peer-reviewed papers.

METHODS

A systematic review was conducted to evaluate what has been published on psychosocial interventions in HIV serodiscordant couples in Africa. Electronic databases were searched from January 1990 to December 2015. Quality assessment of included studies was conducted using the Systematic Appraisal of Quality in Observational Research tool.

RESULTS

The electronic database searches initially retrieved 493 records; after cross-referencing, removing duplicates and applying strict inclusion and exclusion criteria, only eight papers were included in this review. All the studies under review showed that couples-focused counselling and educational programmes were associated with positive outcomes including reduced HIV transmission, reduced unprotected sex, increased rates of status disclosure and high levels of treatment adherence.

CONCLUSIONS

The literature on interventions for HIV serodiscordant couples is sparse. However, most interventions indicate that couples-focused interventions are effective in HIV risk reduction. In spite of the limited available data and repeated recommendations by different health authorities, couple-centred approaches to HIV prevention have not been implemented on a large scale.

A comparative study of socio-demographic and substance use correlates in early-onset psychosis

BACKGROUND

Comorbid substance use, particularly cannabis among adolescents with mental illness, is a major public health concern in developing countries with limited mental health resources. Better understanding of the association between cannabis use and other polysubstance use and early mental illness will provide for more targeted early interventions.

AIM

This aim of this study was to examine the socio-demographic profile and cannabis use characteristics among adolescents with first-episode early-onset psychosis (EOP) and compare with age-matched and gender-matched adolescents with first-episode non-psychotic mental illness (controls).

METHOD

Forty-five adolescents with first-episode EOP and 45 controls were assessed using a clinical interview, Positive and Negative Syndrome Scale and World Health Organization Alcohol, Smoking and Substance Involvement Screening test (ASSIST) for substance-related problems.

RESULTS

There were significant socio-demographic differences among the adolescents with EOP (73% Black, 64% from low family income, 44% from rural areas) compared with controls (24% Black, 53% from low family income, 2% from rural areas). Although there was no difference in lifetime cannabis use, EOP adolescents differed in motivation for cannabis use, had increased current cannabis use (38%, P = 0.01) and more frequent use (52%, P = 0.04) compared with controls (16% current and 18% frequent use). EOP adolescents reported more hazardous use with higher ASSIST mean cannabis-specific involvement scores (EOP 10,2; controls 2,3; P = 0.004).

CONCLUSION

The differences in socio-demographic variables may reflect the marked disparity in access to mental health care for rural Black youth. Psychotic youth may be more vulnerable to comorbid cannabis-related problems than other mentally ill adolescents. The study highlights the need for early introduction of substance use interventions among adolescents with mental illness.

Substance use in adolescents with mental illness in Durban, South Africa

Comorbid substance use in adolescents with mental illness is often an indicator of poor treatment outcome. This study aims to determine the prevalence of, and associated risk factors for, substance use in adolescents with mental illness attending a mental health service. Data was collected from hospital records of 162 adolescents, using a structured data sheet, over a two-year period. Substance use was more significant in older adolescents and those with severe mental illness. Sixty-two (38.3%) adolescents used substances. Thirty-seven (38.1%) male adolescents reported substance use compared to 25 (38.5%) female adolescents. Alcohol was the most commonly used substance (n = 48; 29.6%), followed by cannabis (n = 32; 19.8%). There were significant direct associations between substance use and history of abuse or neglect, forensic history, educational setting, admission status, and the psychiatric diagnoses of schizophrenia, other psychotic disorders, and bipolar mood disorder. Inverse associations were found between substance use and adjustment disorders, attention deficit hyperactivity disorder, and intellectual disability. The results of this study indicate an urgent need for substance misuse programmes for at risk youth, and the introduction of dual diagnosis intervention programmes in this age group.

Epidemiological patterns of mental disorders and stigma in a community household survey in urban slum and rural settings in Kenya

PURPOSE

This study investigated the epidemiological patterns of mental illness and stigma in community households in Kenya using a cross-sectional community household survey among 846 participants.

METHODS

A cross-sectional community household survey was conducted around urban slum (Kangemi) and rural (Kibwezi) selected health facilities in Kenya. All households within the two sites served by the selected health facilities were included in the study. To select the main respondent in the household, the oldest adult who could speak English, Kiswahili or both (the official languages in Kenya) was selected to participate in the interview. The Opinion about Mental Illness in Chinese Community (OMICC) questionnaire and the MINI-International Neuropsychiatric Interview-Plus Version 5 (MINI) tools were administered to the participants. Pearson's chi-square test was used to compare prevalence according to gender, while adjusted regression models examined the association between mental illness and views about mental illness, stratified by gender.

RESULTS

The overall prevalence of mental illness was 45%, showing gender differences regarding common types of illness. The opinions about mental illness were similar for men and women, while rural respondents were more positively opinionated than urban participants. Overall, suffering from mental illness was associated with more positive opinions among women and more negative opinions among men.

CONCLUSION

More research is needed into the factors explaining the observed differences in opinion about mental illness between the subgroups, and the impact of mental illness on stigma in Kenya in order to create an evidence-based approach against stigma.

Food Insecurity and Risk of Depression Among Refugees and Immigrants in South Africa

South Africa's refugee population has grown considerably over the last decade. Both food insecurity and mental illness are common in developing countries, but this relationship remains unexamined in an African refugee population. 335 adult refugees in Durban, South Africa were interviewed using a self-report of food insecurity and the Hopkins Symptom Checklist-25. The proportion of those who responded 'often true' to not having enough food and eating less was 23.1 and 54.3 %, respectively. The proportion of individuals with a significant level of anxiety and depressive symptomatology was 49.4 and 54.6 %, respectively. The adjusted logistic regression indicated that not eating enough was significantly associated with anxiety (aOR = 4.52, 95 % CI: 2.09-9.80) and depression (aOR = 4.51, 95 % CI: 2.01-10.09). Similarly, eating less was significantly associated with anxiety (aOR = 2.88, 95 % CI: 1.56-5.31) and depression (aOR = 2.88, 95 % CI: 1.54-5.39). The high prevalence of food insecurity, and its relationship to mental illness, highlight the importance of addressing basic needs among this population.

Income inequality and depression: a systematic review and meta-analysis of the association and a scoping review of mechanisms

Most countries have witnessed a dramatic increase of income inequality in the past three decades. This paper addresses the question of whether income inequality is associated with the population prevalence of depression and, if so, the potential mechanisms and pathways which may explain this association. Our systematic review included 26 studies, mostly from high-income countries. Nearly two-thirds of all studies and five out of six longitudinal studies reported a statistically significant positive relationship between income inequality and risk of depression; only one study reported a statistically significant negative relationship. Twelve studies were included in a meta-analysis with dichotomized inequality groupings. The pooled risk ratio was 1.19 (95% CI: 1.07-1.31), demonstrating greater risk of depression in populations with higher income inequality relative to populations with lower inequality. Multiple studies reported subgroup effects, including greater impacts of income inequality among women and low-income populations. We propose an ecological framework, with mechanisms operating at the national level (the neo-material hypothesis), neighbourhood level (the social capital and the social comparison hypotheses) and individual level (psychological stress and social defeat hypotheses) to explain this association. We conclude that policy makers should actively promote actions to reduce income inequality, such as progressive taxation policies and a basic universal income. Mental health professionals should champion such policies, as well as promote the delivery of interventions which target the pathways and proximal determinants, such as building life skills in adolescents and provision of psychological therapies and packages of care with demonstrated effectiveness for settings of poverty and high income inequality.

The clinical impact of a positive family history of psychosis or mental illness in psychotic and non-psychotic mentally ill adolescents

BACKGROUND

A family history of psychosis is associated with negative clinical characteristics of psychosis.

AIM

We aimed to determine the relationship between a family history (in first-degree relatives) of psychosis (FHP) or of any mental illness (FHM), and the clinical features (including cannabis use) of first episode early onset psychosis (EOP).

METHOD

Forty-five adolescents with first episode EOP presenting to psychiatric services were assessed by clinical interview with the following tools: socio-demographic questionnaire, Positive and Negative Syndrome Scale (PANSS), Symptom Onset in Schizophrenia (SOS) inventory, and the World Health Organisation's (WHO) Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) for cannabis misuse. Forty-five gender and age matched controls with incident non-psychotic mental illness were recruited from the same clinical sites.

RESULTS

While there was evidence of trend associations, EOP adolescents and controls did not differ in terms of either FHP or FHM. However, adolescents with a non-psychotic mental illness (controls) were significantly more likely to have a family history of non-psychotic mental illness (EOP = 13%; controls = 47%, p = 0.001). In EOP adolescents, a positive FHP was associated with a significantly lower mean PANSS positive score (p = 0.009), but not with other clinical features.

CONCLUSION

FHP may be a diagnostic clue in adolescents and is not necessarily associated with negative clinical characteristics at disease onset in EOP. However, this requires further research.

Spinal Muscular Atrophy: More than a Disease of Motor Neurons?

Spinal muscular atrophy (SMA) is the most common genetically inherited neurodegenerative disease resulting in infant mortality. SMA is caused by genetic deletion or mutation in the survival of motor neuron 1 (SMN1) gene, which results in reduced levels of the survival of motor neuron (SMN) protein. SMN protein deficiency preferentially affects α- motor neurons, leading to their degeneration and subsequent atrophy of limb and trunk muscles, progressing to death in severe forms of the disease. More recent studies have shown that SMN protein depletion is detrimental to the functioning of other tissues including skeletal muscle, heart, autonomic and enteric nervous systems, metabolic/endocrine (e.g. pancreas), lymphatic, bone and reproductive system. In this review, we summarize studies discussing SMN protein's function in various cell and tissue types and their involvement in the context of SMA disease etiology. Taken together, these studies indicate that SMA is a multi-organ disease, which suggests that truly effective disease intervention may require body-wide correction of SMN protein levels.

At zero and turning in circles: refugee experiences and coping in Durban, South Africa

Millions of refugees are on the move globally, mostly settling in low- and middle-income (LMIC) "host" countries, where they often receive insufficient assistance and encounter a multitude of barriers. Despite a risk for developing mental illness, limited research exists on their struggles and coping strategies in these settings, especially outside of camps. Against this backdrop, our qualitative study aimed to gain a deeper understanding of refugee experiences in Durban, South Africa. We conducted semistructured individual interviews with 18 adult refugees from Zimbabwe and the Democratic Republic of Congo at a community-based support center in Durban. Participants described their problems, effects on mental health, and coping abilities. Interviews were recorded and analyzed for themes. Major problems were reported with work, xenophobia/racism, mental health, physical safety, housing, healthcare, and quality of life. Participants discussed feelings of worry, fear, emotional pain, anger, powerlessness, hopelessness, worthlessness, and passive suicidal ideation. Coping mechanisms consisted of friendships, church, praying, work, physical activities, family, learning the local language, and avoidance of thoughts. Many interviewees expressed a strong desire to either return to their homeland or move elsewhere. Refugees in South Africa face considerable hardships including xenophobia, physical abuse, and work/legal obstructions. More research is needed in LMICs to identify the challenges, psychological effects, and coping in such populations so that appropriate and accessible mental health services can be created for those who require them.

Counting the cost of Afrophobia: Post-migration adaptation and mental health challenges of African refugees in South Africa

There are few studies on the role of migration within sub-Saharan Africa and its relation to the development of mental illness. We investigated post-resettlement adaptation and mental health challenges of African refugees/migrants in Durban, South Africa. We interviewed 335 African help-seeking refugees/migrants for anxiety, depression (25-item Hopkins Symptom Checklist) and post-traumatic stress symptoms (30-item Harvard Trauma Questionnaire). Socio-demographic and migration history, focusing on post-migration circumstances and experiences of discrimination in the host country, were obtained. Association between migration and post-settlement factors and mental health outcomes were assessed using adjusted logistic regression models. Prevalence of mental distress was high: 49.4% anxiety, 54.6% depression and 24.9% post-traumatic stress symptoms. After adjustment for family separation since migration, recent arrival in South Africa was associated with increased risk for depression (aOR = 4.0, 95% CI:1.3-11.8) and post-traumatic stress (aOR = 5.2, 95% CI:1.7-15.9), while in unadjusted models, older age on arrival was associated with anxiety (aOR = 5.3, 95% CI:1.4-19.8) and depression (aOR = 6.2, 95% CI:1.6-24.3). History of family separation since migration was independently associated with depression and post-traumatic stress in all models. Discriminatory experiences since migration was also an independent risk factor for all three mental health outcomes. Finally, being divorced/widowed was associated with an increased risk for post-traumatic stress, while higher income earners were protected against post-traumatic symptoms, even after adjustment. Refugees/migrants in South Africa show a significant burden of mental distress that is linked to challenges of adjustment in an often hostile context. Services addressing these and other health-related, social-economic needs should be developed as a priority.

Proximity to healthcare clinic and depression risk in South Africa: geospatial evidence from a nationally representative longitudinal study

Proximity to primary healthcare facilities may be a serious barrier to accessing mental health services in resource-limited settings. In this study, we examined whether the distance to the primary healthcare clinic (PHCC) was associated with risk of depression in KwaZulu-Natal Province, South Africa. Depressive symptoms and household coordinates data were accessed from the nationally representative South African National Income Dynamics Study. Distances between households and their nearest PHCCs were calculated and mixed-effects logistic regression models fitted to the data. Participants residing <6 km from a PHCC (aOR = 0.608, 95% CI 0.42-0.87) or 6-14.9 km (aOR = 0. 612, 95% CI 0.44-0.86) had a lower depression risk compared to those residing ≥15 km from the nearest PHCC. Distance to the PHCC was independently associated with increased depression risk, even after controlling for key socioeconomic determinants. Minimizing the distance to PHCC through mobile health clinics and technology could improve mental health.

Green environment and incident depression in South Africa: a geospatial analysis and mental health implications in a resource-limited setting

BACKGROUND

Unprecedented levels of habitat transformation and rapid urbanisation are changing the way individuals interrelate with the natural environment in developing countries with high economic disparities. Although the potential benefit of green environments for mental health has been recognised, population-level evidence to this effect is scarce. We investigated the effect of green living environment in potentially countering incident depression in a nationally representative survey in South Africa.

METHODS

We used panel data from the South African National Income Dynamics Study (SA-NIDS). Our study used SA-NIDS data from three waves: wave 1 (2008), wave 2 (2010), and wave 3 (2012). Households were sampled on the basis of a stratified two-stage cluster design. In the first stage, 400 primary sampling units were selected for inclusion. In the second stage, two clusters of 12 dwelling units each were drawn from within each primary sampling unit (or 24 dwelling units per unit). Household and individual adult questionnaires were administered to participants. The main outcome, incident depression (ie, incident cohort of 11 156 study participants without significant depression symptoms at their first entry into SA-NIDS), was assessed in the adult survey via a ten item version of the Center for Epidemiologic Studies Depression Scale; a total score of ten or higher was used as a cutoff to indicate significant depressive symptoms. Each participant was assigned a value for green living space via a satellite-derived normalised difference vegetation index (NDVI) based on the GPS coordinates of their household location.

FINDINGS

Overall, we found uneven benefit of NDVI on incident depression among our study participants. Although the green living environment showed limited benefit across the study population as a whole, our final analysis based on logistic regression models showed that higher NDVI was a predictor of lower incident depression among middle-income compared with low-income participants (adjusted odds ratio [aOR] 0·98, 0·97-0·99, p<0·0001), although when this analysis was broken down by race, its positive effect was particularly evident amongst African individuals. Living in rural areas was linked to lower odds of incident depression (aOR 0·71, 0·55-0·92, p=0·011) compared with study participants residing in urban informal areas that often lack formal planning.

INTERPRETATION

Our results imply the importance of green environments for mental wellbeing in sub-Saharan African settings experiencing rapid urbanisation, economic and epidemiological transition, reaffirming the need to incorporate environmental services and benefits for sustainable socioeconomic development.

FUNDING

South African Medical Research Council, National Institutes of Health, and Academy of Finland.

The clinical value of brain computerised tomography in a general hospital psychiatric service

Background

The use of neuroimaging modalities in psychiatry has been evaluated in several studies. The vast majority seem to suggest that neuroimaging may be overutilised in psychiatry. There is a significant constraint on availability and cost related to neuroimaging of patients at general state medical facilities. The routine use of computerised tomography (CT) scanning is thus questioned.

Methods

A retrospective analysis was undertaken of all psychiatric inpatients who had CT scans performed from 01 January 2011 to 31 December 2012. Demographic data, mental state examination, physical examination findings, substance use and diagnosis upon admission were recorded. The relationship between these variables and CT scan findings was analysed.

Results

A total of 897 admissions were retrospectively analysed. One hundred and three patients had documented CT scan imaging. In total, 17 of the 23 patients with abnormal findings on CT scan were found to be psychotic (74.0%). The remaining 26.0% included depression and dementia. There was no statistically significant difference between the normal and abnormal CT scan groups with regard to gender, age, family history, substance use and physical examination. The majority (65.2%) had cerebral atrophy and/or cerebral calcifications. A smaller group of other documented findings was noted.

Conclusions

Selective indications and clinical markers may be utilised in order to justify brain imaging studies rather than performing them routinely. That being true, a multicentre study with a larger sample size is indicated to further improve the statistical significance and assist in formulating a more concrete guideline for neuroimaging of psychiatric patients.

High risk of metabolic syndrome among black South African women with severe mental illness

Background

There is an increased prevalence of metabolic syndrome (MetS) in individuals with severe mental illness (SMI) globally. The prevalence of MetS is higher in black women compared to black men from South Africa.

Aim

To compare the prevalence of MetS between black South African men and women with SMI taking antipsychotic medication. Further, this prevalence was compared to the prevalence in a matched control group of black South African men and women without SMI.

Setting

A general hospital psychiatric unit.

Methods

A cross-sectional study was undertaken to compare the prevalence of MetS in a group of multi-ethnic participants with SMI treated with antipsychotic medication and a matched control group without SMI, applying the 2009 Joint Interim Statement (JIS) criteria. Here, we included only the black African participants to compare MetS prevalence between men and women.

Results

There were 232 participants in the group with SMI (male 155 and female 77) and without SMI (male 156 and female 76). The prevalence of MetS was more than three times higher in women with SMI compared to men with SMI (37.7% vs. 10.3%, p < 0.001). There was no significant difference in the prevalence of MetS in men or women between the groups with and without SMI. In multivariate logistic regression analysis, female gender (odds ratio [OR] 7.66), advancing age (OR 1.08) and longer duration of illness (OR = 1.15) were significant risk factors for MetS in SMI.

Conclusion

In black South Africans with SMI on antipsychotic medication, there is a higher prevalence and risk for MetS in women compared to men.

Psychosis and help-seeking behavior in rural KwaZulu Natal: unearthing local insights

Background

Growing interest in strategies regarding early intervention for psychosis has led to a parallel interest in understanding help-seeking behavior, especially in low- and middle-income countries (LMICs). Nevertheless, few LMIC studies have examined individuals with psychosis in non-urban, non-hospital settings. Using the perspective of formal and informal community service providers, we aimed to uncover descriptions of people with psychosis in a rural South African community and illuminate the potential complexities of their help-seeking journeys.

Methods

We conducted a qualitative study of 40 key informant interviews and seven focus groups with stakeholders (traditional leaders, traditional healers, religious leaders, health care nurses, heads of non-governmental organizations, schoolteachers, community caregivers) in a rural Zulu community (Vulindlela). Thematic analysis of the data was performed using the inductive analysis approach.

Results

Interviewees discussed 32 individuals with probable psychosis in their community and provided rich descriptions of their symptoms. A complex picture of help-seeking behavior, primarily involving informal mental health service providers, emerged. Over half of the reported cases had no contact with formal health services in the course of their help-seeking journey; while more than two-thirds never attended a hospital and only 1 in 8 accessed a psychiatric hospital.

Conclusions

Our results highlight the important role of informal care providers in LMICs as well as the need for more research on mental illness and local providers in non-hospital contexts. Community stakeholders can contribute to a fuller understanding of these issues, thereby assisting in the creation of appropriate and effective mental health interventions for rural South African communities like Vulindlela.

The relationship between immigration and depression in South Africa: evidence from the first South African National Income Dynamics Study

Few studies have examined depression among immigrants in post-apartheid South Africa, and factors that strengthen the relationship between immigration and depression. The first wave of the National Income Dynamics Study was used to investigate links between immigration and depression (n = 15,205). Depression symptoms were assessed using a 10-item version of the Center for Epidemiologic Studies Depression (CES-D) Scale. Immigrants in South Africa had fewer depressive symptoms (CES-D ≥ 10) than locally-born participants (17.1 vs. 32.4%, F = 13.5, p < 0.01). Multilevel mixed-effects logistic regression analyses found that among immigrant populations, younger age (adjusted OR 1.03, 95% CI 1.01-1.05) and black African ethnicity (adjusted OR 3.72, 95% CI 1.29-10.7) were associated with higher depression. Younger age was associated with lower depression among locally-born study participants (adjusted OR 0.98, 95% CI 0.97-0.98). The varying relationship between certain demographic factors, depression and the different mental health challenges among these groups requires closer attention.

Clinical correlates of first episode early onset psychosis in KwaZulu-Natal, South Africa

BACKGROUND

The study of first episode early onset psychosis can yield many clues to understanding the early development of psychosis and guide interventions to decrease psychosis risk and improve outcome. The aim of the study was to investigate the socio-demographic profile and clinical correlates in early onset psychosis.

METHOD

Forty-five adolescents with first episode early onset psychosis were assessed by a clinical interview, socio-demographic questionnaire, the Positive and Negative Syndrome Scale (PANSS), Symptom Onset in Schizophrenia (SOS) score, the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (WHO ASSIST) questionnaire for substance misuse and a urine cannabis level.

RESULTS

The mean age of the respondents was 15.9 years (SD 1.8, range 10-18 years). Thirty-one (69%) were male. There was a poor recognition of the prodromal period in 22 (49%) patients and caregivers. The mean duration of untreated psychosis (DUP) was 27.2 weeks (SD 56.7). There was a negative correlation between DUP and age of onset (p<0.05). Mean age at onset of psychosis (males 15.7 years, SD 2.2, and females 15.3 years, SD 2.6) and mean age of presentation (males 16.0 years, SD 1.8, and females 15.5 years, SD 1.7) was slightly younger in the females than males, but not statistically significant. A total of 25 (56%) adolescents reported lifetime cannabis use and 24 (96%) were male.

CONCLUSION

Symptoms of the prodromal period were poorly recognised. The mean DUP suggests a significant delay in treatment and younger children had a longer DUP. The gender differences in presentation (marginal) and substance use (highly significant) suggests that there may be different environmental risk factors for males and females in early onset psychosis or that early onset psychosis is more genetically homogenous and less dependent on environmental triggers.

Substance use and duration of untreated psychosis in KwaZulu-Natal, South Africa

BACKGROUND

Substance use and psychiatric disorders cause significant burden of disease in low- and middle-income countries. Co-morbid psychopathology and longer duration of untreated psychosis (DUP) can negatively affect treatment outcomes.

OBJECTIVES

The study assessed substance use amongst adults with severe mental illness receiving services at a regional psychiatric hospital in KwaZulu-Natal (South Africa). We describe the prevalence and correlates of lifetime substance use and examine the association between substance use and DUP.

METHODS

A cross-sectional survey recruited adults diagnosed with severe mental illness and assessed lifetime and past 3-month substance use using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test. Regression analyses were conducted to determine associations between lifetime substance use (other than alcohol and tobacco) and DUP as measured by the World Health Organization Encounter Form.

RESULTS

Amongst 87 participants, alcohol (81.6%), tobacco (75.6%) and cannabis (49.4%) were the most common substances reported for lifetime use. Risk of health-related problems (health, social, financial, legal and relationship) of cannabis use was associated with younger age, single marital status and lower education. Adjusted regression analyses indicated that use of amphetamines and methaqualone is associated with longer DUP.

CONCLUSIONS

Substance use is prevalent amongst psychiatric patients in KwaZulu-Natal and may contribute to longer DUP. Mental health services in this region should address co-morbid substance use and psychiatric disorders.

Spirituality, depression and quality of life in medical students in KwaZulu-Natal

BACKGROUND

The majority of studies on spirituality demonstrate its positive association with mental health. Despite the increasing number of studies, there remains a dearth of studies emanating from African countries looking at the relationship between mental illness, quality of life and measures of spirituality. The present study evaluates the role of spirituality in relation to current depression and quality of life in medical students, who are known to be at high risk for depression.

OBJECTIVES

The aim of this study was to determine the prevalence of moderate and severe depressive symptoms in this population and explore potential correlations between spirituality, depression and quality of life.

METHODS

230 medical students were surveyed at the University of KwaZulu-Natal Medical School, using the Zung Self-Rating Depression Scale (Zung SDS), Spiritual Involvement and Beliefs Scale (SIBS), WHO Quality of Life Scale (WHOQOL) and a demographic data sheet.

RESULTS

There was a high prevalence of depressive symptoms in the medical students, with a significant proportion (15.6%) showing evidence of severe depressive symptoms (indicating likely depressive illness). Those with a history of mental illness or of having attended traditional, complementary or alternate medical practitioners showed higher levels of depression. Lower spirituality was associated with non-adherence to a major religion and a history of mental illness. Quality of life was better in second and fifth year students and poorer in those with a history of mental illness.

CONCLUSION

Medical students' experiences of depression (most probably due to stress) and its relationship with spirituality and quality of life merit further investigation with a view to establishing policy guidelines for dealing with this issue.

Beyond symptom management: Family relations, unmet needs of persons living with severe mental illnesses, and potential implications for social work in South Africa

This study examined the quality of family relationships and its associations with the severity of unmet needs of individuals admitted to a tertiary psychiatric hospital in South Africa. The quality of family relations and perceived unmet needs were assessed using the Lehman Quality of Life Interview and Camberwell Assessment of Needs, respectively. The results show that higher total unmet needs were associated with lower quality of family relations. The main areas of serious unmet needs included accessing government benefits and information, and establishing social relations. The results have implications for hospital-based social workers beyond managing psychiatric symptoms in South Africa.

Use of short messaging services to assess depressive symptoms among refugees in South Africa: Implications for social services providing mental health care in resource-poor settings

INTRODUCTION

Few studies in developing nations have assessed the use of short messaging services (SMS) to identify psychological challenges in refugee populations. This study aimed to assess the feasibility of SMS-based methods to screen for depression risk among refugees in South Africa attending mental health services, and to compare its reliability and acceptability with face-to-face consultation.

METHODS

Of the 153 refugees enrolled at baseline, 135 were available for follow-up assessments in our cohort study. Depression symptomatology was assessed using the 16-item Quick Inventory of Depressive Symptomatology (QIDS) instrument.

RESULTS

Nearly everyone possessed a mobile phone and utilized SMS. Furthermore, low incomplete item response in QIDS and high perceived ease of interacting via SMS with service providers supported the feasibility of this method. There was a fair level of reliability between face-to-face and SMS-based screening methods, but no significant difference in preference rating between the two methods.

CONCLUSION

Despite potential implementation barriers (network delay/phone theft), depression screening using SMS may be viable for refugee mental health services in low-resource settings.

Cannabis use and family history in adolescent first episode psychosis in Durban, South Africa

OBJECTIVES

To investigate the clinical correlates of cannabis use in adolescents with first episode psychosis (FEP).

METHODS

Inpatient psychiatric records provided demographic, lifetime cannabis use, family history of mental illness, and clinical data on 45 FEP adolescents, aged 12-18 years, admitted to a psychiatric unit in Durban, KwaZulu-Natal, South Africa, over a 2-year period.

RESULTS

Thirty-one (68.8%) of the 45 FEP adolescents reported a history of lifetime cannabis use. The age of FEP presentation and pre-diagnosis symptom duration was not significantly different in cannabis users versus non cannabis users. Of the 15/43 (34.8%) FEP patients with family history of mental illness, 10 had a history of cannabis use. The 26 (57.8%) schizophrenia spectrum disorder patients did not differ significantly from the 19 (42.2%) with other psychoses in terms of cannabis use and family history of mental illness. They were, however, significantly younger at age of presentation and had a significantly longer duration of pre-diagnosis symptoms.

CONCLUSIONS

These preliminary findings suggest a high prevalence of cannabis use in adolescents with FEP and highlight the public health concern of addressing substance abuse in the adolescent population.

Why searching for psychosis in diverse settings is important for global research and mental health systems development

BACKGROUND

The INTREPID programme of research aims to establish comparable studies of incident psychosis in a number of low- and middle-income countries (LMICs).

DISCUSSION

The importance of this cannot be under-estimated, as this will enable the testing of existing findings and evidence across differing environmental contexts; and will permit the identification of new and unique evidence that is only apparent within specific contexts. The epidemiological, aetiological and phenomenological insights derived from this programme are likely to inform major research advances of the next decades. Of equal importance, by adopting novel methods for detecting psychosis 'cases' in low-resourced settings, the researchers will be able to test two key hypotheses that could revolutionize clinical research and service provision within LMIC settings: (1) that informal providers can be incorporated successfully into an adequate (and perhaps even superior) case-detection system that is community and population-based (rather than hospital-based); and (2) that informal providers can be integrated meaningfully into the pathway to care (and perhaps even long-term management) of patients with incident psychosis living in low-resourced settings.

A multilevel analysis of the relationship between neighborhood social disorder and depressive symptoms: evidence from the South African National Income Dynamics Study

The apartheid regime that governed South Africa from 1948-1994 established spatial segregation that is understood to have contributed to the magnitude of neighborhood social disorder in the postapartheid era. Although a number of neighborhood social disorder characteristics, such as perceived violence and crime in the community, are prominent issues in South Africa, the extent to which these perceived spatial attributes are linked to depression is unknown at the population level. Multilevel modeling of data from the second wave of the South African National Income Dynamics Study (SA-NIDS) was utilized to examine the relationship between depressive symptomatology and neighborhood social disorder as indicated by the perceived frequency of violent, criminal and illicit activities in the community. Depressive symptomatology was assessed using the 10-item version of the Center for Epidemiologic Studies Depression Scale. A cut-off score of 10 or higher was used to indicate the presence of significant depressive symptomatology. Results showed that perception of neighborhood social disorder was independently associated with significant levels of depressive symptomatology. Gender, race or ethnicity, perceived health status, and education were significant for individual-level covariates of depression. Community intervention strategies that reduce the risk of neighborhood disorganization and emphasize positive social norms in the neighborhood are warranted. Taking into account the residential deracialization of a country transitioning from apartheid to nonracial democracy, a longitudinal spatial study design assessing the dynamics between depression and the aforementioned perceptions of neighborhood attributes may also be warranted.

Impact of antiretroviral therapy on health-related quality of life among South African women in the CAPRISA 002 acute infection study

Concerns are often raised regarding potentially adverse effects of antiretroviral therapy (ART) on health-related quality of life (HRQoL), but there is limited longitudinal data to prove this. Building on our prior investigation, we examined the impact of ART on HRQoL among HIV-infected South African women with extensive follow-up in the CAPRISA 002 Acute Infection Cohort Study. Overall HRQoL and five sub-domains [physical well-being (PWB), emotional well-being (EWB), functional and global well-being (FGWB), social well-being (SWB) and cognitive functioning (CF)] were assessed using the Functional Assessment of HIV Infection (FAHI) instrument. Our analyses comparing FAHI scores between pre-ART (established infection) and ART phases using paired Wilcoxon signed-rank tests and adjusted mixed-effects regression models revealed improvements on ART in overall HRQoL, and in PWB, EWB, and SWB, but not in FGWB and CF. No long-term adverse impact of ART on HRQoL was detected, providing additional non-biomedical support to early treatment strategies.

Social and ethical implications of psychiatric classification for low- and middle-income countries

<p>With the publication of the <em>Diagnostic and Statistical Manual</em>, 5th edition, and the ongoing revision of the <em>International Classification of Diseases</em>, currently 10th edition, it is timely to consider the wider societal implications of evolving psychiatric classification, especially within low- and middle-income countries (LMICs). </p><p>The author reviewed developments in psychiatric classification, especially the move from categorical to dimensional approaches based on biobehavioural phenotypes. While research supports this move, there are several important associated ethical challenges. Dimensional classification runs the risk of ‘medicalising’ a range of normality; the broadening of some definitions and the introduction of new disorders means more people are likely to attract psychiatric diagnoses. Many LMICs do not have the political, social, legal and economic systems to protect individuals in society from the excesses of medicalisation, thus potentially rendering more citizens vulnerable to forms of stigma, exploitation and abuse, conducted in the name of medicine and psychiatry. Excessive medicalisation within such contexts is also likely to worsen existing disparities in healthcare and widen the treatment gap, as inappropriate diagnosis and treatment of mildly ill or essentially normal people has an impact on health budgets and resources, leading to relative neglect of those with genuine, severe psychiatric disorders.<strong> </strong></p><p>In an era of evolving psychiatric classification, those concerned for, and involved in, global mental health should be critically self-reflective of all aspects of the modern psychiatric paradigm, especially changes in classification systems, and should alert the global profession to the sociopolitical, economic and cultural implications of changing nosology for LMIC regions of the world.</p>

Very low rates of screening for metabolic syndrome among patients with severe mental illness in Durban, South Africa

BACKGROUND

Sub Saharan African is experiencing the largest increase in the prevalence of type 2 diabetes mellitus and cardiovascular disease globally. Metabolic syndrome (MetS) is a cluster of risk factors for these conditions. There is a consistently higher prevalence of cardiometabolic disease among individuals with severe mental illness (SMI) compared to the general population worldwide. However, it is known from research in high income countries that screening for MetS in patients with SMI is low. The objective of this study was to document the extent of the expected low frequency of testing for all the components of the metabolic syndrome (MetS) in patients with SMI in a low middle income country.

METHODS

This was a cross sectional study, undertaken from January to June 2012 on out-patients with SMI who were treated with antipsychotic medication for at least 6 months. The study measured the proportion of participants who were tested for MetS in the previous year.

RESULTS

The study included 331 (M: F; 167:164) participants with a mean age of 35.2 ± 11.98 years. The majority (78.8%) were black South Africans. Only 2 subjects (0.6%) were screened for all five components of MetS. Regarding the individual components, 99%, 0.6%, 3.9% and 1.8% were screened for raised blood pressure, abdominal obesity, hyperglycaemia, hypertriglyceridaemia and decreased high density lipoprotein cholesterol respectively.

CONCLUSION

It is unacceptable that less than one percent of our participants were adequately screened for modifiable risk factors for type 2 diabetes mellitus and cardiovascular disease which are the most common causes of mortality among patients with SMI. These results highlight the need for translating guidelines into action in low and middle income countries.

Health-related quality of life dynamics of HIV-positive South African women up to ART initiation: evidence from the CAPRISA 002 acute infection cohort study

Few studies have investigated the long-term dynamics in health-related quality of life (HRQoL) among HIV-positive persons from acute infection. From 2004, 160 women were enrolled into the CAPRISA 002 Acute Infection study at two sites in the province of KwaZulu-Natal and underwent 3-6 monthly HRQoL assessments using the functional assessment of HIV infection (FAHI) instrument. Overall and 5 sub-scale FAHI scores [physical well-being (PWB), emotional well-being (EWB), functional and global well-being (FGWB), social well-being (SWB) and cognitive functioning (CF)] were calculated up to antiretroviral therapy (ART) initiation and scores at enrollment were compared to the acute, early and established infection phases. Mixed-effects regression models adjusting for behavioral and clinical factors were applied to assess HRQoL trends and the proportion of women meeting minimally important differences was calculated. Our analyses revealed that overall/sub-scale scores improved over time, except from PWB and CF. A higher educational status, contraceptive use and a higher BMI were the strongest predictors of higher overall/sub-scale FAHI scores. CD4 count and HIV viral load were strongly associated with PWB and CF, but not overall FAHI and other sub-scales. Women newly diagnosed with acute HIV infection face profound HRQoL challenges. While early ART delivery may be important for PWB and CF, factors such as education, contraception provision and good nutritional status should be promoted to maximize HRQoL in HIV positive individuals.

The burden of untreated mental disorders in KwaZulu-Natal Province – mapping the treatment gap

<p><strong>Background.</strong> Low- and middle-income countries carry the major burden of mental disorders, yet owing to a significant lack of resources, they experience a ‘treatment gap’ in the range of 75 - 85%.</p><p><strong>Methods.</strong> Epidemiological data on mental disorders in South Africa, national census data and locally developed models for establishing treatment needs were used to calculate expected annual acute admissions and inpatient care, as well as expected annual ambulatory visits in KwaZulu-Natal (KZN) Province, South Africa. These were compared with actual acute admission and inpatient care rates as well as actual ambulatory visits to mental health services in the province, derived from the District Health Information Systems. These comparisons allowed an estimation of the treatment gap for mental disorders in the province.</p><p><strong>Results.</strong> Approximately 956 000 adults were estimated to live with mental disorders in KZN. Only 19.8% (10 620) of expected admissions (53 623) took place during the one-year reporting period; while the total number of acute inpatient days accounted for 26.1% of the expected number. Average length of stay (ALOS) for acute admissions was longer (21 days) than the expected ALOS (16 days). At the recommended level of 30% coverage, ambulatory visits to mental health facilities accounted for 21% of the expected visits during the one-year period.</p><p><strong>Conclusion.</strong> In keeping with previous estimates, these results provide evidence that the ‘treatment gap’ for acute inpatient and ambulatory mental healthcare in KZN is ~80%. This rate is similar to the estimated mental health resource gap in the province, suggesting that gross inadequacies in mental health service provision translate directly into major unmet needs for those living with mental disorders.</p>

Income inequality and schizophrenia: increased schizophrenia incidence in countries with high levels of income inequality

BACKGROUND

Income inequality is associated with numerous negative health outcomes. There is evidence that ecological-level socio-environmental factors may increase risk for schizophrenia.

AIMS

The aim was to investigate whether measures of income inequality are associated with incidence of schizophrenia at the country level.

METHOD

We conducted a systematic review of incidence rates for schizophrenia, reported between 1975 and 2011. For each country, national measures of income inequality (Gini coefficient) along with covariate risk factors for schizophrenia were obtained. Multi-level mixed-effects Poisson regression was performed to investigate the relationship between Gini coefficients and incidence rates of schizophrenia controlling for covariates.

RESULTS

One hundred and seven incidence rates (from 26 countries) were included. Mean incidence of schizophrenia was 18.50 per 100,000 (SD = 11.9; range = 1.7-67). There was a significant positive relationship between incidence rate of schizophrenia and Gini coefficient (β = 1.02; Z = 2.28; p = .02; 95% CI = 1.00, 1.03).

CONCLUSIONS

Countries characterized by a large rich-poor gap may be at increased risk of schizophrenia. We suggest that income inequality impacts negatively on social cohesion, eroding social capital, and that chronic stress associated with living in highly disparate societies places individuals at risk of schizophrenia.