Adverse childhood experiences, mental illness, HIV and offending among female inmates in Durban, South Africa.

Background: Childhood adversities and adult trauma are common among female inmates. Associations have been documented with childhood adversities and mental illness, personality disorders, human immunodeficiency virus (HIV) and violent offending. However, no such study had been conducted in South Africa (SA), despite the high prevalence of HIV and trauma in SA. Aim: To measure the prevalence of childhood adversities and adult trauma; and to determine if there is a relationship between childhood adversities, mental illness, personality disorders, HIV and violent offending among female inmates. Setting: The study was conducted at the largest correctional centre in Durban, KwaZulu-Natal, South Africa. Methods: This cross-sectional, descriptive study randomly recruited 126 female inmates. The World Health Organization's Adverse Childhood Experiences- International Questionnaire (WHO ACE-IQ) was used to measure childhood adversities; the Structured Clinical Interview for the Diagnostics and Statistical Manual-5 Research Version (SCID 5-RV) was used to diagnose mental illness; and a structured questionnaire was used to measure adult trauma. Human immunodeficiency virus data was confirmed from prison medical records. Results: Elevated rates of individual childhood adversities and adult trauma were found. Associations were found between cumulative childhood adversities and post-traumatic stress disorder (PTSD), alcohol use disorder, substance use disorder, borderline personality disorder, and HIV. Conclusion: Female inmates are a highly traumatised population. Prison mental health services should provide trauma-informed and trauma-focussed care to improve inmates' mental health outcomes and decrease recidivism. Contribution: This study contributes to the emerging literature on adverse childhood experiences (ACEs) and their associations among incarcerated female populations, in a low- and middle-income, South African setting.

The gendered context of women charged with violent offences in the forensic psychiatric setting.

Background: Women charged with violent offences may be referred by courts for forensic psychiatric assessment to determine whether mental disorder or intellectual disability impacts their fitness to stand trial and/or criminal responsibility. The profile of these women is a poorly researched area in South Africa. Aim: This study examined the socio-demographic, offence-related, and clinical profile of South African women charged with violent offences referred for forensic assessment. Setting: Fort England Hospital (FEH), a forensic psychiatric institution in the Eastern Cape. Methods: The clinical records of 173 women referred by courts for forensic psychiatric evaluation over a 24-year period (1993-2017) to FEH were systematically reviewed. Results: Most women were single, black mothers with dependent children, who were unemployed and socio-economically impoverished. Many had backgrounds of pre-offence mental illness, alcohol use and alleged abuse. The majority were first-time offenders whose victims were known to them. Most child victims were biological children killed by their mothers. Likely primary motives for violence were related to psychopathology in half of cases, and interpersonal conflict in a third. Forensic assessment most frequently confirmed psychotic disorders and dual diagnoses. Half the cases were fit to stand trial and under half were criminally responsible. Conclusion: Violent female offending occurs within a gendered context, with high rates of prior trauma, alcohol use and psychosocial distress in perpetrators. An emphasis on gender-sensitive psychosocial interventions is required. Contribution: This study highlights the nature and context of violent offending by women referred for forensic psychiatric assessment in South Africa.

Prior trauma experiences among state patients charged with murder: A retrospective records review.

Background: Trauma experiences, particularly in childhood, have been associated with criminality and mental illness. There is a paucity of research into the crime of murder, trauma and mental illness. Aim: This research study focused on state patients charged with murder and sought to determine associations with prior trauma experiences, and specific types of traumas (sexual, physical and emotional). Setting: The study was conducted at a forensic psychiatric hospital in Johannesburg, South Africa. Methods: The records of state patients admitted over a 21-year period on a charge of murder were reviewed and analysed with respect to sociodemographic variables, clinical profiles, trauma experience and victim characteristics. Results: Experience of trauma in this population, with a much higher number of males compared with females, was lower than previous studies. Neurocognitive disorder was significantly associated with physical trauma. Physical trauma was found to have a significantly negative association with psychotic disorders, compared with other mental disorders. Conclusion: Although trauma is common in psychiatric patients, the study's findings are lower than previous studies. Noting the male bias in state patients that commit murder, greater sample sizes are needed to adequately address issues of specific types of traumas, the development of mental illness and murder. Contribution: Exploring and managing prior trauma in state patients who commit murder is important while considering rehabilitation efforts, such that reintegration into the community and non-recidivism are encouraged.

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.

Mental illness and HIV amongst female inmates in Durban, South Africa.

BACKGROUND: There is limited data regarding the prevalence of mental illness and human immunodeficiency virus (HIV) amongst female inmates in South Africa. Rehabilitation programmes can only be formulated once the needs of this population have been identified. AIM: This study aimed to measure the prevalence of mental illnesses, borderline and antisocial personality disorders and HIV amongst female inmates. SETTING: The study was based at a correctional centre in Durban, KwaZulu-Natal, South Africa. METHODS: This study forms part of a larger two-phased, mixed methods, sequential, explanatory design study. In phase one, 126 female inmates were interviewed using a clinical questionnaire and the Structured Clinical Interview for Diagnostics and Statistical Manual (DSM)-5 diagnoses - Research Version. RESULTS: The following lifetime prevalence rates were found: depressive disorder 70.6%, alcohol use disorder 48.4%, post-traumatic stress disorder (PTSD) 46.8%, borderline personality disorder 33.3%, substance use disorder 31.7%, antisocial personality disorder 15.1% and psychotic disorder 4.8%. The prevalence of current adult attention-deficit and hyperactivity disorder was 9.5%. A total of 39% of the participants admitted to past suicide attempts, whilst 64.3% reported past suicidal ideation and 36.5% had a current episode of a psychiatric disorder. A total of 64.3% of the participants were living with HIV. Although 90.4% had a lifetime psychiatric disorder, only 16.7% were previously diagnosed with a mental illness. The majority of inmates with lifetime disorders had psychiatric comorbidities. CONCLUSION: The high prevalence of mental illness and HIV amongst female inmates, and the fact that most with mental illness remain undiagnosed, is concerning. Improved screening, identification and treatment of mental illnesses in this population is needed to ensure optimal mental health outcomes and decreased recidivism.

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.

Characteristics of persons accused of intimate partner homicide amongst forensic psychiatric observations.

BACKGROUND: Intimate partner homicide (IPH) is a global public health problem. One study conducted over 66 countries found that 13.5% of all homicides and 38.6% of female homicides were committed by an intimate partner. In South Africa, there were no published studies that examine alleged perpetrators of IPH that were referred for forensic psychiatric observation. AIM: To describe the profile of accused persons referred for forensic psychiatric observation for a charge of murder or attempted murder of their intimate partners. Certain characteristics were further examined according to the psychiatric observation outcomes. SETTING: The study was conducted at Sterkfontein Hospital, a forensic psychiatric hospital in Gauteng, South Africa. METHODS: A retrospective record review of accused persons referred for forensic psychiatric observation for a charge of murder or attempted murder of their intimate partners was conducted. The period of the review was 19 years. The definition of intimate partners included current or former spouses and partners, same-sex partners and rejected suitors. RESULTS: One hundred and sixty-three files, which included forensic psychiatric reports, were reviewed. The findings related to the profile of accused persons and offence characteristics indicated that: (1) history of violent behaviour is prevalent; (2) homicides mostly occur in private homes; (3) knives and firearms are most often used; (4) infidelity, separation and jealousy are common motives; (5) psychotic disorders, personality disorders and substance use disorders feature prominently. A total of 88% of the sample were found fit to stand trial and 82% were found criminally responsible. Factors significantly associated with being found fit to stand trial and criminally responsible following the forensic psychiatric observation were: male gender, having received a tertiary education, employment prior to the offence, earning a salary of more than R10 000, having no previous psychiatric or medical illness, a positive forensic history, previous intimate partner violence (IPV) perpetration, indicating a motive for the homicide, having no psychiatric illness at the time of the offence which would impact fitness to stand trial and criminal responsibility.Factors significantly associated with being found not fit to stand trial and not criminally responsible following the forensic psychiatric observation were: female gender, having received a primary education, unemployment prior to the offence, having a previous psychiatric or medical illness, no forensic history, no previous IPV perpetration, not indicating a motive for the homicide, having a psychiatric illness at the time of the offence which would impact fitness to stand trial and criminal responsibility. CONCLUSION: The characteristics highlighted in this study can contribute to the development of risk assessment tools which can be used to identify likely perpetrators of IPH. Other interventions, for example controlling access to knives and firearms, reducing substance abuse and improving mental health services, are also important in the prevention of IPH.

A prospective observational study of heroin users in Johannesburg, South Africa: Assessing psychiatric comorbidities and treatment outcomes.

BACKGROUND: Despite the rise in heroin use in sub Saharan-Africa opioid agonist maintenance treatment (OAMT) is still not state-funded in South Africa and many other African countries. In South Africa there has been little data published on the profile of heroin users and the outcomes of treatment for those who attend public treatment services. METHODS: 300 heroin users from two state-funded rehabilitation centres in Johannesburg were studied at entry into rehabilitation and 3-months after treatment. Treatment consisted of inpatient detoxification and inpatient psychosocial rehabilitation. Structured interviews measured changes in drug use, psychopathology and criminality post rehabilitation. RESULTS: Most (65.7%) smoked heroin in combination with cannabis while 29.7% were injecting users. Almost half the sample (49.3%) had at least one mental illness. Of the 252 (84%) participants seen at 3-month follow-up, 6.3% were abstinent of all substances (excluding tobacco), 65.5% had continued heroin use (CHU) and the balance used other substances. At follow-up there were significant decreases in heroin use (p<0.0001) and criminality (p<0.0001). There were however significant increases in alcohol use (p<0.0001), crystalmetamphetamine use (p=0.032) and the prevalence of current episode of major depression (p<0.0001). Just 11.9% received formal psychosocial treatment after leaving rehabilitation. None were on OAMT and only three participants were on psychotropic medication. None were tested for Hepatitis C during the study period and the majority (53%) did not know their HIV status. CONCLUSION: There are significant gaps in current treatment services for heroin users in South Africa. Retention in treatment and assessment and management of psychiatric and non-psychiatric comorbidities is low. Services need to be more integrated and should also include the provision of OAMT.

Smoking heroin with cannabis versus injecting heroin: unexpected impact on treatment outcomes.

BACKGROUND: In several countries, especially in Africa, the dominant method of heroin intake is smoking a joint of cannabis laced with heroin. There is no data exploring the impact of smoking heroin with cannabis on treatment outcomes. AIM: To compare treatment outcomes between people who inject heroin and people who smoke heroin with cannabis. METHODOLOGY: Three hundred heroin users were assessed on admission to inpatient rehabilitation and after treatment. We compared drug use, psychopathology, criminality, social functioning and general health between heroin injectors and heroin-cannabis smokers at treatment entry, and at 3 and 9 months after rehabilitation. RESULTS: The sample comprised 211 (70.3%) heroin-cannabis smokers and 89 (29.7%) heroin injectors. Eighty-four percent were followed up at 3 months and 75% at 9 months. At 9 months, heroin-cannabis smokers had a higher proportion of those who relapsed to heroin use compared with intravenous (IV) users (p = 0.036). The median number of heroin use episodes per day was lower for IV users than heroin-cannabis smokers at both follow-up points (p = 0.013 and 0.0019). A higher proportion of IV users was HIV positive (p = 0.002). There were no significant differences in psychopathology, general health, criminality and social functioning between IV users and heroin-cannabis smokers at all three time points. CONCLUSIONS: Heroin users who do not inject drugs but use other routes of administration may have increased risk for relapse to heroin use after inpatient rehabilitation and should therefore have equal access to harm reduction treatment services. Advocating a transition from injecting to smoking heroin in an African context may pose unique challenges.

Absconding from a psychiatric hospital in Johannesburg, South Africa: Are we seeing a decrease since the implementation of the Mental Healthcare Act?

BACKGROUND: Absconding from psychiatric facilities, the aetiology and impact of which have major socio-economic implications, has a multifactorial aetiological basis. Absconding patients are at higher risk of self-harm, violence, non-adherence, relapses, substance use and negative media attention. Most health professionals associate absconding with the escape of potentially dangerous psychiatric patients. Absconding causes fear and uncertainty, and portrays psychiatric services negatively. Identification of potential absconders would assist with risk assessment and prevention. AIM: The aim of this study was to formulate an absconding rate as well as a descriptive profile of absconders since the inception of democracy and deinstitutionalisation. SETTING: The study was conducted at Sterkfontein Hospital, a specialised psychiatric hospital outside Johannesburg. METHODS: A retrospective record review of absconders from Sterkfontein Hospital in Johannesburg over 1 year was conducted. RESULTS: The absconding rate was 7.83%. The characteristics of the typical absconder included single, unemployed male, early 30s, known to psychiatric services, diagnosed with schizophrenia and co-morbid substance use. An absconder is more likely to be a forensic patient not returning from official leave of absence. CONCLUSION: The absconding rate has decreased to less than half that of a previous study, and is within international norms. While the descriptive profile is of limited value, it does appear that psychiatric patients are being treated in a less restrictive manner resulting in fewer absconders and a change in the method of absconding. The implications for clinical practice are firstly that a clearer definition of the term absconding is needed as this will impact risk assessment and management. It is recommended that future studies separate forensic and general populations. Lastly, the formulation and use of a risk assessment tool may be of value.