Brief Report: A Randomized Control Trial Assessing the Influence of a Telephone-based Intervention on Readmissions for Patients with Severe Mental Illness in a Developing Country.

Whilst comprehensive post-discharge interventions have been successful in reducing readmissions in our setting, they are possibly not sustainable due to limited resources. We assessed the impact of a more cost-effective telephone-based intervention on readmissions in a developing country over 12 months. 100 patients with severe mental illness were randomized to facilitated care or treatment as usual. All were interviewed prior to discharge and after 12 months. Facilitated care consisted of structured telephonic interviews and motivational support to patients and families. At 12 months no significant differences in either readmissions (p = 0.10) or days in hospital (p = 0.44) could be demonstrated. Substance use was high (64%), particularly methamphetamine (44%) in both groups. The intervention did not have any impact on inpatient usage in our setting. Though this study was limited by its small sample size, the results indicated that affordable post-discharge services may not be comprehensive enough to reduce readmission rates and would have to be tailored to the distinct population of dual diagnosis patients identified in this study.

HIV/AIDS risk behaviour in South African schizophrenia patients.

BACKGROUND: Initially the risk of HIV in people with severe mental illness (SMI) was grossly underestimated, but comparisons with the general population have in fact revealed higher infection rates in this particular group. Not only are patients with SMI sexually active but it has also been demonstrated that this group and especially patients with schizophrenia are less knowledgeable about HIV risk behaviours than the general population. Currently no data concerning the participation in and knowledge of HIV/AIDS risk behaviours by South African schizophrenic patients is available. METHODS: Patients with schizophrenia and a control-group were recruited from community clinics in the Western Cape, South Africa, whereafter 43 from each group were matched (race, age, sex). The patient group was subjected to a structured clinical interview and both groups completed the AIDS Risk Behaviour Assessment (ARBAQ) and Knowledge (ARBKQ) Questionnaires. RESULTS: Comparatively, significant knowledge deficits could be demonstrated for the patient group in overall terms (p<0.001) as well as for five specific items (all p<0.05) on the ARBKQ. Furthermore, 10% of the patients believed that the depot antipsychotic injection placed individuals at risk for contracting HIV. Both groups also admitted participation in various high risk sexual behaviours. CONCLUSION: Our results suggest that patients with schizophrenia should be a target group when developing AIDS prevention programmes. In order to identify particularly at risk individuals, a comprehensive risk behaviour assessment should form part of the psychiatric interview.

Emotional face processing deficit in schizophrenia: A replication study in a South African Xhosa population.

Schizophrenia is associated with a deficit in the recognition of negative emotions from facial expressions. The present study examined the universality of this finding by studying facial expression recognition in African Xhosa population. Forty-four Xhosa patients with schizophrenia and forty healthy controls were tested with a computerized task requiring rapid perceptual discrimination of matched positive (i.e. happy), negative (i.e. angry), and neutral faces. Patients were equally accurate as controls in recognizing happy faces but showed a marked impairment in recognition of angry faces. The impairment was particularly pronounced for high-intensity (open-mouth) angry faces. Patients also exhibited more false happy and angry responses to neutral faces than controls. No correlation between level of education or illness duration and emotion recognition was found but the deficit in the recognition of negative emotions was more pronounced in familial compared to non-familial cases of schizophrenia. These findings suggest that the deficit in the recognition of negative facial expressions may constitute a universal neurocognitive marker of schizophrenia.

The factor structure for positive and negative symptoms in South African Xhosa patients with schizophrenia.

Most studies investigating the symptom dimensions of schizophrenia utilising the Scale for the Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive Symptoms (SAPS) favour a three factor model. This study sought to investigate the factor structure of both the global and individual items of the SANS and SAPS in a large sample of South African Xhosa patients with schizophrenia. A total of 422 subjects participated. Both principal components and factor analytical procedures were applied. For the global items, a two-factor solution representing positive and negative symptoms accounted for 59.9% of the variance. Alternatively, the three-dimensional model of negative, psychotic and disorganisation factors was supported by a five-factor solution if the more heterogeneous items of attention and alogia were ignored. Analysis of the individual items yielded a five-factor solution with the negative symptoms splitting into diminished expression and disordered relating, and the positive symptoms separating into factors for psychosis, thought disorder and bizarre behaviour. Our findings are very similar to those from other parts of the world, providing evidence that the factor structure for the symptoms of schizophrenia is relatively resistant to cultural influences. This is particularly true for negative symptoms.

Obsessive-compulsive disorder and a novel polymorphism adjacent to the oestrogen response element (ERE 6) upstream from the COMT gene.

Family and twin studies have consistently provided evidence for involvement of genetic mechanisms in obsessive-compulsive disorder (OCD). This has given rise to association studies involving several candidate genes in an endeavour to identify susceptibility factors. One of the more promising candidate genes appears to be the catecol-O-methyltransferase (COMT) gene. Recent association studies in North American and Afrikaner populations have reported a likely association between a functional polymorphism of COMT (linked with COMT enzyme activity levels) and OCD. COMT expression has been demonstrated to be regulated by oestrogen through the oestrogen-response elements (EREs) in the promoter region of the gene. In the light of this association, the authors tested for an association between a novel polymorphism (C --> T transition) adjacent to ERE 6 in the promoter area of COMT and OCD in 48 Afrikaners and 48 ethnically matched controls. The C --> T transition was not significantly associated with OCD (P = 0.93) or gender (P = 0.67). These findings, although limited by a small sample size, suggest that the novel polymorphism adjacent to ERE 6 in the promoter area of COMT does not play a major role in the genetic predisposition to OCD.

Association between a catechol-o-methyltransferase polymorphism and obsessive-compulsive disorder in the Afrikaner population.

BACKGROUND: It has been proposed that the catechol-o-methyl transferase gene (COMT) may play a role in the pathogenesis of obsessive-compulsive disorder (OCD). Whereas studies in a North American population showed that the low activity (L) allele of a functional polymorphism in COMT was associated with OCD in male patients, this result was not supported by studies in a Japanese population. The present association study assessed the risk for OCD conferred by this COMT polymorphism in a geographically different patient group, namely, the relatively genetically homogeneous Afrikaner population of South Africa. METHODS: Fifty-four unrelated OCD patients and fifty-four sex-matched controls were recruited from the same Afrikaner community. Patients and controls were phenotyped (DSM-IV) and genotyped for a NlaIII polymorphism with H (high activity) or L (low activity) alleles in the COMT gene. RESULTS: The H/L genotype was significantly more common than expected in the OCD patient group (P = 0.0017). LIMITATIONS: Replication studies with related individuals may be useful in discovering factors underpinning the H/L genotype abundance in the Afrikaner population. CONCLUSIONS: These results emphasise the need for further studies in genetically homogeneous populations to help define the complex etiology of this disease.

Suicide attempts in an African schizophrenia population: an assessment of demographic risk factors.

This study investigated demographic variables, including affected sibling pair status, as risk factors for suicidal behavior in schizophrenia patients of African (Xhosa) descent. Xhosa subjects with schizophrenia were interviewed with the Diagnostic Interview for Genetic Studies (DIGS) and then stratified into two groups: those with ( n = 90) and those without ( n = 364) a history of previous suicide attempts. Demographic parameters (including gender, age, and social circumstances, sib ship) were then compared across these groups. Demographic predictors of suicide included sib ship status ( p = 0.038; OR = 1.7) and age of onset of illness ( p = 0.008; OR = 2.5). On further analysis of suicide in siblings, only a minority of sib pairs was found to be concordant for a lifetime history of suicide attempts (3%). These findings raise the possibility that affected sib pair status may be protective in nature. Given the counter-intuitive nature of this finding, further work is needed to replicate it, and to explore possible underlying mechanisms.

Management of violent behaviour in acutely relapsed schizophrenics.

The management of aggressive behaviour has always been a critical issue in psychiatry. Finding measures that can be used to accurately predict the likelihood of assaultative behaviour and thus ensure timeous appropriate pharmacological management remains a dilemma. The study objective was to investigate the naturalistic, pharmacological management of inpatient aggressive behaviour in a group of 50 schizophrenic subjects with a view to determine: (1) whether a presenting history of recent violence lead to altered pharmacological management and (2) whether the NOSIE could be regarded as a useful assessment tool with regards to inpatient behaviour management. No significant difference could be demonstrated between the 2 subsets of subjects (history of violence vs none) with respect to total doses of medication administered. No statistical correlation could be found between the total NOSIE score and the dose of psychotropic medication used. The relationship between a subset of NOSIE-items and the total dose of medication was more complex and a clear linear relationship could be demonstrated for a total score of 0 to 5. In this particular ward setting a presenting history of recent violent behaviour did not influence the administration of medication and neither could the clinical judgement employed by the nursing staff to manage inpatient behaviour be captured by the NOSIE. However, a five-item subset of the NOSIE with questions relating to aggression and irritability warrants further scrutiny in this regard.

Attitudes towards and beliefs about schizophrenia in Xhosa families with affected probands.

OBJECTIVE: The development of effective psychoeducational programs for the management of schizophrenia requires an understanding of attitudes towards and beliefs about the disorder in families of affected probands. In order to establish the need for adaptation of Western psychoeducational programs, these variables were investigated in Xhosa speaking families in South Africa. DESIGN: Xhosa speaking family members of patients with DSM-IV schizophrenia were recruited on a voluntary basis, and interviewed with a structured belief and attitudes questionnaire adapted from previous studies in the West. SETTING: The study population was drawn from both urban and rural Xhosa communities in South Africa. SUBJECTS: 100 Xhosa speaking family members participated in the study. RESULTS: Family members most often recommended treatment with psychotropic medications (88%) and traditional healers (32%), and least often recommended psychotherapy (4%) and meditation (1%). Of the respondents who recommended traditional healing methods, 92% also recommended simultaneous use of allopathic treatment. CONCLUSION: Attitudes towards and beliefs about schizophrenia in family members of patients with schizophrenia may differ substantially from those described in previous work in the West. An understanding of local attitudes and beliefs is crucial for the successful development of local psychoeducational programs.

Retrospective review of trends in assaults and seclusion at an acute psychiatric ward over a 5-year period.

In developing countries such as South Africa, not much is known about the prevalence of assaults and seclusion occurring in mental health wards over time. Here, we describe a 5-year trend in assaults and seclusions, stratified by gender, at Stikland Hospital, South Africa. A retrospective review of clinical records of patients admitted to the acute psychiatric admission wards at Stikland and involved in assault and secluded was undertaken between 1 January 2005 and 31 December 2010. Data on the number of patient and staff assaults as well as seclusions, gender, age, marital status, level of education, level of income, duration of hospital admission and primary psychiatric diagnosis were collected. Significantly (P < 0.01) more men than women engaged in patient assaults, while significantly (P < 0.01) more men were secluded than women. On a monthly basis, the number of gender-stratified patient assaults and seclusions significantly increased (P < 0.01) throughout the study period. In conclusion, we show here that gender had a significant effect on both patient assault and seclusion numbers, which increased towards the end of the study period. Monitoring of these events is therefore important to continuously improve quality of care.

Applicability and fairness of the oral examination in undergraduate psychiatry training in South Africa.

OBJECTIVE: There are several methods of evaluating medical students' performance, such as written examination, oral examination and objective structured clinical examination (OSCE). Many studies have focused on the reliability and validity of these methods but few studies have explored comparison between these methods. Psychiatry is the only subject at the University of Stellenbosch where the final assessment consists of solely an oral component. The aim of the study was to compare students' final overall and discipline specific examination marks (i.e. in the other subjects) with the examination marks in psychiatry, and to determine if content or structure (e,g. oral, written or OSCE format) of examination impacts more on the student performance in the examination. METHOD: 343 final year medical students were included. All undertook their psychiatry rotation at the University of Stellenbosch, South Africa during 2008 and 2009. Data of marks obtained in all the disciplines during 2008 and 2009 were collected and class marks were compared with their final examination marks across all disciplines. Bland-Altman plots were used to assess the level of agreement between the class and examination marks. Cases below the lower threshold were compared to all other cases across all disciplines. The odds ratio for group status was calculated for gender distribution of examiners. RESULTS: The psychiatry class mark and final oral examination mark provided similar measures within a width of 31.5. Cases below the threshold had poorer performance in two other disciplines. The gender distribution of the examiners (female-female) significantly increased the odds ratio for poorer performance in the oral examination. CONCLUSION: The results suggest that a group of students underperform in their final examination independent of method of evaluation and that the gender of examiners impacts on examination marks. Therefore future research should focus on identifying and modifying factors (including choice of examiner combinations) that contribute to the poor performance of medical students in their final examination, in order to help students perform better. Gender distribution of examiners should also be considered when examinations are structured and designed.

Neurological soft signs as an endophenotype in an African schizophrenia population - a pilot study.

OBJECTIVE: The use of endophenotypes, such as neurological soft signs (NSS), is advocated as one possible method to elucidate the heterogeneity of schizophrenia. Exploring the associations between NSS and specific illness symptoms has revealed some trends, although results have been conflicting. To date, such studies have been conducted largely on Caucasian populations and our pilot study represents the first attempt to gather such data in a homogenous African population. METHOD: Fifty-one patients, all of Xhosa ethnicity and participating in a larger schizophrenia genetic study were recruited. NSS were evaluated using a modified Neurological Evaluation Scale. Data were analysed using SPSS with the strength of the overall relationships between NES groups and SANS and SAPS components analyzed by means of canonical correlation analysis. RESULTS: The canonical correlation of SANS domains (excluding asociality) with the NES conceptual groups was 0.53 (SE=0.11, p=0.024) and of the SAPS domains 0.38 (SE=0.13, p=0.943). CONCLUSION: Our results suggest a correlation between negative symptoms of schizophrenia and the presence of NSS, supporting the recruitment of a larger sample to more comprehensively evaluate a possible role for NSS as an endophenotype in the Xhosa schizophrenia population. Taking into account that NSS evaluations allow for inexpensive, relatively easy-to-do objective evaluations, this method presents us with a valuable research tool that can be used effectively within our under-resourced environment to help inform on the neurobiological substrate of schizophrenia.

Psychiatric genetics in South Africa: cutting a rough diamond.

Psychiatric disorders place a considerable healthcare burden on South African society. Incorporating genetic technologies into future treatment plans offers a potential mechanism to reduce this burden. This review focuses on psychiatric genetic research that has been performed in South African populations with regards to obsessive-compulsive disorder, schizophrenia and bipolar disorder. Preliminary findings from these studies suggest that data obtained in developed countries cannot necessarily be extrapolated to South African population groups. Psychiatric genetic studies in South Africa seem to involve relatively low-cost methodologies and only a limited number of large national collaborative studies. Future research in South Africa should therefore aim to incorporate high-throughput technologies into large scale psychiatric studies through the development of collaborations. On a global level, the vast majority of psychiatric genetic studies have been performed in non-African populations. South Africa, as the leading contributor to scientific research in Africa, may provide a foundation for addressing this disparity and strengthening psychiatric genetic research on the continent. Although the elucidation of the genetic architecture of psychiatric disorders has proved challenging, examining the unique genetic profiles found in South African populations could provide valuable insight into the genetics of psychiatric disorders.

Subjective awareness of tardive dyskinesia and insight in schizophrenia.

BACKGROUND: Lack of awareness of tardive dyskinesia (TD) and poor insight into mental illness are common in schizophrenia, raising the possibility that these phenomena are manifestations of a common underlying dysfunction. METHODS: We investigated relationships between low awareness of TD and poor insight into mental illness in 130 patients with schizophrenia and TD. We also examined selected demographic and clinical correlates of these two phenomena. RESULTS: Sixty-six (51%) patients had no or low awareness of TD and 94 (72%) had at least mild impairment of insight into their mental illness. Low awareness of TD was not significantly correlated with greater impairment of insight into mental illness. Regression analyses indicated that the Positive and Negative Syndrome Scale (PANSS) disorganised factor (ß=0.72, t=11.88, p<0.01) accounted for 52% of the variance in insight into mental illness (adjusted R(2)=0.55) (F[2, 127]=81.00, p<0.01) and the Extrapyramidal Symptom Rating Scale (ESRS) dyskinesia subscale score (ß=0.47, t=6.80, p<0.01), PANSS disorganised factor (ß=-0.26, t=-3.73, p<0.01), and ESRS parkinsonism subscale score (ß=0.31, t=4.55, p<0.01) together accounted for 37% of the variance in awareness of TD (adjusted R(2)=0.37) (F[3, 126]=26.87, p<0.01). CONCLUSION: The two phenomena appear to be dissociated, and may be domain-specific.

Antipsychotic prescription patterns in Xhosa patients with schizophrenia or schizoaffective disorder.

OBJECTIVE: To examine the degree to which South African physicians use similar treatment guidelines in their prescription of antipsychotic medication. METHOD: Data on the prescriptions for Xhosa patients with schizophrenia and schizoaffective disorder were retrospectively examined to investigate differences between three catchment areas in the Western Cape, especially in terms of clozapine use. RESULTS: There was an overall low rate (10.0%) of clozapine use and a relatively high occurrence of polypharmacy (28.6% of 510 patients). There were statistically significant differences between the three catchment areas in terms of clozapine (p=0.002) and haloperidol (p=0.001) use. Valkenberg hospital had the highest number of clozapine prescriptions and the lowest of haloperidol. Prescriptions of depot antipsychotics did not differ between catchment areas. CONCLUSION: Discrepancies in antipsychotic medicine prescription patterns were evident between the examined hospitals. It is becoming paramount for practical implementation of guidelines to be improved in South Africa to address, e.g., low clozapine use and the high frequency of polypharmacy.

Schizophrenia-Window-of-Hope.com: development of a psycho-educational internet resource for the South African setting

Psycho-educational programmes for families of persons with schizophrenia have been shown to reduce relapse rates; subsequently reducing the burden on the family as well as health care systems. Although various South African helplines and psycho-educational websites exist, none of these focused specifically on schizophrenia. The South African Depression and Anxiety Group SADAG was approached for assistance to enable us to develop a piggy-back schizophrenia service on their already established helpline. A multidisciplinary mental health team compiled a manual for use by SADAG helpline operators, but owing to the huge amount of information it was realised that the resource would be more efficient if both a helpline and an Internet resource could be created. The website (www.schizophrenia-window-of-hope.com) was then developed with the help of an IT professional. This site represents the first attempt to create an internet-based schizophrenia-specific educational resource for the South African setting. The next step will be to obtain formal feedback from helpline and website users in order to inform the ongoing development of the site

An audit of non-urgent general adult referrals to Stikland State Psychiatric Facility

Objectives. The national Department of Health strongly advocates the strengthening of primary health care systems; and recommendations for appropriate level of care referrals exist. Very few published data on the scope of current ambulatory specialised psychiatric hospital services in South Africa are currently available; making it difficult to assess whether these recommendations are being followed. As a starting point; an audit was conducted to obtain a profile of new non-urgent general adult patients seen at Stikland Hospital with a view to evaluating system needs and demands. Methods. The folders of 103 consecutively seen patients were selected for retrospective review. Patient demographic; referral and assessment information was entered into a single database. Descriptive statistics were compiled with reference to the above variables using SPSS. Results. Overall 58.3 of referrals were from the private sector. More than a third (36.7) of referral letters stated no clear reason for referral and 41.7 no psychiatric diagnosis; and 29.1 of patients were referred without psychotropic medication being started. On assessment 62.1 of patients were found to have a single Axis I diagnosis. Despite virtually no referral letters making any mention of them; substance use disorders (30.1); personality traits/disorders (35.9) and co-morbid medical illness (36.7) were commonly found on assessment. Conclusions. A significant portion of the patients in our sample could have been managed at primary care level and were referred prematurely. The overall quality of referral letters was poor; and they lacked vital information required for appropriate preassessment decision making. Undergraduate training focusing on these skills should be intensified; and consideration should be given to incorporating aspects of our findings into primary health care updates

Duration of untreated psychosis and outcome in first-episode psychosis. Perspective from a developing country.

OBJECTIVE: To investigate the association between duration of untreated psychosis (DUP) and treatment outcome in a sample of subjects from a developing country. METHOD: Forty-eight subjects with a first episode of psychosis were evaluated prior to treatment and at 3-month intervals over a period of 24 months. We first examined correlations between DUP and symptom improvement as measured on the Positive and Negative Symptom Scale (PANSS), and then performed multivariate analysis to determine the validity of DUP as a predictor of outcome. RESULTS: DUP was significantly correlated with improvement in PANSS total and negative subscale scores as well as the PANSS depression factor at 21 and 24 months. Multivariate analysis found DUP to be the only significant predictor of improvement in negative symptoms at 24 months. CONCLUSION: DUP was a significant predictor of outcome in a cohort form a developing country. This study provides support for early detection and intervention strategies.

Characteristics and phenomenology of hair-pulling: an exploration of subtypes.

This study was designed to detail the demographic and phenomenological features of adult chronic hair-pullers. Key possible subtypes were identified a priori. On the basis of the phenomenological data, differences between the following possible subtypes were investigated: hair-pullers with and without DSM-IV trichotillomania (TTM), oral habits, automatic versus focused hair-pulling, positive versus negative affective cues prior to hair-pulling, comorbid self-injurious habits, obsessive-compulsive disorder (OCD), and tics. Forty-seven participants were drawn from an outpatient population of chronic adult hair-pullers. A structured interview that focused on hair-pulling and associated behaviors was administered to participants. Six of the participants (12.8%) were male, and 41 (87.7%) were female. A large number of hair-pullers (63.8%) had comorbid self-injurious habits. A greater proportion of male hair-pullers had comorbid tics when compared with females. Certain subgroups of chronic hair-pullers (e.g., hairpullers with or without automatic/focused hair-pulling, comorbid self-injurious habits, and oral habits) were found to differ on a number of phenomenological and hair-pulling characteristics. However, differences between other possible subgroups (e.g., hair-pullers with or without DSM-IV TTM, comorbid OCD, and negative versus positive affective cues) may reflect greater severity in hair-pulling symptomatology rather than distinct subtypes of chronic hair-pulling. The findings of the present study also indicated that chronic hair-pulling (even in cases where DSM-IV criteria for TTM were not met) has a significant impact on quality of life. The present study provided limited support for the existence of possible subtypes of chronic hair-pulling. Recommendations are made for further investigations into such subtypes.