Neurocognitive improvement in HIV-positive patients treated with dolutegravir-based regimens.

Background: Neurocognitive disorders due to human immunodeficiency virus (HIV) remain highly prevalent, specifically mild forms despite effective antiretroviral therapy (ART). Dolutegravir-based regimens are the first line of treatment for adult HIV-positive patients. Controversies exist regarding the neurocognitive effects of dolutegravir. Evidence regarding the neurocognitive effects of dolutegravir is important, in support of its use in patients with HIV-associated neurocognitive disorders (HAND). Aim: This study aimed to describe the change in cognitive function using the International HIV Dementia Scale (IHDS) and Brief Neuropsychological Cognitive Examination (BNCE) in HIV positive, treatment naïve patients before and 3 months after initiation of ART using a dolutegravir-based regimen. Setting: The HIV initiation clinic of Hillbrow Community Health Centre in Johannesburg. Methods: This prospective, quantitative cohort study assessed adult HIV-positive patients who were ART naïve being initiated on a dolutegravir-based regimen, using the BNCE and IHDS at baseline and after 3 months of treatment. Results: Neurocognitive test results of 26 participants showed significant improvements for IHDS (Z = 1.84, p = 0.033) and time to complete BNCE (Z = 2.47, p = 0.007). BNCE total results showed improvements that were not significant (Z = 1.44, p = 0.075); however, Part 2 of the BNCE reflecting that of executive function showed significant improvements (Z = 66.5, p = 0.043). Conclusion: The trend of neurocognitive function is towards improvement in HIV-positive treatment naïve patients who receive 3 months of dolutegravir-based ART. Contribution: The findings support the use of dolutegravir-based regimens in the treatment of patients with HIV-associated neurocognitive disorders. Keywords: HIV-associated neurocognitive disorders; BNCE; IHDS; dolutegravir; neurocognitive screening; neurocognitive impairment; South Africa.

Assessing the prevalence of psychotic symptoms in epileptic patients at a tertiary clinic.

Background: The International League against Epilepsy (ILAE) defines epilepsy as a brain disorder characterised by an enduring risk to generate seizures with neurobiological, cognitive, psychological and social consequences. Psychotic disorders in epilepsy are a serious psychiatric complication affecting the prognosis, morbidity and mortality of patients. There is a paucity in literature with regard to the prevalence of psychotic symptoms in epileptic patients in low- to middle-income countries. Aim: This study aimed to look at the prevalence of psychotic symptoms in epileptic patients at an outpatient clinic using the prodromal questionnaire 16 (PQ-16). Setting: The study was conducted at the epilepsy clinic at Charlotte Maxeke Academic Hospital (CMJAH), a tertiary hospital located in Johannesburg, South Africa. Method: The PQ-16 was distributed to patients at the epilepsy clinic at CMJAH. Results: The study consisted of 121 participants. The prevalence of patients found to be at high risk of psychosis (i.e., PQ-16 score > 6) was 61.2% (95% lower confidence interval (LCI): 0.53, upper confidence interval (UCI): 0.70). None of the demographic variables showed significant associations in the percentage of patients found to be at high risk. No association was found between any antiepileptic drug and high risk of psychosis. Conclusion: The high prevalence of psychotic like experiences found suggests it is imperative to screen for psychotic disorders in epileptic patients and if required to involve neuropsychiatrists in their management. Contribution: This study highlights the importance of assessing psychotic symptoms in epileptic patients and the importance of a multidisciplinary approach in managing these complex patients.

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.

Assessing HIV transmission knowledge in psychiatric patients in Johannesburg, South Africa.

Background: The bidirectional relationship between human immunodeficiency virus (HIV) and psychiatric illnesses is well documented. Misinformation about HIV transmission and prevention is associated with high rates of HIV-related risky behaviours, and therefore, HIV infection risk. Aim: To assess basic HIV transmission knowledge in psychiatric patients. Setting: Outpatient psychiatric clinic at Tara Psychiatric Hospital, Johannesburg, South Africa. Methods: A cross-sectional, quantitative study was conducted employing a self-administered HIV knowledge questionnaire, the 18- item HIV knowledge questionnaire (HIV-KQ18). Consent, demographic, and clinical profile information were obtained from participants meeting the selection criteria. Results: This study indicated a mean knowledge score of 12.6 (69.7%) out of 18, and therefore good knowledge. The highest HIV-KQ18 mean scores were found in patients with personality disorders (78.9%), anxiety disorders (75.6%) and bipolar and related disorders (71.1%). Participants with schizophrenia, depressive disorders and substance use disorders had scores ranging between 66.1% and 69.4%. Statistically significant differences in knowledge were evident based on age, marital status, level of education and employment status. Interestingly, participants who used substances had higher average basic HIV transmission knowledge scores compared to those who did not use substances. Conclusion: Good overall HIV transmission knowledge was found in this population, albeit lower than in the general population. Statistically, correlates were found between psychiatric diagnosis, substance use, age, marital status, level of education, and employment status and basic level of HIV knowledge. Contribution: HIV knowledge remains lower in psychiatric patients than in the general population, with correlates between demographic and clinical factors, calling for psychoeducation efforts to take all these into consideration.

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.

Case study: New onset of neuropsychiatric symptoms following switching to a dolutegravir regimen.

Although reports of neuropsychiatric side effects have been reported with efavirenz, these have been limited in comparison with regard to the now recommended dolutegravir regimens. We present a patient with new onset neuropsychiatric manifestations secondary to dolutegravir that resulted in significant physical injuries. The patient was initiated on risperidone for symptomatic control which was subsequently weaned and discontinued following reverting to an original efavirenz antiretroviral regimen, with resolution of neuropsychiatric symptoms. Neuropsychiatric side effects are increasingly noted with dolutegravir, and these should be monitored for on initiation and switching of treatment regimens.

Assessing the clinical utility of the severity dependence scale for benzodiazepine use disorder.

BACKGROUND: Benzodiazepines are often used as a part of mental health pharmacological management; however, often when prescribed for extended periods, they increase the risk of benzodiazepine use disorder (BUD). Clinical interviews are at the centre of diagnosing this disorder. However, in addition to clinical assessment a simple, validated questionnaire conducted by any healthcare professional may aid in screening for BUD and referral for further management. AIM: To compare the accuracy of the severity dependence scale (SDS) as a screening tool for BUD against the standard clinical interviews using the Diagnostic and Statistical Manual of Mental Disorders, edition 5, (DSM 5) checklist amongst benzodiazepine users with primary psychiatric disorders. SETTING: Outpatient psychiatric clinic in South Rand Hospital, Johannesburg, South Africa. METHODS: A cross-sectional study was conducted, once informed consent was attained, looking at demographic and clinical profiles of benzodiazepine users. Clinical interviews were conducted in 81 patients who completed the SDS. In comparing the results of the SDS and clinical interview outcomes, chi-square tests were used to determine an association between categorical variables. A receiver-operating characteristic (ROC) curve was generated in determining the cut-off score in the SDS with the highest sensitivity and specificity. RESULTS: This study indicated that a cutoff score of greater than or equal to six of the SDS showed 86% sensitivity and 90.3% specificity compared to a diagnosis of BUD made with clinical interview. The only categorical variables of marginal significance (p~0.06) in comparison to a BUD diagnosis were with benzodiazepine type (oxazepam) and longer duration of use (greater than 24 months). CONCLUSION: This study identified the SDS as a useful screening tool for BUD with a high sensitivity and specificity compared to interview outcomes. Statistically, correlates were identified between duration and type of benzodiazepine prescribed and BUD suggesting emphasis on these factors when prescribing benzodiazepines.