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.

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