Rationale: Antipsychotic polypharmacy (APP) appears to be a common practice worldwide despite treatment guidelines advising against the practice for most patients in view of lack of evidence and possible risk of harm. Our study aimed to address deficiencies in local and international research by examining the current prevalence of APP in a South African context and investigating a broad range of patient, illness and treatment characteristics that may be associated with the practice. In doing so, we aimed to provide an indication of possible areas to be addressed in order to improve local mental health care practice. Methods: We conducted a cross-sectional study of discharge records using Valkenberg Hospital's electronic patient database. We collected data on patient, illness and treatment characteristics for patients discharged on one or more antipsychotic agent from January to June 2014. Hierarchical multivariable logistic regression analysis was conducted to assess the relationship between APP and demographic and clinical variables and prescription patterns were analysed. Results: Discharge records of 565 patients were examined. The prevalence of APP in our study population was 29.03% (95% CI= 25.31%-32.96%). Analysis of demographic and clinical characteristics revealed that age>29, male sex, diagnosis of schizophrenia compared to bipolar and substance-induced disorders, co-morbid intellectual disability, co-morbid substance use, greater number of hospital admissions and high-dose prescribing were significantly associated with APP. While highest rates of APP in patients with schizophrenia and schizoaffective disorders occurred, APP was also observed in a number of patients with bipolar and substance-induced disorders. Prescription patterns demonstrated the prominent use of first-generation antipsychotics and long acting injectables in APP combinations. Patients receiving APP were significantly more likely to have anticholinergic agents and sodium valproate co-prescribed in their treatment regimen. Discussion: The prevalence of APP found in our study is fairly high in comparison with international rates. Antipsychotic prescription patterns reflect a complex interplay among patient, illness and treatment characteristics of our population. Our findings indicate that patients receiving APP may be those with greater illness severity, complexity, chronicity and treatment resistance, with complicating factors including co-morbid substance use involved. While APP is most common in patients with schizophrenia, antipsychotics may also be used in combination to manage mood and psychotic symptoms in patients with schizoaffective, bipolar and substance-induced disorders. The frequent use of long acting injectables in combinations may suggest concern over compliance in our population. The positive associations of APP with high-dose prescribing and co-prescription of anticholinergic medication contributes to concern over the safety of APP. Conclusion Our study suggests concern over current local practice in that combination antipsychotic agents were prescribed for a number of patients with a range of psychiatric diagnoses without sufficient evidence for efficacy of this practice and at possible cost of increased adverse effects. Additional research is needed examining the practice of APP across diagnoses, focusing on the multiple aspects affecting local practice and various contributing factors that could be targeted for intervention. This would be a positive step towards improving the quality of our service and providing optimal patient management in a resource-limited setting.

People with severe mental illnesses (SMI) face barriers that contribute to poor physical health outcomes. However, these barriers have not been systematically investigated in Ethiopia. Aim: The aim of this study was to examine barriers to care for physical co-morbidities among SMI patients. It achieves this by: i) estimating the prevalence of physical co-morbidities in SMI in-patients in a psychiatric referral hospital over a two month period; ii) describing potential associations of various socio-demographic and clinical factors with the occurrence of physical co- morbidities in admitted patients with SMI; and iii) exploring barriers in recognition and management of these physical comorbidities in the immediate curative medical care environment of admitted SMI patients in the psychiatric referral hospital. Methods: The study used a mixed methods design that included: i) a quantitative cross-sectional facilitybased record review; and ii) a qualitative exploration of potential or experienced barriers to physical health care provision by patients, caregivers, mental and general health professionals. The quantitative component estimated prevalence and examined risk factors associated with the presence of co-morbid physical health conditions among people with SMI. For this, clinical records of all admitted patients with diagnosis of SMI were reviewed over a two-months period. To check the reliability of the clinical records, a pilot test was done for two weeks before actual data collection. By using systematic random sampling of the records reviewed, 30 patients were selected for physician assessment in order to check the accuracy of the information included in records. The qualitative section was conducted using semistructured interviews with SMI patients and their caregivers and focus group discussions with service providers.

Includes bibliographical references / Introduction: The worldwide commitment to increasing services and access to antiretroviral therapy have resulted in a decline in HIV related mortality. As a result, the focus of HIV care is shifting towards improving the psychological health and quality of life. HIV infected adolescents are a group with unique psychosocial challenges. Given that HIV self disclosure has been recognized as an important challenge affecting their physical as well psychological health it warrants further exploration. Methods: A qualitative study was conducted during September to November 2014 among adolescents (12-19years) attending the HIV care clinic at a tertiary hospital in Harare. Twenty adolescents who were vertically infected with HIV were recruited using purposive sampling techniques to achieve maximum variability in age and sex. In depth interviews were conducted to determine the views of adolescents regarding when, whom and how to self disclose. All the interviews were transcribed verbatim. Data was analyzed using the framework approach. Results: Adolescents identified stigma and discrimination from peers as well as lack of HIV knowledge as important barriers to status disclosure and suggested societal resources like support groups and media to assist them in the disclosure process. Conclusion: HIV status disclosure to others is a challenging task for adolescents and it can be affected by personal as well as social factors. In order to deal with disclosure dilemmas, we have to work with adolescents keeping all these factors in mind to assist them in decision making, there by facilitating healthy supportive relationships and contributing to the wellbeing of HIV-positive adolescents.

Background: Mental, neurological and substance use (MNS) disorders significantly contribute to the burden of diseases worldwide. Schizophrenia is one of the severe forms of MNS disorders. Antipsychotic medications play a significant role in the treatment and management of schizophrenia. However, non-adherence to antipsychotic medication is a recognized problem. At the present time, a majority of the research investigating non-adherence to medication in this population has been conducted in high income countries, with only a few studies available from low and middle income countries such as Malawi. This study aimed at determining the prevalence and predictors of antipsychotic non-adherence among clients with psychosis in Mzimba district, Malawi. The factors were categorized into patient-related, medication related and environmental related. Methodology: This was a hospital based quantitative study conducted in Mzimba, Malawi. 150 patients attending outpatient treatment facilities from three mental health clinics were recruited in the study. All recruited participants had a diagnosis of psychosis. The recruitment process targeted every potential participant during a clinic day. Potential participants were approached by the research assistant after their appointment with the healthcare provider to participate in the study. The following measures were included in the interview administered survey: 1) the Morisky Medication Adherence Scale-8; the Birchwood Insight Scale; the Drug Attitude Inventory-10; the Glasgow Antipsychotic Side-effects Scale; a Social Support questionnaire, and the Alcohol Use Disorder Identification Test. A logistic regression model was developed to investigate the associations between socio demographic and illness related factors and non-adherence to medication. Ethical approval to conduct the study was obtained from the Faculty of Health Sciences Research Ethics Committee at the University of Cape Town before the beginning of the study. Ethical approval was also obtained from National Health Sciences Research Ethics Committee in Malawi. Results: More than half of the participants were male (n=84). The average age of all participants was 34 years of age (sd=9.40). 43.9% of the respondents were identified as non-adherent (n=66). In the unadjusted logistic regression model, the amount of insight a client had about their mental illness, the side effects of antipsychotic medication, and the form or type of medication, were all found to be significantly associated with antipsychotic medication non-adherence. For example, participants with poor insight were less likely to adhere to antipsychotic medication (OR=0.48, 95% CI 0.24-0.95). When these three variables were adjusted for age and gender, they all predicted non-adherence to antipsychotic medication; insight (OR=0.42, 95% CI 0.20-0.90); side effects (OR=1.10. 95% CI 1.03-1.17); and medication type or form (OR=0.30, 95% CI 0.15-0.91). Conclusion: The study was the first study conducted in Mzimba, Malawi to investigate nonadherence rates among patients with psychosis. Similar to other studies conducted globally, the non-adherence rates to antipsychotic medication reported in the present study was high. The risk factors predicting non-adherence have the potential to assist in the development and delivery of interventions to address among this population.

Background: Hospital-based research provides important insight into the burden of suicide behaviour and methods used in deliberate self-harm (DSH). The information on methods used in DSH may be useful to plan suicide-related intervention and prevention programmes. We aimed to investigate the socio-demographic and clinical factors associated with the methods used in DSH at a tertiary hospital in Cape Town, South Africa. Methods: Socio-demographic, clinical and treatment data were collected from 238 consecutive DSH patients who presented for emergency department treatment at the hospital. Univariate analyses and a logistic regression model were used to explore the associations between these variables and violent and non-violent method of DSH. Results: Self-poisoning was the most common method of self-harm (80.3%, n=191). Prescription medication was the most common form of self-poison (57.6%, n=137) while a large number of patients used the non-prescription medication paracetamol (40.9%, n=54). In the bivariate regression analysis, male gender, stating that the reason for DSH was to escape a situation and history of substance use were associated with violent method of DSH. Conclusion: This study contributes to emerging literature on methods used in DSH in South Africa. There is an urgent need to improve monitoring of prescription medication commonly used in DSH. More research on the source of prescription medication and its relationship to DSH is needed. Limiting the quantity and reviewing the packaging of paracetamol available in supermarkets may be effective strategies of means restriction that could be adopted in South Africa. This study underscores the need for increased collaboration between the Department of Social Development and the Department of Health in providing substance use interventions to high-risk population groups.

Introduction: Globally, there is a substantial gap between the number of individuals in need of mental health care and those who receive treatment. It is reported that 86.3% people with anxiety, mood, or substance disorders in low and middle-income countries (LMICs) received no treatment in the 12 months preceding the survey. The Programme for improving mental health care (PRIME) aims to generate new evidence on implementation and scale up of mental health programs in primary health care settings to minimize this enormous treatment gap on mental health care, especially in the LMICs. The aim of this study was to report on the change in treatment coverage, barriers and other factors associated with help-seeking behaviour of adults with depression and alcohol use disorder (AUD) in Chitwan district, Nepal before and three years after implementation of the PRIME district mental health care plan (MHCP). Methods: The study was conducted in 10 Village Development Committees of Chitwan district in southern Nepal. The repeat population-based cross-sectional community survey applied a random sampling technique to select 1983 and 1499 adults in the baseline and the follow-up survey, respectively. The Patient Health Questionnaire (PHQ-9) and Alcohol Use Disorder Identification Test (AUDIT) were used to screen people with depression and AUD. Barriers for seeking mental health care were assessed by using a standardized tool, the Barriers to Care Evaluation Scale (BACE). Results: Overall, 11.7% (n=13) people with depression in the follow-up survey reported that they had received mental health treatment from any provider in the 12 months preceding the survey; this proportion was not significantly different from the proportion reported at the baseline (n=18; 8.1%;χ2=1.02, p=0.424). Similarly, the proportion of the participants receiving treatment for AUD from any provider at the follow-up survey (n=9; 10.3%) was also not significantly different than that found at baseline (n=5; 5.1%; χ2=1.68, p=0.235). Significant reductions were found in the overall BACE score (p=0.004) and the specific BACE domains scores pertaining to financial barriers (p<0.001); stigma (p=0.004) and lack of support (p<0.001) in the follow-up survey among participants with depression. In the AUD group, there was also a significant reduction between the baseline and follow-up survey in the overall BACE score (p=0.011) and the specific BACE domains scores pertaining to financial barriers (p<0.001) and lack of support (p<0.001). There was no association between socio-demographic characteristics and help seeking behaviour of the participants at the follow-up survey. Participants who reported greater cultural practices and beliefs were less likely (OR 0.65, 95% CI 0.46 – 0.92) to receive mental health care compared to those who reported less cultural beliefs and practices (p=0.015). Conclusion: The study found non-significant improvements in treatment coverage and significant reductions in barriers to mental health care following implementation of the PRIME district mental health care plan. The non-significant improvements in the treatment coverage could be explained by a number of potential factors, including lack of targeted community level interventions for specific barriers in the PRIME MHCP, the distal nature of the outcome in relation to the intervention, and the small number of screen positive participants. The key areas for improvement in the implementation of the district mental health care plan include establishment of confidential place for consultation in each health facility and targeted community awareness and sensitization programmes to improve help-seeking attitudes, intention and behaviour.

Includes bibliographical references / Background: Mental illness increases risk for substance use and the presence of substance use in people living with mental illness makes diagnosis and treatment of both disorders more complicated. For treatment of either disorder to be successful, both must be identified and treated individually. The substance use burden and service needs of psychiatric inpatients in Malawi are unknown. Objectives: The study aimed to determine prevalence of risky substance use and service needs among psychiatric inpatients. Methods: A cross-sectional study was conducted examining subjective substance use using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) version 3.1 in 323 new inpatients aged ≥18 years. The prevalence of risky and lifetime substance use was calculated in addition to bivariate analysis and linear regression. The kappa statistic was calculated to compare diagnosis of substance use during routine clinical assessment on admission with screening using the ASSIST. Results: ASSIST-linked lifetime prevalence for each substance were alcohol 54.8 %, (95 % CI: 49.3-60.1 %), followed by tobacco 43.7 %, (95 % CI: 38.4-49.1 %), and cannabis 39.0 %, (95 % CI: 33.9-44.4 %). No-one reported any use of amphetamine-type stimulants, hallucinogens, or opioids. The prevalence of moderate risk use, requiring brief intervention were tobacco 19.2 %, (95 % CI: 15.3-23.9 %), cannabis 9.9 %, (95 % CI: 7.1-13.7 %), alcohol 7.1 %, (95 % CI: 4.8-10.5 %), sedatives 1.2 %, (95 % CI: 0.4-3.3 %) and cocaine 0.6 %, (95 % CI: 0-2.4 %). High risk use requiring specialist care was identified for alcohol 18.6 %, (95 % CI: 14.7-23.2 %), cannabis 16.7 %, (95 % CI: 13.0-21.2 %), tobacco 10.8 %, (95 % CI: 7.9 -14.7 %) and inhalants 0.3 %, (95 % CI: -0.1-2.0 %). Interrater agreement for diagnosis of substance use disorder between routine clinical assessment compared to ASSIST questionnaire was Kappa = 0.530 (p < 0.001) which is moderate but statistically significant. The multivariate linear regression to determine the risk factors associated with tobacco, alcohol and cannabis. Males are more likely to use all these substances and have a higher ASSIST score than female patients (p < 0.001). The model indicated that risky alcohol use is significantly higher in Christians than other religions or no religious affiliation (p =.044) while risky cannabis use is significantly higher in rural residents compared to urban residents (p =.042). Conclusions: Results suggest that tobacco, alcohol and cannabis are commonly used among psychiatric inpatients in this population. Most patients use substances at risky levels requiring both brief intervention and specialist care. Although substance use is common, the detection of substance use disorders in admission assessments is moderate and could be improved. The ASSIST questionnaire is useful in screening for substance use in psychiatric inpatient populations and is likely to improve detection and management.

Background Individuals with methamphetamine use disorder (MUD) frequently present with psychiatric comorbidities with impulsive features. Little research has been conducted on comorbidity with impulsive features in MUD. Therefore, this cross-sectional study aimed to delineate comorbid disorders with impulsivity in adult patients with a primary diagnosis of MUD. Methods Participants with lifetime MUD were included. Well established measures screened for comorbid psychiatric disorders with impulsive features. Illness severity was measured by the Yale Brown Obsessive-Compulsive Scale – adapted for drug use. The UPPS-P Impulsive Behavior Scale was used to assess impulsivity levels. A cluster analysis (CA) of lifetime comorbid disorders with impulsive features was performed. Demographic and clinical correlates of each identified cluster were identified. Results Sixty five (n = 65) adults with a primary diagnosis of MUD took part in the study. They were predominantly female (44 females; 21 males), with ages ranging between 18 and 44 years (mean = 30 years; SD = 6.53). The CA rendered 4 groups. Cases (n=12) in the “alcohol cluster” presented with AUD as their only impulsive disorder other than MUD. Cases (n=19) in the “healthy cluster” had no comorbidity. Cases (n=15) in the “antisocial cluster” all had comorbid antisocial personality disorder as well as polysubstance use disorders. Cases (n=19) in the “borderline cluster” had borderline personality disorder and polysubstance use disorders. Illness severity (Y-BOCS-du: p=0.03) and impulsivity levels (UPPS-P: p=0.01) differed significantly between the clusters. The “alcohol cluster” had the highest illness severity and the “antisocial cluster reported the highest levels of impulsivity. Conclusion The findings of this contribute to the paucity data on impulsivity in MUD and may have implications for treatment. Understanding how these conditions cluster in MUD, and remaining cognizant of the demographic and clinical correlates of each cluster in MUD, could potentially enable clinicians to identify patients who are at higher risk for engaging in risky behaviors rendering them more vulnerable to treatment non-adherence or relapse

BACKGROUND: Rape is associated with a range of negative health and mental health consequences. Despite the establishment of post-rape care centres in South Africa, challenges of retaining rape survivors in care continue to be faced across the country. Very little evidence on the characteristics associated with rape survivors who return for follow-up and those lost to care at post-rape care centres has been documented in South Africa. This study sought to identify the demographic factors, rape incident characteristics and social support factors that are associated with attendance of follow-up appointments at a post-rape care centre in Cape Town, South Africa. METHOD: A retrospective case file analysis was conducted on 254 files of rape survivors who presented and were given follow-up appointments at a post-rape care centre in Cape Town, South Africa from September 2010 to August 2011. Data were extracted using a data collection form which was developed using counselling and medical records in the survivors' files and analysed using SPSS version 21. Descriptive statistics were generated on the survivors' demographic information, rape incident information, medical information, and support systems. Chi-squared test and Fisher's exact test were used to test for differences between survivors who completed all their follow-up appointments, those who attended but did not complete follow-up appointments and those lost to care. RESULTS: Of the total sample 64.6% (164) attended their one week follow-up appointment. From those who attended their one week follow-up appointment, 47% (77) came for their six weeks appointment and approximately half of those who attended their six weeks appointments (51%, n=39) attended their three month appointments. Survivors of rape were significantly more likely to attend follow-up appointments if they were female, incurred injuries during the time of the rape, or received family support post-rape. CONCLUSIONS: Female gender, injury during rape and family support were associated with attendance of follow up care in this sample of rape survivors. Recommendations for future research and for enhancing attendance rates at rape treatment centres are considered.

Includes bibliographical references. / In the last decade, multiple diffusion tensor imaging (DTI) studies have revealed changes in the microstructure of white matter in bipolar disorder. The results are poorly replicated and inconsistent, however, with some authors suggesting a predominance of alterations in fronto-limbic white matter. Preliminary reading of the literature suggests that white matter changes as revealed by DTI may be more widespread throughout the brain. Two extant reviews have each been limited by including all affective disorders or by a methodology which ignores tracts and discards potentially meaningful data. This background in the review includes a detailed exposition of the main DTI techniques and shortcomings. The review aims to determine whether certain white matter tracts are affected preferentially in the brain, as opposed to more diffuse white matter involvement. It also aims to determine if there is an anterior-posterior gradient of abnormalities. This review systematically collates data relating to tract involvement as demonstrated by DTI, as well as data regarding anterior-posterior distribution of abnormalities. Medline and EMBASE databases are searched systematically to select original papers comparing a bipolar group with healthy controls, using DTI, in adults, and reporting at least fractional anisotropy (FA). Subject, scan and analysis characteristics are extracted. Details of affected tracts are collated, as is the y-axis (anterior/posterior) of the most affected ('peak') voxels.