Substance use and duration of untreated psychosis in KwaZulu-Natal, South Africa.

BACKGROUND: Substance use and psychiatric disorders cause significant burden of disease in low- and middle-income countries. Co-morbid psychopathology and longer duration of untreated psychosis (DUP) can negatively affect treatment outcomes. OBJECTIVES: The study assessed substance use amongst adults with severe mental illness receiving services at a regional psychiatric hospital in KwaZulu-Natal (South Africa). We describe the prevalence and correlates of lifetime substance use and examine the association between substance use and DUP. METHODS: A cross-sectional survey recruited adults diagnosed with severe mental illness and assessed lifetime and past 3-month substance use using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test. Regression analyses were conducted to determine associations between lifetime substance use (other than alcohol and tobacco) and DUP as measured by the World Health Organization Encounter Form. RESULTS: Amongst 87 participants, alcohol (81.6%), tobacco (75.6%) and cannabis (49.4%) were the most common substances reported for lifetime use. Risk of health-related problems (health, social, financial, legal and relationship) of cannabis use was associated with younger age, single marital status and lower education. Adjusted regression analyses indicated that use of amphetamines and methaqualone is associated with longer DUP. CONCLUSIONS: Substance use is prevalent amongst psychiatric patients in KwaZulu-Natal and may contribute to longer DUP. Mental health services in this region should address co-morbid substance use and psychiatric disorders.

Beyond symptom management: Family relations, unmet needs of persons living with severe mental illnesses, and potential implications for social work in South Africa.

This study examined the quality of family relationships and its associations with the severity of unmet needs of individuals admitted to a tertiary psychiatric hospital in South Africa. The quality of family relations and perceived unmet needs were assessed using the Lehman Quality of Life Interview and Camberwell Assessment of Needs, respectively. The results show that higher total unmet needs were associated with lower quality of family relations. The main areas of serious unmet needs included accessing government benefits and information, and establishing social relations. The results have implications for hospital-based social workers beyond managing psychiatric symptoms in South Africa.

Duration of untreated psychosis and the pathway to care in KwaZulu-Natal, South Africa.

Considerable controversy surrounds the role of traditional health practitioners (THPs) as first-contact service providers and their influence on the duration of untreated psychosis (DUP) in sub-Saharan Africa. This study examined first-contact patterns and pathways to psychiatric care among individuals with severe mental illness in South Africa. A cross-sectional study was conducted at a referral-based tertiary psychiatric government hospital in KwaZulu-Natal Province. Information on pathways to care was collected using the World Health Organization's Encounter Form. General hospital was the most common first point of contact after mental disorder symptom onset and the strongest link to subsequent psychiatric treatment. Family members were the most common initiators in seeking care. First contact with THPs was associated with longer DUP and higher number of provider contacts in the pathway based on adjusted regression analyses. Strengthening connections between psychiatric and general hospitals and provision of culturally competent family-based psychoeducation to reduce DUP are warranted.

Antiretroviral medication: an emerging category of prescription drug misuse.

BACKGROUND AND OBJECTIVES: Prescription drug abuse has been a focus of public health concern over the past two decades with many studies addressing patterns of narcotic analgesic abuse and diversion. Most research in this domain has centered on controlled substances with known abuse liability. However, the scientific literature has been virtually silent regarding other prescribed medications with previously undocumented addictive potential, such as antiretroviral (ARV) medications for treatment of human immunodeficiency virus. METHODS: This article reviews the available evidence that suggests a growing problem of ARV diversion and abuse and explores the reasons for the misuse of these medications based on the theoretical neuropsychiatric effects of ARVs and the drug-drug interactions between ARVs and other drugs of abuse. RESULTS: Review of media reports and qualitative studies suggest that ARV medications are emerging drugs of abuse. Claims about the psychoactive effects of ARV medications are supported by scientific case reports. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This article reviews the evidence to date of an emerging problem of diversion and misuse of ARV medications for recreational purposes. Implications of ARV misuse and diversion are discussed with suggestions for future research and intervention.

Association between cannabis use, psychosis, and schizotypal personality disorder: findings from the National Epidemiologic Survey on Alcohol and Related Conditions.

BACKGROUND: Studies to date showing an association between cannabis use and schizophrenia-spectrum disorders are of relatively small sample sizes with limitations in generalizability. The present study addresses this gap by examining the relationship between cannabis use and psychotic-like symptoms in a large representative community sample. METHOD: Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, Wave 2), a large, nationally representative sample of 34,653 adults from the United States population. We evaluated the association between lifetime cannabis use, psychosis, and schizotypal personality features. RESULTS: The prevalence of psychosis and schizotypal personality disorder increased significantly with greater cannabis use in a dose-dependent manner. The associations between cannabis use and psychosis were 1.27 (95% CI 1.03-1.57) for lifetime cannabis use, 1.79 (95% CI 1.35-2.38) for lifetime cannabis abuse, and 3.69 (95% CI 2.49-5.47) for lifetime cannabis dependence. There was a similar dose-response relationship between the extent of cannabis use and schizotypal personality disorder (OR=2.02 for lifetime cannabis use, 95% CI 1.69-2.42; OR=2.83 for lifetime cannabis abuse, 95% CI 2.33-2.43; OR=7.32 for lifetime cannabis dependence, 95% CI 5.51-9.72). Likelihood of individual schizotypal features increased significantly with increased extent of cannabis use in a dose-dependent manner. CONCLUSION: This is the first population-based study to examine the association between lifetime cannabis use, psychosis, and schizotypal personality traits. These results add to evidence that cannabis use may be a risk factor for psychosis liability.

Dimensions of impulsivity and aggression associated with suicide attempts among bipolar patients: a preliminary study.

Impulsivity and hostility are often thought to be interrelated among depressed patients with suicidal behavior, but few studies have examined this relationship empirically. In this study, we assessed trait impulsivity and hostility among 52 DSM-IV bipolar subjects with and without histories of suicide attempts. Impulsivity and hostility were correlated among attempters (r = .41, p = .03) but not non-attempters (r = .22, p = .28). As compared to non-attempters, attempters had significantly higher levels of overall hostility, more extensive subcomponents of hostility, and a trend toward higher overall impulsivity. Associations between lifetime suicide attempts and overall hostility were significant while controlling for current depression severity and lifetime illness duration. Aggression and impulsivity appear linked among bipolar patients with lifetime suicide attempts but may be independent constructs among non-attempters. The presence of both factors may elevate risk for suicidal behavior.

Characteristics of first suicide attempts in single versus multiple suicide attempters with bipolar disorder.

Although suicidality remains highly prevalent among patients with bipolar disorder, little research exists examining the characteristics of successive attempts among individuals who make and survive a first suicide attempt. We compared bipolar subjects with a history of one suicide attempt to those with multiple attempts and assessed demographic characteristics, family histories, psychopathology, and clinical dimensions of suicidal behavior. Fifty-two DSM-IV bipolar patients (age 21 to 74 years) with a history of at least one suicide attempt were consecutively evaluated in the Bipolar Disorders Research Clinic of the New York Presbyterian Hospital. Circumstances surrounding each lifetime suicide attempt were assessed by direct interviews, questionnaires, and chart reviews along with family psychiatric histories, substance abuse histories, current psychopathology, and features of impulsivity and aggression. Multiple suicide attempts occurred in approximately two thirds of the study group. Single attempters were significantly more likely than multiple attempters to show high seriousness of intent at their first attempt (OR = 0.65, 95% CI = 0.43 to 0.99), and tended to be less likely than multiple attempters to exhibit mixed states at their first attempt (OR = 0.54, 95% CI = 0.28 to 1.01). Seriousness of intent was consistent across the first and second attempts (r =.48, P <.01) and second and third attempts (r =.74, P <.05). Single and multiple attempters differed in no other clinical or demographic characteristics studied. We conclude that multiple suicide attempts are common among bipolar patients. Those who survive an initial suicide attempt involving high seriousness of intent appear less likely than those with low intent to make subsequent attempts. Consequently, single attempters may represent a group more closely resembling those who complete suicide on a first attempt, in terms of the risk for death associated with their first attempt. However, multiple suicide attempts among bipolar patients are not necessarily associated with a higher risk for lethality in first suicide attempt survivors.