Burnout in emergency department staff: The prevalence and barriers to intervention.

Background: Burnout impacts patient care and staff well-being. Emergency department (ED) staff are at an elevated risk for burnout. Despite an acceleration in burnout research due to the coronavirus disease 2019 (COVID-19) pandemic, there is limited data on the nature and prevalence of burnout in the South African emergency medicine setting. Aim: This study determined the prevalence of burnout in ED staff (doctors, nurses and non-clinical staff) at Tygerberg Hospital and explored staff awareness and utilisation of interventions. Setting: The study was conducted at Tygerberg Hospital, South Africa. Methods: This cross-sectional study used the Maslach Burnout Inventory to assess burnout via a self-administered electronic survey in a convenience sample of 109 ED staff. Quantitative data were analysed with descriptive and inferential statistics. Qualitative data were analysed using thematic analysis. Results: A total of 46 participants (45.10%) experienced burnout, with 73 participants (71.57%) at high risk for emotional exhaustion or depersonalisation. The prevalence of burnout in doctors was 57.89%, non-clinical staff was 25.93%, and nursing staff was 50.00%. Burnout was higher in doctors and nursing staff compared to non-clinical staff, with high emotional exhaustion and depersonalisation found in interns and specialist professional nurses. The level of intervention awareness was 41.8% and the level of intervention utilisation was 8.82%. Thematic analysis identified awareness, accessibility and reactive utilisation as barriers to utilisation with opportunities to reduce burnout and enhance resilience. Conclusion: Coordinated health system and organisational efforts are required to optimise intervention strategies to reduce burnout. Contribution: Guidance on the design and planning of intervention strategies considering at risk groups, intervention-related factors, and non-clinical staff.

Attention deficit hyperactivity disorder: Insights into underfunding in the private healthcare sector in South Africa.

Background: Although the prevalence of attention deficit hyperactivity disorder (ADHD) has remained stable, the number of patients diagnosed with ADHD has increased in recent years owing to increased awareness. Despite this increase, medical schemes in South Africa have not improved their funding models for this condition. Aim: The study aimed to provide an account of the funding that medical schemes provisioned for treating ADHD in South Africa during 2022. Setting: All the South African medical schemes that were registered with the Council of Medical Schemes during 2022 (n = 72) and all their listed options were evaluated (n = 279). Methods: The study analysed secondary data published on the medical schemes' websites in the public domain. Statistical minimum, average, maximum and correlation analyses were performed using Excel version 16.58. Results: Attention deficit hyperactivity disorder is not regarded as a prescribed minimum benefit (PMB) condition and therefore each medical scheme used its own approach to providing its beneficiaries with some or no benefits for ADHD. It was evident that ADHD was underfunded and lacked structured or standardised funding approaches. Conclusion: Attention deficit hyperactivity disorder is underfunded in the private healthcare sector in South Africa. Better funding models are needed or ADHD needs to be registered as a PMB condition. Contribution: Findings from this study highlight the urgency for structured and sufficient ADHD-specific funding by medical schemes. Considerations based on these findings may be applied in the National Health Insurance and in other countries around the world.

Attention-deficit hyperactivity disorder stigma: The silent barrier to care.

Background: Attention-deficit hyperactivity disorder (ADHD) is the most common psychiatric disorder in childhood, with symptoms persisting into adulthood in 60% of individuals. If left untreated, the emotional, social and financial consequences can be dire, with many children and adults not reaching their full potential and having a reduced quality of life. Aim: The study explored parents' and educators' understanding and experience of stigma in relation to their children's ADHD. Setting: Participants were recruited from six schools in the Cape Town metropole, in which the Goldilocks and The Bear Foundation (which delivers mental health services to underprivileged children) were active. Methods: A convergent parallel mixed methods research design (consisting of a quantitative survey and an in-depth interview component) was conducted to explore the lack of knowledge about ADHD and stigma as potential barriers to help-seeking behaviour, diagnosis and treatment for children with ADHD. Results: Instrumental barriers to care had a bigger impact on practical access to care, while attitudinal and stigma-related resources were found to have a significant impact on well-being of individuals. Core to the themes arising from the interviews were questions of how lack of knowledge influences stigma, how stigma materialises in discriminatory behaviour and how stigma acts as a barrier to care. Conclusion: The findings contribute to the literature by exploring parents' and educators' understanding and experience of stigma in relation to their children's ADHD. A collaborative stakeholder approach is needed for effective, comprehensive and relevant interventions to combat stigma and enhance early identification of and interventions for ADHD. Contribution: In order to improve access to care, treatment, and well-being of individuals directly or indirectly affected by ADHD, it is crucial that stigma needs to be addressed.

Significance of dietary folate intake, homocysteine levels and MTHFR 677 C>T genotyping in South African patients diagnosed with depression: test development for clinical application.

Low folate intake in the presence of the functional MTHFR 677 C > T (rs1801133) polymorphism is an important cause of elevated homocysteine levels previously implicated in major depressive disorder (MDD) and many other chronic diseases. In this study the clinical relevance and inter-relationship of these aspects were evaluated in 86 South African patients diagnosed with MDD and 97 population-matched controls participating in a chronic diseases screening program. A questionnaire-based clinical and nutrition assessment was performed, homocysteine levels determined, and all study participants genotyped for MTHFR 677 C > T (rs1801133) using allele-specific TaqMan technology. The folate score was found to be significantly lower in the patient group compared to controls (p = 0.003) and correlated with increased body mass index (BMI), particularly in females with MDD (p = 0.009). BMI was significantly higher in the MDD patients compared with controls after adjustment for age and sex (p = 0.015), but this association was no longer significant after further adjustment for the level of folate intake in the diet. In MDD patients but not controls, the minor T-allele of MTHFR 677 C > T was associated with increased BMI (p = 0.032), which in turn correlated significantly with increased homocysteine levels. The significant association between BMI and homocysteine levels was observed in both the MDD patient (p = 0.049) and control (p = 0.018) study groups. The significantly higher homocysteine levels observed in MDD patients compared to controls after adjustment for age and sex (p = 0.030), therefore appears to be mediated by the effects of MTHFR 677 C > T and low folate intake on BMI. Detection of the low-penetrance MTHFR 677 C > T mutation reinforces the importance of folate intake above the recommended daily dose to prevent or restore dysfunction of the methylation pathway.

Radiologists' experiences and perceptions regarding the use of teleradiology in South Africa.

Background: Teleradiology was implemented in South Africa in 1999, but the subsequent uptake was low and slow. The onset of the coronavirus disease 2019 (COVID-19) pandemic catapulted South African healthcare into the arena of teleradiology. This created the environment for re-examining the factors that enable or inhibit the uptake of teleradiology in both the public and private sectors. Objectives: This article reports on a study of a select sample of private and public sector radiologists' experiences with, and perceptions of, the benefits, opportunities, challenges and barriers to the implementation of teleradiology in the South African context. Method: Qualitative data on the perceived benefits and challenges of teleradiology, as well as on its enablers and the barriers to its implementation, were collected and analysed. Results: The uptake of teleradiology in the sample increased by 15.9% during the COVID-19 pandemic. The results demonstrated that teleradiology was perceived to have clear benefits on operational, personal and societal levels. Conclusion: It is important to address structural barriers to the implementation of teleradiology. Clear communication strategies and multistakeholder engagement are also required. Contribution: By investigating radiologists' experience with teleradiology, this study provides an understanding of the benefits, opportunities, challenges and barriers to implementation of services. These insights enable informed decision-making and stakeholder engagement and provide a foundation for establishing recommendations for the viable implementation of teleradiology in South Africa and other lower- and middle-income countries to promote access to healthcare.

Patients' perception of service quality in a healthcare not-for-profit organisation.

BACKGROUND: Service organisations should be aware of those elements that are perceived as excellent quality and incorporate these as part of their service offering. However, a not-for-profit (NPO) healthcare organisation consists of a diverse group of stakeholders who have different perspectives and interests. Service quality therefore requires a multidimensional definition that comprehends all their needs and expectations. METHODS: Perceived service quality experienced by patients was measured by completion of the Service Performance (SERVPERF) questionnaire. A total of 111 patients completed the questionnaire across three mobile clinics supported by an NPO. RESULTS: The research results suggested that service quality at the mobile clinics was of a very high standard, with no meaningful differences between clinics, age groups or gender. However, the responses had very little variance and could have been subjected to response bias or extreme bias. The absence of a comparator organisation could also have had an influence on responses given by respondents. CONCLUSION: Healthcare service organisations should strive towards maintaining high standards and engage in continuous measurement and improvement of their service quality as part of their quality management process. By measuring the current level of service experienced by patients, insights have been identified where adjustments might have a positive effect on perceived value. Future research recommendations include suggestions to increase the sample population, taking the service setting into account and further studies to confirm the validity and reliability of solicited service quality questionnaires in a NPO setting.

White matter correlates of apathy in HIV-positive subjects: a diffusion tensor imaging study.

Apathy is commonly reported by patients infected with HIV. No previous work has assessed the relationship between white matter and apathy in HIV. The authors aimed to determine whether apathy in HIV reflects a direct effect of the virus on subcortical brain regions or a secondary neuropsychiatric symptom. Thirteen HIV+ participants with apathy, 13 HIV+ participants with no apathy, and 10 healthy comparison subjects were examined using diffusion tensor imaging in the region of the anterior cingulate and corpus callosum. Results of the study confirmed the hypothesis which anticipated changes associated with apathy in white matter tracts that relay through the medial prefrontal cortex.

Trauma and posttraumatic stress disorder in South African adolescents: a case-control study of cognitive deficits.

Despite the prominence of neuropsychological deficits in memory, attention and learning in adults exposed to trauma and those who develop posttraumatic stress disorder (PTSD), few studies have explored these cognitive deficits in adolescents. This study aimed to assess the impact of PTSD on various neurocognitive functions in South African adolescents. In a case-control study, 40 traumatized adolescents (20 with PTSD and 20 without) were evaluated for the presence of PTSD and were then referred for neuropsychological evaluation using a standardized neuropsychological test battery. The presence of PTSD itself, rather than trauma exposure, was associated with cognitive deficiencies in attention, visual memory and nonverbal concept formation. This study highlights the impact of PTSD itself-and particularly current symptoms-on the cognitive development of adolescents. As this effect appears to be stronger than the impact of trauma alone, more studies on the long-term consequences of PTSD on youth cognitive development are crucial.

Deficits in facial affect recognition in unaffected siblings of Xhosa schizophrenia patients: evidence for a neurocognitive endophenotype.

The present study in an African Xhosa sample examined whether familial vulnerability to schizophrenia is associated with deficits in facial affect recognition. Healthy comparison subjects, unaffected siblings of schizophrenia patients, and schizophrenia patients were tested with a task requiring rapid recognition of matched positive (happy), negative (angry), and neutral facial expressions. Siblings and patients demonstrated impaired recognition of negative relative to positive facial expressions whereas comparison subjects recognized negative and positive expressions at an equal level of accuracy. These results suggest that deficits in the processing negative affect from social cues are transmitted in families and may represent a heritable endophenotype of schizophrenia.

Summary of the 1st Schizophrenia International Research Society Conference oral sessions, Venice, Italy, June 21-25, 2008: the rapporteur reports.

The Schizophrenia International Research Society held its first scientific conference in Venice, Italy, June 21 to 25th, 2008. A wide range of controversial topics were presented in overlapping and plenary oral sessions. These included new genetic studies, controversies about early detection of schizophrenia and the prodrome, treatment issues, clinical characteristics, cognition, neuropathology and neurophysiology, other etiological considerations, substance abuse co-morbidity, and animal models for investigating disease etiology and for use as targets in drug studies. Young investigators in the field were awarded travel grants to participate in the congress and one of their roles was to summarize the oral sessions and subsequent discussions. The reports that follow are the culmination of this work produced by 30 young investigators who attended the congress. It is hoped that these summaries will be useful synopses of what actually occurred at the congress for those who did not attend each session or were unable to be present. The abstracts of all presentations, as submitted by the authors a few months prior, were previously published as supplement 2 to volume 102/1-3, June 2008.

Allocation of attention to the eye and mouth region of faces in schizophrenia patients.

INTRODUCTION: The present study examined whether reduced attentiveness to facial features and biased weighting of attention to the eye and mouth region might explain deficits in face processing in schizophrenia. METHODS: Healthy controls (n=21) and schizophrenia patients (n=28) from an African Xhosa population were asked to detect target stimuli (dots) superimposed on pictures of faces. General attentiveness to facial features was assessed by measuring overall reaction times to targets superimposed on feature areas of faces and attentiveness to the eye versus mouth region by comparing reaction times to targets on the upper and lower parts of faces. RESULTS: Patients exhibited generally slower target detection speed than comparison subjects but the strength of the attentional bias towards the eyes did not differ between groups (i.e., the reaction time gain for targets in the eye region). A regression analysis indicated, however, that generally slower target detection speed and an attentional bias away from the mouth predicted a deficit in the recognition of open-mouth angry facial expressions in schizophrenia patients. CONCLUSIONS: The results give partial support for hypothesis that reduced overall attentiveness to faces and a failure to utilise visual information in salient facial features may underlie affect processing deficits in schizophrenia.

Predictors of long-term outcome in schizophrenia.

PURPOSE OF REVIEW: Further clarification of factors predicting the outcome in schizophrenia is needed. The present review examines recent research into some of these predictors, focusing on insight, duration of untreated psychosis, cognition and early treatment response. It also addresses the need for standard outcome measures. RECENT FINDINGS: There is good evidence that poor insight predicts poor outcome, although perhaps not simply as a consequence of poor compliance. Further support is provided for a link between duration of untreated psychosis and long-term outcome. The relationship between cognition and outcome is complex, with specific cognitive deficits apparently predicting particular outcome domains. Early treatment response is closely related to long-term outcome. Outcome studies may be flawed by sample selection bias, and a lack of standardized outcome measures. SUMMARY: Several predictors are potentially modifiable, indicating that they should be targets for therapeutic intervention. More carefully designed studies are needed. Recently proposed criteria for remission are helpful, and should facilitate cross-sample comparisons.

Genetics and personality traits in patients with social anxiety disorder: a case-control study in South Africa.

BACKGROUND: Social anxiety disorder (SAD) is among the most common of all psychiatric disorders with lifetime prevalence estimates ranging from 7% to 13%. Although there is evidence that SAD has a strong familial basis, there are few studies of potential candidate genes. In addition to a genetic association, there is also the possibility that temperamental risk factors for the disorder may be genetically transmitted. Against this background, our aims were threefold: i.) to compare patients and controls with respect to personality traits, ii.) to genotype a subgroup of these participants to investigate the role of genes encoding components of serotonergic (5-HT) and dopaminergic (DA) pathways in patients with SAD and iii.) to compare differences in temperament dimensions between carriers of different (dominant vs. recessive) alleles for selected polymorphisms in SAD patients. METHODS: Sixty-three patients (n=63; 35 male, 28 female) with a DSM-IV diagnosis of generalized SAD and SPIN-scores >18, and age-matched control participants (n=150; 31 male, 119 female) were included in the study. The Temperament and Character Inventory (TCI) was used to measure behaviours associated with specific personality dimensions (i.e. temperament/character). DNA was extracted and genotyped to investigate the role of select candidate genes encoding components in serotonergic and dopaminergic pathways in mediating the development of SAD. To achieve this, the frequency of variants in 5-HT and DA genes was compared between a Caucasian subset of SAD patients (n=41) and a convenience sample of Caucasian controls (n=88), using case-control association analyses. We also investigated the frequency of variants in 5-HT and DA-related genes across temperament characteristics in SAD patients, using analyses of variance (ANOVA). RESULTS: Patients scored significantly higher on harm avoidance (p<0.001) but lower on novelty seeking (p=0.04) and self-directedness (p=0.004) compared to controls. In the Caucasian subset, there was a difference between patients and controls in distribution of the 5-HT(2A)T102C polymorphism, with significantly more patients harboring T-containing genotypes (T-containing genotypes: [T/T+T/C] vs. [C/C]) (chi2=7.55; p=0.012). Temperament dimensions did not, however, differ significantly between carriers of different (dominant vs. recessive) alleles for the 5-HT(2A)T102C polymorphism in SAD patients. CONCLUSIONS: The results suggest a possible role for the 5-HT(2A)T102C polymorphism in the development of SAD. To date genetic findings in SAD have been inconsistent; nevertheless, serotonergic variants, and their associations with temperaments (e.g. reward dependence) deserve further exploration, in the hope that endophenotypes relevant to SAD can ultimately be delineated.

The South African Society of Psychiatrists/Psychiatry Management Group management guidelines for adult attention-deficit/hyperactivity disorder.

DISCLAIMER: These guidelines do not aim to provide a comprehensive review of all the pertinent literature comprising the evidence base and, as such, should be utilised in conjunction with other guidelines as well as the responsibility of practitioners to maintain a high level of personal knowledge and expertise. Despite the known efficacy of treatment and the substantial costs of untreated attention-deficit/hyperactivity disorder (ADHD), access to healthcare and treatment is not a given for many patients in South Africa (SA). In SA, there is poor identification and treatment of common mental disorders at primary healthcare level and limited access to specialist resources with a service delivery and treatment gap of up to 75%. Medication options are also often limited in emerging markets and in SA psychiatrists, and patients do not have access to the medication armamentarium available in established markets. Furthermore, the majority of South Africans currently utilise the public healthcare sector and may not have access to treatment options referred to in these guidelines. These guidelines should therefore not be seen as a policy document. THE PROCESS: The South African Society of Psychiatrists' Special Interest Group (SIG) for adult ADHD was launched on 25 September 2015, with doctors Rykie Liebenberg and Renata Schoeman as convenor and co-convenor, respectively. The overall objective of the ADHD SIG is to improve the basket of care available to patients with ADHD. This is only possible through a combined and concerted effort of individuals with a special interest in and passion for ADHD to improve knowledge about and funding for the care of individuals with the disorder. One of the specific aims of the ADHD SIG was to develop South African guidelines for the diagnosis and treatment of adult ADHD specifically and update guidelines for the treatment of child, adolescent and adult ADHD. Dr Schoeman has recently completed her MBA at the University of Stellenbosch Business School with a thesis entitled 'A funding model proposal for private health insurance for adult attention-deficit/hyperactivity disorder in the South African context'. This is first South African study exploring the situation with regard to the prevalence and treatment of adult ADHD. Dr Schoeman was tasked by the SIG with the drafting of guidelines. Dr Liebenberg provided valuable input. The guidelines were then circulated to the SIG members, as well as the Chair of the Public Sector SIG, for written feedback and evidence-based suggestions which were then incorporated into the guidelines. The final guidelines were circulated for written approval by the SIG members, followed by formal approval at a SIG meeting held on 14 August 2016, after which it was submitted to the South African Society of Psychiatrists (SASOP) and Psychiatry Management Group (PsychMG) boards for recommendation and ratification.

Adult attention-deficit hyperactivity disorder: A database analysis of South African private health insurance.

BACKGROUND: Adult attention-deficit hyperactivity disorder (ADHD) is a chronic, costly and debilitating disorder. In South Africa (SA), access to funding for care and treatment of ADHD is limited, and research is lacking. AIM: This study aimed to establish the current situation with regard to the psychiatric management of and funding for treatment of adult ADHD in the private sector in SA. METHODS: A diagnostically refined retrospective claims database analysis was conducted. We examined the prevalence, costs and funding profile of claims over a 2-year period for adult beneficiaries with possible ADHD of a large medical administrator in SA. RESULTS: The prevalence of adult ADHD was lower than published international rates. The presence of adult ADHD increased the prevalence of comorbidity and doubled the health care costs of beneficiaries. Contrary to public belief, comorbidities (including their medicine costs) rather than psychiatric services or medicines were the main cost drivers. CONCLUSION: The current private health insurance funding model for ADHD limits access to funding. This affects early diagnosis and optimal treatment, thereby escalating long-term costs. Improved outcomes are possible if patients suffering from ADHD receive timely and accurate diagnosis, and receive chronic and comprehensive care. Balanced regulation is proposed to minimise the risk to both medical schemes and patients. A collaborative approach between stakeholders is needed to develop an alternative cost-effective funding model to improve access to treatment and quality of life for adults with ADHD in SA.

Adult attention-deficit hyperactivity disorder: Why should we pay attention?

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, with a chronic, costly and debilitating course if untreated. Limited access to diagnosis and treatment for adults with ADHD contributes to the cost of the disorder and the burden of disease. AIM: This study aims to identify the barriers to care for adults with ADHD. METHODS: A qualitative analysis of semi-structured interviews with 10 key opinion leaders in the field of adult ADHD in SA was conducted to obtain narratives regarding frustrations experienced when treating adults with ADHD and needs of patients regarding management of ADHD. Qualitative content analysis was completed using Atlas.ti (version 7). RESULTS: Four key themes which emerged from the interviews were 'lack of recognition of the disorder', 'lack of access to diagnosis', 'lack of access to treatment' and 'a life of perpetual failure'. Core to these themes are the lack of knowledge amongst health care professionals, funders, and society at large. CONCLUSION: Our findings expand on previous research regarding the need to increase the knowledge base on adult ADHD. A collaborative stakeholder approach is needed to provide research and training for improved diagnosis and treatment for adults with ADHD in the South African context.