Antipsychotic treatment effects and structural MRI brain changes in schizophrenia.

BACKGROUND: Progressive brain structural MRI changes are described in schizophrenia and have been ascribed to both illness progression and antipsychotic treatment. We investigated treatment effects, in terms of total cumulative antipsychotic dose, efficacy and tolerability, on brain structural changes over the first 24 months of treatment in schizophrenia. METHODS: A prospective, 24-month, single-site cohort study in 99 minimally treated patients with first-episode schizophrenia, schizophreniform and schizoaffective disorder, and 98 matched healthy controls. We treated the patients according to a fixed protocol with flupenthixol decanoate, a long-acting injectable antipsychotic. We assessed psychopathology, cognition, extrapyramidal symptoms and BMI, and acquired MRI scans at months 0, 12 and 24. We selected global cortical thickness, white matter volume and basal ganglia volume as the regions of interest. RESULTS: The only significant group × time interaction was for basal ganglia volumes. However, patients, but not controls, displayed cortical thickness reductions and increases in white matter and basal ganglia volumes. Cortical thickness reductions were unrelated to treatment. White matter volume increases were associated with lower cumulative antipsychotic dose, greater improvements in psychopathology and cognition, and more extrapyramidal symptoms. Basal ganglia volume increases were associated with greater improvements in psychopathology, greater increases in BMI and more extrapyramidal symptoms. CONCLUSIONS: We provide evidence for plasticity in white matter and basal ganglia associated with antipsychotic treatment in schizophrenia, most likely linked to the dopamine blocking actions of these agents. Cortical changes may be more closely related to the neurodevelopmental, non-dopaminergic aspects of the illness.

Cannabis use and psychotic disorders in diverse settings in the Global South: findings from INTREPID II.

BACKGROUND: Cannabis use has been linked to psychotic disorders but this association has been primarily observed in the Global North. This study investigates patterns of cannabis use and associations with psychoses in three Global South (regions within Latin America, Asia, Africa and Oceania) settings. METHODS: Case-control study within the International Programme of Research on Psychotic Disorders (INTREPID) II conducted between May 2018 and September 2020. In each setting, we recruited over 200 individuals with an untreated psychosis and individually-matched controls (Kancheepuram India; Ibadan, Nigeria; northern Trinidad). Controls, with no past or current psychotic disorder, were individually-matched to cases by 5-year age group, sex and neighbourhood. Presence of psychotic disorder assessed using the Schedules for Clinical Assessment in Neuropsychiatry and cannabis exposure measured by the World Health Organisation Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). RESULTS: Cases reported higher lifetime and frequent cannabis use than controls in each setting. In Trinidad, cannabis use was associated with increased odds of psychotic disorder: lifetime cannabis use (adj. OR 1.58, 95% CI 0.99-2.53); frequent cannabis use (adj. OR 1.99, 95% CI 1.10-3.60); cannabis dependency (as measured by high ASSIST score) (adj. OR 4.70, 95% CI 1.77-12.47), early age of first use (adj. OR 1.83, 95% CI 1.03-3.27). Cannabis use in the other two settings was too rare to examine associations. CONCLUSIONS: In line with previous studies, we found associations between cannabis use and the occurrence and age of onset of psychoses in Trinidad. These findings have implications for strategies for prevention of psychosis.

Antiretroviral therapy non-adherence and its relationship with cognitive impairment, alcohol use disorder, and depression in adolescents living with HIV.

OBJECTIVE: We aimed to compare antiretroviral non-adherence in the behaviourally infected (BIAs) and congenitally infected adolescents (CIAs) and explore its associations with depression, cognitive impairment, and alcohol use disorder (AUD) in adolescents living with HIV(ALWHIV) in Botswana. METHODS: This study was a cross-sectional, comparative, multi-center research that involved collecting samples from different HIV clinics in Botswana. Of the 622 ALWHIV, 223 were identified as BIAs and 399 as CIAs. They were evaluated using various tools such as MINI-KID for psychiatric disorders, DSM-5 for AUD, CAT-rapid for cognitive assessment, and Visual Analogue Scale (VAS) for non-adherence (the outcome). The data were analysed using both bivariate and multivariate regression analyses. RESULTS: The participants' mean age (SD) was 17.7(1.60). The CIAs were more likely to have cognitive impairment (t -7.25; p < 0.01), while the BIAs had more depression (χ2 = 5.86; p = 0.016) and AUD (χ2 = 4.39; p = 0.036) and were more likely to be non-adherent (t = 3.14; p = 0.002). In the CIA group, cognitive impairment (AOR = 2.86; 95% CI:1.77-4.64) (AOR = 2.79; 95%CI:1.73-4.48) and depression (AOR = 2.69; 95%CI:1.48-4.90 were associated with ART non-adherence. In the BIA group, depression (AOR = 2.55; 95%CI:1.27-5.16), AUD (AOR = 2.58; 95%CI:1.21-5.49) and struggling to accept status (AOR = 2.54; 95%CI:1.41-4.56) predicted non-adherence to treatment. CONCLUSION: The two groups of adolescents differ regarding ART non-adherence and associated psychosocial issues, indicating the need for differentiated care to address non-adherence in the ALWHIV, especially in high-burden, resource-constrained settings, such as Botswana.

Psychiatric disorders in adolescents living with HIV in Botswana.

BACKGROUND: As children living with HIV transition from adolescence into adulthood, they face a considerable burden of psychiatric disorders (PDs) which may vary between the perinatally and behaviorally infected. The knowledge of the pattern of these PDs in relation to the varying needs of the adolescents living with HIV (ALWHIV) is unclear but necessary for maximizing their linkage to care and improving their quality of life in Botswana.  AIM: To determine the pattern of PDs in ALWHIV in Botswana; to compare and explore the differences in the pattern and their associated factors between congenitally infected adolescents (CIAs) and behaviorally infected adolescents (BIAs). METHODS: A cross-sectional survey of 622 ALWHIV (399 CIA and 223 BIA) with the Mini International Neuropsychiatric Interview-Kid Screen. RESULTS: The participants' mean age (SD) was 17.71 (1.60) years, with more males (54%), of whom 52.9% had at least one PD, with depression (23.6%) and generalised anxiety disorder (18.0%) being the most prevalent. The externalising disorders were associated with being CIA (OR = 3.99; 95% CI:1.87-8.54), male gender (OR = 3.93; 95% CI:2.02-7.64), and a viral load of 400 and above copies (OR = 3.53; 95%CI:1.92-6.48). Internalising disorders were associated with being BIA (OR = 3.64; 95%; CI: 2.39-5.56), females (OR = 2.59; 95% CI:1.75-3.83), poor counselling (OR = 2.23; 95% CI: 1.42-3.51) and struggling to accept HIV status (OR = 1.73; 95% CI:1.14-2.62). CONCLUSIONS: Depression and anxiety disorders were the most prevalent PDs in ALWHIV, who differed in psychiatric presentations, the BIAs being more likely to present with internalizing disorders, while the CIAs had more externalizing disorders. Due to the varying needs of ALWHIV, individualized management plans that consider gender, mode of infection, and other psycho-social needs, should be further studied and encouraged.

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.

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 disorders and associated risk factors in a sample of adolescents in Gaborone, Botswana: a cross-sectional study.

BACKGROUND: Despite the high proportion of adolescents living with mental health issues in low- to middle-income countries (LMICs), especially in Botswana, there is a significant deficit of local research to guide an increase in prevention and treatment. We, therefore, aimed to assess the prevalence and associated risk factors of psychiatric disorders (PD) in a sample of secondary school students in Botswana. METHODS: This cross-sectional study included 750 students from the 13 public secondary schools in Gaborone using a multi-stage sampling technique. The Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) was used to screen for PDs. RESULTS: The participant's mean age was 15.26 and SD 1.57 years, with 53.6% being female. Approximately 34% had a PD, with depression being the commonest, of whom 35% were neither receiving treatment nor aware of the available services. Perinatal complications (AOR = 4.29; 95%CI: 1.04-17.70), a family history of mental illness (AOR = 2.19; 95%CI: 1.17-4.11) and substance-related problems (AOR = 1.80; 95% CI:1.22-2.65) predicted the likelihood of developing PD. CONCLUSIONS: Our findings revealed that adolescents in Botswana have many mental health issues which may affect their developmental phases. A multi-sectoral collaboration is needed for the timely detection of identified risk factors and initiation of the necessary prevention and treatment measures.

Psychiatric Disorders in Adolescents Living with HIV and Association with Antiretroviral Therapy Adherence in Sub-Saharan Africa: A Systematic Review and Meta-analysis.

In sub-Saharan Africa (SSA), a systematic approach to exploring the prevalence of psychiatric disorders (PDs) and adherence to antiretroviral treatment (ART) in adolescents living with HIV (ALWHIV) is lacking. This study aimed to systematically review the studies conducted in SSA on the prevalence of PDs among ALWHIV and their association with ART adherence. A systematic search of all English studies assessing PDs among ALWHIV using the Web of Science, PubMed, and EBSCO databases was conducted between March 1 and September 30, 2019. Forty-two studies published between 2009 to 2019 met the inclusion criteria, of which 15 were included in the meta-analysis. The most common PDs were depression (0.24, 95% CI 0.14-0.36) and anxiety disorder (0.26, 95% CI 2-0.44). The available evidence could not conclude on the definitive association between PDs and ART adherence; therefore, further research is required. However, the need for mental health integration in the care for ALWHIV is evident.

RESUMEN: En África subsahariana (SSA), falta un enfoque sistemático para explorar la prevalencia de los trastornos psiquiátricos (PDs) y la adherencia al tratamiento antirretroviral (ART) en adolescentes que viven con el VIH (ALWHIV). Este estudio tuvo como objetivo revisar sistemáticamente los estudios realizados en la SSA sobre la prevalencia de PDs en ALWHIV y su asociación con la adherencia al ART. Se realizó una búsqueda sistemática de todos los estudios en inglés que evalúan PDs entre ALWHIV utilizando las bases de datos Web of Science, PubMed y EBSCO entre el 1 de marzo y el 30 de septiembre de 2019. Cuarenta y dos estudios publicados entre 2009 y 2019 cumplieron los criterios de inclusión, de los cuales 15 se incluyeron en el metanálisis. Los TP más frecuentes fueron depresión (0.24, 95% CI 0.14­0.36) y trastorno de ansiedad (0.26, 95% CI 2­0.44). La evidencia disponible no pudo concluir sobre la asociación definitiva entre los PDs y la adherencia al ART; por lo tanto, se requiere más investigación. Sin embargo, la necesidad de la integración de la salud mental en la atención de ALWHIV es evidente.

The Dual Burden of HIV Infection and First-Episode Psychosis in Africa: A Systematic Review and Meta-Analysis.

ABSTRACT: A systematic review and meta-analysis was conducted to synthesize data on HIV prevalence in individuals with first-episode psychosis (FEP) and to provide an overview of the association of HIV with clinical variables of FEP. Electronic databases were searched for quantitative studies published from January 1986 to November 2019. Meta-analyses were undertaken to calculate the pooled HIV/FEP proportion based on random effects modeling with inverse variance method. Seven HIV/FEP studies from sub-Sahara Africa (SSA) met inclusion criteria. The prevalence of HIV in FEP ranged from 24% to 40%, and FEP in people living with HIV (PLWHIV) ranged from 17% to 29%. The pooled proportion of HIV in FEP was 26% (95% confidence interval [CI], 10%-43%), with significant heterogeneity (n = 3, I2 = 89%, p < 0.01), and of FEP in PLWHIV was 23% (95% CI, 15%-32%), without significant heterogeneity (n = 3, I2 = 0%, p = 0.43). There are concerning levels of HIV and FEP comorbidity in SSA, necessitating an integrated health care service.

Factors Affecting Specialist Psychiatry Training in South Africa: Are Psychiatry Residents Satisfied with Their Training?

OBJECTIVE: The authors investigated South African psychiatry residents' satisfaction with their training, physical, and mental health to inform the development of a strategy to improve the quality and experiences of training. METHOD: A cross-sectional online survey was undertaken to assess the factors affecting residents' satisfaction with their current training program. The authors conducted a comparative analysis of residents across the training institutions in South Africa. RESULTS: Of 179 psychiatry residents in the country, 70 responses were received (39.1% response rate). Most were satisfied with the overall quality of their training, various aspects of training, and access to training resources. However, significant differences across universities were identified with regard to residents' perception of the quality of their training, quality of their experiences, access to training resources, quality of supervision, and clinical workload. More than a quarter were dissatisfied with their mental and/or physical health. The top four factors contributing to stress were all training-related. CONCLUSION: While most residents were satisfied with their specialist training, institutional differences in access to training and training resources, quality of training, and availability of quality supervision were evident and need to be addressed to ensure equitable training. There is a need to actively address staff shortages not only for clinical cover during protected academic time but also to meet training needs. A centralized examination process should remain in place to ensure that there is a national standard. Workplace-based assessments could facilitate standardization across institutions, should these assessments be standardized and accompanied by rigorous training of supervisors.

Spontaneous and emergent extrapyramidal syndromes in Black Africans with first-episode schizophrenia and first exposure to antipsychotics.

BACKGROUND: Persons of African ancestry are thought to carry a higher risk for extrapyramidal syndromes (EPS) in schizophrenia. AIM: We investigated the phenomenon of spontaneous and treatment-emergent EPS in a sample comprising Xhosa (South Africa) and Yoruba (Nigeria) Africans with first-episode schizophrenia and first exposure to antipsychotics. METHODS: The Extrapyramidal Symptom Rating Scale (ESRS) and a variety of validated tools were used for the assessment of participants before, and two-weekly after treatment with low dose flupenthixol decanoate. Participants were followed up for 12 months. Association of EPS with clinical characteristics was investigated using Pearson's correlation and linear regression analyses. RESULTS: Of 88 participants at baseline, 16 (18.1%) had at least one definite EPS prior to antipsychotic exposure and 34 (38.6%) had treatment-emergent EPS. While spontaneous Parkinsonism was associated with negative symptoms (r = 0.2, p = 0.043; ß = 0.6, p = 0.043), treatment-emergent EPS demonstrated non-significant correlations with clinical characteristics. Apart from dyskinesia, the frequency of treatment-emergent EPS decreased over 12 months observation. CONCLUSION: These findings support the hypothesis suggesting that spontaneously occurring Parkinsonism in schizophrenia may be the motor spectrum of negative symptomatology. Future studies of this relationship may lead to early identification of patients who may be more sensitive to EPS.

The profile of suspected criminal offenders referred for psychiatric evaluation on an outpatient basis at Ngwelezana Hospital.

BACKGROUND: Some suspected criminal offenders in South Africa are required to undergo forensic psychiatry assessments before or during the trial, which can be delayed as a result of the shortage of psychiatrists and inpatient forensic psychiatry beds. In KwaZulu-Natal (KZN) province, only one hospital (Fort Napier Hospital [FNH]) is designated for the 30-day inpatient forensic psychiatry assessments and there is a long waiting list for suspected criminal offenders awaiting assessment. There is a need to find ways of alleviating the backlog in the waiting list, with the use of outpatient forensic assessments being a possible adjunctive method. AIM: To determine the demographic, clinical and forensic profile of suspected criminal offenders referred for outpatient preliminary assessment to Ngwelezana Hospital, and identify the profile of those who most likely require referral to FNH for a 30-day inpatient assessment. SETTING: The study was conducted at Ngwelezana Tertiary Hospital, in KZN, South Africa. METHODS: We conducted a retrospective chart review of 207 suspected criminal offenders referred for outpatient forensic assessment from January 2009 to June 2015. RESULTS: The majority of the participants were males (94.2%), with a diagnosis of substance use disorder (28.2%), intellectual disability (23.4%) or psychotic disorders (21.8%). Forty three per cent were charged with sexual crimes and 10.7% with murder. Fifty seven per cent were recommended for referral to FNH for a 30-day inpatient forensic assessment, whilst 43% were not recommended for referral. Those recommended for inpatient assessment were significantly more likely to have a lower level of education (p = 0.02), to be on a disability grant (p < 0.01), and to have been diagnosed with intellectual disability (p < 0.01), than those not recommended for referral. CONCLUSION: Identifying the characteristics of suspected criminal offenders who are most likely to be recommended for referral to FNH will potentially reduce the number of unnecessary referrals.

Erratum: Extrapyramidal side effects in first-episode schizophrenia treated with flupenthixol decanoate.

[This corrects the article DOI: 10.4102/sajpsychiatry.v27i0.1568.].

Factors associated with dropout at 2 years post-initiation of treatment in the first episode of schizophrenia.

BACKGROUND: Prevention of new episodes during the first 2 years after a first episode of schizophrenia (FES) may delay treatment refractoriness and brain morphological changes over time. However, adherence to treatment is characteristically poor in these patients. AIM: The aim of this study was to examine clinical and sociodemographic factors associated with patient dropout in patients with FES. SETTING: This study was set at inpatient and outpatient services at a psychiatric hospital in the Western Cape, between 2007 and 2011. METHODS: Data were collected as part of a prospective longitudinal study, which followed up patients with FES treated with flupenthixol decanoate. We examined the relationship between treatment adherence and sociodemographic and clinical factors at baseline and at 24 months. Unadjusted and adjusted logistic regression models were used to determine adherence variables. RESULTS: A total of 62% of patients completed the 24 months of treatment. Participants with FES and a substance use disorder (dual diagnosis) were at greater risk of dropout (p = 0.01). On univariate analysis, dual diagnosis participants who dropped out were older (p = 0.04) had completed more years of schooling (p = 0.001), older age of onset (p = 0.02) and higher baseline positive symptoms (p = 0.05). On regression analysis, non-completer substance users achieved a higher level of education (odds ratio [OR]: 3.87, confidence interval [CI]: 1.34-11.11, p = 0.01). CONCLUSION: Substance use disorder was associated with non-adherence to follow up in a cohort of FES patients treated with flupenthixol decanoate. Interventions that take into account age, education and baseline positive symptoms may afford the opportunity to influence adherence and patient outcome.

Extrapyramidal side effects in first-episode schizophrenia treated with flupenthixol decanoate.

BACKGROUND: Concern for the development of extrapyramidal side effects (EPSEs) represents a barrier to the routine use of long-acting injectable (LAI) antipsychotic medication in patients with first-episode schizophrenia (FES). Flupenthixol decanoate is a first-generation antipsychotic, which is readily available in the public healthcare system in South Africa. AIM: The aim of this study was to describe the nature, occurrence and severity of EPSEs and their impact on patients with FES over 12 months of treatment with flupenthixol decanoate (fluanxol depot). SETTING: The study was based in Cape Town, South Africa, and patients with FES were recruited from inpatient services at Stikland and Tygerberg Hospitals and surrounding psychiatric clinics. This was a sub-study of a larger study, which examined several outcomes in patients with FES treated with the lowest effective dose of flupenthixol decanoate. METHODS: The Extrapyramidal Symptom Rating Scale (ESRS) was used to assess both subjective experience and objective measures of EPSEs in a cohort of patients with FES (N = 130). The relationship between demographic and clinical risk factors for individual subsets of EPSEs was also determined. RESULTS: In the context of an overall good 12-month tolerability, EPSEs peaked at month 3. Patients with akathisia were more likely to have greater symptoms of depression, and Parkinsonism was predicted by higher Positive and Negative Syndrome Scale scores (independent of medication dosage). Black and white patients showed higher total ESRS and higher subjective ESRS scores, compared with patients of mixed ancestry, and white patients scored higher on Parkinsonism ratings. CONCLUSION: Flupenthixol decanoate is well tolerated in patients with FES. Certain clinical features of schizophrenia may be related to EPSEs. Ethnicity is a socio-cultural construct, and hence the differential risk of EPSEs should be interpreted according to ethnicity. Variations in the environment, diet, substance use and genetics may all affect the pharmacokinetics and pharmacodynamics of psychotropic drugs and warrant further investigation.

Correction: National and regional prevalence of posttraumatic stress disorder in sub-Saharan Africa: A systematic review and meta-analysis.

[This corrects the article DOI: 10.1371/journal.pmed.1003090.].

National and regional prevalence of posttraumatic stress disorder in sub-Saharan Africa: A systematic review and meta-analysis.

BACKGROUND: People living in sub-Saharan Africa (SSA) are disproportionately exposed to trauma and may be at increased risk for posttraumatic stress disorder (PTSD). However, a dearth of population-level representative data from SSA is a barrier to assessing PTSD. This manuscript sought to calculate pooled PTSD prevalence estimates from nationally and regionally representative surveys in SSA. METHODS AND FINDINGS: The search was conducted in PubMed, Embase, PsycINFO, and PTSDpubs and was last run between October 18, 2019, and November 11, 2019. We included studies that were published in peer-reviewed journals; used probabilistic sampling methods and systematic PTSD assessments; and included ≥ 450 participants who were current residents of an SSA country, at least 50% of whom were aged between 15 and 65 years. The primary outcomes were point prevalence estimates of PTSD across all studies, and then within subgroups. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42016029441). Out of 2,825 unique articles reviewed, 25 studies including a total of 58,887 eligible participants (54% female) in 10 out of the 48 countries in SSA were identified. Most studies enrolled any adult aged 18 years or older. However, some studies only enrolled specific age brackets or persons as young as 15 years old. Six studies were national surveys, and 19 were regional. There were 4 key findings in the meta-analysis: (1) the overall pooled prevalence of probable PTSD was 22% (95% CI 13%-32%), while the current prevalence-defined as 1 week to 1 month-was 25% (95% CI 16%-36%); (2) prevalence estimates were highly variable, ranging from 0% (95% CI 0%-0%) to 74% (95% CI 72%-76%); (3) conflict-unexposed regions had a pooled prevalence of probable PTSD of 8% (95% CI 3%-15%), while conflict-exposed regions had a pooled prevalence of probable PTSD of 30% (95% CI 21%-40%; p < 0.001); and (4) there was no significant difference in the pooled prevalence of PTSD for men and women. The primary limitations of our methodology are our exclusion of the following study types: those published in languages other than English, French, and Portuguese; smaller studies; those that focused on key populations; those that reported only on continuous measures of PTSD symptoms; and unpublished or non-peer-reviewed studies. CONCLUSIONS: In this study, PTSD symptoms consistent with a probable diagnosis were found to be common in SSA, especially in regions exposed to armed conflict. However, these studies only represent data from 10 of the 48 SSA countries, and only 6 studies provided national-level data. Given the enormous heterogeneity expected across the continent, and also within countries and regions, this review cannot speak to rates of PTSD in any regions not included in this review. Thus, substantial gaps in our knowledge of PTSD prevalence in SSA remain. More research on population-level prevalence is needed to determine the burden of trauma symptoms and PTSD in SSA and to identify acceptable and feasible approaches to address this burden given limited mental healthcare resources.

Prolactin, flupenthixol decanoate and first episode schizophrenia - clinical and laboratory correlates.

First-episode psychosis (FEP) patients are more sensitive to neuroleptic side-effects such as hyperprolactinemia. We examined the prolactin levels of previously minimally treated patients with first episode schizophrenia over their first year of treatment with flupenthixol decanoate and the relationship between prolactin levels, gender and clinical features of schizophrenia. Prolactin levels were assessed at three monthly intervals in 126 patients with first-episode schizophrenia in a single-site study conducted over 12 months during treatment with flupenthixol decanoate according to a fixed protocol. The mean prolactin level for the total sample was 11.91 ng/ml (standard deviation [SD]15.52) at baseline. Women had higher levels of prolactin than men at month 3, 6 and 12, reaching statistical significance at month 12 (p = 0.02). At 12 months more women than men had hyperprolactinemia (defined as more than 20 ng/ml for males, and as more than 25 ng/ml for females (p = 0.007). Using a mixed effect model, there was a significant association between prolactin change scores over 12 months and gender (p = 0.025) as well as Positive and Negative Syndrome Scale (PANSS) total scores (p = 0.001). In addition female gender (p = 0.04) and age (p = 0.02) correlated with the risk of hyperprolactinemia as categorical variable. In this study treatment with flupenthixol decanoate was associated with relatively low levels of hyperprolactinemia, likely owing to flupenthixol's relatively atypical mode of action, as well as to the low doses used in our study. We found an inverse correlation between total PANSS scores and prolactin levels, which could support the suggested theory of prolactin having antipsychotic properties. Our study confirms the importance of gender on the prolactin raising effects of antipsychotic treatment.

Prevalence and clinical correlates of police contact prior to a first diagnosis of schizophrenia.

BACKGROUND: Little is known about the reasons why people with schizophrenia have contact with police, especially prior to the first episode of illness. AIM: To investigate the prevalence and correlates of police contact in first-episode schizophrenia. METHODS: The prevalence and type of police contact was established among all 110 patients presenting to psychiatric services in one catchment area during a first episode of schizophrenia and among 65 non-mentally ill controls, by participant and collateral interview and from records. Socio-demographic and clinical characteristics were also recorded and the two groups compared. RESULTS: The first episode of schizophrenia patients had more contact with police than controls, despite the higher prevalence of conduct disorder symptoms among the controls. The patients were not, however, more likely to be incarcerated or arrested. Among the patients, over half of the police call-outs occurred during the period of untreated psychosis. Positive psychotic symptoms were independently associated with police contact, after allowing for socio-demographics. CONCLUSIONS: As over a third of people in a first episode of schizophrenia had been in contact with the police - more than twice the proportion among non-psychotic controls - and contact was associated with untreated positive psychotic symptoms, better early detection and treatment of psychosis seems indicated. In the meantime, police services may be playing an important role in reducing the duration of untreated psychosis. Copyright © 2015 John Wiley & Sons, Ltd.

The identification of novel genetic variants associated with antipsychotic treatment response outcomes in first-episode schizophrenia patients.

BACKGROUND: Although antipsychotics are integral to the treatment of schizophrenia, drug efficacy varies between patients. Although it has been shown that antipsychotic treatment response outcomes are heritable, our understanding of the genetic factors that are involved remains incomplete. Therefore, this study aims to use an unbiased scan of the genome to identify the genetic variants contributing toward antipsychotic treatment response outcomes. MATERIALS AND METHODS: This study utilized whole-exome sequencing of patients on extreme ends of the treatment response spectrum (n=11) in combination with results from previous antipsychotic studies to design a panel of variants that were genotyped in two well-characterized first-episode schizophrenia cohorts (n=103 and 87). Association analyses were carried out to determine whether these variants were significantly associated with antipsychotic treatment response outcomes. RESULTS: Association analyses in the discovery cohort identified two nonsynonymous variants that were significantly associated with antipsychotic treatment response outcomes (P<2.7 × 10(-5)), which were also significantly associated with the corresponding treatment response outcome in an independent replication cohort. Computational approaches showed that both of these nonsynonymous variants--rs13025959 in MYO7B (E1647D) and rs10380 in MTRR (H622Y)--were predicted to impair the functioning of their corresponding protein products. CONCLUSION: The use of whole-exome sequencing in a subset of patients from a well-characterized cohort of first-episode schizophrenia patients, for whom longitudinal depot treatment response data were available, allowed for (i) the removal of confounding factors related to treatment progression and compliance and (ii) the identification of two genetic variants that have not been associated previously with antipsychotic treatment response outcomes and whose results were applicable across different classes of antipsychotics. Although the genes that are affected by these variants are involved in pathways that have been related previously to antipsychotic treatment outcomes, the identification of these novel genes will play an important role in improving our understanding of the specific variants involved in antipsychotic treatment response outcomes.