Correlates of high-dose antipsychotic prescription amongst outpatients with Schizophrenia in a Nigerian Hospital.

Background: Treatment guidelines recommend the use of antipsychotic monotherapy at effective doses for the treatment of schizophrenia, although about a third of the sufferers still receive high-dose antipsychotic treatment. Current evidence suggests that high-dose antipsychotic prescription (HDAP) not only fails to improve outcomes but also increases side effects. Aim: Our study aimed to determine the prevalence of HDAP and its association with illness severity, medication adherence behaviour and side effects amongst outpatients with schizophrenia. Setting: The Federal Neuro-Psychiatric Hospital, Benin-City, Nigeria. Methods: A cross-sectional study of 320 attendees with schizophrenia at the outpatient department was undertaken. We administered a sociodemographic and antipsychotic medication questionnaire, Mini-International Neuropsychiatric Interview, Positive and Negative Syndrome Scale, Liverpool University Neuroleptic Side Effects Rating Scales and Medication Adherence Rating Scales. High-dose antipsychotic prescription was determined by the ratio of prescribed daily dose to defined daily dose greater than 1.5. Results: The prevalence of HDAP was 38.4%. Greater severity of illness, experiencing more side effects and poor medication adherence were significantly associated with HDAP.The major predictors of HDAP were antipsychotic polypharmacy and concurrent anticholinergic use. Conclusion: We conclude that although the use of HDAP amongst patients with schizophrenia remains common, its persistent use should be discouraged.

Antipsychotic prescription and polypharmacy among outpatients with schizophrenia in a Nigerian hospital.

BACKGROUND: International guidelines recommend antipsychotic monotherapy as the ideal treatment option in pharmacotherapy for schizophrenia, though this yields modest outcomes in a third of patients. Antipsychotic polypharmacy (APP) has been tried in many patients with schizophrenia to improve outcomes in those with poor treatment response. OBJECTIVES: This study examined the pattern of antipsychotic prescription and polypharmacy among outpatient attendees with schizophrenia in a Nigerian psychiatric hospital. METHODS: A cross-sectional study of 320 attendees with schizophrenia at the consultant outpatient department was undertaken. We administered a socio-demographic questionnaire, antipsychotic medication and health questionnaire to record the general health indices and the prescribed antipsychotic medication of participants and the Mini-International Neuropsychiatric Interview (MINI) Version 6.0 (psychosis module). RESULTS: Oral second-generation antipsychotics (SGAs) monotherapy was most commonly prescribed. The prevalence of APP was 50.9%. Participants on simultaneous anticholinergic agents (P < 0.001), a twice-daily antipsychotic dosing interval (P < 0.001,) alcohol use (P = 0.02), antidepressant use (P = 0.02) and a current episode of schizophrenia on the MINI (P < 0.001) were more likely to be on an APP regimen. CONCLUSION: Although a preference for SGA monotherapy was observed, the prevalence of APP remained high. Clinicians, therefore, should be cautious regarding the clinical utility of APP and discourage its persistent use.

Drug treatment presentations at a treatment centre in southern Nigeria (2015-2018): Findings and implications for policy and practice.

INTRODUCTION: Recent evidence suggests that rates of drug use and abuse in Nigeria exceed the global average. There is a strong treatment demand for psychoactive drug use disorders in Nigeria; however, it is not known whether available treatment facilities are attending to the array of treatment needs. This audit compares the pattern of presentations at a tertiary facility with a community-based survey. METHODS: A review of cases (n = 212) seen at a regional drug treatment facility over a 4-year period, using local data retrieved from the Nigerian Epidemiological Network of Drug Use (NENDU) and comparison with data from the recently published national drug use survey. RESULTS: Nine out of ten clients seen were male (93.4%). About half (49.5%) of the clients used psychoactive substances for the first time between ages 10 and 19 years. Cannabis was the primary drug of use overall and also among males, while females were more likely to present with opiate abuse. Over half had a co-occurring physical or mental disorder, and a minority had received testing for hepatitis C in the past 12 months. CONCLUSION: Although patterns of drug abuse presentations were consistent with findings from a national community-based survey, there was an under-representation of females in treatment. Implications for policy development and practice are discussed.

Barriers to care among people with schizophrenia attending a tertiary psychiatric hospital in Nigeria.

BACKGROUND: Individuals with schizophrenia in low- and middle-income countries and their caregivers face multiple barriers to care-seeking and continuous engagement with treatment services. Identifying specific barrier patterns would aid targeted interventions aimed at improving treatment access. AIM: The aim of this study was to determine stigma- and non-stigma-related barriers to care-seeking among persons with schizophrenia in Nigeria. SETTING: This study was conducted at the Outpatient Clinics of the Federal Neuro-Psychiatric Hospital, Benin City, Nigeria. METHODS: A cross-sectional study of a dyad of persons with schizophrenia and caregivers (n = 161) attending outpatient services at a neuro-psychiatric hospital in Nigeria. Stigma- and non-stigma-related barriers were assessed using the 30-item Barriers to Access to Care Evaluation (BACE) scale. RESULTS: Lack of insight, preference for alternative care, illness severity and financial constraints were common barriers to care-seeking among persons with schizophrenia. Females were significantly more likely to report greater overall treatment barrier (p < 0.01) and stigma-related barriers (p < 0.02). CONCLUSION: This study shows that attitudinal barriers impede care access and engagement among persons with schizophrenia in Nigeria.

Global Study of Social Odor Awareness.

Olfaction plays an important role in human social communication, including multiple domains in which people often rely on their sense of smell in the social context. The importance of the sense of smell and its role can however vary inter-individually and culturally. Despite the growing body of literature on differences in olfactory performance or hedonic preferences across the globe, the aspects of a given culture as well as culturally universal individual differences affecting odor awareness in human social life remain unknown. Here, we conducted a large-scale analysis of data collected from 10 794 participants from 52 study sites from 44 countries all over the world. The aim of our research was to explore the potential individual and country-level correlates of odor awareness in the social context. The results show that the individual characteristics were more strongly related than country-level factors to self-reported odor awareness in different social contexts. A model including individual-level predictors (gender, age, material situation, education, and preferred social distance) provided a relatively good fit to the data, but adding country-level predictors (Human Development Index, population density, and average temperature) did not improve model parameters. Although there were some cross-cultural differences in social odor awareness, the main differentiating role was played by the individual differences. This suggests that people living in different cultures and different climate conditions may still share some similar patterns of odor awareness if they share other individual-level characteristics.

Psychoactive substance use and psychiatric morbidity among pregnant women attending an ante-natal clinic in Benin City, Nigeria.

OBJECTIVE: This study sought to determine the prevalence, patterns and feasibility of screening for psychoactive substance use among pregnant women in an antenatal clinic in Nigeria. It also aimed to determine the relationship between psychoactive substance use risk severity and psychiatric morbidity. METHODS: A cross-sectional study was undertaken among 395 pregnant women previously booked for ante-natal care. A sociodemographic questionnaire, the Alcohol Smoking and Substance Involvement Test (ASSIST) and the 20-item self-reporting questionnaire-20 were interviewer administered. The t-test and ANOVA were used to analyse the relationship between substance use risk severity of probable psychiatric symptoms and lifetime use of psychoactive substance/risk severity, respectively. RESULTS: Participants reported lifetime (50.4%) and preceding 3 months (17%) use of alcohol. Nicotine and sedatives use was rare (n = 2; 0.5%). About a tenth (11.6%) screened positive for psychiatric morbidity. Those reporting alcohol use were significantly more likely to report a greater severity of probable psychiatric symptoms (1.79 vs. 0.92; t = 3.43, P < 0.002). Significant differences were observed according to severity of risk (moderate risk [2.08] vs. low risk [1.72] vs. never used [0.92], F = 6.043, P = 0.03). CONCLUSION: ASSIST is feasible screening tool among pregnant women. At least, half of the participants report alcohol use in pregnancy and use was significantly associated with psychiatric morbidity.

Satisfaction with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries.

PURPOSE: There is disregard in the scientific literature for the evaluation of psychiatric in-patient care as rated directly by patients. In this context, we aimed to explore satisfaction of people treated in mental health in-patient facilities. The project was a part of the Young Psychiatrist Program by the Association for the Improvement of Mental Health Programmes. METHODS: This is an international multicentre cross-sectional study conducted in 25 hospitals across 11 countries. The research team at each study site approached a consecutive target sample of 30 discharged patients to measure their satisfaction using the five-item study-specific questionnaire. Individual and institution level correlates of 'low satisfaction' were examined by comparisons of binary and multivariate associations in multilevel regression models. RESULTS: A final study sample consisted of 673 participants. Total satisfaction scores were highly skewed towards the upper end of the scale, with a median total score of 44 (interquartile range 38-48) out of 50. After taking clustering into account, the only independent correlates of low satisfaction were schizophrenia diagnosis and low psychiatrist to patient ratio. CONCLUSION: Further studies on patients' satisfaction should additionally pay attention to treatment expectations formed by the previous experience of treatment, service-related knowledge, stigma and patients' disempowerment, and power imbalance.

Prevalence and correlates of major depression among Nigerian adults with sickle cell disease.

Objective To ascertain the current and lifetime prevalence of depression among adults with sickle cell disease and identify relevant socio-demographic and clinical correlates. Method A cross-sectional study of 205 stable adult out-patient attendees at a treatment center in southern Nigeria between April and September, 2014. A socio-demographic questionnaire, the depression module of Mini International Neuropsychiatric Interview, and the eight-item Morisky Medication Adherence Scale were administered. Categorical and continuous variables associated with a diagnosis of depression were tested using chi-squared and t-tests respectively. Level of significance was set a priori at P < 0.05. Results Prevalence of current depression was 16.6%, while lifetime prevalence was 29.8%. Current depression was significantly associated with frequent analgesic use ( P < 0.03), unemployment ( P = 0.04), low income ( P < .04), low educational status ( P < 0.01), and subjective pain ( P < 0.001). Subjective pain was nearly twice as likely to predict a current depressive episode (AOR: 1.81, 95%CI: 1.42-2.02, P < 0.03). Conclusions Depression is common among adults with sickle cell disease and is significantly associated with severity of subjective pain.

Pattern of experienced and anticipated discrimination among people with depression in Nigeria: a cross-sectional study.

PURPOSE: Stigma is commonly encountered by individuals with mental illness and leads to discrimination. These phenomena restrict access to and use of mental health care services. This study evaluated the impact of stigma and discrimination among individuals with major depression in Nigeria. METHODS: A cross-sectional study was conducted across four tertiary psychiatric facilities located in different regions of Nigeria. Consenting adults attending the psychiatric units in the participating sites with a diagnosis of a major depressive disorder and having an episode within the past 12 months were recruited. Interviews were conducted using a socio-demographic questionnaire, the Discrimination and Stigma Scale, the Internalized Stigma of Mental Illness Scale, the Boston University Self Empowerment Scale, and the Rosenberg Self Esteem Scale. RESULTS: One hundred and three interviews were completed. The mean age of the participants was 35.5 years. The most frequent item for experienced discrimination was being unfairly treated in dating or intimate relationships (13.6%), while concealment of mental illness was the most common for anticipated discrimination (51.5%). Younger people (age less than 40 years) with a higher level of education appear to be at high risk for experienced discrimination. CONCLUSIONS: Important suggestions may be derived for clinicians, caregivers, and policy makers to appreciate the role of stigma in the burden, treatment, and rehabilitation of individuals with depression, especially for younger people with higher level of education.

Implementing modified electroconvulsive therapy in Nigeria: current status and psychiatrists' attitudes.

The current status of modified electroconvulsive therapy (ECT) practice in Nigeria and the attitudes toward the procedure was explored in a cross-sectional study of psychiatrists and trainees. Most psychiatric facilities still make use of the unmodified type of ECT. Although half of the respondents considered their knowledge of ECT as inadequate, most (92.2%) considered ECT relevant in contemporary times and preferred that the modified format be used (73.7%). They, however, identified cost and a lack of physician anesthetists as impediments to the widespread implementation of modified ECT and would welcome the establishment of minimum standards for ECT practice in Nigeria.

Nigerian medical students' opinions about the undergraduate curriculum in psychiatry.

OBJECTIVE: The number of psychiatrists in Nigeria is inadequate to meet the treatment needs for neuropsychiatric disorders. Developing mental health competency in the future Nigerian physician workforce is one approach to filling the treatment gap. The authors aimed to assess medical students' attitudes to this training and its relevance to their future practice and to assess whether they are getting adequate or relevant training. METHOD: A cross-sectional, questionnaire-based survey was undertaken among a sample (N=375) of 5th- and 6th-year students across four medical schools in Nigeria. RESULTS: Over one-tenth (12%) chose psychiatry as a future career choice. Most expressed positive attitudes toward psychiatry and its relevance to their future careers. A majority were enthusiastic about receiving training in psychiatry in primary-care settings and welcomed a curriculum that emphasized the learning and management of common psychiatric disorders seen in general practice. CONCLUSION: Medical students surveyed would welcome an undergraduate curriculum that integrates the learning of psychiatry with other specialties and skills-training relevant for primary care. Efforts to modify the current curriculum in psychiatry in Nigerian medical schools should be encouraged.

Prevalence and predictors of poor medication adherence among out-patients at a psychiatric hospital in Benin City, Nigeria.

OBJECTIVE: To determine the prevalence and predictors of poor or non-compliance with medications among respondents attending an adult psychiatry out-patient clinic in Benin City, Nigeria. METHODS: Respondents (n = 137) were randomly selected over a 3-month period using a cross-sectional study design. They were administered a questionnaire adapting the Factors Influencing Neuroleptic Medication Taking Scale as well as the Brief Psychiatric Rating Scale (BPRS) to ascertain medication, illness-related and psychosocial variables. Medication adherence was determined by self report and for the purpose of the study confined to the week prior to interview. RESULTS: Almost half (42.3%) were poorly adherent to medications. Most admitted to good psychosocial support, but believed that their illness had a spiritual aetiology. Stigma, higher frequency of medication dosing as well as illness severity as measured by their BPRS scores were significant predictors of poor medication adherence. CONCLUSION: The prevalence of poor medication adherence in this environment is higher than in studies from Western cultures, and replicates rates from previously published reports in this environment. Factors responsible for poor adherence can form the template for intervention studies and programs to improve compliance.

Unmodified electroconvulsive therapy: the perspective of patients from a developing country.

BACKGROUND: The controversy that exists over the relevance of electroconvulsive therapy (ECT) in contemporary psychiatric care often excludes the opinion of patients. Optimizing ECT service delivery must include the perspectives and input of service users. In Nigeria, the opinions of patients have not been explored. AIM: To evaluate the perspective of patients who have previously received ECT toward the process of delivery and the benefits and adverse effects of unmodified ECT. METHOD: Ninety consecutive consenting stable outpatients who had received unmodified ECT between 6 and 12 months from the time of study were surveyed in a cross-sectional study design over a 3-month period using a semistructured Likert-type questionnaire at a referral psychiatric hospital in Nigeria. RESULTS: Most (75.5%) of the patients did not find the procedure stressful and reported ECT being beneficial (82.2%). Most complained of deficiency in the process of ECT service delivery and reported not been adequately informed before receiving ECT (88.9%). A third reported experiencing memory impairment after ECT. Headaches and muscle pains were reported in 8.9% and 17.8% of patients, respectively. Patients who experienced headaches after ECT were more likely to perceive ECT as stressful (P < 0.005), whereas those who experienced memory impairment were less likely to receive ECT again if indicated (P < 0.001). CONCLUSIONS: Unmodified ECT is fairly well accepted among patients, although a majority complained of deficiencies in information provided about and consent toward the procedure. Improving ECT service delivery and addressing adverse effects may improve treatment acceptability.

The association between intimate partner violence, psychiatric morbidity amongst pregnant women and partner alcohol use in southern Nigeria.

BACKGROUND: Intimate partner violence (IPV) against women is common, although prevalence and correlates amongst pregnant women in developing countries are poorly researched. AIM: To identify the magnitude of IPV, and its relationship with psychiatric morbidity and partner alcohol use. SETTING: This study was conducted among women receiving routine ante-natal care at a secondary level healthcare facility in southern Nigeria. METHODS: A cross-sectional descriptive study was conducted by recruiting pregnant women (n = 395) attending the Ante-Natal Clinic of the Central Hospital, Benin-City, Edo State, Nigeria, between August 2015 and February 2016 and undertaking face-to-face interviews utilising a socio-demographic questionnaire, the Composite Abuse Scale and the 20-item Self-reporting Questionnaire. RESULTS: Past 12-month prevalence of IPV was 24.8%, with emotional abuse being the commonest type (89.8%). Forty-six participants (11.6%) screened positive for probable psychiatric morbidity. Predictors of IPV included partner alcohol use in the past 12 months (adjusted odds ratio [aOR]: 2.67; 95% confidence interval [CI]: 1.16-6.16; p 0.02), having a psychiatric morbidity (aOR: 2.53; 95% CI: 1.27-5.04; p 0.01), being single (aOR: 2.12; 95% CI: 1.25-3.58; p 0.01) and multiparous (aOR: 2.5; 95% CI: 1.43-4.38; p 0.001). CONCLUSION: Intimate partner violence was common amongst pregnant women in Nigeria. Identified modifiable risk factors can be targets for screening and intervention for women in these settings.

Nigerian medical students attitudes to unmodified electroconvulsive therapy.

UNLABELLED: Electroconvulsive therapy (ECT) is an effective and affordable form of treatment for a range of psychiatric disorders. Historical antecedents, the media, and movies have generated myths about its continued use and relevance. OBJECTIVES: We explored medical students' knowledge of and attitude to ECT on completion of an 8-week clinical rotation (clerkship) in psychiatry. METHODS: A cross-sectional survey was carried out among final-year medical students at the end of a clerkship in psychiatry using a self-administered questionnaire adapted from previously published work, to assess their attitudes to and knowledge of unmodified ECT. RESULTS: Knowledge of medicine, psychiatry, and ECT were self-rated as average by most students. Most had an interest in pursuing psychiatry as a profession and would receive ECT if judged clinically appropriate. Most students had positive attitudes toward ECT; the vast majority thought it was a relevant form of treatment and did not think that ECT was used to control violent or used by government to torture opponents. Although an overwhelming majority did not think ECT was outmoded or causes permanent brain damage, answers about pain associated with ECT and about the dangers associated with the procedure seem to be more evenly split. A minority thought that ECT was used only in the poor and should not be given to the elderly or children. A substantial majority thought that ECT was the treatment of last resort. Respondents who were likely to choose psychiatry as a profession agreed that ECT causes pain, but disagreed that it was used by governments to torture political opponents or that it causes permanent brain damage. Students with minimal knowledge of ECT showed more negative attitudes toward the myth that ECT is misused and should be a treatment of last resort. CONCLUSION: The similarity of the attitudes of students exposed to unmodified ECT with attitudes of students exposed to modified ECT suggests that modification has made little impact on the attitudes of health professionals. The importance of lectures, patient follow-up while on clinical rotations has significant contributions in shaping attitudes and should be harnessed during training.

Stigma and suicidality among people living with HIV attending a secondary healthcare facility in Nigeria.

PURPOSE: To ascertain the relationship between HIV-related stigma and suicidality among people living with HIV receiving care at a hospital in Nigeria. DESIGN AND METHODS: Four hundred and ten participants were administered a socio-demographic and clinical history questionnaire, the 40-item Berger's HIV-stigma scale, and the Mini International Neuropsychiatric Interview (MINI) to diagnose suicidality and depression in a cross-sectional study. FINDINGS: Fifty-four (13.2%) reported suicidality; suicidal ideation was commonest and suicide plans least, in the month preceding the study. Higher suicidality risk was significantly associated with stigma (P < 0.001) and major depressive disorder ( P < 0.001). PRACTICE IMPLICATIONS: Suicidality is common and is associated with HIV-related stigma.

Reliability and validity of the Medication Adherence Rating Scale in a cohort of patients with schizophrenia from Nigeria.

INTRODUCTION: Assessing adherence in schizophrenia facilitates interventions that optimize outcomes. Adherence rating questionnaires are feasible and non-intrusive; however, no validated measure exists in sub-Saharan Africa. We aimed to assess the psychometric properties of the 10-item Medication Adherence Rating Scale (MARS). METHODS: This was a cross-sectional study of a cohort of patients with schizophrenia (n=230). A sociodemographic questionnaire, the Mini International Neuropsychiatric Interview (MINI), Positive and Negative Syndrome Scale (PANSS), Scale for the Unawareness of Mental Disorder (SUMD) and the MARS were all administered by an interviewer. RESULTS: The MARS demonstrated good reliability (Cronbach's alpha: 0.76). The scale was reducible to a 3-factor construct (1 - medication adherence behavior, 2 - attitude to taking medications, and 3 - negative side effects and attitude to psychotropics), with significant though weak external validity in relation to psychopathology (p<0.001) and insight (p<0.001). The first factor showed good internal consistency (α=0.80), comprising six items that could serve as a reliable proxy measure of adherence in place of the MARS. CONCLUSION: The MARS demonstrated fair psychometric characteristics in assessing adherence in patients with schizophrenia in this cohort. The scale may be useful in the dimensional assessment of medication adherence for schizophrenia in sub-Saharan African settings.

Effect of Short Message Service Reminders on Clinic Attendance Among Outpatients With Psychosis at a Psychiatric Hospital in Nigeria.

OBJECTIVE: The objective of this study was to determine whether patients with first-episode psychosis who were seeking treatment at a regional tertiary psychiatric facility for the first time would be more likely to attend their next scheduled clinic visit after receiving short message service (SMS) reminders about the upcoming appointment. METHODS: Two hundred patients seeking treatment for a psychotic episode for the first time were randomly assigned to a control group or an intervention group by using simple randomization. Both groups received appointment dates on appointment cards, and the intervention group also received SMS text reminders of their appointments. Proportion of missed next appointments was the primary outcome measured. RESULTS: A total of 192 patients were included in a per-protocol analysis. A majority of them were single and cared for by a first-degree relative. The mean±SD age of the patients was 33.7±11.9 years. The median duration of untreated psychosis was 12 weeks, and the mean score on the Brief Psychiatric Rating Scale was 47.3±12.9 (possible scores range from 13 to 168). Participants who received the SMS reminders were almost twice as likely to attend their appointment compared with the control group. After adjusting for sociodemographic and clinical variables, the analysis showed that receiving an SMS reminder independently reduced the risk of a missed next appointment by 50%. CONCLUSIONS: SMS reminders of appointments were an effective intervention to improve clinic attendance among persons treated for first-episode psychosis at the Federal Neuro-Psychiatric Hospital in Benin City, Nigeria.

Prevalence and correlates of antipsychotic polypharmacy among outpatients with schizophrenia attending a tertiary psychiatric facility in Nigeria.

BACKGROUND: The study aimed to determine the prevalence, pattern and correlates of antipsychotic polypharmacy (APP) among outpatients with schizophrenia attending a tertiary psychiatric facility in Nigeria. METHOD: A cross-sectional study of 250 patients with schizophrenia attending the outpatient clinic of a regional tertiary psychiatric facility in Nigeria was undertaken. They were administered a sociodemographic questionnaire, the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning (GAF) scale and the Liverpool University Side Effects Rating Scale (LUNSERS). RESULTS: Of the 250 subjects interviewed, 176 (70.4%) were on APP. APP was significantly associated with higher prescribed chlorpromazine equivalent doses of antipsychotics (p < 0.001), increased frequency of dosing (p < 0.001), negative symptoms (p < 0.01), poorer functioning (p = 0.04) and greater side-effect burden (p = 0.04). CONCLUSION: The APP rate reported from this study is high. Clinicians should be mindful of its impact on dosage and side-effect profiles as APP use is associated with negative symptoms and poor psychosocial functioning.