Brief online negative affect focused functional imagery training (FIT) improves four-week drinking outcomes in hazardous student drinkers: A pilot randomised controlled trial replication in South Africa.

Background: Previous study has shown that functional imagery training (FIT) to utilise positive mental imagery in response to negative affect could improve alcohol-related outcomes. The current study aimed to replicate whether this negative affect focused FIT would improve alcohol-related outcomes in hazardous student drinkers in South Africa at four-week follow-up. Methods: 50 hazardous student drinkers who reported drinking to cope with negative affect were randomised into two groups. The active group (n = 25) was trained online over two weeks to respond to personalised negative drinking triggers by retrieving a personalised adaptive strategy they might use to mitigate negative affect, whereas the control group (n = 25) received standard risk information about binge drinking. Outcome measures including alcohol consumption, drinking motives, anxiety and depression, self-efficacy and use of protective behavioural strategies were obtained at baseline and four-week follow-up. Results: FIT effects were revealed by three significant group-by-timepoint interactions in a per-protocol analysis: there was a significant decrease in depressive symptoms, drinking to cope and drinking for social reasons from baseline to follow-up in the active group, but not the control group. No effects were observed on alcohol consumption, self-efficacy, protective behaviour strategies and anxiety. Conclusions: Preliminary evidence supports that online negative affect focused FIT can improve depression as well as coping and social drinking motives in South African hazardous student drinkers who drank to cope, at four-week follow-up, suggesting that the principles of this FIT approach might be adapted and incorporated into a clinical intervention to test for efficacy in mitigating substance use problems.

EMDR v. other psychological therapies for PTSD: a systematic review and individual participant data meta-analysis.

BACKGROUND: This systematic review and individual participant data meta-analysis (IPDMA) examined the overall effectiveness of eye movement desensitization and reprocessing (EMDR) in reducing posttraumatic stress disorder (PTSD) symptoms, achieving response and remission, and reducing treatment dropout among adults with PTSD compared to other psychological treatments. Additionally, we examined available participant-level moderators of the efficacy of EMDR. METHODS: This study included randomized controlled trials. Eligible studies were identified by a systematic search in PubMed, Embase, PsyclNFO, PTSDpubs, and CENTRAL. The target population was adults with above-threshold baseline PTSD symptoms. Trials were eligible if at least 70% of study participants had been diagnosed with PTSD using a structured clinical interview. Primary outcomes included PTSD symptom severity, treatment response, and PTSD remission. Treatment dropout was a secondary outcome. The systematic search retrieved 15 eligible randomized controlled trials (RCTs); 8 of these 15 were able to be included in this IPDMA (346 patients). Comparator treatments included relaxation therapy, emotional freedom technique, trauma-focused cognitive behavioral psychotherapies, and REM-desensitization. RESULTS: One-stage IPDMA found no significant difference between EMDR and other psychological treatments in reducing PTSD symptom severity (ß = -0.24), achieving response (ß = 0.86), attaining remission (ß = 1.05), or reducing treatment dropout rates (ß = -0.25). Moderator analyses found unemployed participants receiving EMDR had higher PTSD symptom severity at the post-test, and males were more likely to drop out of EMDR treatment than females. CONCLUSION: The current study found no significant difference between EMDR and other psychological treatments. We found some indication of the moderating effects of gender and employment status.

Explanatory models, illness, and treatment experiences of patients with psychosis using the services of traditional and faith healers in three African countries: Similarities and discontinuities.

As part of formative studies to design a program of collaborative care for persons with psychosis, we explored personal experience and lay attributions of illness as well as treatment among persons who had recently received care at traditional and faith healers' (TFHs) facilities in three cultural groups in Sub-Saharan Africa. A purposive sample of 85 individuals in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya) were interviewed. Data was inductively explored for themes and analysis was informed by the Framework Method. Across the three sites, illness experiences featured suffering and disability in different life domains. Predominant causal attribution was supernatural, even when biological causation was also acknowledged. Prayer and rituals, steeped in traditional spiritual beliefs, were prominent both in traditional faith healing settings as well as those of Christianity and Islam. Concurrent or consecutive use of TFHs and conventional medical services was common. TFHs provided services that appear to meet the therapeutic goals of their patients even when harmful treatment practices were employed. Cultural and linguistic differences did not obscure the commonality of a core set of beliefs and practices across these three groups. This similarity of core worldviews across diverse cultural settings means that a collaborative approach designed in one cultural group would, with adaptations to reflect differences in context, be applicable in another cultural group. Studies of patients' experience of illness and care are useful in designing and implementing collaborations between biomedical and TFH services as a way of scaling up services and improving the outcome of psychosis.

FKBP5 intron 7 methylation is associated with higher anxiety proneness and smaller right thalamus volume in adolescents.

Dysregulation of stress response systems may mediate the detrimental effects of childhood trauma (CT) on mental health. FKBP5 regulates glucocorticoid receptor sensitivity and exerts pleiotropic effects on intracellular signaling, neurobiology and behavior. We investigated whether CT, alone and in combination with rs1360780 genotype, is associated with altered FKBP5 methylation and whether CT-associated methylation profiles are associated with anxiety proneness (AP) and structural brain volumes. Ninety-four adolescents completed the Childhood Trauma Questionnaire, and a composite AP score was generated from the Childhood Anxiety Sensitivity Index and the State-Trait Anxiety Inventory-Trait measure. Mean methylation values for 12 regulatory regions and 25 individual CpG sites were determined using high-accuracy measurement via targeted bisulfite sequencing. FKBP5 rs1360780 genotype and structural MRI data were available for a subset of participants (n = 71 and n = 75, respectively). Regression models revealed an inverse association between methylation of three intron 7 CpG sites (35558438, 35558566 and 35558710) and right thalamus volume. CpG35558438 methylation was positively associated with AP scores. Our data indicate that an intron 7 methylation profile, consistent with lower FKBP5 expression and elevated high sensitivity glucocorticoid receptor levels, is associated with higher AP and smaller right thalamus volume. Research into the mechanisms underlying the intron 7 methylation-thalamus volume relationship, and whether it confers increased risk for long-term psychopathology by altering the regulatory threshold of stress responding, is required.

Clinician guidelines for the treatment of psychiatric disorders with nutraceuticals and phytoceuticals: The World Federation of Societies of Biological Psychiatry (WFSBP) and Canadian Network for Mood and Anxiety Treatments (CANMAT) Taskforce.

OBJECTIVES: The therapeutic use of nutrient-based 'nutraceuticals' and plant-based 'phytoceuticals' for the treatment of mental disorders is common; however, despite recent research progress, there have not been any updated global clinical guidelines since 2015. To address this, the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Disorders (CANMAT) convened an international taskforce involving 31 leading academics and clinicians from 15 countries, between 2019 and 2021. These guidelines are aimed at providing a definitive evidence-informed approach to assist clinicians in making decisions around the use of such agents for major psychiatric disorders. We also provide detail on safety and tolerability, and clinical advice regarding prescription (e.g. indications, dosage), in addition to consideration for use in specialised populations. METHODS: The methodology was based on the WFSBP guidelines development process. Evidence was assessed based on the WFSBP grading of evidence (and was modified to focus on Grade A level evidence - meta-analysis or two or more RCTs - due to the breadth of data available across all nutraceuticals and phytoceuticals across major psychiatric disorders). The taskforce assessed both the 'level of evidence' (LoE) (i.e. meta-analyses or RCTs) and the assessment of the direction of the evidence, to determine whether the intervention was 'Recommended' (+++), 'Provisionally Recommended' (++), 'Weakly Recommended' (+), 'Not Currently Recommended' (+/-), or 'Not Recommended' (-) for a particular condition. Due to the number of clinical trials now available in the field, we firstly examined the data from our two meta-reviews of meta-analyses (nutraceuticals conducted in 2019, and phytoceuticals in 2020). We then performed a search of additional relevant RCTs and reported on both these data as the primary drivers supporting our clinical recommendations. Lower levels of evidence, including isolated RCTs, open label studies, case studies, preclinical research, and interventions with only traditional or anecdotal use, were not assessed. RESULTS: Amongst nutraceuticals with Grade A evidence, positive directionality and varying levels of support (recommended, provisionally recommended, or weakly recommended) was found for adjunctive omega-3 fatty acids (+++), vitamin D (+), adjunctive probiotics (++), adjunctive zinc (++), methylfolate (+), and adjunctive s-adenosyl methionine (SAMe) (+) in the treatment of unipolar depression. Monotherapy omega-3 (+/-), folic acid (-), vitamin C (-), tryptophan (+/-), creatine (+/-), inositol (-), magnesium (-), and n-acetyl cysteine (NAC) (+/-) and SAMe (+/-) were not supported for this use. In bipolar disorder, omega-3 had weak support for bipolar depression (+), while NAC was not currently recommended (+/-). NAC was weakly recommended (+) in the treatment of OCD-related disorders; however, no other nutraceutical had sufficient evidence in any anxiety-related disorder. Vitamin D (+), NAC (++), methylfolate (++) were recommended to varying degrees in the treatment of the negative symptoms in schizophrenia, while omega-3 fatty acids were not, although evidence suggests a role for prevention of transition to psychosis in high-risk youth, with potential pre-existing fatty acid deficiency. Micronutrients (+) and vitamin D (+) were weakly supported in the treatment of ADHD, while omega-3 (+/-) and omega-9 fatty acids (-), acetyl L carnitine (-), and zinc (+/-) were not supported. Phytoceuticals with supporting Grade A evidence and positive directionality included St John's wort (+++), saffron (++), curcumin (++), and lavender (+) in the treatment of unipolar depression, while rhodiola use was not supported for use in mood disorders. Ashwagandha (++), galphimia (+), and lavender (++) were modestly supported in the treatment of anxiety disorders, while kava (-) and chamomile (+/-) were not recommended for generalised anxiety disorder. Ginkgo was weakly supported in the adjunctive treatment of negative symptoms of schizophrenia (+), but not supported in the treatment of ADHD (+/-). With respect to safety and tolerability, all interventions were deemed to have varying acceptable levels of safety and tolerability for low-risk over-the-counter use in most circumstances. Quality and standardisation of phytoceuticals was also raised by the taskforce as a key limiting issue for firmer confidence in these agents. Finally, the taskforce noted that such use of nutraceuticals or phytoceuticals be primarily recommended (where supportive evidence exists) adjunctively within a standard medical/health professional care model, especially in cases of more severe mental illness. Some meta-analyses reviewed contained data from heterogenous studies involving poor methodology. Isolated RCTs and other data such as open label or case series were not included, and it is recognised that an absence of data does not imply lack of efficacy. CONCLUSIONS: Based on the current data and clinician input, a range of nutraceuticals and phytoceuticals were given either a supportive recommendation or a provisional recommendation across a range of various psychiatric disorders. However several had only a weak endorsement for potential use; for a few it was not possible to reach a clear recommendation direction, largely due to mixed study findings; while some other agents showed no obvious therapeutic benefit and were clearly not recommended for use. It is the intention of these guidelines to inform psychiatric/medical, and health professional practice globally.

Becoming a Xhosa traditional healer: The calling, illness, conflict and belonging.

BACKGROUND: Traditional healers (THs) are an important part of the healthcare system in sub-Saharan Africa. Understanding their training, experiences of becoming healers and their perceived roles in society is critical. AIM: This study aimed to explore the experience of becoming a TH, including accepting the calling, and sheds light on how the experience is conceptualised within the cultural and communitarian context of THs. SETTING: This study was conducted amongst Xhosa THs in the Western Cape, South Africa. METHODS: In-depth phenomenological interviews (n = 4) were conducted with Xhosa THs and analysed using Giorgi's descriptive pre-transcendental Husserlian phenomenological analysis. RESULTS: The experience of becoming a TH can be summarised in the context of three units of significance: (1) the gift of healing as an illness; (2) the experience of conflict (including with their families, the church and self-conflict); and (3) the experience of belonging. Familial conflict, specifically, was fuelled by the financial burden of becoming a TH and a lack of understanding of the process. CONCLUSION: To develop a workable model of collaboration in the future, it is crucial that mental healthcare providers develop a better understanding of the experiences of THs in becoming care providers. The findings highlight an appreciation of the challenging process of becoming a TH. Finally, further research and culturally appropriate psychoeducation can provide trainee THs and their family members with the skills and knowledge to support each other through a difficult process.

Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial.

BACKGROUND: Traditional and faith healers (TFH) provide care to a large number of people with psychosis in many sub-Saharan African countries but they practise outside the formal mental health system. We aimed to assess the effectiveness and cost-effectiveness of a collaborative shared care model for psychosis delivered by TFH and primary health-care providers (PHCW). METHODS: In this cluster-randomised trial in Kumasi, Ghana and Ibadan, Nigeria, we randomly allocated clusters (a primary care clinic and neighbouring TFH facilities) 1:1, stratified by size and country, to an intervention group or enhanced care as usual. The intervention included a manualised collaborative shared care delivered by trained TFH and PHCW. Eligible participants were adults (aged ≥18 years) newly admitted to TFH facilities with active psychotic symptoms (positive and negative syndrome scale [PANSS] score ≥60). The primary outcome, by masked assessments at 6 months, was the difference in psychotic symptom improvement as measured with the PANSS in patients in follow-up at 3 and 6 months. Patients exposure to harmful treatment practices, such as shackling, were also assessed at 3 and 6 months. Care costs were assessed at baseline, 3-month and 6-month follow-up, and for the entire 6 months of follow-up. This trial was registered with the National Institutes of Health Clinical Trial registry, NCT02895269. FINDINGS: Between Sept 1, 2016, and May 3, 2017, 51 clusters were randomly allocated (26 intervention, 25 control) with 307 patients enrolled (166 [54%] in the intervention group and 141 [46%] in the control group). 190 (62%) of participants were men. Baseline mean PANSS score was 107·3 (SD 17·5) for the intervention group and 108·9 (18·3) for the control group. 286 (93%) completed the 6-month follow-up at which the mean total PANSS score for intervention group was 53·4 (19·9) compared with 67·6 (23·3) for the control group (adjusted mean difference -15·01 (95% CI -21·17 to -8·84; 0·0001). Harmful practices decreased from 94 (57%) of 166 patients at baseline to 13 (9%) of 152 at 6 months in the intervention group (-0·48 [-0·60 to -0·37] p<0·001) and from 59 (42%) of 141 patients to 13 (10%) of 134 in the control group (-0·33 [-0·45 to -0·21] p<0·001), with no significant difference between the two groups. Greater reductions in overall care costs were seen in the intervention group than in the control group. At the 6 month assessment, greater reductions in total health service and time costs were seen in the intervention group; however, cumulative costs over this period were higher (US $627 per patient vs $526 in the control group). Five patients in the intervention group had mild extrapyramidal side effects. INTERPRETATION: A collaborative shared care delivered by TFH and conventional health-care providers for people with psychosis was effective and cost-effective. The model of care offers the prospect of scaling up improved care to this vulnerable population in settings with low resources. FUNDING: US National Institute of Mental Health.

A survey of traditional and faith healers providing mental health care in three sub-Saharan African countries.

BACKGROUND: Traditional and faith healers constitute an important group of complementary and alternative mental health service providers (CAPs) in sub-Sahara Africa. Governments in the region commonly express a desire to integrate them into the public health system. The aim of the study was to describe the profile, practices and distribution of traditional and faith healers in three sub-Saharan African countries in great need for major improvements in their mental health systems namely Ghana, Kenya and Nigeria. MATERIALS AND METHODS: A mapping exercise of CAPs who provide mental health care was conducted in selected catchment areas in the three countries through a combination of desk review of existing registers, engagement activities with community leaders and a snowballing technique. Information was collected on the type of practice, the methods of diagnosis and the forms of treatment using a specially designed proforma. RESULTS: We identified 205 CAPs in Ghana, 406 in Kenya and 82 in Nigeria. Most (> 70%) of the CAPs treat both physical and mental illnesses. CAPs receive training through long years of apprenticeship. They use a combination of herbs, various forms of divination and rituals in the treatment of mental disorders. The use of physical restraints by CAPs to manage patients was relatively uncommon in Kenya (4%) compared to Nigeria (63.4%) and Ghana (21%). CAPs often have between 2- to 10-fold capacity for patient admission compared to conventional mental health facilities. The profile of CAPs in Kenya stands out from those of Ghana and Nigeria in many respects. CONCLUSION: CAPs are an important group of providers of mental health care in sub-Saharan Africa, but attempts to integrate them into the public health system must address the common use of harmful treatment practices.

The Gut Microbiome and Mental Health: Implications for Anxiety- and Trauma-Related Disorders.

Biological psychiatry research has long focused on the brain in elucidating the neurobiological mechanisms of anxiety- and trauma-related disorders. This review challenges this assumption and suggests that the gut microbiome and its interactome also deserve attention to understand brain disorders and develop innovative treatments and diagnostics in the 21st century. The recent, in-depth characterization of the human microbiome spurred a paradigm shift in human health and disease. Animal models strongly suggest a role for the gut microbiome in anxiety- and trauma-related disorders. The microbiota-gut-brain (MGB) axis sits at the epicenter of this new approach to mental health. The microbiome plays an important role in the programming of the hypothalamic-pituitary-adrenal (HPA) axis early in life, and stress reactivity over the life span. In this review, we highlight emerging findings of microbiome research in psychiatric disorders, focusing on anxiety- and trauma-related disorders specifically, and discuss the gut microbiome as a potential therapeutic target. 16S rRNA sequencing has enabled researchers to investigate and compare microbial composition between individuals. The functional microbiome can be studied using methods involving metagenomics, metatranscriptomics, metaproteomics, and metabolomics, as discussed in the present review. Other factors that shape the gut microbiome should be considered to obtain a holistic view of the factors at play in the complex interactome linked to the MGB. In all, we underscore the importance of microbiome science, and gut microbiota in particular, as emerging critical players in mental illness and maintenance of mental health. This new frontier of biological psychiatry and postgenomic medicine should be embraced by the mental health community as it plays an ever-increasing transformative role in integrative and holistic health research in the next decade.

COllaborative Shared care to IMprove Psychosis Outcome (COSIMPO): study protocol for a randomized controlled trial.

BACKGROUND: Psychotic disorders are a group of severe mental disorders that cause considerable disability to sufferers and a high level of burden to families. In many low- and middle-income countries (LMIC), traditional and faith healers are the main providers of care to affected persons. Even though frequently canvassed as desirable for improved care delivery, collaboration between these complementary alternative health providers (CAPs) and conventional health providers has yet to be rigorously tested for feasibility and effectiveness on patient outcomes. METHODS/DESIGN: COSIMPO is a single-blind, cluster randomized controlled trial (RCT) being conducted in Nigeria and Ghana to compare the effectiveness of a collaborative shared care (CSC) intervention program implemented by CAPs and primary health care providers (PHCPs) with care as usual (CAU) at improving the outcome of patients with psychosis. The study is designed to test the hypotheses that patients receiving CSC will have a better clinical outcome and experience fewer harmful treatment practices from the CAPs than patients receiving CAU at 6 months after study entry. An estimated sample of 296 participants will be recruited from across 51 clusters, with a cluster consisting of a primary care clinic and its neighboring CAP facilities. CSC is a manualized intervention package consisting of regular and scheduled visits of PHCPs to CAP facilities to assist with the management of trial participants. Assistance includes the administration of antipsychotic medications, management of comorbid physical condition, assisting the CAP to avoid harmful treatment practices, and engaging with CAPs, caregivers and participants in planning discharge and rehabilitation. The primary outcome, assessed at 6 months following trial entry, is improvement on the Positive and Negative Symptom Scale (PANSS). Secondary outcomes, assessed at 3 and 6 months, consist of levels of disability, experience of harmful treatment practices and of victimization, and levels of perceived stigma and of caregivers' burden. DISCUSSION: Information about whether collaboration between orthodox and complementary health providers is feasible and can lead to improved outcome for patients is important to formulating policies designed to formally engage the services of traditional and faith healers within the public health system. TRIAL REGISTRATION: National Institutes of Health Clinical Trial registry, ID: NCT02895269 . Registered on 30 July 2016.

Associations between societal disapproval and changes in symptoms of PTSD and appetitive aggression following treatment among high-risk South African males.

Background: In violent communities, social rejection as a person with victim-offender attributes is associated with more intense symptoms of posttraumatic stress disorder (PTSD) and a higher propensity towards violence, i.e. appetitive aggression. Successful community reintegration encompassing adequate social acknowledgment of individuals with both a history of violence exposure and perpetration may be necessary to enhance the treatment effects of interventions addressing PTSD and aggression. Objective: In this study, the effects of treatment and post-treatment traumatic events, violent offenses, and social acknowledgment (with sub-dimensions of general disapproval, family disapproval, and recognition as a person with both a history of violence exposure and commission) on changes in PTSD symptom severity and appetitive aggression from baseline to 8-month follow-up were investigated. Method: Data were collected from 54 males recruited through a Cape Town offender reintegration programme for an intervention study targeting trauma and aggression (n = 28 treatment; n = 26 wait-list). Changes in PTSD symptom severity after treatment were assessed with the PTSD Symptom Scale-Interview, changes in appetitive aggression with the Appetitive Aggression Scale (AAS), post-treatment traumatic events with an adapted version of the Child's Exposure to Violence Checklist, offenses with an adapted checklist from the AAS, and social acknowledgment with an adapted form of the Social Acknowledgment Questionnaire. Results: Path analyses revealed negative relationships between ongoing societal disapproval and changes in PTSD symptom severity and appetitive aggression at 8-months, controlling for age. All other variables were non-significant, except for treatment, which was associated with PTSD symptom reduction. Conclusions: As a complementary strategy to effective psychotherapeutic treatment, increased social acknowledgment may contribute significantly to the alleviation of PTSD symptoms and appetitive aggression. Psychological interventions should, therefore, not neglect the impact of societal factors on treatment effects.

Planteamiento: En comunidades violentas, el rechazo social como persona con atributos de víctima-agresor se asocia con síntomas más intensos del trastorno por estrés postraumático (TEPT) y una mayor propensión a la violencia, es decir, a la apetencia por la agresión. Puede que sea necesaria una reintegración con éxito en la comunidad ­que incluya un adecuado reconocimiento social de aquellos individuos con una historia tanto de exposición a la violencia como de agresión­ para mejorar los efectos del tratamiento de las intervenciones que abordan el TEPT y la agresión.Objetivo: En este estudio, se investigaron los efectos del tratamiento y los eventos traumáticos post-tratamiento, los delitos violentos y el reconocimiento social (con subdimensiones de desaprobación general, desaprobación familiar y reconocimiento como persona con antecedentes tanto de exposición a la violencia como de perpetración) sobre los cambios en la gravedad de los síntomas del TEPT y la apetencia por la agresión desde el inicio hasta el seguimiento a los 8 meses.Método: Se recogieron datos de 54 varones reclutados a través de un programa de reintegración de delincuentes de Ciudad del Cabo para un estudio de intervención dirigido a trauma y agresión (n = 28 tratamiento, n = 26 lista de espera). Se evaluaron los cambios en la gravedad de los síntomas del TEPT después del tratamiento con la Escala-Entrevista de Síntomas de TEPT (PTSD Symptom Scale-Interview), los cambios en la apetencia por la agresión con la Escala de Apetencia por la Agresión (AAS, siglas en ingles de Appetitive Aggression Scale), los eventos traumáticos posteriores al tratamiento con una versión adaptada de la Lista de verificación de exposición a la violencia para niños (Child's Exposure to Violence Checklist), las agresiones con una lista de verificación adaptada del AAS, y el reconocimiento social con una forma adaptada del Cuestionario de Reconocimiento Social (Social Acknowledgment Questionnaire).Resultados: Los análisis de ruta revelaron relaciones negativas entre la desaprobación social continuada y los cambios en la gravedad de los síntomas del TEPT y la apetencia por la agresión a los 8 meses, controlando la edad. Todas las demás variables no fueron significativas, excepto por el tratamiento, que se asoció con la reducción de los síntomas de TEPT.Conclusiones: Como estrategia complementaria a un tratamiento psicoterapéutico efectivo, el aumento del reconocimiento social puede contribuir significativamente al alivio de los síntomas del TEPT y la apetencia por la agresión. Por lo tanto, las intervenciones psicológicas no deben descuidar el impacto de los factores sociales sobre los efectos del tratamiento.

Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways.

We examined the scope of collaborative care for persons with mental illness as implemented by traditional healers, faith healers, and biomedical care providers. We conducted semistructured focus group discussions in Ghana, Kenya, and Nigeria with traditional healers, faith healers, biomedical care providers, patients, and their caregivers. Transcribed data were thematically analyzed. A barrier to collaboration was distrust, influenced by factionalism, charlatanism, perceptions of superiority, limited roles, and responsibilities. Pathways to better collaboration were education, formal policy recognition and regulation, and acceptance of mutual responsibility. This study provides a novel cross-national insight into the perspectives of collaboration from four stakeholder groups. Collaboration was viewed as a means to reach their own goals, rooted in a deep sense of distrust and superiority. In the absence of openness, understanding, and respect for each other, efficient collaboration remains remote. The strongest foundation for mutual collaboration is a shared sense of responsibility for patient well-being.

Neuroimaging abnormalities in clade C HIV are independent of Tat genetic diversity.

Controversy remains regarding the neurotoxicity of clade C human immunodeficiency virus (HIV-C). When examined in preclinical studies, a cysteine to serine substitution in the C31 dicysteine motif of the HIV-C Tat protein (C31S) results in less severe brain injury compared to other viral clades. By contrast, patient cohort studies identify significant neuropsychological impairment among HIV-C individuals independent of Tat variability. The present study clarified this discrepancy by examining neuroimaging markers of brain integrity among HIV-C individuals with and without the Tat substitution. Thirty-seven HIV-C individuals with the Tat C31S substitution, 109 HIV-C individuals without the Tat substitution (C31C), and 34 HIV- controls underwent 3T structural magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI). Volumes were determined for the caudate, putamen, thalamus, corpus callosum, total gray matter, and total white matter. DTI metrics included fractional anisotropy (FA), radial diffusivity (RD), and axial diffusivity (AD). Tracts of interest included the anterior thalamic radiation (ATR), cingulum bundle (CING), uncinate fasciculus (UNC), and corpus callosum (CC). HIV+ individuals exhibited smaller volumes in subcortical gray matter, total gray matter and total white matter compared to HIV- controls. HIV+ individuals also exhibited DTI abnormalities across multiple tracts compared to HIV- controls. By contrast, neither volumetric nor diffusion indices differed significantly between the Tat C31S and C31C groups. Tat C31S status is not a sufficient biomarker of HIV-related brain integrity in patient populations. Clinical attention directed at brain health is warranted for all HIV+ individuals, independent of Tat C31S or clade C status.

Effectiveness of traditional healers in treating mental disorders: a systematic review.

Traditional healers form a major part of the mental health workforce worldwide. Despite this, little systematic examination has been done of their effectiveness in treating mental illness or alleviating psychological distress. In this Review, we aim to fill this gap, with a focus on quantitative outcomes. We searched four databases and reference lists for papers that explicitly measured the effectiveness of traditional healers on mental illness and psychological distress. Eligible papers were assessed for quality, and outcomes and other details were extracted with the use of a standardised template. 32 eligible papers from 20 countries were included. The published literature on this topic is heterogeneous and studies are generally of poor quality, although some findings emerge more consistently. Some evidence suggests that traditional healers can provide an effective psychosocial intervention. Their interventions might help to relieve distress and improve mild symptoms in common mental disorders such as depression and anxiety. However, little evidence exists to suggest that they change the course of severe mental illnesses such as bipolar and psychotic disorders. Nevertheless, qualitative changes that are captured poorly by conventional rating scales might be as important as the quantitative changes reviewed here. We conclude by outlining the challenges involved in assessing the effectiveness of traditional healers.

The role of global traditional and complementary systems of medicine in the treatment of mental health disorders.

Traditional and complementary systems of medicine include a broad range of practices, which are commonly embedded in cultural milieus and reflect community beliefs, experiences, religion, and spirituality. Two major components of this system are discernible: complementary alternative medicine and traditional medicine, with different clientele and correlates of patronage. Evidence from around the world suggests that a traditional or complementary system of medicine is commonly used by a large number of people with mental illness. Practitioners of traditional medicine in low-income and middle-income countries fill a major gap in mental health service delivery. Although some overlap exists in the diagnostic approaches of traditional and complementary systems of medicine and conventional biomedicine, some major differences exist, largely in the understanding of the nature and cause of mental disorders. Treatments used by providers of traditional and complementary systems of medicine, especially traditional and faith healers in low-income and middle-income countries, might sometimes fail to meet widespread understandings of human rights and humane care. Nevertheless, collaborative engagement between traditional and complementary systems of medicine and conventional biomedicine might be possible in the care of people with mental illness. The best model to bring about that collaboration will need to be established by the needs of the extant mental health system in a country. Research is needed to provide an empirical basis for the feasibility of such collaboration, to clearly delineate its boundaries, and to test its effectiveness in bringing about improved patient outcomes.

Clinical and neuropsychological predictors of posttraumatic stress disorder.

Although acute responses to traumatic stress generally resolve within a few weeks, some individuals experience severe and persistent problems, such as posttraumatic stress disorder (PTSD). While studies have identified a variety of predictors of PTSD, not all data are consistent. This longitudinal study examined the predictive power of neurocognitive deficits with regard to PTSD severity.One hundred thirty one road traffic collision (RTC) survivors were included within 2 weeks of the RTC and followed up 3 and 6 months later to determine severity of PTSD.Impairment on tests of information processing, executive functioning, verbal learning, and motor speed predicted PTSD severity when neuropsychological, clinical, and sociodemographic factors were all taken into account. Clinical variables (initial symptoms, psychiatric diagnoses, disability, trait anxiety, perceived stress, negative cognitions, and sleep) were associated with 3 and 6-month PTSD severity, but only trait anxiety was predictive of PTSD severity. Ethnicity and education were also found to be predictive.These findings suggest implementation of a holistic approach to screening for PTSD and support a need for interventions that target neurocognitive, clinical, and social variables. Early targeted profiling of this group of trauma survivors can inform early clinical interventions and policy.

Traditional healers in the treatment of common mental disorders in South Africa.

There are few population-level insights into the use of traditional healers and other forms of alternative care for the treatment of common mental disorders in sub-Saharan Africa. We examined the extent to which alternative practitioners are consulted, and predictors of traditional healer visits. A national survey was conducted with 3651 adult South Africans between 2002 and 2004, using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate DSM-IV diagnoses for common mood, anxiety, and substance use disorders. A minority of participants with a lifetime DSM-IV diagnosis obtained treatment from Western (29%) or alternative (20%) practitioners. Traditional healers were consulted by 9% of the respondents and 11% consulted a religious or spiritual advisor. Use of traditional healers in the full sample was predicted by older age, black race, unemployment, lower education, and having an anxiety or a substance use disorder. Alternative practitioners, including traditional healers and religious advisors, appear to play a notable role in the delivery of mental health care in South Africa.

Twelve-month treatment of psychiatric disorders in the South African Stress and Health Study (World Mental Health Survey Initiative).

BACKGROUND: The proportion of people with mental disorders in treatment is relatively small in low and middle income countries. However, little is known about patterns of recent service use in a country like South Africa. METHODS: A nationally representative household survey of 4,351 adult South Africans was carried out. Twelve-month DSM-IV disorders were determined using the WHO composite international diagnostic interview (CIDI). Prevalence and correlates of treatment were assessed among respondents with anxiety, mood and substance use disorders. RESULTS: One-fourth (25.5%) of respondents with a 12-month disorder had received treatment in the past 12 months either from a psychiatrist (3.8%), nonpsychiatrist mental health specialist (2.9%), general medical provider (16.6%), human services provider (6.6%), or complementary-alternative medical (CAM) provider (5.9%). Only 27.6% of severe cases had received any treatment. In addition, 13.4% of respondents with no disorder had accessed services in the past year. Blacks were significantly more likely than other racial groups to access the CAM sector while Whites were more likely to have seen a psychiatrist. CONCLUSIONS: The majority of South Africans with a 12-month mental disorder have unmet treatment needs. In addition to a greater allocation of resources to mental health services, more community outreach and awareness initiatives are needed.

Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation.

BACKGROUND: The weight of evidence suggests that women who freely choose to terminate a pregnancy are unlikely to experience significant mental health risks, however some studies have documented psychological distress in the form of posttraumatic stress disorder and depression in the aftermath of termination. Choice of anaesthetic has been suggested as a determinant of outcome. This study compared the effects of local anaesthesia and intravenous sedation, administered for elective surgical termination, on outcomes of pain, cortisol, and psychological distress. METHODS: 155 women were recruited from a private abortion clinic and state hospital (mean age: 25.4 +/- 6.1 years) and assessed on various symptom domains, using both clinician-administered interviews and self-report measures just prior to termination, immediately post-procedure, and at 1 month and 3 months post-procedure. Morning salivary cortisol assays were collected prior to anaesthesia and termination. RESULTS: The group who received local anaesthetic demonstrated higher baseline cortisol levels (mean = 4.7 vs 0.2), more dissociative symptoms immediately post-termination (mean = 14.7 vs 7.3), and higher levels of pain before (mean = 4.9 vs 3.0) and during the procedure (mean = 8.0 vs 4.4). However, in the longer-term (1 and 3 months), there were no significant differences in pain, psychological outcomes (PTSD, depression, self-esteem, state anxiety), or disability between the groups. More than 65% of the variance in PTSD symptoms at 3 months could be explained by baseline PTSD symptom severity and disability, and post-termination dissociative symptoms. Of interest was the finding that pre-procedural cortisol levels were positively correlated with PTSD symptoms at both 1 and 3 months. CONCLUSION: High rates of PTSD characterise women who have undergone surgical abortions (almost one fifth of the sample meet criteria for PTSD), with women who receive local anaesthetic experiencing more severe acute reactions. The choice of anesthetic, however, does not appear to impact on longer-term psychiatric outcomes or functional status.

Single photon emission computed tomography in posttraumatic stress disorder before and after treatment with a selective serotonin reuptake inhibitor.

BACKGROUND: Posttraumatic stress disorder (PTSD) is recognized as a disorder mediated by specific neurobiological circuits. Functional imaging studies using script-driven trauma imagery and pharmacological challenges have documented altered cerebral function (activation and deactivation) in several brain regions, including the amygdala, hippocampus, prefrontal cortex and anterior cingulate. However, the neural substrates of PTSD remain poorly understood and the effect of selective serotonin reuptake inhibition on regional cerebral activity is deserving of further investigation. METHODS: Eleven adult patients (seven men, four women) (mean age+S.D.=33.6+/-9.2 years) with a DSM-IV diagnosis of PTSD, as determined by the Structured Clinical Interview for DSM-IV (SCID-I) and the Clinician-Administered PTSD Scale (CAPS), underwent single photon emission computed tomography (SPECT) with Tc-99m HMPAO pre- and post-8 weeks of treatment with the selective serotonin reuptake inhibitor, citalopram. Symptoms were assessed at baseline and at 2-week intervals with the Clinician-Administered PTSD Scale (CAPS), Montgomery-Asberg Depression Rating Scale (MADRS), and the Clinical Global Impression Scale (CGI). Image analysis of baseline and post-treatment scans was performed using Statistical Parametric Mapping (SPM). RESULTS: Treatment with citalopram resulted in significant deactivation in the left medial temporal cortex irrespective of clinical response. On covariate analysis, a significant correlation between CAPS score reduction and activation in the left paracingulate region (medial prefrontal cortex) was observed post-treatment. No significant pre-treatment differences were observed between responders and non-responders in anterior cingulate perfusion. CONCLUSIONS: These preliminary findings are consistent with clinical data indicating temporal and prefrontal cortical dysfunction in PTSD and preclinical data demonstrating serotonergic innervation of these regions. However, further studies, in particular in vivo receptor imaging studies, are needed to confirm whether these regional abnormalities correlate with clinical features and treatment response.