The impact of stress on depression, ill health and coping in family members caring for patients with acquired brain injury

Background

This study investigated the impact of stress on levels of depression and ill health as an indication of psychological coping. The research sample consisted of 80 family caregivers (who are members of Headway Gauteng, located in Johannesburg, South Africa) of patients with acquired brain injury.

Methods

A mixed method design of data collection was utilised that included self-report procedures (structured questionnaires and interviews) and post-interview content analyses. In addition, two individually administered measures that have been widely used in clinical practice and research were administered (a stress symptom checklist and the Beck Depression Inventory).

Results

The majority of the research participants experienced high levels of stress along with an inordinate physical and mental health impact indicating that they were not able to cope up with the ongoing chronic stress of caregiving.

Conclusion

Findings provide compelling evidence of the value of psychological screening for elevated stress and poor coping in family members caring for a patient with acquired brain injury in a resource-limited healthcare society. We recommend a collaborative effort between medical and psychological health practitioners in order to ensure a holistic and inclusive approach towards treatment procedures and interventions to improve coping skills in family members caring for a patient with acquired brain injury.

Trends in Adult Parasuicide in an Urban Environment

This study reports on a cohort of 389 adult in-hospital parasuicides. The female to male ratio was 2,5:1,3. Age peaked between 20–29 years with a decline corresponding with age advance. An increase in and a lowering of age in parasuicide were found. Most patients were married and had a history and family history of psychological problems including inordinate drug/alcohol consumption. Self-poisoning by overdose predominated, with benzodiazepines, antidepressants, and non-narcotic analgesics being most common. A sex-linked difference in choice of method was evident. Adjustment disorders with depressed mood associated with interpersonal problems with a key person, substance abuse and social problems, and affective disorders were the most common psychiatric diagnoses. Increased subintentional parasuicide numbers were found. Results are discussed in terms of the implications these findings have for a clearer understanding of parasuicidal behaviour.

Medical Psychology in Southern Africa: Future Concerns in the General Teaching Hospital

The challenge facing the contribution of clinical psychology to general health care from within the medical teaching establishment, in a changing society, is explored. Factors providing an impetus for psychology to participate in the quest for a mind — body synthesis in understanding and treating physical disease are discussed, along with related joint collaborative and other psychological aspects. The importance of cross-cultural issues and implications for future training and functioning of clinical psychologists within the general teaching hospital are mentioned.

Health Psychology in South Africa: An Introduction

Health psychology's public debut may be historically identified as having occurred in 1978 internationally and in 1989 in South Africa. It has since developed its own important role in disease prevention and health enhancement due to several good reasons highlighted in this article. This includes an increased sophistication in health-care consumerism which has also found expression in a renewed awareness of accepting personal responsibility for one's health because of the acknowledgement that lifestyle and behaviour change play crucial roles in health and disease. These developments have unfolded within an ever rapidly changing arena of health care. Both health-risk behaviour and lifestyle diseases have been identified as critical areas which have to be addressed in southern Africa. Although health psychology has made significant strides it remains in its early development stages in southern Africa, and thorough conceptual and methodological foundations continue to be required for its effective development. There are many challenges facing the health-care needs of South Africans, and health psychology researchers are in an excellent position to make a meaningful contribution in the ‘New South Africa’ to the health-care priorities of the Government of National Unity's Reconstruction and Development Programme, and to dealing with or preventing potential psychological problems that might arise from the transitional phase the country is going through. In line with international developments, increased accountability of health psychologists and a research and clinical focus on emotions, stress-induced immunomodulation and psychological intervention to modify the course of disease are likely to become major trends in southern Africa as we enter the 21st century.

Health Beliefs of a Sample of Black Patients Attending a Specialized Medical Facility

Cross-cultural research has highlighted the influential role of health beliefs in shaping responses to health messages and subsequent health behaviour. Research into health behaviour constitutes an interdisciplinary field which studies personal attributes related to health maintenance, restoration and improvement and it embraces concepts related to biopsychosocial health care and behavioural medicine. Health behaviour research is in its infancy in Africa. Particularly in South Africa, where there is a high incidence of diseases requiring high technology medical intervention within a large spectrum of an underprivileged population, there is a need to gain more cross-cultural health behaviour knowledge that would permit the formulation of a health-care education programme specifically designed for local needs. Given this, this study investigated health beliefs amongst a group of black patients who required highly specialized medical treatment. The sample consisted of a random selection of black patients attending a university-affiliated specialized teaching hospital's out-patient clinic for ‘high-tech’ medical or surgical procedures. Results showed statistically significant differences between the health beliefs of rural and urbanized patients and the importance of religious concepts in health beliefs. Further, the patients' health beliefs related to health behaviour were influenced by several other variables including the interaction between socio-economic, cultural, environmental, and other factors. It is argued that, in order to introduce health behaviour changes, these complex sets of beliefs must be taken into account when health-care education programmes are designed.

Psychological Stress, Adjustment and Cross-Cultural Considerations in Breast Cancer Patients

There is a dearth of information regarding the psychological experience of breast cancer in the South African context, particularly within the black population. Existing psychological studies have focused mainly on the healthy breast or instances of non-malignant disease, largely within the white population from a Western perspective. This study addressed some of these concerns and examined and compared the nature and degree of psychological distress with reference to specific variables experienced by South African black and white breast cancer patients. Fifty women, comprising two equal groups of 25 black and white breast cancer patients were assessed and compared in terms of their levels of depression, body image dysphoria and styles of psychological adjustment during the course of their post-surgical chemotherapy treatment. There were several differences in the psychological experiences of black and white breast cancer patients. Most of the black patients were found to experience greater levels of somatisation, depression and body image dysphoria and tended to utilise less adaptive styles of adjustment to their disease. The only measure on which both groups more closely resembled each other was that of anxiety. The greater levels of psychological distress reported by most of the black patient group may be due to traditional cultural reasons which possibly predispose them to suppress emotions or somatise them rather than display these outwardly, and because of a lack of knowledge and of psycho-oncological services for this group. These patients could be regarded as being at high risk for elevated distress levels requiring psychological intervention.

Parasuicide among Indian Adolescents: Some Cultural Perspectives

From the significant amount of research devoted to parasuicide it is evident that parasuicidal adolescents experience many unique problems. There is however a paucity of research in this regard on South African Indian patients. Culturally oriented research is necessary in order to gain a better understanding of the problems facing these patients, and for appropriate management and ultimate prevention of parasuicide. Accordingly a preliminary study of parasuicide among Indian adolescents was undertaken. The patients ( N = 54) were mostly older adolescent females who engaged in self-poisoning by overdose of medicinal substances. Culturally rooted authoritarian parenting and the effects of acculturation emerged as important causal considerations and are discussed in relation to the aetiology of parasuicidal behaviour in this group of patients.

On Suicide in a South African General Hospital Psychiatric Inpatient Unit

Few studies have reported specifically on suicide in general hospital psychiatric inpatient units. Results of a study over a 10-year period of nine patients who committed suicide while being treated in such a unit are presented. Total admissions during the study period were 6 961 giving an average suicide rate of 1,4 suicides per 1 000 admissions. More males committed suicide than females. Most patients were unemployed with a history of parasuicide and psychiatric hospitalization. Psychiatric diagnoses of schizophrenia, affective disorder, and alcohol dependence predominated. Jumping from high-rise buildings near the hospital was the most common suicide method. Ward milieu and staff changes may have influenced suicide rates and the results are discussed in terms of psychological aspects with reference to system theory.

Medical Psychology and Psychonephrology: Contributions of Clinical Psychology

Clinical psychology is developing into an integral part of modern health care delivery systems as evidenced by its role in the establishment of services in clinical psychology in general hospitals, training programmes in medical psychology, and the increased teaching of medically applied psychology in medical schools. This extended role of clinical psychology is discussed against the background of a subspecialization in psychonephrology. The aim is to illustrate the development of psychological treatment for chronically ill patients with end-stage renal disease, in the context of a developing country with a multi-ethnic society.

The Measurement of Stress in Breast Cancer Patients

The assessment of stress among breast cancer patients is reported in the present article. The aim of the study was to evaluate the complex interplay of stress-related physical, psychological, and behavioural reactions to breast cancer. The further validation of a stress measure, the Stress Symptom Checklist (SSCL), assisted this process. The sample consisted of a cross-cultural group of randomly selected black ( n = 100) and white ( n = 100) women patients with breast cancer. The statistical methods included descriptive, inferential, and multivariate analyses, which were used to analyse the research data. The results clearly indicated that symptoms of unhealthy stress, as evidenced by the SSCL, emerged as separate from the symptoms of associated variables, such as loneliness, depression, body-image dysphoria, and quality of life, further validating the SSCL as a reliable instrument for measuring stress. Both groups of patients showed clinically significant levels of stress, although there was no significant difference in overall stress between the black and white patient groups. The absence of unhealthy levels of stress is expected to contribute positively to breast cancer patients' quality of life and subjective well-being.

South African families raising children with autism spectrum disorders: relationship between family routines, cognitive appraisal and family quality of life

BACKGROUND

The purpose of this study was to investigate the relationship between family routines, cognitive appraisal of the impact of autism spectrum disorders (ASD) on the family and family quality of life (FQOL) in families raising children with ASD in South Africa.

METHODS

A sample of 180 families of young children with ASD who were receiving disability-related services in the Gauteng province of South Africa completed a self-administered survey. Structural equation modelling was used to examine the direct relationship between the regularity of family routines and FQOL, and the mediating effect of cognitive appraisal on this relationship.

RESULTS

The results suggested a direct, positive relationship between the regularity of family routines and families' satisfaction with their FQOL. Furthermore, cognitive appraisal of the impact of ASD on the family mediated this relationship in a partial manner.

CONCLUSION

A higher frequency of regular family routines was strongly associated with a higher satisfaction level of FQOL. Also, cognitive appraisal of the impact of ASD acted as a mechanism through which the regularity of family routines influenced FQOL. We discuss the research and clinical implications of these findings.

Sociodemographic characteristics of persons committing suicide in Durban, South Africa: 2006-2007

Background

Suicidal behaviour is a leading contributor to the burden of disease worldwide and varies widely between countries. South African figures are amongst the highest in the world, with recent trends indicating a disturbing rise, especially amongst the younger age groups, across all races.

Aim

This study analysed sociodemographic characteristics and trends relating to suicides committed in Durban, South Africa during the period of 2006–2007.

Method

A retrospective analysis of suicidal deaths (during 2006–2007), extracted from autopsy registers at all three government-run mortuaries in Durban, was conducted.

Results

The total number of suicides in Durban increased by 6.68% from 2006 to 2007. Suicide accounted for an average of 8.8% of all non-natural deaths per year of the study. The overall suicide rates of 14.53 (2006) and 15.53 (2007) per 100 000 population are comparable with national and global figures. The majority of suicides occurred in single unemployed persons, men and younger age groups. The largest number of suicides per year was recorded in black people, followed by Indian, white and mixed-race people. Hanging was the preferred method in the majority of victims, followed by self-poisoning, shooting and jumping.

Conclusions

The findings indicate a disturbingly high suicide rate amongst the various population and age groups in Durban. The dominant methods used may be influenced by ease of access. The reported trends may worsen unless there is a swift and decisive public health response and cohesive community-based programmes which include a supportive multidisciplinary network.

A suicide risk screening scale for HIV-infected persons in the immediate post-diagnosis period

Background. The risk of suicidal tendencies in HIV-infected persons appears high and may parallel the increasing prevalence of suicidal behaviour in South Africa.Objective. To construct a brief suicide risk screening scale (SRSS) as a self-administered instrument to screen for suicidal ideation in recently diagnosed HIV-infected persons.Methods. An SRSS was developed, drawing 14 items from two established screening tests, and assessed using a sample of 150 HIV-infected consenting adults identified at a voluntary counselling and testing (VCT) clinic at an academic district level hospital in Durban, South Africa. Participants returned three weeks after their initial assessment for a re-assessment.Results. The internal consistency of the SRSS was good (Cronbach’s alpha, 0.87), and its sensitivity (81%) was higher than its specificity (47%). The findings suggest that, despite certain limitations, the SRSS may be a valuable screening tool for suicidal ideation at VCT clinics.Conclusion. Screening for suicide risk and possible suicidal behaviour in HIV-positive persons may form a routine aspect of comprehensive patient care at VCT clinics to assist with effective prevention and treatment.

Suicidal ideation in seropositive patients seen at a South African HIV voluntary counselling and testing clinic

OBJECTIVE

Suicidal behaviour and HIV/AIDS are significant public health concerns. The aim of this study was to investigate suicidal ideation in patients who were referred to a voluntary HIV counselling and testing (VCT) clinic and who were found to be seropositive. This in order to improve suicide prevention and intervention strategies amongst such patients.

METHOD

The sample studied consisted of volunteer adult patients referred over a three-month period to a HIVVCT clinic based at a university-affiliated general state hospital. Patients completed a questionnaire on sociodemographic data. Suicidal ideation was measured using the Beck Hopelessness Scale and the Beck Depression Inventory (BDI), at two time points (within 72 hours after notification and again at a 6 week follow-up). All patients received extensive pre-and post-test counselling.

RESULTS

HIV-test results were available for 189 (99.5%) of the original sample of 190 patients studied, with 157 (83.1%) testing positive. More females tested positive as did unemployed and single/divorced patients. The mean age for HIV-positive patients was 33.49 (SD = 9.449), and for HIV-negative patients it was 37.94 (SD = 15.238). Age was a significant factor in that for each year increase in age, the risk of testing HIV-positive decreased by 4.1%. Lower education and traditional beliefs were also significantly associated with testing HIV-positive. At 72 hours suicidal ideation was present in 17.1% (95% confidence interval 12.16% to 23.45%), and at 6 weeks in 24.1% (95% confidence interval 17.26% to 32.39%) of the seropositive patients. Their average BDI scores were 15.20 and 14.23 respectively at the two time points.

CONCLUSION

Suicidal ideation was present in a significant number of the seropositive cohort studied and increased over a six week period among these patients. The average BDI scores at both time points imply a clinical depression. The findings also suggest an association between positive HIV-test results and certain socio-demographic variables that can act as indicators for suicidal ideation in HIV-infected persons, although this requires further research. Although the relationship between suicidal ideation and HIV-infection is complex, it is an important consideration when assessing patient suicide vulnerability at HIV VCT clinics and when implementing suicide prevention and management strategies.

HIV-infection as a self-reported risk factor for attempted suicide in South Africa

OBJECTIVE

The aim of this study was to examine variables associated with recently diagnosed HIV-infection as a self-reported attempted suicide risk factor.

METHOD

The study cohort consisted of 112 general hospital in-patients who attempted suicide because of HIV-infection. All the patients were subject to a comprehensive mental state examination and administration of a semi-structured questionnaire to obtain biographical, sociodemographic and other relevant information. Pearson uncorrected Chi-square (X(2)) or Fisher's Exact Probability Test were used to analyze data utilising Epicalc 2000, version 1.02.

RESULTS

Most patients expressed a heterosexual preference. The average age was 34.9 years. Females predominated and in both genders depression and substance abuse (mainly alcohol-related) accounted for the most common psychiatric diagnoses. Less than half of the patients were married. Partner relational problems was a statistically significant variable. The most prevalent co-morbid stressors were poor social support, fear of disclosure/stigmatization and socio-economic pressures. Cognitive deficits included problems with cognitive flexibility, concentration and memory. Based on estimated national suicidal behaviour prevalence rates, a descriptive HIV-related attempted suicide rate of 67.2 per 100 000 and an increased risk for attempted suicide of 13.33% to 18.87% were calculated.

CONCLUSION

HIV-infection can be an underestimated suicide risk factor. Effective management and prevention programmes should include as imperatives early diagnosis of HIV-related suicidal behaviour, recognition of underlying psychopathology, neurocognitive deficits, associated stressors, the dynamics of partner relationship problems, as well as cultural awareness and sensitivity. Potential neurocognitive complications that can act as additional risk factors require further research.

Age, gender and suicidal ideation following voluntary HIV counseling and testing

The aim of this study was to determine the prevalence of suicidal ideation in patients who were tested for HIV-infection and whether along with their HIV status, age and gender influenced their risk for suicidal ideation. The sample consisted of 189 patients who attended a voluntary HIV counseling and testing clinic (VCT) at a general state hospital in Durban, South Africa. Their mean age at baseline was 34.2 years, with an age range of between 16-79 years. Seropositivity, age and gender were significantly associated with suicidal ideation. The majority of these patients were in the younger age group, and young males had a 1.8 times higher risk for suicidal ideation than females. Although risk factors for seropositive-related suicidal ideation can be complex and multi-factorial, this study identified a young age and male gender as important high risk factors in the sample studied. It is recommended that all, but especially young male HIV-infected patients seen at a VCT clinic be screened for suicidal ideation and that early intervention to prevent subsequent suicides or suicidal attempts be included in pre- and post-test HIV counseling.

Hopelessness, depression and suicidal ideation in HIV-positive persons

<p><strong>Background and objectives.</strong> HIV/AIDS and suicidal behaviour are major public health concerns. The aim of this study was to examine the relationship between hopelessness, depression and suicidal ideation in HIV-infected persons.</p><p><strong>Methods.</strong> The sample consisted of all adult volunteers attending a voluntary counselling and testing (VCT) HIV clinic at a university affiliated state hospital. Suicidal ideation and depression were measured using the Beck Hopelessness Scale (BHS) and the Beck Depression Inventory (BDI), respectively, at two intervals, viz. 72 hours and 6 weeks after HIV diagnosis.</p><p><strong>Results.</strong> Of the 156 patients who tested positive for HIV, 32 (20.5%) had a hopelessness score of 9 or above on the BHS and 130 patients (82.8%) were depressed according to the BDI at 72 hours after diagnosis. Of the 109 patients assessed 6 weeks after diagnosis, 32 (28.8%) had a hopelessness score of &gt;9 on the BHS and 86 (78.2%) were depressed according to the BDI. A moderately positive correlation at both time periods was found between hopelessness and depression. A ROC analysis showed optimal sensitivity, indicating that the HIV-positive depressed patients were at risk for suicidal behaviour.</p><p><strong>Conclusion.</strong> The significant correlations between hopelessness, depression and suicidal ideation are important markers that should alert healthcare professionals to underlying suicide risks in HIV-positive patients. Early recognition of this and suicide prevention strategies should be incorporated into the treatment offered at VCT HIV clinics.</p>

Repetition of suicide attempts: data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS Study

BACKGROUND

Attempted suicide is a strong risk factor for subsequent suicidal behaviors. Innovative strategies to deal with people who have attempted suicide are needed, particularly in resource-poor settings.

AIMS

To evaluate a brief educational intervention and periodic follow-up contacts (BIC) for suicide attempters in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, People's Republic of China) as part of the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS).

METHODS

Among the 1,867 suicide attempters enrolled in the emergency departments of the participating sites, 922 (49.4%) were randomly assigned to a brief intervention and contact (BIC) group and 945 (50.6%) to a treatment as usual (TAU) group. Repeated suicide attempts over the 18 months following the index attempt - the secondary outcome measure presented in this paper - were identified by follow-up calls or visits. Subsequent completed suicide - the primary outcome measure - has been reported in a previous paper.

RESULTS

Overall, the proportion of subjects with repeated suicide attempts was similar in the BIC and TAU groups (7.6% vs. 7.5%, chi(2) = 0.013; p = .909), but there were differences in rates across the five sites.

CONCLUSIONS

This study from five low- and middle-income countries does not confirm the effectiveness of brief educational intervention and follow-up contacts for suicide attempters in reducing subsequent repetition of suicide attempts up to 18 months after discharge from emergency departments.

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries

OBJECTIVE

To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries.

METHODS

Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up.

FINDINGS

Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; chi2 = 13.83, P < 0.001).

CONCLUSION

This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.

Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries

OBJECTIVE

To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries.

METHODS

Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up.

FINDINGS

Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; chi2 = 13.83, P < 0.001).

CONCLUSION

This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.

Risk factors in repeat non-fatal suicidal behaviour

NO ABSTRACT AVAILIBLE

Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries

BACKGROUND

The objective was to describe patients presenting themselves at emergency-care settings following a suicide attempt in eight culturally different sites [Campinas (Brazil), Chennai (India), Colombo (Sri Lanka), Durban (South Africa), Hanoi (Viet Nam), Karaj (Iran), Tallinn (Estonia), and Yuncheng, (China)].

METHOD

Subjects seen for suicide attempts, as identified by the medical staff in the emergency units of 18 collaborating hospitals were asked to participate in a 45-minute structured interview administered by trained health personnel after the patient was medically stable.

RESULTS

Self-poisoning was the main method of attempting suicide in all eight sites. Self-poisoning by pesticides played a particularly important role in Yuncheng (71.6% females, 61.5% males), in Colombo (43.2% males, 19.6% females), and in Chennai (33.8% males, 23.8% females). The suicide attempt resulted in danger to life in the majority of patients in Yuncheng and in Chennai (over 65%). In four of the eight sites less than one-third of subjects received any type of referral for follow-up evaluation or care.

CONCLUSIONS

Action for the prevention of suicide attempts can be started immediately in the sites investigated by addressing the one most important method of attempted suicide, namely self-poisoning. Regulations for the access to drugs, medicaments, pesticides, and other toxic substances need to be improved and revised regulations must be implemented by integrating the efforts of different sectors, such as health, agriculture, education, and justice. The care of patients who attempt suicide needs to include routine psychiatric and psychosocial assessment and systematic referral to professional services after discharge.

Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey

BACKGROUND

The objectives were to assess thoughts about suicide, plans to commit suicide and suicide attempts in the community, to investigate the use of health services following a suicide attempt, and to describe basic socio-cultural indices of the community.

METHOD

The community survey was one component of the larger WHO multisite intervention study on suicidal behaviours (SUPRE-MISS). In each site, it aimed at randomly selecting and interviewing at least 500 subjects of the general population living in the catchment area of the emergency department where the intervention component of the study was conducted. Communities of eight SUPRE-MISS sites (in Brazil, China, Estonia, India, Iran, South Africa, Sri Lanka, and Viet Nam) participated plus two additional sites from Australia and Sweden conducting similar surveys.

RESULTS

Suicide attempts (0.4-4.2%), plans (1.1-15.6%), and ideation (2.6-25.4%) varied by a factor of 10-14 across sites, but remained mostly within the ranges of previously published data. Depending on the site, the ratios between attempts, plans, and thoughts of suicide differed substantially. Medical attention following a suicide attempt varied between 22% and 88% of the attempts.

CONCLUSIONS

The idea of the suicidal process as a continuous and smooth evolution from thoughts to plans and attempts of suicide needs to be further investigated as it seems to be dependent on the cultural setting. There are indications, that the burden of undetected attempted suicide is high in different cultures; an improved response from the health sector on how to identify and support these individuals is needed.

The Development of a Stress Symptom Checklist

The development of a stress measure, and indications of its reliability and validity are reported in the present article. The human stress response and its deleterious consequences are discussed, including the fact that stress is a major problem in society at all levels of human interaction. South African stress levels are particularly high, and many lifestyle diseases, health-risk behaviours, suicidal behaviours, violence, trauma-producing behaviours, performance levels and difficulties in coping with change are stress-related, as are numerous medical, psychological and/or psychiatric disorders. Given this, a Stress Symptom Checklist (SSCL) was constructed as a user-friendly stress measurement. It was developed as part of a major stress research initiative. The aim was to produce an authoritative, reliable and valid stress checklist that can stand up to critical inspection, yet be an easy-to-use measure. It focuses on the respondent's stress level rather than on the stimuli leading to that stress. It is not intended to be a diagnostic tool that measures specific stress-related psychopathological conditions or disorders, but rather the intensity (or severity) of stress as reflected by an individual's physical, psychological and behavioural reactions. To date, the data show that the SSCL is a useful measure of non-pathological stress in the general population. Further refinements and validation studies are in progress.

Suicidal behavior in black South Africans

In the past suicidal behavior among Black South Africans has been largely underresearched. Earlier studies among the other main ethnic groups in the country showed suicidal behavior in those groups to be a serious problem. This article briefly reviews some of the more recent research on suicidal behavior in Black South Africans. The results indicate an apparent increase in suicidal behavior in this group. Several explanations are offered for the change in suicidal behavior in the reported clinical populations. This includes past difficulties for all South Africans to access health care facilities in the Apartheid (legal racial separation) era, and present difficulties of post-Apartheid transformation the South African society is undergoing, as the people struggle to come to terms with the deleterious effects of the former South African racial policies, related socio-cultural, socio-economic, and other pressures.

Suicidal behavior in black South Africans

In the past suicidal behavior among Black South Africans has been largely underresearched. Earlier studies among the other main ethnic groups in the country showed suicidal behavior in those groups to be a serious problem. This article briefly reviews some of the more recent research on suicidal behavior in Black South Africans. The results indicate an apparent increase in suicidal behavior in this group. Several explanations are offered for the change in suicidal behavior in the reported clinical populations. This includes past difficulties for all South Africans to access health care facilities in the Apartheid (legal racial separation) era, and present difficulties of post-Apartheid transformation the South African society is undergoing, as the people struggle to come to terms with the deleterious effects of the former South African racial policies, related socio-cultural, socio-economic, and other pressures.

Suicidal Behavior in Patients Diagnosed with Cancer of the Cervix

Summary: There is a paucity of literature on suicide and cancer, especially cancer of the cervix. This study reports on suicidal behavior in these patients. The sample consisted of adult, black, Zulu-speaking women from palliative and radical oncology treatment groups who volunteered for the study. There were more patients in the palliative group who were younger, and had a more significant delay between cancer symptom presentation and seeking oncology treatment. Patients experienced: significant depression, anxiety, stress, hopelessness/helplessness, anxious preoccupation about their disease, poor current or delayed social support, feelings of being a burden to their significant others, beliefs that they would be better off dead, perceptions that they were stigmatized by society or that their communities suspected them of being HIV-AIDS positive, and suppressed anger. More patients in the palliative, compared to the radical treatment, group were inclined toward suicidal ideation with serious intent. Overall, most patients coped inadequately with their disease and its management. These patients are a high risk group for suicidal behavior and should be identified in time for appropriate psychological intervention.

Suicidal behavior in patients diagnosed with cancer of the cervix

There is a paucity of literature on suicide and cancer, especially cancer of the cervix. This study reports on suicidal behavior in these patients. The sample consisted of adult, black, Zulu-speaking women from palliative and radical oncology treatment groups who volunteered for the study. There were more patients in the palliative group who were younger, and had a more significant delay between cancer symptom presentation and seeking oncology treatment. Patients experienced: significant depression, anxiety, stress, hopelessness/helplessness, anxious preoccupation about their disease, poor current or delayed social support, feelings of being a burden to their significant others, beliefs that they would be better off dead, perceptions that they were stigmatized by society or that their communities suspected them of being HIV-AIDS positive, and suppressed anger. More patients in the palliative, compared to the radical treatment, group were inclined toward suicidal ideation with serious intent. Overall, most patients coped inadequately with their disease and its management. These patients are a high risk group for suicidal behavior and should be identified in time for appropriate psychological intervention.

A double-blind, placebo-controlled, double-centre study of the effects of an oral multivitamin-mineral combination on stress

OBJECTIVES

To assess the effects of a multivitamin-mineral combination (Berocca Calmag) treatment on stress in a large sample of South Africans.

METHOD

This was a multiple-dose, double-blind, placebo-controlled, double-centre study. Patients were drawn from two centres with high stress levels (Durban and Johannesburg), each study recruiting the same number of patients (150) from 1,000 adults with predetermined high stress levels. Dropouts from the study were replaced. Study medication safety was evaluated by recording adverse events. On day 1 (baseline) patients were subjected to an individual in-depth assessment that included a biographical questionnaire, four psychological scales, and collateral information from close relatives. On day 30 (end of the study period) or at the latest 7 days after the last planned medication intake, the assessment was repeated for purposes of pre- and post-response comparison.

RESULTS

Thirty-three patients dropped out and were replaced, leaving 300 patients who completed the study--151 in group 1 (multivitamin-mineral combination), and 149 in group 2 (placebo). There were no statistically significant differences between the two groups regarding demographics and baseline stress scores at study entry. Both groups improved between baseline and the end of treatment as assessed. The degree of improvement was statistically significant and greatest in group 1 for all psychometric instruments, with this beneficial effect increasing over the course of the day. Subgroup analyses for age (18-44 and 45-65 years), gender and ethnicity showed no general effect on the overall study outcome.

CONCLUSIONS

The multivitamin-mineral combination tested is well tolerated and can be used as part of a treatment programme for stress-related symptoms at the recommended dose.

Controlling the environment to prevent suicide: international perspectives

BACKGROUND

Suicide and suicidal behaviour are multifaceted events requiring complex solutions. Controlling the environment is a neglected solution, despite strong support for this approach from the World Health Organization (WHO).

METHOD

To discuss this approach from a global view, this review is written by authors from various cultures: American, Australian, Canadian, Chinese, Cuban, Dutch, Indian, Irish, Japanese, Lithuanian, Native North American, Russian, and South African.

RESULTS

We examine gun control to illustrate the environmental control approach; however, the worldwide diversity of suicide methods calls for diverse responses. Further, controlling the environment encompasses more than restricting the means of suicide, which we illustrate with examples of toned-down media reports and restricted medicine availability.

CONCLUSIONS

Controlling the environment may be a viable strategy for preventing suicide, although research shows that few clinicians implement such approaches.

Stress, social support and biopsychosocial dynamics in HIV-AIDS

Research trends in psychosocial aspects of HIV-AIDS are reviewed, exploring the role of psychosocial cofactors in disease progression. This is undertaken within a biopsychosocial model and gives cognisance to the role of psychosocial stress, social support, and emotional adjustment. Research data from a study of biopsychosocial interrelationships in a sample of HIV-positive patients show a significant correlation between social support and emotional adjustment and that social support exerts a mediatory, stress-buffering effect in these patients. Some observations are made on aspects of the social conditions of South Africans with HIV-AIDS.

Long-term psychological sequelae of augmentation mammoplasty

A request for elective surgery for augmentation mammoplasty (AM) is often associated with underlying psychopathology and high expectations of a positive psychological outcome. This study was designed to ascertain the long-term psychological sequelae of AM in a group of patients who were reassessed 3 years or more after surgery. The postoperative study cohort of 20 patients constituted 67% of the original sample that was psychologically assessed pre-operatively. The results show that the majority of patients benefited psychologically from the AM and had experienced an improvement in psychosexual functioning and a reduction of high pre-operative levels of negative body image, anxiety and depression. Although not all expectations had been met and basic personalities remained unchanged, most women had no regrets and would recommend AM to other women in similar circumstances. They had not, however, seriously considered the possibility of unsatisfactory postoperative outcome. The value of close liaison between mental health specialists and plastic surgeons is emphasised.

Body-Image Differences in Live-Related and Cadaver Renal Transplant Recipients

Differences in body-image between live-related and cadaver renal transplant recipients were investigated. A body-image questionnaire as part of a comprehensive psychological assessment was individually administered to ten live-related and 30 cadaver renal transplant patients. A factor analysis of the questionnaire items disclosed eight factors in the ratings of body-image. Separate factor scores were then calculated for each participant in the study on each factor. Further statistical analysis of these scores revealed no significant sex-related differences in the ratings, but indicated that live-related renal recipients overall felt less positive than cadaver renal recipients concerning the body's physical attractiveness, and physical contact. The implications of these findings for a psychonephrology service are discussed.

Illness behaviour in live-related and cadaver renal transplant recipients

Illness behaviour was compared in 10 biologically live-related and 30 cadaver renal donor recipients in respect of their long-term psychological adjustment. The results indicated few long-term statistically significant differences postoperatively in illness behaviour between the two groups of patients, but a factor analysis revealed 8 items that were significantly related to illness behaviour associated with post-transplant psychological adjustment for all 40 transplantees studied. These were feelings of inadequacy; the renal graft being 'alien'; an inability to cope with the transplant; the disease resulting in the transplant being an external imposition beyond their control; responsibility for and acceptance of the transplant as a 'gain'; culpability for what has happened to them; anxious preoccupation with long-term prognosis; and dependence on others. Further analysis of these findings and their relevance for optimal patient management are discussed. Appropriate psychological support for these patients is important and, although long-term illness behaviour of biologically live-related and cadaver-related renal transplant recipients was found to be relatively similar, the various issues related to post-transplant illness behaviour in both groups of patients should be addressed in the provision of a psychonephrology service to a renal unit.

Health care professionals' knowledge about AIDS, prejudice and attitudes towards AIDS

In this study the authors examined knowledge of and attitudes to AIDS in a group of health care pofessionals. The results indicated high levels of knowledge about the disease. These results are regarded as positive findings, since their AIDS awareness showed the subjects were well informed and had formulated this knowledge from a relatively objective rather than judgemental/moralistic point of view. Three categories of attitudes were studied, that is, attitudes towards AIDS per se, attitudes towards homosexuality, and attitudes towards the sexuality of blacks. Attitudes towards AIDS per se varied considerably despite the relatively high levels of knowledge about the disease. Attitudes towards homosexuality had a substantial negative relationship with attitudes towards AIDS, a finding common to other studies. Attitudes towards AIDS were also related to attitudes towards the sexuality of blacks. It is concluded that attitudes towards AIDS in the group studied were substantially determined by historically grounded attitudes concerning the sexuality of marginalized groups. The implications of these findings as an additional component in combatting AIDS are discussed.

Neuropsychological deficits associated with uraemic encephalopathy. A report of 5 patients

Although uraemic patients with end-stage renal disease (ESRD) often present with impaired cognitive functions, little information exists concerning the identification of some of the neuropsychological processes underlying overt behaviour that affect adjustment to ESRD. The results of a neuropsychological investigation of a sample of adult patients with ESRD, before being accepted for dialysis, is documented in order to determine their altered neuropsychological status, since this may have a bearing on patient management and compliance. The patients were assessed by a single-case study methodology and the Luria-Nebraska Neuropsychological Battery in which parts requiring verbal patient response were taped for later detailed analysis. Neuropsychological complications occurred in conjunction with high urea levels in all patients, indicating varying degrees of impaired performance in motor tactile, receptive language, arithmetic, and intellectual functions. A common underlying pattern of performance decrement revolved around disturbed spatial synthesis and orientation in relation to visual perception, activity, logical-grammatical and arithmetical operations, and in intellectual tasks requiring identification of visual signs and spatial organisation. Further research is necessary to establish a possible correlation between physiological, biochemical and neuropsychological indices, and to compare neuropsychological differences between patients on different forms of treatment for ESRD.

Cross-Cultural Indicators of Help-Seeking Behaviour in Aggressive General Hospital Patients

In this study the authors researched cross-cultural identification of aggressive behaviour disturbances as identifying factors for patients' family members to seek professional help for the patients. Patients ( N = 40), mainly Zulu-speaking were drawn from the outpatient clinic of a large academic general hospital. In all 23 (57,5%) of the patients and 25 (62,5%) of the relatives were urbanized. A comparison was made between what the patients' families considered problematic as opposed to formal professional diagnostic and aetiological considerations in the same patients. Several trends emerged from the results. It was demonstrated that the behavioural disturbances formed the most important set of identifying criteria for the family of the index patient. It held true for people in various stages of urbanization. Cognitive, mood and perceptual disturbances were of a lesser identifying value to families. Predictably, there were some differences between urban and rural families. Rural families were more attuned to the patient's problems but generally remained more tolerant of the aggressive behaviour and were less ready to seek professional help. These findings, some known from clinical observations and anecdotal communications, have seldom been objectively analysed — particularly in Africa. Implications for management, along with various related cross-cultural issues, are discussed.