Background The Transgender Clinic at Groote Schuur Hospital (GSH) – a large government funded academic hospital in Cape Town, South Africa - assists with the mental health assessment of transgender individuals and facilitates access to other gender affirming services, such as hormone therapy, plastic and reconstructive surgery, psychosocial, and legal services. Objectives This clinical audit aimed to gain a clearer understanding of the service and areas within the service which could be improved. To this end the general compliance of the clinical services of the multidisciplinary team (MDT) as recommended by the World Professional Association for Transgender Health 7th Version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH SOC 7) was assessed. In addition, an analysis of the demographic and clinical characteristics of individuals attending the clinic and a review of waiting times and distance travelled to attend the clinic, was conducted. Methods The study was a clinical audit without a repeat data collection cycle. Participants included the MDT members working at GSH's Transgender Unit and individuals attending the Transgender Clinic from September 2018 to December 2019 (n = 50). All 11 MDT members were invited to participate in the study and were required to complete a data collection sheet related to their competency and experience. Data collection with respect to services provided, and waiting times for services, was captured from clinician administered standardized historytaking and assessment booklets and patient hospital folder reviews. Results All members of the MDT who participated met the WPATH SOC 7 competency requirements. The mean age of the individuals attending the GSH Transgender Clinic was 28 years. Forty-eight percent were employed, 36% unemployed and 16% full time scholars. The 7 mean waiting time for an initial appointment with mental health was 75 days, 73 days for endocrinology and 255 days for plastic surgery. Non- attendance at initial appointment was a factor across gender affirming services – 18% mental health service, 20.5% endocrinology and 27% plastic surgery. Forty-two percent of individuals screened positive for a co-occurring mental health condition with a third of these individuals having more than one mental health disorder. Mood and anxiety disorders co-occurred together most frequently. Seventy-five percent of individuals with an untreated or partially treated mental health concern were provided a therapeutic intervention at the time of initial assessment. The introduction of laboratory investigations being performed prior to the initial appointment with endocrinology resulted in a significant improvement in waiting time to the initiation of hormone therapy. Conclusion WPATH SOC 7 competency requirements were met by the GSH Transgender clinical team. Inconsistencies were found in the documentation of WPATH SOC 7 recommended clinician tasks within the mental health and endocrinology service. This is secondary to the layout of the standardized history taking and assessment booklet, and documentation of certain tasks being clinician dependent. Limited hospital resources and subsequent understaffing, long waiting times for appointments and gender-affirming surgery and lack of access to other services (e.g. fertility services) result in continued barriers to gender-affirming care.

The central premise of this thesis was that pain is a problem in persons living with HIV/AIDS (PLWHA), that this pain is biopsychosocial in nature, and as such may have different characteristics in different sub-groups. It was also hypothesised that pain in PLWHA can be effectively managed using a biopsychosocial treatment.

Background. Psychotic Disorders affect more than 1% of the South African adult population and have a chronic course that is associated with high rates of morbidity and mortality. The implementation of early intervention strategies may reduce the severity of these disorders. Little is known about the effectiveness of these interventions in South Africa and few longerterm studies have been undertaken internationally. Aim. This study aimed to measure the effectiveness of an Early Intervention and Support (EISH) service at reducing readmission to hospital in patients with psychotic disorders. Setting. Valkenberg Psychiatric Hospital, Cape Town. The EISH Team is an outpatient service consisting of psychiatrists, a psychologist, an occupational therapist, psychiatric nurses and social workers. Methods. Retrospective cohort study. Hospitalisation during the two years after discharge from the index admission was measured in 100 subjects who attended EISH and 100 who had treatment as usual (TAU). Readmission rate, average length of stay (ALOS), and time to readmission to District Hospitals (DH) and Tertiary Psychiatric Hospitals (TPH) were calculated. Results. Readmission Rates were three times higher in TAU compared to EISH patients for both types of Hospital. For TAU subjects compared to EISH subjects: ALOS was longer (59 vs 13 days), and days to readmission were fewer (187 vs 320 days). All differences were statistically significant (ps < .05). Conclusion. EISH intervention at Valkenberg Hospital was useful in reducing readmission rate, ALOS, and time to readmission in patients with Psychotic disorders. Prospective controlled trials are required to confirm the efficacy of this intervention.

Background: Substance-induced psychotic disorder (SIPD) is prevalent in South Africa, yet there is a paucity of research regarding its longitudinal course, with studies finding that diagnostic conversion occurs often, mostly to schizophrenia (SCZ). Aim: We examined the rate of, and factors associated with, diagnostic conversion in first-episode SIPD to primary, non-substance-related mental disorders. Setting: Adult inpatients with a diagnosis of first-episode SIPD discharged between 2012 to 2014 from Valkenberg psychiatric hospital, Cape Town. Methods: We conducted a retrospective cohort study of first-episode patients discharged from hospital, followed-up for a four-year period. We used survival analysis and Cox-proportional hazard regression to determine factors associated with diagnostic conversion to a primary mental disorder. Results: Of the sample of 225 patients, the majority were young, male and polysubstance users. Diagnostic conversion occurred in 26.2%, the majority within 3 years - 71.2% to SCZ-spectrum disorders and 28.8% to major affective disorders. In the adjusted analysis, diagnostic conversion remained significantly associated with male sex (HRadj=1.85, 95% CI=1.00– 3.42, p=0.045) and greater length of index admission (HRadj=1.02, 95% CI=1.01 – 1.04, p=0.006). Compared to nonconverters, significant associations with conversion to SCZ-spectrum disorders were male sex and length of index admission. Conversions to both SCZ-spectrum and major affective disorders were significantly associated with number of re-admissions during follow-up. Conclusion: Diagnostic conversion occurred in a substantial proportion of SIPD cases, often to SCZ. This warrants enhanced follow-up of high-risk cases, with attention to indicators such as sex and length of index hospitalisation.

Vertical transmission of human immunodeficiency virus (HIV) from mother to child is a major problem in sub-Saharan Africa. As in adults, a variety of cognitive impairments may be evident in HIV infected children being treated with combined antiretroviral therapy (ART). The HIV virus compromises visual perception, attention, memory, language and executive functioning. Prior imaging studies have shown abnormal brain structure in adults and children infected by HIV. Graph theory analyses have been applied to HIV neuropathogenesis previously, these have demonstrated significant disruptions to brain connectivity in older HIV+ adults on treatment. However, no previous studies have investigated the same topological organization or structural connectivity of brain structure in infected children, or correlated this with markers of disease severity. The aims of this project were first, to delineate the topological organization of brain structure in children living with HIV currently on treatment and contrast it with healthy HIV negative children, second to investigate differences in measures of brain structure between healthy controls and children living with HIV and third to correlate brain imaging measures with markers of disease severity. The studies presented here examine the structural connectivity between nodes in the brain by utilizing magnetic resonance imaging and graph theory methods, and also investigated gray matter structure and cortical complexity. Children living with HIV displayed abnormal structural connectivity in regions of the dorsal posterior cingulate and inferior frontal gyrus of the frontal lobe, as well as in superior regions of the temporal lobe when compared to healthy HIV negative children. Significantly decreased cortical thickness was found in precentral and postcentral regions and the superior and middle frontal regions of children living with HIV compared to the healthy group. Deficits in cortical complexity of the inferior frontal gyrus and fusiform gyri were also apparent in the HIV infected group. Cortical thickness, surface area and gyrification were positively associated with CD4 count as a marker of disease severity. In conclusion, this project demonstrated abnormal brain structure and structural connectivity of brain structure in regions involved with motor development, executive function, and language fluency and generation in treated children living with HIV. Abnormal structural connectivity may indicate disruption to brain network integrity in developing children. Even in the post-ART era, infected children remain at risk for abnormal brain development. Longitudinal studies in larger cohorts are needed to address the issue of changes in brain structure and topology over time during adolescent brain development.

Depression in the perinatal period carries a significant burden of disease and can have negative impacts on foetuses and infants of mothers suffering from the illness. Risk factors for perinatal depression are particularly high in Low- and Middle-Income Countries (LMICs), and include partner abuse, economic insecurity, HIV, unwanted pregnancy, and food insecurity. Despite the substantial burden, there is a considerable 'treatment gap' between the need for treatment and the provision of services for perinatal depression in LMICs. Task sharing using non-specialist health workers has been recommended as a costeffective means to address this treatment gap and reduce the burden on mental health specialists in public health services. Evidence has shown moderate effects of task-shared treatments on the reduction of perinatal depression, but little is known about the processes, mechanisms and elements that lead these treatments to be effective. This thesis is nested within the Africa Focus on Intervention Research for Mental Health - South Africa (AFFIRM-SA) randomised controlled trial (RCT), which aimed to test a task-shared psychological treatment for perinatal depression in Khayelitsha, a low-income township outside of Cape Town in South Africa. The aim of this thesis was to explore the mechanisms of implementation and change of this intervention through a process evaluation. Before implementation of the intervention, qualitative research was employed to explore the idioms, symptoms and perceived causes of depression particular to perinatal women living in Khayelitsha, using semistructured interviews and a framework analysis approach. This was conducted with 12 depressed and nine non-depressed pregnant women and mothers of young babies, and 13 health care providers. These idioms and symptoms were also compared with the ICD 10 and DSM-5 criteria for major depression. The research found that local idioms used to describe depression included 'stress', 'thinking too much', being sad or unhappy, and being scared. Some of the common symptoms of depression were expressed as withdrawal and not wanting to talk, crying or sadness, poor concentration, thinking too much, fear and anxiety, stress, sleep problems, headaches, and body pain. The primary causes that women attributed to these depressive symptoms were lack of support, having an unwanted pregnancy, death of a loved one, poverty, unemployment, thinking too much, coping with a new baby, and stress. These were exacerbated by the extreme risk factors the women faced in Khayelitsha such as low income levels, poverty, partner abuse, low education levels, poor housing and living conditions, and poor health care. The findings from this research were recommended for inclusion in the development of the counselling intervention manual for the RCT. Following implementation of the AFFIRM-SA RCT counselling intervention, the trial outcome assessments found non-significant effects in the reduction of depressive symptoms on the Hamilton Depression Rating scale (HDRS) at three and 12 months post-partum, but also found significant improvements on the Edinburgh Postnatal Depression Scale (EPDS) at both time points for the intervention group, compared to the control group. The process evaluation for this thesis subsequently examined mechanisms and contextual factors that may have influenced the intervention outcome. This involved reviewing the counselling manual and conducting a grounded theory analysis of a sample of the counselling session transcripts from the intervention. The review of the counselling manual found that the structure, layout, instructions and grammar in the manual may have led to some difficulties in its interpretation and use for counsellors and participants. The grounded theory analysis included 39 participants who had completed all six sessions of the intervention (totalling 234 sessions). The use of grounded theory allowed for findings to emerge which had not been prespecified before analysis. This process began with the identification of 'open codes', which was anything that 'stood out' from the data. Following this, a secondary 'axial coding' of the data then identified four themes that encompassed all of the open codes. The themes were: therapeutic breakdowns in the counselling sessions, the adverse influence of socio-economic context on therapeutic effectiveness, reported positive outcomes, and attributes given for the reported changes. In turn, these themes could be represented by one of two 'core concepts' that characterised the processes that occurred during the counselling sessions. These were deviations from the intended counselling protocol (when things fall apart), and effectiveness of the counselling sessions (when things come together). The third level of coding, termed 'selective coding', examined the potential reasons for the deviations from protocol and the mechanisms or elements behind the attributions of the reported outcomes. Possible reasons for deviations include the original context of the development of the intervention, not fully incorporating the formative research and pilot findings, the limited skill base of the counsellors, limited training and supervision, the structure and design of the intervention, ownership by the counsellors of the intervention, the role of advice in this context, and contextually related need from the participants. This also explained potential reasons for the non-significant effects of the intervention on the HDRS. In terms of the attributions that the participants gave for their outcomes of change, many of these acted as 'mechanisms' or therapeutic elements of the counselling, and these elements were similar to previous research on common or 'non-specific' elements in the therapeutic space. These elements played an important role in participants' feelings of connection and reduction of distress, despite evidence of deviations from the counselling protocol. This was in keeping with the significant effects of the intervention on the EPDS outcomes. The thesis presents two models of processes that occurred in the intervention. The first posits that the intervention did not sufficiently disrupt the mechanisms or context that creates and perpetuates depression to enable long term shifts or significant changes in clinical depressive symptoms. The second suggests that the intervention provided a sense of connection and a subsequent 'buffer' of resilience to handle every-day stressors, but that this buffer was short-term and could not provide longer-term resilience against the extreme context of poverty, unemployment, abuse and trauma. Through a process evaluation of the design and implementation of the AFFIRM-SA intervention, this thesis presents a wide range of contextual considerations and therapeutic elements relevant to designing and implementing more acceptable and responsive public mental health interventions that aim to bring about real and sustainable change for perinatal depression in South Africa and other LMICs.

Introduction: Mental health in the workplace has emerged as an important issue and a number of pieces of legislation at the international and regional level provide a good framework for ensuring that people with mental disorders have equal opportunities for employment and support within the workplace. This issue has not been sufficiently addressed in Namibia. This study therefore explored how mental illness is addressed in human resources policies, processes, procedures, and mental health programmes in the Namibian Public Service workplace. Methods: This study comprised two components: a review of legal documents and a qualitative study with relevant people addressing mental illness in the workplace. Five existing Laws, Policies and Rules were reviewed. The review looked at any reference to Mental Illness or Mental Health and in instances where both were not used, identified other terms used like, severe psychiatric illness, psychological disorders, MNS disorders (mental, neurological and substance abuse). In cases where none of the terms were used to identify the two concepts or general health or illness in all documents, the review identified other terms or phrases that may have been used to identify physical or mental illness. The review further pinpointed the legal provisions in the laws which have direct reference to mental illness in the workplace. These provisions ranged from recruitment, management, and boarding of people with mental illness in the workplace. In the second component, a qualitative study design was used comprising of three semi-structured interviews and seven focus group discussions. The study had a total of thirty nine participants selected through a purposeful sampling method. Two representatives, one from each of the unions representing employees in the public service and one participant from the Medical Review Board were interviewed individually. Sixteen Government Ministries were selected and invited to participate in the study, but only nine sent a total of twelve representatives from HR Departments to participate. The Public Service Commission focus group discussion had twelve participants, while members of the Mental Health Association of Namibia representing people with mental illness (MI) and their support persons participated in two focus groups. Four participants who had experienced being medically boarded due to MI, participated in two focus group discussions. All sessions were audio recorded and transcribed verbatim. A Framework Data Analysis approach was used to extract themes to address the aim and objectives. Results: The findings from the document review show that the legislation framework lacked clear documentation of how to identify and manage mental illness in the workplace, resulting in inconsistencies in how mental illness is managed in the Namibian public sector. The findings of the qualitative study show that participants have limited knowledge of what mental illness is, although people seemed able to describe how to recognize someone with mental illness from the way they act. There is confusion between the concepts of disability and ill-health resulting in many people being boarded prematurely or inappropriately. Conclusion: The participants appreciated and recognized the importance of the study in all the discussions, suggesting that there is a need for platforms to be created where issues of mental illness and mental health can be discussed. The lack of a coordinating structure for mental illness in the Public Service was seen a stumbling block in addressing mental illness in an appropriate way. The recommendations to have at least one trained health worker who will be dedicated to employee wellness, will be a step in the right direction. There is an urgent need to reform some of the legal instruments to be able to create a positive impact for people with mental illness in the workplace.

Includes bibliographical references / There are still no diagnostic criteria for a spectrum of neurocognitive disorders (ND) secondary to HIV infection for children. The American Academy of Neurology (AAN) proposes guidelines for assessment of HIV associated neurocognitive disorders (HAND) in HIV infected adults. A cross-sectional clinical cohort study was initiated in Cape Town, in which 120 participants, including a HIV negative healthy control group for comparison, completed clinical and neurocognitive assessments. HIV infected children were either stable on antiretroviral treatment (ART) for a minimum of 6 months or ART naïve. Neuroimaging was completed on 105 children in the cohort study. We compared 75 children vertically infected with HIV aged 6 to 16 years, including both children on antiretroviral therapy (ART) and ART-naïve, with 30 matched controls using diffusion tensor imaging (DTI) measures. We then used the detailed neurocognitive battery; an assessment of adaptive functioning and the AAN system for diagnosing ND to establish whether this system could detect a spectrum of ND in HIV infected older children and adolescents. When comparing HIV uninfected children to HIV infected children this DTI study found damaged neuronal microstructure in the HIV infected children. Significant associations were found between failing first line ART regimen, socio-demographic factors, nutritional-hematological status, HIV-relevant clinical variables, cognitive functioning and white matter integrity in children stable on ART. Children with a clinical diagnosis of encephalopathy (HIVE) had greater white matter damage when compared ART treated children without encephalopathy. DTI also found significant myelin loss in ART naïve children when compared with ART treated children. Using the AAN criteria for HAND, we found that 45.35% of the HIV infected children had a ND. ART naïve slow progressors, who receive limited attention from heath care service s, as they are thought to be 'well', were found to have neurocognitive impairment and white matter microstructural damage. HIV infected children were also more likely to have impaired competence in various domains of functioning. The current findings also underline the possible association of first line treatment failure with white matter brain dysfunction in children on ART. Despite the use of ART and improved virological control with immune reconstitution, there were still a significant percentage of children in this study who were found to have ND. Our findings also suggest that children on ART remain at risk for developing CNS disease, and that this risk extends to physically well ARV naïve slow progressors. The AAN HAND criteria designed for adults was able to identify children and adolescents with important functional cognitive impairments who don't fit criteria for HIVE and would therefore not have been identified otherwise.

Mestrado em Psiquiatria e Saúde Mental / Master Degree Course in Psychiatry and Mental Health

Mestrado em Psiquiatria e Saúde Mental / Master Degree Course in Psychiatry and Mental Health