Profile of the current psychiatrist workforce in South Africa: establishing a baseline for human resource planning and strategy.

The World Health Organization Global Health Observatory Data Repository reports South Africa with 1.52 psychiatrists per 100 000 of the population among other countries in Africa with 0.01 psychiatrists per 100 000 (Chad, Burundi and Niger) to more than 30 per 100 000 for some countries in Europe. The overall situation, while being cognizant that mental health care is not only provided by specialist psychiatrists and that the current treatment gap may have to be addressed by strategies such as appropriate task sharing, suggests that there are actually too few psychiatrists to meet the country's mental health care needs. To address the need to develop a strategy to increase the local specialist training and examination capacity, a situational review of currently practicing psychiatrists was undertaken by the [BLINDED] and the [BLINDED] using the South African Society of Psychiatrists membership database. The number, distribution and attributes of practicing psychiatrists were compared with international figures on the ratio of psychiatrists per 100 000 population. In April 2019, there were 850 qualified psychiatrists actively practicing in the country and based on the national population figure of 55.6 million people (2016 Census), the psychiatrists per 100 000 ratio was 1.53. This indicates no improvement between 2016 to 2019. From the South African Society of Psychiatrists database, we determined that about 80% of psychiatrists are working in the private sector-a much higher proportion than is usually quoted. As the vast majority of psychiatrists are practicing in urban areas in two provinces, Gauteng (n = 350) and Western Cape (n = 292), the ratio of psychiatrists per 100 000 in these areas is relatively higher at 2.6 and 5.0, respectively, whereas rural areas in South Africa are largely without specialist mental health expertise at a rate of 0.03 per 100 000 population. This investigation provides a discipline-specific situational review of the attributes and distribution of the current workforce of specialists in the country.

Factors Affecting Specialist Psychiatry Training in South Africa: Are Psychiatry Residents Satisfied with Their Training?

OBJECTIVE: The authors investigated South African psychiatry residents' satisfaction with their training, physical, and mental health to inform the development of a strategy to improve the quality and experiences of training. METHOD: A cross-sectional online survey was undertaken to assess the factors affecting residents' satisfaction with their current training program. The authors conducted a comparative analysis of residents across the training institutions in South Africa. RESULTS: Of 179 psychiatry residents in the country, 70 responses were received (39.1% response rate). Most were satisfied with the overall quality of their training, various aspects of training, and access to training resources. However, significant differences across universities were identified with regard to residents' perception of the quality of their training, quality of their experiences, access to training resources, quality of supervision, and clinical workload. More than a quarter were dissatisfied with their mental and/or physical health. The top four factors contributing to stress were all training-related. CONCLUSION: While most residents were satisfied with their specialist training, institutional differences in access to training and training resources, quality of training, and availability of quality supervision were evident and need to be addressed to ensure equitable training. There is a need to actively address staff shortages not only for clinical cover during protected academic time but also to meet training needs. A centralized examination process should remain in place to ensure that there is a national standard. Workplace-based assessments could facilitate standardization across institutions, should these assessments be standardized and accompanied by rigorous training of supervisors.

The clinical and demographic profile of women living with HIV admitted to the acute unit at Stikland Psychiatric Hospital.

BACKGROUND: There is a paucity of research on the clinical profile of women living with human immunodeficiency virus (HIV) (WLWH) admitted with acute mental health illness. Existing studies are small and did not look at factors that could have an impact on medication adherence. As a first step to inform service delivery for this vulnerable population, a thorough understanding of the composition and needs of these patients should be identified. OBJECTIVES: To describe the socio-demographic and clinical profile that could have an influence on the antiretroviral therapy (ART) adherence of WLWH at an inpatient psychiatric unit. METHODS: In this retrospective audit, the medical records of all WLWH (18-59 years of age), discharged from the acute unit at Stikland Psychiatric Hospital, were reviewed over a 12-month period. RESULTS: Of the 347 female patients discharged, 55 patients were positive for HIV (15.9%). The majority of them were unmarried (78.2%), unemployed (92.7%), had a secondary level of education (Grade 8-10) (58.2%), lived with a family member (83.6%) and had children (61.8%). The most common psychiatric diagnosis on discharge was substance use disorder with 78.2% of patients being categorised as substance users. Interpersonal violence was only reported by 5.5% of patients. Although most patients performed poorly on the Montreal Cognitive Assessment (MoCA) and International HIV Dementia Scale (IHDS), only 12% of patients received a diagnosis of HIV-associated neurocognitive disorder (HAND) upon discharge. Antiretroviral therapy (ART) was initiated in 21.8% of patients. Only eight patients had a viral load of < 200 copies/mL, indicating viral suppression. CONCLUSION: Our findings may inform service planning and emphasise the need for targeted intervention strategies to improve treatment outcomes in this vulnerable group.

The prevalence and spectrum of mucocutaneous disease in South African people living with HIV and accessing care at a district-level hospital.

BACKGROUND: Although the association between human immunodeficiency virus (HIV) and mucocutaneous diseases has been well studied within South African specialist centres, there is limited data from district-level hospitals. Available data may, therefore, fail to reflect the prevalence and full spectrum of dermatoses seen in people living with HIV (PLWH). OBJECTIVES: To determine the prevalence and spectrum of dermatoses seen in PLWH. METHOD: We conducted a cross-sectional, descriptive study of 970 PLWH (men and women, ≥ 18 years old) accessing care at Karl Bremer Hospital, a district-level hospital located in the Western Cape province, South Africa, between 01 September 2016 and 28 February 2017. RESULTS: The prevalence of mucocutaneous disease in this sample was 12.7% (95% confidence interval [CI] 0.11-0.15). Non-infectious dermatoses comprised 71.0% of the disorders. Pruritic papular eruption (20.0%) and seborrheic dermatitis (6.0%) were the most common non-infectious dermatoses. Tinea corporis (8.0%) and oral candidiasis (6.0%) were the most prevalent infectious dermatoses. There was no significant association between skin disease category (infectious or non-infectious dermatoses) and patient demographics (gender and ethnicity) or HIV-disease characteristics (CD4+ cell count, viral load and duration of antiretroviral therapy [ART]). CONCLUSION: This study provides valuable scientific data on the prevalence and spectrum of mucocutaneous disease in PLWH attending a South African district-level hospital. Prospective studies conducted in other district-level centres across the country are required to determine the lifetime prevalence and spectrum of dermatoses in PLWH in the ART era.

Demographic and clinical profile of patients utilising a transitional care intervention in the Western Cape, South Africa.

BACKGROUND: The World Health Organization's action plan for 2020 has identified the need for service-based data to motivate for more appropriate community-based services. To date, there is no published data from step-up or step-down facilities in South Africa. AIM: To describe the demographic and clinical profile of all patients admitted to New Beginnings between 01 January 2011 and 31 December 2015. SETTING: New Beginnings is an intermediary care facility focused on psychosocial rehabilitation and accommodates 40 patients in a step-up or step-down setting. METHODS: In this retrospective audit, we reviewed the medical records of all patients (N = 730) admitted to New Beginnings between 01 January 2011 and 31 December 2015. RESULTS: Most admissions were male (n = 600; 82.2%), unmarried (92.1%) and unemployed (92.7%) patients with a mean age of 28 years. Only 20.7% had completed their schooling and 37.9% were receiving a disability grant. Most patients lived in the Cape Town Metro area (89%) with their families (94.7%), and 75.6% had no children. Schizophrenia (53.7%) was the most common primary psychiatric diagnosis, and most patients were on a combination of oral and depot treatment (46.8%). Illicit substances were used by 75.9% of patients with 30% using both cannabis and methamphetamine. Most patients (74.9%) had only one admission to New Beginnings. CONCLUSIONS: These baseline data could inform improved service delivery. Further research is needed to evaluate the success of New Beginnings and highlight the need for more of these facilities in the Western Cape and across South Africa.

Self-Induced Vomiting and Other Impulsive Behaviors in Alcohol Use Disorder: A Cross-sectional Descriptive Study.

OBJECTIVE: To determine the prevalence of self-induced vomiting (SIV) in a sample of patients with Alcohol Use Disorder (AUD), and to explore whether such behavior is associated with a comorbid eating disorder psychopathology and other clinical symptomatology, such as impulsivity. Methods: This cross-sectional descriptive study was carried out at the Alcohol Rehabilitation Unit at Stikland Psychiatric Hospital, South Africa. All consecutive inpatient admissions between April and June 2017 were invited to participate in an hour-long data interview. The Alcohol Use Disorders Identification Test (AUDIT), Bulimic Investigatory Test, Edinburgh (BITE), and the Barratt Impulsiveness Scale (BIS-11) were used to collect data from 104 adults. Results: A total of 29% of patients with AUD reported SIV. The main reason stated for SIV was to prevent hangover (66%). There were no significant differences in BITE and BIS110 scores between participants who reported SIV and those who did not. Conclusions: Almost a third of patients with AUD reported SIV. BITE scores indicated no relationship between eating disorders and alcohol-related SIV in this sample. Our findings also did not support an etiological role for impulsivity in alcohol-related SIV.

Eating disorders and substance use at a South African tertiary hospital over a 21-year period.

BACKGROUND: Eating disorders (EDs) and substance-related disorders pose a challenge when they co-occur and have implications for patient management. Clinical information on EDs and substance-related disorders as independent disorders is fairly well established in South Africa, but our understanding of the coexistence of these disorders is limited. AIM: To determine the prevalence, the concurrent nature and the possible trends of substance use among patients diagnosed with EDs at a South African tertiary hospital over a 21-year period. SETTING: The ED unit at Tygerberg Hospital, Cape Town, South Africa. METHODS: We performed a retrospective chart review of 162 patients who were treated for EDs between January 1993 and December 2014. RESULTS: The prevalence of ED subtypes was 40.1% bulimia nervosa (BN), 33.3% EDs not otherwise specified (EDNOS) and 26.5% anorexia nervosa. Most participants (71.0%) used at least one substance. Alcohol was the most prevalent substance of choice (54.8%). Most patients had an additional psychiatric disorder (62.3%), of which major depressive disorder was the most prevalent (46.3%). Apart from the use of alcohol and cannabis, which remained consistent, the use of most other substances as well as the prevalence of BN declined during the study period. CONCLUSION: Understanding the prevalence and trends of EDs and the corresponding patterns of substance misuse is essential to improve service provision. This study emphasises the need to better understand the ongoing and changing behavioural trends in EDs to improve patient management.

Caregiver anxiety and the association with acute postoperative pain in children undergoing elective ambulatory surgery in a lower-middle-income country setting.

BACKGROUND AND AIMS: Moderate to severe postoperative pain complicates surgeries performed on children in upper-income countries. The successful management of postoperative pain in children requires a biopsychosocial approach. Situational anxiety and anxiety disorders among caregivers influence a child's perioperative experience. This study aims to determine whether there is an association between caregiver's preoperative anxiety and children's postoperative pain in a lower-middle-income country (LMIC) setting. METHODS: In this cross-sectional, descriptive study, we recruited 76 children aged 4-12 years, undergoing elective ambulatory tonsillectomy or adenotonsillectomy. Primary caregivers completed validated measures of anxiety (the Beck Anxiety Inventory [BAI] and the Kessler Psychological Distress Scale [K10]) prior to the children undergoing surgery. Postoperative pain was measured using the Wong-Baker Faces Pain Rating Scale 4 hours after surgery. RESULTS: Caregiver anxiety was found in 31.7% of participants using the K10 and in 42.1% using the BAI. Moderate to severe postoperative pain was reported by 51% of children. There was a statistically significant correlation of moderate strength between anxiety scores of caregivers and children's self-reported postoperative pain scores (r = .47 for K10, r = .44 for BAI, P < .001 for both). Two median quantile regression models confirmed that K10 was positively associated with caregiver anxiety (WBFS) with slope = 0.16 and pseudo R2  = 0.25 (P = .002, 95CI: 0.06-0.26) as was BAI with slope = 0.12 and pseudo R2  = 0.22 (P = .013 95CI: 0.03-0.22). CONCLUSIONS: This study showed that preoperative caregiver anxiety is significantly associated with postoperative pain in children undergoing elective, ambulatory surgery in a LMIC setting (correlation of moderate strength). Interventions aimed at reducing caregiver anxiety should become an important component of the biopsychosocial management of postoperative pain in children.

Prevalence of iron deficiency in a South African adolescent inpatient psychiatric population: Rates, risk factors and recommendations.

BACKGROUND: Severe iron deficiency is associated with anaemia, but iron deficiency with normal haemoglobin (Hb) may also affect morbidity and quality of life and contribute to psychiatric illness onset and severity. Psychiatric presentations in adolescence are often indicative of serious long-term morbidity, and addressing contributing health risk factors, such as iron deficiency, is important. OBJECTIVES: To determine rates of iron deficiency in a South African inpatient adolescent psychiatric population and possible associations between psychiatric diagnosis and iron deficiency risk factors. METHODS: We conducted a retrospective chart review of all adolescent patients (13-18 years old) who were admitted to the Adolescent Psychiatric Inpatient Unit at Tygerburg Hospital (Cape Town, South Africa) during 2016. Patient records were limited to those with haemoglobin and ferritin levels available, as well as a psychiatric disorder diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders. The final sample consisted of 93 patients. RESULTS: Of all participants, 7.6% were anaemic, while 22.6% were iron deficient. We found 29% of our population to have anaemia in the absence of iron deficiency. Gender was the only statistically significant correlate, with adolescent females at particular risk of compromised iron status as indicated by a low ferritin level (45% of female sample). CONCLUSION: Iron deficiency rates remain a relevant health concern, and testing Hb alone is inadequate to assess iron status in this population. Ferritin is a necessary additional parameter and should be included in the usual medical workup.

Iron deficiency in South African children and adolescents with attention deficit hyperactivity disorder.

Objective: Iron deficiency may play a role in the pathophysiology of attention deficit hyperactivity disorder (ADHD) by causing dopamine dysfunction, but there is conflicting evidence in the literature regarding this relationship. This study investigates the possible correlation between iron deficiency and ADHD in children and adolescents attending a South African child and adolescent psychiatry outpatient service. Method: In this retrospective study, we gathered data from 245 outpatient children and adolescents who had their serum ferritin and/or iron levels tested between February 2011 and January 2016. Relevant statistical methods were used to test for correlations between ADHD and various demographic and clinical factors, including iron deficiency. Results: Out of 245 patients, 88 (35.9%) had iron deficiency, 156 (63.7%) had ADHD and 55 (22.4%) had both iron deficiency and ADHD. Variables found to be significantly correlated with ADHD included gender, age, and methylphenidate treatment, but there was no significant correlation between ADHD and iron deficiency. Conclusions: Our study emphasizes the great complexity involved in understanding ADHD. Comparisons between mentally-ill paediatric patients and matched healthy controls from the same communities are required to further explore the possible association between iron deficiency and ADHD.

Iron deficiency in South African children and adolescents with attention deficit hyperactivity disorder

Objective: Iron deficiency may play a role in the pathophysiology of attention deficit hyperactivity disorder (ADHD) by causing dopamine dysfunction, but there is conflicting evidence in the literature regarding this relationship. This study investigates the possible correlation between iron deficiency and ADHD in children and adolescents attending a South African child and adolescent psychiatry outpatient service.Method: In this retrospective study, we gathered data from 245 outpatient children and adolescents who had their serum ferritin and/or iron levels tested between February 2011 and January 2016. Relevant statistical methods were used to test for correlations between ADHD and various demographic and clinical factors, including iron deficiency.Results: Out of 245 patients, 88 (35.9%) had iron deficiency, 156 (63.7%) had ADHD and 55 (22.4%) had both iron deficiency and ADHD. Variables found to be significantly correlated with ADHD included gender, age, and methylphenidate treatment, but there was no significant correlation between ADHD and iron deficiency.Conclusions: Our study emphasizes the great complexity involved in understanding ADHD. Comparisons between mentally-ill paediatric patients and matched healthy controls from the same communities are required to further explore the possible association between iron deficiency and ADHD

HPA-axis genes as potential risk variants for neurocognitive decline in trauma-exposed, HIV-positive females.

PURPOSE: Previous studies have independently provided evidence for the effects of HIV infection, hypothalamic-pituitary-adrenal (HPA) axis dysfunction and early life trauma on neurocognitive impairment (NCI). This study examined the interaction between single-nucleotide polymorphisms (SNPs) of two HPA axis genes, corticotrophin-releasing hormone receptor 1 (CRHR1; rs110402, rs242924, rs7209436, and rs4792888) and corticotrophin-releasing hormone-binding protein (CRHBP; rs32897, rs10062367, and rs1053989), childhood trauma, and HIV-associated NCI. PATIENTS AND METHODS: The sample comprised 128 HIV-positive Xhosa females of whom 88 (69%) had a history of childhood trauma. NCI was assessed using a battery of 17 measures sensitive to the effects of HIV, and the history of childhood trauma was assessed using the validated retrospective Childhood Trauma Questionnaire-Short Form. Generalized linear regression models were used to compare allelic distribution by trauma status and global NCI. The association between genotype, childhood trauma, and cognitive scores was also evaluated using generalized linear regression models, assuming additive models for the SNPs, and ANOVA. RESULTS: Of the seven polymorphisms assessed, only the rs10062367 variant of CRHBP was significantly associated with global NCI (P=0.034), independent of childhood trauma. This polymorphism was not significantly associated with z-scores on any specific cognitive domain. The interaction of childhood trauma and variants of CRHR1 was associated with poorer learning (rs110402) and/or recall (rs110402 and rs4792888). CONCLUSION: These findings suggest that CRHBP rs10062367 A allele is a possible risk variant for NCI in HIV, independent of childhood trauma. Furthermore, results show that the interaction of childhood trauma with variants of CRHR1, rs110402 and rs4792888, confer added vulnerability to NCI in HIV-infected individuals in cognitive domains that are known to be impacted by HIV. While these findings need independent replication in larger samples, it adds CRHBP and CRHR1 to the list of known genes linked to HIV- and childhood trauma-associated neurocognitive phenotypes.

Body dysmorphic disorder: A diagnostic challenge in adolescence.

Body dysmorphic disorder (BDD) is a chronic and disabling condition that is characterised by distressing preoccupations with perceived defects in one's own appearance, which might be slight or not observable to others. It is considered to be an obsessive-compulsive spectrum disorder and is associated with depression, feelings of shame and poor quality of life. It is primarily a disorder of childhood or adolescent onset, and sub-clinical BDD symptoms begin, on average, several years before an individual's symptoms meet full criteria for the disorder. Here we report the case of an adolescent admitted to an inpatient psychiatric unit for treatment of psychotic symptoms that were poorly responsive to standard treatments. This challenging case of BDD in an adolescent highlights the various comorbidities of the disorder, as well as the difficulties associated with BDD diagnosis.

Isolation of a phenol-utilizing marine bacterium from Durban Harbour (South Africa) and its preliminary characterization as Marinobacter sp. KM2.

Many aromatic hydrocarbons assigned to the so-called high production volume chemicals (HPVCs) are frequently encountered constituents of wastewaters that end up in the sea. Although the pollutant-degrading capabilities of freshwater bacteria are well known, the catabolism of pollutants by marine bacteria has received limited attention. A marine bacterium with the ability to aerobically utilize phenol - an HPVC and common aromatic pollutant - as its sole source of carbon and energy, was isolated from water samples from Durban Harbour, South Africa. The isolate, designated strain KM2, was assigned to the genus Marinobacter based on a variety of phenotypic properties and by analysis of the 16S rRNA gene sequence. The isolate displays an absolute growth requirement for NaCl which cannot be offset by replacement of NaCl with other salts. In addition to 4-methylphenol and 3,4-dimethylphenol, it utilizes a range of aliphatic hydrocarbons such as butan-1-ol and hexadecane under aerobic conditions. The transient formation of an intermediate exhibiting the UV-Vis spectral characteristics for 2-hydroxymuconic semialdehyde in cultures growing on phenol suggests that the isolate catabolizes this compound via the meta cleavage pathway. These results indicate that members of the genus Marinobacter might participate in the elimination of aromatic pollutants in South African marine environments.