South African Journal of Psychiatry

HIV prevalence and access to HIV testing and care in patients with psychosis in South Africa

BACKGROUND: Human immunodeficiency virus (HIV) and psychosis share a complex bidirectional relationship, with people living with HIV being at increased risk of psychosis and those with psychosis at increased risk of HIV. However, people living with severe mental illness often have limited or reduced access to HIV testing and care. AIM: This study aimed to determine the prevalence of HIV and describe the access to HIV testing and care among adult patients with recent-onset psychosis who were admitted to a psychiatric hospital in KwaZulu-Natal (KZN) province, South Africa SETTING: A psychiatric hospital in Pietermaritzburg, KZN province, South Africa. METHOD: A retrospective chart review of 294 patients with recent-onset psychosis admitted between May 2018 and November 2020. RESULTS: A total of 291 (99%) patients had access to HIV testing during the study period, with the HIV seroprevalence rate being 21.5% among the 294 patients; HIV seropositivity was associated with the 25-49 age category (adjusted odds ratio [aOR] = 3.09, 95% confidence interval [CI] 1.27-7.50), female gender (aOR = 9.55, 95% CI 4.40-20.74), current alcohol and cannabis use (aOR = 3.43, 95% CI 1.01-11.62), family history of psychosis (aOR = 3.22, 95% CI 1.03-10.02) and no tertiary education (aOR = 3.7, 95% CI 0.14-0.99). All those living with HIV were on antiretroviral treatment. CONCLUSION: This study showed that HIV testing and care was accessible at a psychiatric hospital but the prevalence of HIV in people living with recent onset psychosis remains high. CONTRIBUTION: The study findings suggest the importance of integrating mental health and HIV management

Assessing the revised Clinical Institute Withdrawal for Alcohol Scale use at Stikland Hospital

BACKGROUND: Alcohol use disorder (AUD) is a major public health concern in South Africa (SA). Abrupt cessation or reduction of alcohol intake in chronic users can result in withdrawal symptoms. Benzodiazepines are the treatment of choice but need to be used cautiously in patients with a lifetime history of substance abuse given their highly addictive potential. Symptom-triggered prescription of benzodiazepines during alcohol withdrawal using the Revised Clinical Institute Withdrawal for Alcohol Scale (CIWA-Ar) has been associated with improved safety and reduced benzodiazepines use. AIM: To investigate if implementation of the CIWA-Ar during alcohol detoxification impacted the dose of benzodiazepines used and withdrawal-related outcomes. SETTING: Alcohol rehabilitation unit (ARU) at Stikland Psychiatric Hospital. METHODS: A retrospective cohort study of 135 admissions over a six-month period comparing two groups: before (2015) and after (2017) the implementation of the CIWA-Ar. RESULTS: The study noted no differences in sociodemographic and alcohol-associated variables between the two groups, and there were no recorded complications in either group. The 2017 group had a lower percentage of patients that required benzodiazepines (33.8% vs. 51.4%, p = 0.04) and a lower median total amount of benzodiazepines used during alcohol withdrawal (0 mg vs. 5 mg, p = 0.01). CONCLUSIONS: The CIWA-Ar rating scale was an effective alternative to prescribing benzodiazepines pro re nata and decreased the total dose of benzodiazepines used during alcohol withdrawal. CONTRIBUTION: The use of a symptom triggered regime, like the CIWA-Ar rating scale, during withdrawal can be implemented safely in a SA treatment setting for patients with low-risk AUD.

Electroconvulsive therapy (ECT) with ketamine induction for catatonia in an HIV positive patient

INTRODUCTION: The successful use of ECT as treatment for catatonia, in the context of HIV (human immunodeficiency virus) infection, has been described previously. Ketamine has been used as an anaesthetic induction agent for ECT, although not considered the induction agent of choice. There are also case reports suggesting that ketamine may be an alternative treatment specifically for catatonia PATIENT PRESENTATION: This case report describes the management of a female patient who presented with catatonia, evidenced by stupor, waxy flexibility, mutism, negativism, and stereotypy, as well as stage four HIV infection, with poor response to previous psychotherapeutic interventions Management and outcome: We describe the course of management of this patient with ECT, following poor initial clinical response to ECT with propofol induction, the subsequent use of ketamine as an anaesthetic induction agent for ECT, with associated improvement in seizure quality, and good overall clinical response to ECT demonstrated thereafter. Conclusion and contributions: This case report suggests that ketamine may be a viable induction agent for ECT in this clinical setting.

Strengthening a mental illness management questionnaire for clinical associates through expert validation and cognitive interviews

Trauma survivors' perceptions and experiences of prolonged exposure for PTSD at a psychology clinic

BACKGROUND: Several trauma-focused treatments have been developed to treat post-traumatic stress disorder (PTSD). Yet there are limited studies on how trauma survivors perceive and experience trauma-focused treatments such as prolonged exposure therapy (PE) for PTSD, especially in low- and middle-income countries (LMIC AIM: The study aimed to explore the perceptions and experiences of trauma survivors receiving prolonged exposure therapy for PTSD and the general acceptability of PE for PTSD in a LMIC SETTING: The study was conducted at a community psychology clinic in the Eastern Cape, South Africa METHOD: Using a qualitative method, seven adult trauma survivors who completed six sessions of brief PE for PTSD were interviewed. Thematic analysis was used to identify relevant themes and to understand how participants perceived and experienced PE for PTSD RESULTS: The analysis yielded five themes, namely structure, obstacles, gender, exposure and experiences of recovery CONCLUSION: The findings suggested that participants perceived and experienced PE to be generally beneficial for the treatment of PTSD. Moreover, the study suggested that PE is an acceptable trauma therapy in a contextually diverse setting such as the Eastern Cape, South Africa. Overall, considering the evidence base of PE for PTSD, this study contributed to the literature on the acceptability of PE in a South African setting CONTRIBUTION: The findings of the study are in keeping with the extant literature on how persons perceive and experience PE for PTSD. The findings of the study suggests that PE is an acceptable and beneficial trauma therapy for PTSD in a contextually diverse setting such as South Africa. It is recommended that large scale implementation studies be conducted to further investigate the effectiveness, feasibility, and acceptability of PE in South Africa

A retrospective data analysis of psychiatric cases in Hargeisa, Somaliland between 2019 and 2020

BACKGROUND: In Somaliland, an estimated one person in every two households suffers from psychiatric disorders. Despite this, access to mental health care is limited because of shortages in facilities, human resources, funding and stigma AIM: To present the proportion of psychiatric disorders encountered in outpatient psychiatry clinics SETTING: The University if Hargeisa (UoH), Hargesisa, Somaliland METHODS: De-identified data on patients accessing psychiatric care from doctor trainees in the dual psychiatry-neurology residency program at UoH from January 2019 to June 2020 were included in the analysis. The Institutional Review Board from UoH approved data collection and analysis. The most common psychiatric diagnoses were summarised overall and by sex and age RESULTS: A total of 752 patients were included in the analysis. Most were male (54.7%), with an average age of 34.9 years. The most common psychiatric diagnoses were schizophrenia (28.0%), major depressive disorder (MDD) (14.3%) and bipolar disorder type 1 (BD1) (10.5%). When stratified by sex, patients with schizophrenia and BD1 were more likely to be male (73.5% and 53.3%, respectively), and those with MDD were more likely to be female (58.8%). Trauma- and stressor-related disorders accounted for 0.4% of cases, while 0.8% of patients presented with substance use disorders (alcohol and khat), which is an underestimate of the widespread use in Somaliland CONCLUSION: Additional research using structured clinical interviews is needed to determine the epidemiology of psychiatric disorders and promote policies aiming to decrease neuropsychiatric mortality and morbidity CONTRIBUTION: This work presents the first data collection related to neuropsychiatric disorders in Somaliland

Provision of HIV services to psychiatric inpatients in Botswana: Challenges and recommendations

BACKGROUND: The high prevalence of HIV among psychiatric inpatients is well-documented, yet little is known about the provision of HIV services for these patients AIM: This qualitative study aimed to explore and understand healthcare providers' challenges with providing HIV services to psychiatric inpatients SETTING: This study was conducted at the national psychiatric referral hospital in Botswana METHODS: The authors conducted in-depth interviews with 25 healthcare providers serving HIV-positive psychiatric inpatients. Data analysis was performed using a thematic analysis approach RESULTS: Healthcare providers reported challenges with transporting patients to access off-site HIV services, longer waiting periods for antiretroviral therapy (ART) initiation, patient confidentiality, fragmented services for treatment of comorbidities, and a lack of patient data integration between the national psychiatric referral hospital and other facilities such as the Infectious Diseases Care Clinic (IDCC) at the nearby district hospital. Providers' recommendations for addressing these challenges included the establishment of an IDCC at the national psychiatric referral hospital, connecting the psychiatric facility to the patient data management system to ensure integration of patient data, and provision of HIV-related in-service training to nurses CONCLUSION: Psychiatric healthcare providers advocated for on-site integration of care for psychiatric illness and HIV among inpatients to address the challenges of ART provision CONTRIBUTION: The findings suggest the need to improve the provision of HIV services in the psychiatric hospitals in order to ensure better outcomes for this often-overlooked population. These findings are useful in improving clinical practice for HIV in psychiatric settings

Lived experiences of adolescents admitted for first-episode psychosis in South Africa

BACKGROUND: First-episode psychosis is common in adolescents and can be distressful to the person experiencing it for the first time. However, there is limited research globally and specifically in Africa about the lived experiences of adolescents admitted into a psychiatric facility for first-episode psychosis AIM: To understand the adolescents' experiences of psychosis and receiving treatment in a psychiatric facility SETTING: Adolescent Inpatient Psychiatric Unit, Tygerberg Hospital, Cape Town, South Africa METHODS: This was a qualitative study that used purposive sampling to recruit 15 adolescents with first-episode psychosis and admitted to the Adolescent Inpatient Psychiatric Unit, Tygerberg Hospital in Cape Town, South Africa. Individual interviews were audio recorded, transcribed and analysed using thematic analysis consisting of both inductive and deductive coding RESULTS: The participants described negative experiences of their first episode psychosis, provided varying explanations for their first episode psychosis and had the insight that cannabis precipitated their episodes. They described both positive and negative interactions with both the other patients and staff. They did not wish to return to the hospital again following their discharge. Participants stated that they wanted to change their lives, return to school and try to prevent a second episode of psychosis CONCLUSION: This study provides insights into the lived experiences of adolescents presenting with first-episode psychosis and calls for future research to delve deeper into factors that support or enable recovery among adolescents with psychosis CONTRIBUTION: The findings of this study call for improving the quality of care in the management of first-episode psychosis in adolescents

Study of burnout and depressive symptoms in doctors at a central level, state hospital

BACKGROUND: Doctors are at high risk of burnout, which has far-reaching consequences on an individual and organisational level. Several studies have shown an association between burnout and depression AIM: This study aimed to determine the rate of burnout and depressive symptoms among doctors, as well as factors associated with both conditions SETTING: Charlotte Maxeke Johannesburg Academic Hospital METHODS: Burnout was measured using the Maslach Burnout Inventory-Human Services Survey and defined as the total score of high emotional exhaustion (≥ 27 points) + high depersonalisation (≥ 13 points). Individual subscales were analysed separately. Depressive symptoms were screened using the Patient-Health Questionnaire-9 (PHQ-9) and a score of ≥ 8 was deemed indicative of depression RESULTS: Of the respondents (n = 327 for burnout and n = 335 for depression), 46.2% screened positive for burnout, whilst 53.73% screened positive for depression. Factors associated with increased burnout risk were younger age; Caucasian race; internship and/or registrarship; the discipline of emergency medicine; and having a prior psychiatric diagnosis of depressive and/or anxiety disorder. Factors associated with increased risk of depressive symptoms were females; younger age; being an intern, medical officer or registrar; disciplines of anaesthetics and obstetrics and gynaecology; having a prior psychiatric diagnosis of depressive and/or anxiety disorder; and family history of psychiatric disorder CONCLUSION: A high rate of burnout and depressive symptoms was determined. Although there is an overlap between the two conditions in terms of both symptomatology and risk factors, specific risk factors were determined for each in this population CONTRIBUTION: This study highlighted the rate of burnout and depressive symptoms experienced by doctors at the state level hospital necessitating individual and institutional interventions to address this

Development and validation of the Redeemer's University Suicidality Scale

BACKGROUND: The need for a culturally suitable scale for suicidality within the multilingual Nigerian society necessitated this research interest. AIM: The study is a development and validation of the Redeemer's University Suicidality Scale (RUSS). SETTING: South western Nigeria. METHODS: This comprised of initial generation of items; face and content validity, item refinement and administration of RUSS to 150 university undergraduates, using exploratory factor analysis at the first, second and third stages. In the fourth stage, 184 undergraduates responded to the 20-item RUSS, Suicide Ideation Scale (SIS) and General Health Questionnaire (GHQ-12). Data gathered at this stage were analysed for congruent validity, reliability and norms. RESULTS: The principal component analysis extracted four components from items whose eigenvalues exceeded one. Twenty-one of the 25 items loaded best in the first, two in the second and one on the third component(s). Only items in the first component were retained. Item-total correlation further showed that the values of one item in the first component fell below the very good discrimination and was deleted from the scale. The RUSS has a Cronbach's alpha of 0.93. Congruence validity coefficient of r = 0.881 (p < 0.001) and r = 0.605 (p < 0.001) was observed between RUSS and SIS and between RUSS and GHQ-12, respectively. CONCLUSION: The RUSS is gender-sensitive, has acceptable psychometric properties and is recommended as a diagnostic tool for assessing suicidal behaviour in adolescents and adults CONTRIBUTION: This article contributes to the development of a culture sensitive measure for suicidality.

Effects of personality traits on mindful self-care practices of healthcare workers

BACKGROUND: Coronavirus disease 2019 (COVID-19) placed healthcare professionals (HCPs) at a higher risk for stress-related conditions. Implementing a brief online mindfulness-based intervention (MBI) was hypothesised to transform the HCPs' ability to cope with stress by enhancing their self-care. AIM: This study aimed to explore the impact of an online MBI on HCPs' self-care practices and determine if personality traits were a moderating variable. SETTING: An online MBI was implemented for HCPs working in South Africa during the COVID-19 pandemic lockdowns. METHODS: A quantitative study design included a pre-assessment and post-assessment component, which allowed paired comparison and regression analysis to confer correlations. Data were collected via two validated instruments: the Mindful Self-Care scale-2018 and the Big Five Personality test RESULTS: Forty-nine HCPs participated in the study. Significant improvements were found in all the major self-care subscales post-intervention (p < 0.05). No significant associations were found between the personality traits and self-care except for neuroticism, which appeared to be an essential moderating variable. CONCLUSION: An online MBI significantly impacted health professionals' ability to care for themselves, despite their personality styles. CONTRIBUTION: The impact of an online MBI on HCPs' self-care during the most intense time of stress and with a cohort of people known to be the most vulnerable to stress, namely those with neuroticism to date, has not been commented on.

South Africa's Psychiatric training capacity in 2008 and in 2018. Has training capacity improved?

BACKGROUND: There is a deficit of psychiatrists in South Africa, and to our knowledge, there is no situational analysis of training posts for psychiatrists in the country. AIM: To compare the number of specialists and subspecialists in training and training posts available in 2008 and 2018. SETTING: South African medical schools with departments of psychiatry. METHODS: A situational analysis involving data collection through a survey completed by eight heads of academic psychiatric departments followed by a comparative analysis of the two aforementioned years. RESULTS: Data shows an 11% increase in funded and unfunded posts combined and a 9.3% increase in funded posts. The occupancy of funded posts decreased (92% in 2008 to 82% in 2018). When considering both funded and unfunded posts, only three more psychiatrists were being trained in 2018. Supernumeraries appointed in unfunded posts can be expected to return to their countries of origin. As such, a decrease in filled funded posts likely reflects a decrease in training psychiatrists destined to work in South Africa. While child and adolescent psychiatry was the only sub-speciality with accredited training posts in 2008, all sub-specialities included on the questionnaire had accredited training posts in 2018, and the number of accredited training posts in child and adolescent psychiatry doubled. That said, many of the posts were unfunded and vacant. CONCLUSION: While there was an increase in posts from 2008 to 2018, many posts remained unfilled. As such, not only are additional funded training posts required but also strategies to increase post-occupancy and successful completion of training. CONTRIBUTION: This study is the first situational analysis of specialist and subspecialist training posts in Psychiatry in South Africa, at two time points over a 10 year period, that draws on academic heads of departments of psychiatry as respondents. The study highlights the nominal increase in funded training posts over this period, especially subspecialist training posts. The majority of Health Professions Council of South Africa (HPCSA) accredited subspecialities in Psychiatry have no funded training posts which is particularly concerning.

Psychiatric morbidity in children involved in bullying treated at the Free State Psychiatric Complex

BACKGROUND: Bullying is a multifaceted problem with many consequences. AIM: This study aimed to determine the psychiatric morbidity of children involved in bullying, either as bullies or victims, treated at the Child and Adolescent Mental Health Care Centre of the Free State Psychiatric Complex (FSPC). SETTING: Free State Psychiatric Complex, Bloemfontein, South Africa. METHODS: This retrospective cross-sectional study included children under 18 years treated at the FSPC Care Centre between January and September 2017. Information was extracted from patient files. RESULTS: Of 288 patients, 98 (34.0%) were involved in bullying: 66 were bullies, 28 victims, 3 bully-victims, and 1 unspecified. For gender and family structure, there were no statistically significant differences between children involved and those not involved in bullying and between bullies and victims. Almost all bullies (95.4%) had aggression as presenting complaint compared with 39.3% of the victims (p < 0.01). Statistically significantly more victims, than bullies, reported sadness (21.4%, 4.6%, p = 0.02). Attention deficit/hyperactivity disorder (ADHD) was diagnosed in most children, both involved (73.5%) and not involved (63.2%). Statistically significant differences for the presence of conduct disorder were found between children involved and those not involved in bullying (31.6%, 10.0%, p < 0.01) and between bullies and victims (39.4%, 14.3%, p = 0.02. CONCLUSION: The prevalence of conduct disorder diagnosis was more common in bullies than in victims and those involved in bullying as opposed to those not involved. CONTRIBUTION: Psychiatric information of bullying victims and perpetrators in the Free State, which had a high prevalence of bullying in a national survey.

Assessing attitudes of fourth year medical students towards psychiatry and mental illness

BACKGROUND: Research revealed a high prevalence of negative attitudes towards psychiatry and mental illness among medical students prior to formal psychiatric education. Anti-stigma interventions at the medical student level have been postulated to reduce the risk of negative attitudes, which may drive stigmatization impacting recruitment into training posts and overall medical care. AIM: To determine the prevalence of negative attitudes towards psychiatry and mental illness in a sample of fourth-year medical students prior to formal psychiatric teaching. To ascertain possible sociodemographic correlations with findings. SETTING: The University of the Witwatersrand. METHODS: A cross-sectional, quantitative, descriptive study was conducted using the Mental Illness: Clinicians' Attitudes Scale 2 questionnaire and a socio-demographic questionnaire. RESULTS: Of the total scores, 97.2% participants fell below the median potential score of 56, reflecting a low prevalence of stigmatising attitudes. The African cohort expressed less interest in psychiatry (P=0.0017), compared to other race cohorts (ranging from 92.1% to 100.0%. CONCLUSION: This study revealed a low prevalence of negative and stigmatising attitudes towards psychiatry and mental illness. Of statistical significance, was a relative difference in attitudes towards psychiatry and mental illness in different race cohorts (P=0.0017); however, overall race cohorts showed a low prevalence of negative and stigmatising attitudes towards psychiatry. CONTRIBUTION: This study creates awareness of the impact factors on attitudes of medical students towards mental illness and specialization in psychiatry.

Clozapine use at a specialised psychiatric hospital in Johannesburg

BACKGROUND: Clozapine is the gold standard medication for treatment-resistant psychosis, with robust evidence supporting its efficacy in multiple symptom domains. However, clozapine's side effect profile contributes to its underutilisation and discontinuation. AIM: This study aimed to explore the magnitude of clozapine use and describe factors that impact on its effective use among in-patients. SETTING: Tara Hospital, a specialised psychiatric hospital in Johannesburg. METHODS: This was a retrospective, cross-sectional file review of clozapine-treated patients admitted over the 2-year study period. Data variables included: demographics, clinical information, discharge prescription, clozapine-related side effects and details of clozapine discontinuation, where applicable. RESULTS: A cohort of 33.2% of patients from Tara's biological wards received a trial of clozapine. Participants experienced anti-cholinergic clozapine-related side effects that included weight gain (79.5%), tachycardia (35.2%) and constipation (35.2%). Clozapine was discontinued in 13.7% of participants, and no life-threatening side effects or deaths occurred. Significantly more use of flupenthixol decanoate (64.3% vs. 30.7%; p = 0.0322) and anticholinergics (35.7% vs. 11.4%; p = 0.0474) occurred in the clozapine-discontinued group. Polypharmacy rates were high for psychiatric and non-psychiatric medications. CONCLUSION: One-third of patients received clozapine trials, most of whom continued at discharge. Although side effects occurred frequently, life-threatening side effects did not. Clozapine monitoring protocols, side effect rating scales, pre-emptive management of side effects, lifestyle interventions and clinician education may improve outcomes of clozapine use. The use of plasma clozapine levels may be beneficial. CONTRIBUTION: This study expands our limited knowledge regarding current clozapine prescribing trends in South Africa.

Electroconvulsive therapy (ECT) with ketamine induction for catatonia in an HIV positive patient

INTRODUCTION: The successful use of ECT as treatment for catatonia, in the context of HIV (human immunodeficiency virus) infection, has been described previously. Ketamine has been used as an anaesthetic induction agent for ECT, although not considered the induction agent of choice. There are also case reports suggesting that ketamine may be an alternative treatment specifically for catatonia. PATIENT PRESENTATION: This case report describes the management of a female patient who presented with catatonia, evidenced by stupor, waxy flexibility, mutism, negativism, and stereotypy, as well as stage four HIV infection, with poor response to previous psychotherapeutic interventions. MANAGEMENT AND OUTCOME: We describe the course of management of this patient with ECT, following poor initial clinical response to ECT with propofol induction, the subsequent use of ketamine as an anaesthetic induction agent for ECT, with associated improvement in seizure quality, and good overall clinical response to ECT demonstrated thereafter. CONCLUSION AND CONTRIBUTIONS: This case report suggests that ketamine may be a viable induction agent for ECT in this clinical setting.

Preparedness of final year medical students in caring for lesbian, gay, bisexual, and transgender patients with mental illness

BACKGROUND: Lesbian, gay, bisexual, and transgender (LGBT) individuals have a higher prevalence of mental illness compared to the general population. Discriminatory behaviour from mental health care providers impedes access to culturally competent mental health care. Undergraduate psychiatry education plays an important role in adequately preparing medical doctors to care for mental illness in LGBT patients. AIM: This study aims to assess the knowledge, attitudes and clinical preparedness of final-year medical students in caring for LGBT patients after completion of their psychiatry rotation. SETTING: Faculty of health sciences at a large public university in Gauteng. METHODS: This was a cross-sectional study using an anonymous self-administered questionnaire. The questionnaire comprised demographic data, the lesbian, gay, bisexual, and transgender development of clinical skills scale (LGBT-DOCSS) and questions relating to their subjective knowledge and preparedness in LGBT mental health care. The LGBT-DOCSS is a validated tool consisting of three subscales: basic knowledge, attitudinal awareness, and clinical preparedness. RESULTS: Data from 170 final-year students were used in the analyses. Participants scored within the low range for clinical preparedness and basic knowledge subscales but high in the attitudinal subscale. Gender, sexual orientation and academic background were associated with higher overall scores and higher basic knowledge and attitudinal awareness scores. CONCLUSION: Final-year medical students were not adequately prepared in caring for LGBT patients with mental illness as indicated by the LGBT-DOCSS. CONTRIBUTION: This study identifies a gap in undergraduate psychiatric training in providing culturally competent mental health care for a vulnerable population.