Includes abstract. / Includes bibliographical references. / Electroconvulsive therapy (ECT) involves the administration of an electrical current to the brain in order to produce a tonic-clonic seizure which is deemed therapeutic. It is an effective and safe procedure for the treatment of severe mental illnesses such as major depression, mania and schizophrenia. Currently little is known about the characteristics of ECT practice in South Africa. This study aims to determine current electroconvulsive therapy (ECT) practice and to compare it with reported ECT practice internationally. This is a retrospective, descriptive study, to determine the characteristics of ECT practice in South Africa; data was collected using a self-report questionnaire. The study population consisted of doctors and nurses who practiced ECT in any 12 month period between 2011 and 2012. Both private and state facilities were included in the study. Initially contact was made with hospital mental health facilities to ascertain whether an ECT machine was present on site. Once formal approval was obtained from the appropriate designated bodies, questionnaires were sent to clinical staff involved in ECT at active sites. The 36-item questionnaire covered relevant questions on: utilization rates, equipment, staffing, practice and monitoring parameters, and indications for use. Forty two institutions had an ECT machine on site, of which thirteen institutions reported non-use. Questionnaires were sent to the 29 active ECT sites. Facilities responding to the questionnaire amounted to 83% (n=24), but of these, 21 units responded to the ECT utilization questions. ECT is performed as a modified procedure in six provinces by psychiatrists, registrars, medical officers and general practitioners. In-and outpatient ECT is offered in 79% (n=19) of hospitals. The number of persons treated with ECT/10 000 population per year (ppy) is 0.22 while the number of ECT procedures/10 000 ppy is 1.19. More patients in the private sector receive ECT as a treatment modality than in the public sector (U = 22, p = 0.045). ECT is performed in a minor theatre/operating room in 79% of units, while the rest is performed in a treatment room. All but one unit had a separate recovery room. Informed consent or assent was used in all institutions. Pre-ECT work-up most commonly involved a physical examination (95.5%, n = 21) and basic blood work investigations (87%, n=20). Bilateral, unilateral and bifrontal electrode placements are used, while various dosage- determination and monitoring methods are employed. The vast majority of patients (89.22%, n=869) receiving ECT are between the ages of 18 and 59. The most common indication for ECT is depression (84.77%, n=796). The utilization rate in South Africa is similar to that of countries like Bulgaria, Poland and India, but less than that of some high-income countries. Even though ECT practices in South Africa generally follow international guidelines, standardisation of practice is still recommended.

Over the past decade, calls to address the increasing burden of mental, neurological and substance-use (MNS) disorders and to include mental health care as an essential component of universal health coverage (UHC) have attracted mounting interest from governments. With the inclusion of mental health in the 2015 Sustainable Development Goals (SDGs) there is now a global policy commitment to invest in mental health as a health, humanitarian and development priority. Low and middle-income countries (LMICs) such as South Africa, contemplating mental health system scale-up embedded into wider SDG- and UHC-related health-sector transformations, must address a number of key mental health financing policy considerations for attaining population-based improvements in mental health. Despite ongoing transformations in the South African health sector, there has been an implicit neglect of the integration of mental health services into general health service development. This has been driven in part by a lack of locally-derived evidence in several areas, including: the economic basis for investing in mental health, the current resourcing of the mental health system, opportunities for improved efficiency and equity, and how reforms may be structured and paid for in light of the country's ongoing efforts to implement a National Health Insurance (NHI) scheme. This thesis therefore attempts to address these gaps and aims to generate new knowledge on the economic costs, impacts and financing strategies for mental health in South Africa. This aim is achieved by fulfilling the following research objectives: 1. To examine the impact of social, national and community-based health insurance on health care utilization for MNS disorders in low- and middle-income countries. 2. To examine the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa. 3. To quantify public health system expenditure on mental health services, by service level and province, and to document and evaluate the resources and constraints of the mental health system in South Africa. 4. To examine the household economic costs and levels of financial risk protection associated with depression symptoms in South Africa. In the first part, the systematic review reports on the impact of social, national and community based health insurance on health care utilization for MNS disorders in LMICs, published until October 2018. As a secondary goal, the systematic review identifies whether there are any specific lessons that can be learnt from existing approaches to integrate mental health care into financing reforms towards universal health coverage. In the second part, a qualitative examination of the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa was conducted through a situational analysis that was complimented with a synthesis of key stakeholder consultations. The findings provide recommendations for how scaled-up mental health services can best be paid for in a way that is feasible, fair and appropriate within the fiscal constraints and structures of the country. In the third part, the thesis then empirically quantified public health system expenditure on mental health services, by service-level and province for the 2016/17 financial year, and documented and evaluated the resources and constraints of existing mental health investments in South Africa through a national survey; achieving one of the highest sample sizes of any costing study conducted for mental health in LMICs. In the fourth and final part, a household survey study was conducted to determine the level of financial protection for persons living with depression symptoms in the Dr. Kenneth Kaunda health district of South Africa, which is serving as a pilot site for the NHI. The household economic factors associated with increased depression symptom severity on a continuum are reported; and demonstrate that financial risk protection efforts are needed across this continuum. The thesis concludes by synthesizing findings towards an improved understanding of the key lessons that can be learned from other LMICs toward sustainable financing for mental health; the economic burden of inadequate mental health care to households in South Africa; and the efficiency of existing mental health investments and inequities in resourcing and access. Through this lens, and borrowing from the experiences of other LMICs, recommendations for key priorities for health service and financing reforms towards the scaled-up delivery of mental health services in South Africa are generated. The thesis is presented as papers embedded in a narrative that includes an introduction and synthesis discussion. Four papers (3 published and 1 under review) form the basis of the results chapters.

Background: More than 13% of the global burden of disease is estimated to be due to neuropsychiatric disorders, with over 70% of this burden in low- and middle-income countries. Characterised by severe shortages of human and material resources, formal mental health services alone are inadequate to meet the burden of mental disorders in low- and middle-income countries. New community models and innovative ways of increasing community participation and systematic delegation of specific tasks to other community level professionals have been recommended. Available evidence documents historic clergy involvement in health and wellbeing issues, but they have rarely been viewed as a partner in community mental health care. Aim: This study examines the clergy's conception, recognition of and responses to people with mental illnesses. The purpose of the study is to inform the potential roles and contributions of the clergy to community mental health either as the only contact or as a step in to formal mental health care. Method: Twenty eight in-depth interviews were conducted with clergy from ten church denominations in Harare, Zimbabwe. A framework analysis approach was used for thematic analysis. Nvivo 10 qualitative data software was used to organise the data. Results: Mental illness was conceived as a multifactor phenomenon attributed to both natural (biological and psychosocial) and supernatural (malevolent and benevolent spiritual) causes. Spiritual factors were a dominant theme in both the clergy's views on the causes of, and in their management of mental illness. The clergy were regularly consulted on a variety of emotional and psychological problems. Assistance was readily provided for these problems by all denominations, despite professed capacity gaps in the recognition and management of mental illness, and lack of appropriate training in basic mental health issues. Basic mental health training was recommended by the clergy to enhance clergy capacity for mental health awareness raising, recognition of mental disorders, brief problem focused counseling, and for improving collaborative management for initial and continued informal and formal health care and support. Implications of clergy conceptions, current responses and the perceived role of the church in community mental health are discussed.

Background: Family planning is a crucial issue for all women of reproductive age, but in women with severe mental illness (SMI) there may be particular challenges and concerns. As primary care-based mental health care is expanded in low- and middle-income countries (LMICs), there is an opportunity to improve family planning services for women with SMI. However, research exploring unmet family planning needs of women with SMI in such settings is scarce. Aim: To explore the family planning experiences, unmet needs and preferences of women with SMI who reside in a predominantly rural area of Ethiopia Methods: A qualitative study design was used. Women with SMI who were participating in the ongoing population-based cohort study in Butajira were selected purposively on the basis of responses to a quantitative survey of current family planning utilization. In-depth interviews were conducted with 16 women with SMI who were of reproductive age until theoretical saturation was achieved. Audio files were transcribed in Amharic, translated into English and analysed using a Framework Approach using Open Code qualitative data analysis software. Results: The findings were grouped into four main themes. The first theme focused on the broader context of intimate relationships and sexual life of women with SMI. Sexual violence, assault and exploitation were reported by several respondents, underlining the vulnerability of women with SMI. Lack of control over sexual contact was associated with unwanted pregnancies. The second theme (childbearing and SMI) was around attitudes towards childbearing in women with SMI. Respondents described negative views from community members and some health professionals about the capacity of a woman with SMI to give birth and bring up a child. In most cases, it was assumed that a woman with SMI should not have a child at all. In the third theme (family planning for women with SMI), respondents spoke of their low access to information about family planning and systematic exclusion from existing services. In the fourth theme (preferred family planning services), the respondents had concerns about the ability of primary care workers to understand their specific family planning needs, but also valued proximity of the service and privacy. The importance of addressing health worker and community attitudes was emphasized. Conclusion: This study has provided in-depth perspectives from women with SMI about the broader context of their family planning experience, needs, barriers and how integrated primary care services could better meet their needs. Empowerment of women with SMI to access information and services needs to be an important focus of future efforts to improve the reproductive experiences of this vulnerable group.

Introduction: Depression in mothers can have debilitating consequences on the women themselves, their infants and their family. Thus, it is imperative to detect and treat perinatal depression early. Due to lack of awareness and stigma, help seeking, detection and treatment for perinatal depression in Nepal remains low. To counter barriers on lack of awareness, stigma and non-detection of mental health problems including depression, alcohol use disorder, psychosis and epilepsy, the PRogramme for Improving Mental Health carE (PRIME) developed and implemented a community sensitization programme and a Community Informant Detection Tool (CIDT). Neither of these programmes has focused on perinatal depression. This study aims to adapt the depression CIDT and the community sensitization programme to include perinatal depression. Methods: The CIDT and community sensitization programme were adapted using the following four steps. Firstly, a qualitative study was conducted with perinatal women with depressive symptoms visiting Meghauli and Dibyanagar health facilities or "gau-ghar clinic" (n=26) and service providers (n=34) to develop a culturally relevant content. Secondly, a draft CIDT and community sensitization manual were prepared based on the qualitative findings. Thirdly, a one-day workshop and several consultation meetings were held with mental health professionals (n=16) to ensure that the content was understandable and applicable to the context. Lastly, based on the workshop findings and consultation meetings, the manual and tools were modified and adapted for perinatal depression. Results: Due to poor awareness and stigma, none of our respondents had ever sought help for depression from the antenatal or postnatal service providers. Using local expressions for common depressive symptoms such as loss of interest, rumination, pessimistic views, extreme worries, restlessness, two separate CIDTs were developed each for antenatal and postnatal depression. Lack of support from the husband and family followed by poverty were the major contributing factors for depression. In addition, cultural factors such as the low position of women in patriarchal society and preference for son exacerbated problems in some women. The community sensitization manual was adapted to include local myths and facts about perinatal depression; causes with examples related to local beliefs; symptoms explained in local idioms; and role of the family. The heads of the families and key community members were recommended as key targets for the community sensitization programmes. Conclusion: It is important for any intervention to be responsive to local understanding and needs. The adapted CIDT and community sensitization manual has integrated the local issues and expressions of symptoms of perinatal depression for women in the Chitwan district.

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.