Mental illness attitudes, service provision interest and further training preferences of clinical associates.

BACKGROUND:  Non-specialist health professionals are required to provide mental health services given the burden of disease due to mental illness. The study aimed to explore the attitudes of clinical associates towards those with mental illness as well as their interest in mental health work and additional mental health training. METHODS:  A cross-sectional study design was utilised. The study population consisted of clinical associates based in South Africa. An electronic questionnaire was developed that incorporated the 16-item Mental Illness Clinicians' Attitudes version 4 scale (MICA-4), which is scored out of 96 with higher scores indicating more stigmatising attitudes. Multivariate linear regression was used to determine factors associated with the MICA-4 score. RESULTS:  The mean MICA-4 score for the 166 participants who completed all 16 questions was 37.55 (standard deviation 7.33). In multivariate analysis, the factors associated with significantly lower MICA-4 scores were falling in the 25- to 29-year-old age category and indicating that a mental health rotation formed part of the undergraduate degree. More than 80% of the participants (140/167, 83.8%) indicated an interest in mental health work. Two-thirds of the participants (111/167, 66.5%) indicated an interest in a specialisation in mental health. CONCLUSION:  The mean MICA-4 score recorded for clinical associates indicates low stigma levels towards those with mental illness. Additionally, there is significant interest in working and training in mental health.Contribution: Training programmes should take note of the contribution of a mental health rotation to a positive attitude to mental health patients. Clinical associates' attitudes towards mental illness together with their interest in working and training in mental health suggest that they could be more widely utilised in mental health service provision.

Validation of a brief screener for broad-spectrum mental and substance-use disorders in South Africa.

In low-resource settings, valid mental health screening tools for non-specialists can be used to identify patients with psychiatric disorders in need of critical mental health care. The Mental Wellness Tool-13 (mwTool-13) is a 13-item screener for identifying adults at risk for common mental disorders (CMDs) alcohol-use disorders (AUDs), substance-use disorders (SUD), severe mental disorders (SMDs), and suicide risk (SR). The mwTool-13 is administered in two steps, specifically, only those who endorse any of the initial three questions receive the remaining ten questions. We evaluated the performance of mwTool-13 in South Africa against a diagnostic gold standard. We recruited a targeted, gender-balanced sample of adults, aged ≥18 years at primary and tertiary healthcare facilities in Eastern Cape Province. Of the 1885 participants, the prevalence of CMD, AUD, SMD, SR, and SUD was 24.4%, 9.5%, 8.1%, 6.0%, and 1.6%, respectively. The mwTool-13 yielded high sensitivities for CMD, SMD, and SR, but sub-optimal sensitivities for AUD and SUD (56.7% and 64.5%, respectively). Including a single AUD question in the initial question set improved the tool's performance in identifying AUD and SUD (sensitivity > 70%), while maintaining brevity, face-validity, and simplicity in the South African setting.

Knowledge, confidence, and practices of clinical associates in the management of mental illness.

Background: Additional human resources are needed to provide mental health services in underserved areas in South Africa (SA). Clinical associates, the mid-level medical worker cadre in SA, could potentially be used to deliver these services. Aim: The study explored the self-reported knowledge, confidence, and current practices of clinical associates related to mental health assessment and management. Setting: South Africa. Methods: A cross-sectional study was conducted. The link to the electronic questionnaire was distributed to clinical associates via databases and social media. Data were analysed with Stata v17. Results: Of the 209 participants, 205 (98.1%) indicated they had training on management of patients with mental illness during their undergraduate degree and 192 (91.9%) had a mental health rotation. Few (10.7%) had any additional mental health training. Most participants rated their knowledge of priority mental disorders as 'good' or 'excellent'. Only 43.2% of the participants felt quite or very confident to perform a mental health examination. Participants who felt quite or very confident to manage patients presenting with suicide risk, aggression, and confusion were 44.9%, 46.9% and 53.1%, respectively. Factors associated with a confidence score of 75% and higher were male gendered, working in Gauteng or Northern Cape provinces, and in a rural area. The majority of participants were already involved in mental health assessment and management in their current work. Conclusion: Clinical associates have a contribution to make in mental health service provision, but this may need to be supplemented by additional practical training. Contribution: Potential gaps in training have been identified.

Enabling mental health task-sharing: a collective case study of undergraduate clinical associate training programmes in South Africa.

BACKGROUND: There is a shortage of the human resources needed to deliver mental health services which is likely to be exacerbated by COVID-19. Due to mental health workforce shortages, task-shifting and task-sharing approaches have been implemented in a number of countries. Clinical associates, a mid-level cadre working under the supervision of medical practitioners, could play a role in delivering mental health services but it is not clear if they are adequately prepared. This study explored the mental health curriculum content of the undergraduate clinical associate training programmes in South Africa and the views of key informants of the adequacy of training in mental health. METHODS: A qualitative collective case study approach was utilised for this multisite study at the three universities in South Africa offering clinical associate degrees. The study consisted of in-depth interviews utilising videoconferencing of individuals involved in each programme and a document review. Thematic analysis of the data was conducted. RESULTS: Nineteen interviews were conducted. Mental health formed part of the curriculum in all three programmes with the bulk of the training taking place in the final year of the three-year degree. Facility-based training ranged from two weeks to four weeks with one university only using hospitals with mental health units while two universities used hospitals at which the students were based for the year regardless of potential mental health exposure they would receive. The list of curricula inclusions extended to seldom-seen conditions. The quality of training and supervision appeared site-dependant and only one university set minimum experiential targets. CONCLUSION: There is a basis on which to build the competencies and skills regarding mental health in this cadre. A training model that integrates mental health early in the undergraduate curriculum, focuses on common conditions and those with high disease burden, includes time in a mental health unit, provides facility-based trainers with detailed guidance to improve standardisation, and includes specific experiential targets that are monitored will enhance the potential utility of this cadre.

Mental health task-sharing in South Africa - a role for clinical associates?

BACKGROUND: South Africa (SA) lacks the specialised workforce needed to provide mental health services particularly in the public sector and in rural areas. Mid-level medical workers offer a potential option for mental health task-sharing in countries where they exist, including SA. The objectives of the study were to explore the roles that SA's mid-level medical worker cadre (clinical associates) could play in mental health service delivery, and to explore views on advanced training in mental health for this cadre. METHODS: This was an explorative, qualitative study involving key informants linked to the three clinical associate training programmes in SA. A total of 19 in-depth interviews were conducted with university-based academic staff, facility-based trainers, and student representatives. The interviews were audio-recorded and professionally transcribed. Thematic analysis was conducted with the aid of Atlas.ti software. Themes and subthemes were identified. RESULTS: The first theme identified was 'there is a place for them at the table'. Participants felt that there was a definite role for clinical associates in mental health service provision. The levels of care thought most appropriate were primary health care facilities and district hospitals. The most frequently identified role for clinical associates was in providing immediate care and stabilising mental health patients presenting in emergency settings. Other potential settings included inpatient wards, outpatients' departments, and in communities (e.g. home visits). The second theme identified was 'earning a seat at the table'. There was virtually unanimous support for additional training and in particular a postgraduate clinical specialisation in mental health. Participants felt a clinical specialisation in mental health would strengthen the health system by addressing workforce shortages as well as access and equity issues. They also held the view it would strengthen the profession by creating a career path and providing more employment opportunities for clinical associates. CONCLUSIONS: There was broad support for a role for clinical associates in mental health service delivery in SA as well as for the establishing a clinical specialisation in mental health for clinical associates. Clinical associates with advanced training in mental health could potentially play an important role in rural settings to alleviate the shortage of specialist mental health practitioners.

Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority.

The COVID-19 pandemic has had an unprecedented impact on health systems in most countries, and in particular, on the mental health and well-being of health workers on the frontlines of pandemic response efforts. The purpose of this article is to provide an evidence-based overview of the adverse mental health impacts on healthcare workers during times of crisis and other challenging working conditions and to highlight the importance of prioritizing and protecting the mental health and well-being of the healthcare workforce, particularly in the context of the COVID-19 pandemic. First, we provide a broad overview of the elevated risk of stress, burnout, moral injury, depression, trauma, and other mental health challenges among healthcare workers. Second, we consider how public health emergencies exacerbate these concerns, as reflected in emerging research on the negative mental health impacts of the COVID-19 pandemic on healthcare workers. Further, we consider potential approaches for overcoming these threats to mental health by exploring the value of practicing self-care strategies, and implementing evidence based interventions and organizational measures to help protect and support the mental health and well-being of the healthcare workforce. Lastly, we highlight systemic changes to empower healthcare workers and protect their mental health and well-being in the long run, and propose policy recommendations to guide healthcare leaders and health systems in this endeavor. This paper acknowledges the stressors, burdens, and psychological needs of the healthcare workforce across health systems and disciplines, and calls for renewed efforts to mitigate these challenges among those working on the frontlines during public health emergencies such as the COVID-19 pandemic.

Identifying a probable suicide cluster in an acute care psychiatric hospital in the Eastern Cape, South Africa.

BACKGROUND: Two young male patients who were diagnosed with drug-induced psychosis committed suicide in a psychiatric hospital in South Africa within a month of each other. The psychiatric nurses working in the hospital had never before had to deal with a similar trauma of suicide cluster. AIM: To assess the psychiatric nurses' experiences of suicide cluster in an inpatient psychiatric setting. SETTING: A psychiatric hospital in the Eastern Cape, South Africa. METHOD: A qualitative design was used. The research population consisted of psychiatric nurses who were purposively selected. Data were gathered using in-depth interviews where the participants narrated their experiences of the incidents. The interviews were transcribed verbatim and the data was coded using descriptive and explanatory codes. Trustworthiness was ensured. Ethical principles of justice, autonomy, beneficence and non-maleficence were ensured. RESULTS: An attempt was made to compare the suicides of two patients with the characteristics of cluster suicide to determine if clustering took place. Two young males committed suicide in an institutional setting within a month of each other. Other characteristics present included using the same method, in the same venue and in the same unit. They had similar educational and social backgrounds. The second victim knew the first victim and was aware of what happened. CONCLUSION: When the two events are analysed together it would seem as if clustering did occur. The suicide victims knew each other and victim number 2 was aware of the facts of the first suicide. They were in their early 20's, were mentally ill and committed suicide in the same site, using the same method and were both institutionalised at the time. Members of the mental healthcare team should be made aware of the characteristics of clustering so that when a suicide attempt occurs in a place where mentally-ill individuals are cared for, measures can be put in place to prevent another patient from copying such an event.

OUTCOMES OF PEOPLE LIVING WITH HIV IN TWO PUBLIC-SECTOR PSYCHIATRIC FACILITIES IN THE EASTERN CAPE USING EFAVIRENZ-CONTAINING REGIMENS.

BACKGROUND: People with mental disorders are more vulnerable to human immunodeficiency virus (HIV) infection. A part of first-line treatment for HIV, efavirenz, is routinely avoided in patients with mental illness due to the risk of potential aggravation of the mental illness. This study aimed to determine the outcomes of people living with HIV/AIDS who were mental healthcare users admitted to two public-sector psychiatric facilities and who were prescribed an efavirenz-containing regimen. MATERIALS AND METHODS: A retrospective drug utilization study was conducted at two public-sector psychiatric hospitals in the Eastern Cape of South Africa. Patients aged 18 years or older living with HIV were included in the study. Follow-up reviews were conducted at four, 12 and 24 weeks. The patients were seen by doctors at the hospital and notes on progress and medication were recorded in medical records. The files were then reviewed. RESULTS: A total of 37 patients were enrolled. However, just 26 were reviewed at 24 weeks. A total of 43.2% (n=16) were female patients and the average age of the patients was 39.38±8.76 years. At the baseline, 32.4% (n=12) patients were diagnosed with schizophrenia. A total of 81.08% (n=30) of patients experienced an improvement in psychiatric symptoms after 24 weeks. Of these, 43.3% (n=13) were on an efavirenz-containing regimen. CONCLUSION: Majority of the patients demonstrated an improvement in their psychiatric conditions to the extent that they were discharged into the community. This finding suggests that patients with psychiatric disorders on efavirenz can experience stabilisation of their psychiatric symptoms.

Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries.

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.

Differences between unipolar mania and bipolar-I disorder: Evidence from nine epidemiological studies.

OBJECTIVES: Although clinical evidence suggests important differences between unipolar mania and bipolar-I disorder (BP-I), epidemiological data are limited. Combining data from nine population-based studies, we compared subjects with mania (M) or mania with mild depression (Md) to those with BP-I with both manic and depressive episodes with respect to demographic and clinical characteristics in order to highlight differences. METHODS: Participants were compared for gender, age, age at onset of mania, psychiatric comorbidity, temperament, and family history of mental disorders. Generalized linear mixed models with adjustment for sex and age as well as for each study source were applied. Analyses were performed for the pooled adult and adolescent samples, separately. RESULTS: Within the included cohorts, 109 adults and 195 adolescents were diagnosed with M/Md and 323 adults and 182 adolescents with BP-I. In both adult and adolescent samples, there was a male preponderance in M/Md, whereas lifetime generalized anxiety and/panic disorders and suicide attempts were less common in M/Md than in BP-I. Furthermore, adults with mania revealed bulimia/binge eating and drug use disorders less frequently than those with BP-I. CONCLUSIONS: The significant differences found in gender and comorbidity between mania and BP-I suggest that unipolar mania, despite its low prevalence, should be established as a separate diagnosis both for clinical and research purposes. In clinical settings, the rarer occurrence of suicide attempts, anxiety, and drug use disorders among individuals with unipolar mania may facilitate successful treatment of the disorder and lead to a more favorable course than that of BP-I disorder.

Perspectives of healthcare professionals of the neuropsychiatric side effects associated with efavirenz and its management.

BACKGROUND: Efavirenz is associated with neuropsychiatric side effects. The consequences of using efavirenz in human immunodeficiency virus (HIV)-positive patients with mental illness has not been conclusively established, the concern being that efavirenz may worsen the condition of an already mentally ill patient. The absence of guidelines and the lack of evidence for the use of efavirenz in this special population lead to uncertainty and, as a result, varying practices in the clinical setting. AIM: To determine the experiences of healthcare professionals caring for mentally ill people living with HIV (PLWH) who are using efavirenz, the associated neuropsychiatric side effects and the management thereof. SETTING: Eastern Cape, South Africa. METHOD: A qualitative, descriptive, exploratory design was used to understand the phenomenon under study and to share the experiences of the participants. Semi-structured interviews were conducted. The data were analysed using thematic framework analysis and coded by the researcher as well as an independent coder. RESULTS: There were conflicting feelings concerning the use of efavirenz in PLWH with active mental illnesses. Some healthcare professionals were willing to prescribe and use efavirenz whilst others were not. All participants indicated that further elucidation in the guidelines on the possible side effects associated with efavirenz and suggested management strategies would be useful. CONCLUSION: The expansion of the South African National Guidelines for the Treatment of HIV should include descriptions of the side effects caused by antiretrovirals and management strategies thereof to empower healthcare professionals to make informed decisions regarding patient care for mentally ill PLWH.

A review of trials investigating efavirenz-induced neuropsychiatric side effects and the implications.

Efavirenz is part of the first-line treatment for HIV patients including those in South Africa with approximately 50% experiencing neuropsychiatric side effects. A systematic review of papers reporting neuropsychiatric side effects with efavirenz published between January 2001 and December 2014 was performed, to provide guidance. 13 articles were reviewed. Patient ages ranged between 37 to 41 years, with a high percentage males. Scales used to measure incidence and severity of side effects were varied; with disease severity or stage not reported. Patients with psychoses were excluded. Most commonly reported side effects were a reduction in sleep quality, depression, dizziness and anxiety. These were generally mild and not warranting discontinuation of efavirenz. It is difficult to directly compare the studies. Standardised methods need to be introduced and all patient groups represented including the elderly, children, patients with active symptomatic illness and more women especially among the African population.

Incidence of neuropsychiatric side effects of efavirenz in HIV-positive treatment-naïve patients in public-sector clinics in the Eastern Cape.

BACKGROUND: It is acknowledged that almost half of patients initiated on efavirenz will experience at least one neuropsychiatric side effect. OBJECTIVES: The aim was to determine the incidence and severity of neuropsychiatric side effects associated with efavirenz use in five public-sector primary healthcare clinics in the Eastern Cape. METHOD: The study was a prospective drug utilisation study. A total of 126 medical records were reviewed to obtain the required information. After baseline assessment, follow-up reviews were conducted at 4 weeks, 12 weeks and 24 weeks from 2014 to 2015. RESULTS: The participant group was 74.60% female (n = 94), and the average age was 37.57±10.60 years. There were no neuropsychiatric side effects recorded for any patient. After the full follow-up period, there were a total of 49 non-adherent patients and one patient had demised. A non-adherent patient was defined as a patient who did not return to the clinic for follow-up assessment and medication refills 30 days or more after the appointed date. Some patients (n = 11) had sent a third party to the clinic to collect their antiretroviral therapy (ART). The clinic pharmacy would at times dispense a two-month supply of medication resulting in the patient presenting only every two months. CONCLUSION: Further pharmacovigilance studies need to be conducted to determine the true incidence of these side effects. Healthcare staff must be encouraged to keep complete records to ensure meaningful patient assessments. Patients being initiated on ART need to personally attend the clinic monthly for at least the first 6 months of treatment. Clinic staff should receive regular training concerning ART, including changes made to guidelines as well as reminders of side effects experienced.

Social Media in the Healthcare Context: Ethical Challenges and Recommendations

The popularity of social media has grown rapidly and healthcare practitioners and students commonly use sites such as Facebook. The ethical and professional implications and their benefits and hazards must be considered. Concerns include blurring of boundaries between an individual's public and professional lives; maintaining privacy and confidentiality of patient information; damaging the public image of the profession and inter-professional relationships. The same laws that apply to conduct in the real world also apply in cyberspace. Harmful or derogatory posts may result in a defamation lawsuit. The internet may also provide opportunities for patient education through peerreviewed websites and to build professional networks. Institutions should have policies on the uses of social media. Emerging technology will continue to change the landscape of social media and social networking and the way patients and practitioners use websites will continue to evolve. Practitioners should proactively manage digital identity by reviewing publicly available material and maintaining strict privacy settings about their information

Posttraumatic Stress Disorder and Barriers to Care in Eastern Cape Province, South Africa.

A range of barriers to seeking mental health care in low- and middle-income countries has been investigated. Little, however, is known of the barriers to care and help-seeking behavior among people with posttraumatic stress disorder (PTSD) in low- and middle-income countries. This was a population-based study including 977 people aged 18-40 years from the Eastern Cape Province in South Africa. Current PTSD was assessed by using a diagnostic questionnaire (Mini International Psychiatric Interview). An additional questionnaire captured socioeconomic and health-related data. The prevalence of current PTSD was 10.8%. Only 48.1% of people with current PTSD accessed health care services. Younger people aged 18 to 29 years were less likely to seek health care, OR = 0.36, 95% CI [0.15, 0.85]. People earning a salary or wage, OR = 2.91, 95% CI [1.26, 6.71]; and those with tuberculosis, OR = 11.63, 95% CI [1.42, 95.56], were more likely to seek health care. A range of barriers to seeking care were identified, the most striking being stigma and a lack of knowledge regarding the nature and treatment of mental illness. People with current PTSD may seek help for other health concerns and brief screening means those affected may be readily identified.

Unipolar mania: a necessary diagnostic concept.

In the classification of mood disorders, major depressive disorder is separate from bipolar disorders whereas mania is not. Studies on pure mania are therefore rare. Our paper reviews the evidence for distinguishing pure mania (M) and mania with mild depression (Md) from bipolar disorder. Two large epidemiological studies found a prevalence of 1.7-1.8% of M/Md in adolescents and adults. Several clinical follow-up studies demonstrated good stability of the diagnosis after a previous history of three manic episodes. Compared to bipolar disorder, manic disorder is characterised by a weaker family history for depression, an earlier onset, fewer recurrences and better remission, and is less comorbid with anxiety disorders. In addition, mania is strongly associated with a hyperthymic temperament, manifests more psychotic symptoms and is more often treated with antipsychotics. Twin and family studies find mania to be more heritable than depression and show no significant transmission from depression to mania or from mania to depression. Cardiovascular mortality is elevated among patients with mood disorders generally and is highest among those with mania. In non-Western countries, mania and the manic episodes in bipolar disorder are reported to occur more frequently than in Western countries.