Introduction Information on the relationship between cigarette use and recovery from substance use disorders (SUDs) is contradictory and limited to studies conducted in high-income countries characterised by a predominance of injection drug use. In South Africa, a low-and-middleincome country where drugs are mainly smoked, there is an absence of research examining the relationship between smoking and SUD treatment outcomes. This study seeks to bridge this gap by exploring service users' perceptions of smoking and how cigarette use affects their recovery from SUDs. Methods This exploratory study employed a qualitative research design. Twenty participants were recruited from six Matrix Outpatient SUD treatment programmes in the greater Cape Town region for in-depth interviews. A semi-structured interview guide structured the interviews. Interviews were audio-recorded before being transcribed verbatim. Qualitative data were analysed using the framework approach. Results Three main findings emerged from the data. First, powerful socio-cultural and contextual factors seem to underpin participants early initiation and maintenance of cigarette use. Participants identified socio-cultural processes that strongly influenced their perceptions of smoking and the social and emotional functions it served, which contributed to continued cigarette use. Second, participants described the intertwining of cigarettes and other substances, with shared modes of administration and mixing of substances - they thought this made it very challenging to maintain recovery from substances while continuing to smoke tobacco. Third, although service users perceive benefits to tobacco cessation for health and recovery from SUDs, most participants using tobacco expressed ambivalence about quitting and seem to lack confidence in their ability to stop smoking and maintain their abstinence from other substances. Conclusion The current study suggests that SUD service users view cigarette use as potentially detrimental to their SUD treatment and recovery. As such, this study provides support, from a service user perspective, for (i) the introduction of interventions to prevent tobacco initiation among young people as part of SUD prevention and (ii) the integration of tobacco cessation interventions into SUD treatment programming to improve the likelihood of successful treatment outcomes for people who smoke tobacco. More specifically, findings highlight the potential value of a client-centred approach in screening service users for tobacco use as they enter SUD treatment, educating them about the potential impacts of continued smoking on SUD recovery, and integrating evidence-based smoking cessation programmes into SUD treatment.

BACKGROUND: Limited research suggests that rates of suicide death among transgender people may be higher than their nontransgender peers. OBJECTIVE: The objective of this study was to compare rates of suicide deaths by different means between transgender and nontransgender patients. RESEARCH DESIGN: This secondary analysis used VHA administrative and electronic health record (EHR) data from October 1, 1999 through December 31, 2016. SUBJECTS: Transgender patients (n=8981) were categorized as such based on a set of International Classification of Disease codes, and a comparison sample was selected by randomly choosing 3 nontransgender patients (n=26,924). MEASURES AND ANALYSES: Cause and date of death data are from the National Death Index. Because of low frequencies amid different methods of suicide death, we combined categories into self-poisoning; hanging, strangulation and suffocation; discharge of firearms; and self-harm by all other and unspecified means. We conducted Cox regression analyses to model time-to-event for each method of suicide, adjusted for age, sex based on EHR, race, ethnicity, marital status, and whether patients had ever been diagnosed with depression. RESULTS: Among transgender patients, 73 died by suicide (22 female EHR-based sex, 51 male EHR-based sex), and among nontransgender patients, 71 died by suicide (4 female EHR-based sex, 67 male EHR-based sex). In adjusted models, transgender patients had significantly greater hazards of death by self-poisoning and firearms than their nontransgender peers. CONCLUSIONS: Differences in methods of suicide death suggest that firearms and self-poisoning may be specific areas of concern for transgender individuals experiencing suicidal crisis, which underscore needs for examining effective delivery of evidence-based care.

Objective: Transgender individuals are vulnerable to negative health risks and outcomes, but research remains limited because data sources, such as electronic medical records (EMRs), lack standardized collection of gender identity information. Most EMR do not include the gold standard of self-identified gender identity, but International Classification of Diseases (ICDs) includes diagnostic codes indicating transgender-related clinical services. However, it is unclear if these codes can indicate transgender status. The objective of this study was to determine the extent to which patients' clinician notes in EMR contained transgender-related terms that could corroborate ICD-coded transgender identity. Methods: Data are from the US Department of Veterans Affairs Corporate Data Warehouse. Transgender patients were defined by the presence of ICD9 and ICD10 codes associated with transgender-related clinical services, and a 3:1 comparison group of nontransgender patients was drawn. Patients' clinician text notes were extracted and searched for transgender-related words and phrases. Results: Among 7560 patients defined as transgender based on ICD codes, the search algorithm identified 6753 (89.3%) with transgender-related terms. Among 22 072 patients defined as nontransgender without ICD codes, 246 (1.1%) had transgender-related terms; after review, 11 patients were identified as transgender, suggesting a 0.05% false negative rate. Conclusions: Using ICD-defined transgender status can facilitate health services research when self-identified gender identity data are not available in EMR.

No description available.

Forty percent of all long-term care hospitalization days are accounted for by patients with schizophrenia. New approaches to managing this disorder are needed, including improved efficacy and better tolerability to enhance compliance with treatment. Sertindole hydrochloride is a novel antipsychotic medication soon to be available in the United States and Canada. As part of multisite phase II and III studies, we studied effects of this medication in five patients with chronic schizophrenia and examined the side effect profile. With more than 30 patient-months of exposure, sertindole treatment was not associated with neurologic side effects and was well tolerated in all patients studied. No evidence of hematologic abnormalities was found. Serial electrocardiograms revealed slight increases in QTc that were not considered clinically significant and did not lead to discontinuance of treatment. While data from larger samples are needed, in this small population sertindole hydrochloride was tolerated well with no evidence of acute neurologic side effects associated with traditional treatments for schizophrenia. Individuals with schizophrenia may benefit from enhanced compliance with treatment and a possible reduction in hospitalizations in the future.

Background: Intellectual Disability (ID) is important and has a major impact on life, quality of life, mental illness, economic and educational well-being. Little research has taken place in Africa about ID. One of the key challenges is to identify appropriate, useful, and free screening tools that might identify those at risk of ID both for clinical purposes and for prevalence studies. One tool that has been used to investigate the broad category of 'disability' (which includes ID) is the Ten Questions Questionnaire (TQQ). The TQQ has given some rates of 'disability' in lowand middle-income countries (LMICS) in the order of 10-25%. However, no further dissection of ID within the broader category of 'disability' has been performed given that the TQQ was not developed with ID in mind. The Wessex Behavioural Schedule (WBS) is a UK screening tool for functional ability for adults with ID, and therefore seemed an appropriate candidate instrument to evaluate for potential use in Africa. However no psychometric data for the tool were available and no clinical cut-off scores for ID had ever been developed. A broader project using the WBS in Khayelitsha, a township area in Cape Town, South Africa, generated a prevalence rate of 19% 'disability'. The purpose of this study was to explore the psychometric properties of WBS to determine its suitability for use in children and adolescents in a South African setting, and to generate clinical cut-offs to define ID. Methods: The study consisted of a secondary analysis of the data from the broader Khayelitsha prevalence study, which was a cluster randomized door-to-door household survey in Khayelitsha using the WBS. Firstly, data were used to evaluate the internal consistency and to perform factor analysis of the WBS. Secondly, the Minimal Difference Perceived 75% of time (MDP75) approach was used on a subset of 100 randomly selected participants to generate an intellectual disability cut-off score for the WBS. Results: Data were available on 452 children and adolescents aged 5-18 years. The mean age was 10.3 (SD 3.9), 54% were female, over 90% were in school, and 53% had a mother as primary carer. The WBS had good internal consistency (alpha = 0.80) and all items appeared to be worthy of retention. Exploratory factor analysis suggested the WBS to be a multidimensional scale composed of four subscales: conceptual abilities, practical skills, sensory abilities and continence. Even though four expert raters were used for the MDP75 calculation, inter-rater reliability was low-58% (Fleiss kappa = 0.08). It was therefore not deemed appropriate to proceed to further analysis to determine the MDP75 and cut-off values for the WBS. Possible reasons for low inter-rater reliability suggested by the raters included age-based expectations, inclusion of physical disabilities, limited information to make a diagnosis of ID contained in the WBS, and the need to take environmental factors into consideration. Conclusion: The good internal consistency and factor analysis structure of the WBS was encouraging, but the low inter-rater reliability brought into question the usefulness of the WBS in a child and adolescent age group. Whilst the WBS may remain useful in an adult age range, we recommend that a more developmentally-sensitive measure be sought or developed as a screening tool for ID. Keywords: Wessex Behavioural Schedule, children and adolescents, intellectual disability, Khayelitsha

Background Mental and substance use disorders cause significant disability worldwide. In spite of the availability of evidence-based treatment, non-adherence rates remain high in people with severe mental illness. Mental health services are however under-resourced, especially in low- and middle-income countries. Interventions that employ task shifting, the delegation of health care delivery tasks to less specialized health workers, have the potential to address this resource shortage. Community health workers, while an established and important delivery agent for task shifting in many forms of chronic illness, including mental illness, have lacked access to standardized structured training in mental health. Together with novel approaches such as mobile health, task-shifting interventions have the potential to improve adherence and clinical outcomes for MHSU, thus reducing the burden on stretched mental health resources. While the evidence for the effectiveness of task shifting interventions is growing, it is unclear whether the combination of a task shifting intervention with mobile health would be acceptable and feasible in low resource settings. It is also unclear to what extent a structured mental health training programme would result in improved knowledge, confidence and attitudes amongst community health workers. Methods First, I conducted an appraisal of current evidence for interventions delivered by non-specialist workers for mental illness in Sub-Saharan Africa. The aim was to characterize the types of such interventions that have been carried out in Sub-Saharan Africa, to ascertain extent of use of non-specialist workers; the outcomes explored; any acceptability and feasibility findings; as well as any efficacy outcomes. Second, I developed and piloted two task shifting interventions geared at improving care for severe mental illness in Cape Town, and evaluated their acceptability, feasibility and preliminary effectiveness. Systematic review: For the systematic review, eligible studies published prior to 21 June 2017 were identified by searching the Cochrane library, PsychInfo, and Medline databases; as well as the World Health Organization International Clinical Trials and Pan African Clinical Trials Registries. The bibliographies of study reports for all eligible trials were scanned for additional studies. Included trials were those of interventions a) delivered by non-specialist health workers for b) adult populations (18-65 years) with c) psychiatric disorders diagnosed in line with ICD or DSM classification systems in d) Sub-Saharan Africa. No restriction was placed on the nature of the psychiatric disorder. Pilot randomized controlled trial: A pilot randomized controlled trial was conducted, in which 77 participants with severe mental illness were recruited from Valkenberg psychiatric hospital in Cape Town, with 42 randomized to receive the intervention and 37 to receive treatment as usual. In the intervention arm, a treatment-partner selected by the participating MHSU underwent a psychoeducation and treatment-partner contracting session. The intervention pair then received two text message reminders of clinic visit appointments monthly. The primary outcomes were acceptability and feasibility of the intervention, measured through qualitative interview and process evaluation at 3 months post-discharge. Secondary outcomes for efficacy were 1) adherence to the first clinic visit; 2) any readmission in the 9 months following discharge; 3) quality of life; 4) symptomatic relief; and 5) medication adherence. These efficacy measures were conducted at baseline and again at 3-month study review. Between-group comparisons were done using an intention to-treat ANOVA analysis for efficacy outcomes. Community Health Worker Training Intervention: My second task shifting intervention was a quasi-experiment evaluating whether structured mental health training would improve the knowledge and skill of community health workers while improving their confidence and attitudes towards mental illness. A training programme was developed in partnership with the Western Cape Department of Health, and piloted with 58 community health workers who had not previously received mental health training. Mental health knowledge and skill were measured though the use of case vignettes and the Mental Health Knowledge Schedule (MAKS). Confidence was measured using the Mental Health Nursing Clinical Confidence Scale (MHNCCS), while attitudes were measured using the Community Attitudes towards the Mental Ill Scale (CAMI). Measures were conducted at baseline, at the end of the training, and again 3 months after the end of training for the knowledge and skill measures. Daily evaluation questionnaires were used to establish acceptability, and a training evaluation questionnaire was used to obtain further acceptability data, as well as to establish feasibility of the training intervention. T-tests and regression models were used to test changes in questionnaire scores before and after each intervention, adjusting for baseline scores. Quantitative data were entered and analysed using STATA 10.0 for the pilot randomized controlled trial and the R statistical programme for the CHW intervention, while qualitative data were managed and analysed using NVIVO 8, a qualitative analysis programme for all analyses, for which a grounded theory approach was used, followed by thematic analysis. Ethics and registration: Ethical approval was obtained from the University of Cape Town Human Research Ethics Committee, Faculty of Health Sciences for the treatment partner and mobile health intervention (HREC REF: 511/2011) and for the community health worker training intervention (HREC 913/2015). Both interventions were registered on the Pan African Clinical Trials Registry (PACTR201610001830190 and PACTR201610001834198 respectively). Finally, Health Impact Assessment Unit clearance was obtained from the Western Cape Department of Health for both trials (RP168/2011 and WC_2016RP59_635 respectively). The systematic review was registered on the International prospective register of systematic reviews (PROPSERO) (CRD42017065190)). Results Systematic Review: Due to heterogeneous methods and treatment outcomes, a meta-analysis was not possible. A narrative synthesis is thus presented. Fifteen trials of interventions delivered by non-specialist workers (5087 participants) were identified. In each of the trials, the intervention was acceptable and feasible, with preliminary efficacy findings favouring the interventions. Pilot randomized controlled trial: The treatment partner and text message intervention components were acceptable. While the treatment partner and psychoeducation components were feasible, the text message component was not, as a consequence of several socioeconomic and individual factors. While efficacy outcomes favoured the intervention, they did not reach statistical significance due to the small sample size. Community Health Worker Training Intervention: Mental health knowledge improved as demonstrated by improved diagnostic accuracy on case vignette response. Sixty-three percent of participants demonstrated improved accuracy in making a diagnosis, with a roughly two-fold increase in performance in these individuals. There was a significant increase in the average scores on the Mental HeAlth Knowledge Schedule pre- to post training (t = -4.523, df = 55, p < 0.001, N=56). This improvement was sustained at 3 months after the end of training assessment scores (t = -5.0, df = 53, p < 0.001, N = 54). There was a significant increase in the average Confidence scores pre-intervention (mean SD): 45.25 (9.97) to post-intervention 61.75 (7.42), t-test: t = -8.749, df = 54, p < 0.001, N=58). Attitude scores (n=45) indicated no change in authoritarian attitudes [mean (SD): Pre 27.87 (2.97); Post 26.38 (4.1), t = 2.720, p-value = 0.995], while benevolence [mean (SD): Pre 37.67 (4.46); Post 38.82 (3.79), t = -1.818, p-value = 0.038] and social restrictiveness [mean (SD): Pre 24.73 (4.28); Post 22.4 (5.3), t = -2.960, p-value = 0.002] attitudes showed improvement pre- and post-training, as did tolerance to rehabilitation of the mentally ill in the community (t = 2.176, p-value = 0.018). Participants responded well to training, appraising it as acceptable and appropriate to their work. They expressed a need for a longer training programme with further training on substance use and geriatric disorders. Stakeholder participation was consistent and contributed to the feasibility of the intervention. Conclusions A review of task shifting interventions by non-specialist health workers indicates that these have yielded positive outcomes for mental health service users in published trials. Such interventions have the potential for reducing the mental health treatment gap in low and middle income countries in a cost-efficient way. Further work is however required to develop specific treatment approaches for particular disorders, and to assess the outcomes of such interventions, including cost-efficiency measures. The measures of outcome used in this field remains somewhat disparate; the development of a common research agenda may assist in developing and replicating further investigations and generalising findings. A treatment-partner intervention is acceptable and feasible in a low- and middle-income setting such as ours. Careful work is, however, needed to ensure that any additional components of such an intervention, such as mobile health, are tailored to the local context. Appropriately powered studies are needed to assess efficacy. Structured training in mental health is acceptable and feasible in our setting. The training intervention led to an improvement in knowledge and skill amongst community health workers while improving confidence and attitudes. Participation of policy stakeholders was key in ensuring the success of the intervention. There is a need for interventions evaluating the outcomes of community health worker training to provide more detailed descriptions of their training interventions. More focus must be placed on measuring service and end-user outcomes to improve the rigor and quality of such investigations, with well-powered randomized controlled trials being best placed to answer questions regarding efficacy and cost-effectiveness. In summary, my systematic review, and my pilot task-shifting interventions in the South African context indicate that task shifting interventions such as these are acceptable and feasible, offering a promising solution to addressing the under-resourcing of mental health care. However, interventions should ideally be tailored to the specific communities they target, taking into account specific individual, community, technological, and sociodemographic factors. Future training interventions should provide more detailed descriptions of programme components and focus on measuring patient outcomes, while all task shifting interventions may benefit from incorporating an evaluation of cost effectiveness. Task shifting presents a viable and accessible opportunity for creative innovation and as we work towards achieving mental health for all.

Bibliography: leaves 106-112. / The primary aim of this dissertation was to gain an understanding of the psychopathology present in the perpetrator of Munchausen Syndrome by Proxy (MSP), exploring Jureidini's (1999) notion that this behaviour can be explained as the perpetrator engaging in a form of pathological play. A systematic literature review regarding MSP, with particular foci on psychopathology in perpetrators of MSP and the notion of pathological play was conducted. The notion that MSP is a form of pathological play was critically evaluated through the use of clinical case material. Two cases were selected, both of which met the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnostic criteria for MSP, based on the assessment of a child psychiatrist with expertise in this area. The case material was analysed through the generation of common themes and identification of repetitive patterns which were then systematically analysed and compared with the findings cited in the literature review, with particular reference to MSP as a form of pathological play. Jureidini's (1999) theoretical statement was analysed in the light of the available evidence and the theoretical basis was then revised. Aspects explained by the theory were presented. Aspects not explained by the theory were rejected. Object Relations Theory was proposed as an alternative to understanding the psychopathology present in a perpetrator of MSP.

Background: Domestic homicide (killing of a person aged 16 or older by a family member or a current or former partner) accounts for 50% - 70% of homicides perpetrated by offenders with mental illness. Despite these statistics, surprisingly little is currently known about the characteristics of domestic homicides perpetrated by those with severe mental illness. To the best of our knowledge, domestic homicide in the context of severe mental illness has not been researched in South Africa. Objective: To investigate domestic homicides by offenders with severe mental illness referred to the Forensic Mental Health Service at Valkenberg Hospital for forensic psychiatric observation. Methods: A five-year retrospective folder review was conducted to obtain data on the characteristics of offenders and victims, as well as the circumstances surrounding the homicide. Results: The majority of the offenders in our sample were young (mean age of 31), single, unemployed males who were known to mental health care services. Substance use disorders and non-adherence to medication were common. Psychotic disorders were the most prevalent diagnoses. The majority of victims were male and a significant minority of the domestic homicides were parricides (28.6%). The incident took place at the victim's residence or the victim and perpetrator's shared residence in most cases. Stabbing was the most common method used. Almost half of the perpetrators were psychotic when the incident took place and 60% of these were first episode psychoses. In spite of the high prevalence of substance use disorders (66.7%), only 23.8% of the sample reported that they were intoxicated when they committed the offence. Conclusions: The majority of our sample was known to mental health care services. This implies that there were potential missed opportunities to prevent these lethal assaults. Our research identified treatment adherence, comorbid substance use disorders and aggressive treatment of first episode psychosis as a possible focus of future interventions in order to prevent domestic homicides due to mental illness.

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.