Background Given the high prevalence of substance use disorders among patients with persistent mental illnesses, with resultant negative health consequences, a brief and easily administered screening test is needed in this population to identify those at risk in order to intervene appropriately. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was developed by the World Health Organisation as a screening instrument. It has been validated in a variety of settings, including in primary care and treatment settings and in first episode psychosis. Aim To determine the validity and reliability of the ASSIST in detecting substance use disorders in patients with multi-episode psychotic disorders. Setting Western Cape, South Africa. Methods The Structured Clinical Interview for DSM-IV Axis I Disorders was used as the gold standard for detecting DSM-IV substance abuse and dependence. Cronbach's alpha was used to determine the internal consistency of the ASSIST, and receiver operating characteristic analysis was used to evaluate its screening properties. Optimal cut off scores were calculated to maximize sensitivity and specificity. Results A total substance involvement lifetime score of 13 was found to have both sensitivity and specificity of just over 74%. A specific substance involvement score of 4 for alcohol and 3 for cannabis, methamphetamine and ‘other drugs' was found to have optimal balance between sensitivity and specificity. Conclusion The ASSIST is a psychometrically valid screening test for substance use disorders in general, as well as for alcohol, cannabis and methamphetamine use disorders, in patients with multi-episode psychotic disorders.

Background The prevalence of violent crime, including murder, is moderately but significantly increased amongst those with severe mental illness compared to the general population. Understanding the characteristics of mentally ill murder offenders may help in the application of evidence-based treatment and rehabilitation strategies. Rationale In the Republic of South Africa (R.S.A), little is known about the characteristics of patients with severe mental illness who are charged with murder. This study has the potential of improving our understanding of these patients. This would subsequently facilitate the development of evidence based interventions in the South African context. Aims The current study aimed to describe the demographic, clinical and criminological characteristics of murder offenders with a diagnosis of schizophrenia or bipolar/schizoaffective disorder and to establish if there are any differences between the two patient groups. Methods Clinical records of male patients diagnosed with schizophrenia or bipolar/schizoaffective disorder following a charge of murder who had been admitted as State patients to the forensic unit of Valkenberg Hospital (VBH) were reviewed. Purposive sampling was used. Data were collected using a questionnaire specifically designed for the study. Those with comorbid intellectual disability (ID) or a neurocognitive disorder and those with missing information were excluded. Ethical approval was obtained from the University of Cape Town, faculty of health sciences human research ethics committee. Results Thirty-seven male patients were included in the study. Twenty-three had a diagnosis of schizophrenia and fourteen had a diagnosis of bipolar/schizoaffective disorder (SCAD). The mean age of the sample was 32.54 years (range: 17-50). Most had a secondary school level of education and were unemployed. There were no sociodemographic differences between the two groups. Persecutory delusions were the most common symptom for both groups (67.57%). The majority of patients had a psychiatric admission prior to the index offence (62.16%). The modal duration of illness for schizophrenia prior to the index offence was less than one year (37.5%) and more than ten years for bipolar/SCAD patients (57.14%). Comorbid personality disorder (PD) was present in 62.5% of the sample. Antisocial PD was the most prevalent. The most commonly used substances were cannabis (70.27%) and alcohol (59.46%). Bipolar/SCAD patients were more likely to use other substances than alcohol or cannabis compared to schizophrenic patients. 89% of the victims were known to the offenders. Family members were victims in 65.2% of the murders. Most of the victims were male (70.27%). Most of the murders occurred at home (75.68%). Schizophrenia patients were more likely than bipolar/SCAD patients to commit the murder at home. Stabbing with a knife was the most common method of murder for both groups (49.45%). Conclusions and Recommendations It can therefore be concluded that patients with schizophrenia or bipolar/SCAD share most demographic, clinical and criminological characteristics which are thought to play a causative role in the commission of murder. Hence, they do not require different rehabilitation strategies. However, general rehabilitation programs for both patient groups should cover several important areas including: social deficits, occupational functioning, substance misuse, treatment adherence and family involvement. Forensic rehabilitation programs should also fully integrate dual diagnosis interventions. Risk assessment and management in both civil and forensic psychiatry services should specifically address persecutory delusions. This should include optimising psychotropic treatment, cognitive behavioural approaches and emphasis on clinicians' duty to warn any potential imminent victims. There should be more robust assessment for comorbid personality disorders as this has a significant impact on the course of illness and the risk for recidivism. In future, a South African multicentre study of similar design should be conducted to increase the sample size and improve the generalisability of the study findings. Future studies should also examine female murder offenders as a separate sample as they may essentially be different from male murder offenders.

Includes abstract. / Includes bibliographical references (leaves 69-74). / Suicide attempts are associated with an increased risk of repeat attempts, completed suicide, chronic psychiatric symptoms, and ongoing psychosocial difficulties. Data is lacking in several areas in the field of suicide prevention and it is vital that clinicians identify factors that increase treatment adherence among patients that attempt suicide. This study aims to examine adherence rates and predictors of adherence to follow-up after a suicide attempt among the patient population of the PEU of Groote Schuur Hospital, Cape Town. Underlying the study is the hypothesis that sociodemographic factors and the nature of the suicide attempt predict adherence with follow-up subsequent to a suicide attempt.

Includes bibliographical references / Objective: To determine the occurrence and associations of Schneiderian first-rank symptoms in patients diagnosed with schizophrenia and methamphetamine psychosis using structured clinical interviews for DSM-IV (SCID-I). Method: Data from SCID-I interviews collected on two samples of patients, diagnosed with schizophrenia and with methamphetamine psychosis, as part of two separate research projects, was retrieved from the respective databases and compared. The two groups were compared on the presence of any one first rank symptom, those who had two first-rank symptoms, and those who had more than two first-rank symptoms. We calculated the prevalence of different first-rank symptoms in schizophrenia and methamphetamine psychosis. We further performed a logistic regression and calculated adjusted and unadjusted odds ratios for the association between first-rank symptoms and diagnosis. Results: One hundred and two patients fulfilled inclusion criteria for the study, 33 from the methamphetamine psychosis sample, and 69 from the schizophrenia sample. Prevalence of one, two, and more than two first-rank symptoms in the methamphetamine psychosis and schizophrenia groups was calculated as 69.6% and 69.7%, 21.2% and 20.3 %, and 27.3% and 27.5% respectively. After adjusting for covariates, thought broadcasting occurred significantly more often in patients with schizophrenia compared to those with methamphetamine psychosis (Odds ratio=3.61; 95% CI: 1.26-10.33; p<0.05). In turn, the odds of having auditory hallucinations in the form of voices conversing was significantly lower in patients with schizophrenia compared to those with methamphetamine psychosis (Odds ratio=0.27; 95% CI: 0.1-0.75; p<0.05). We found no significant association between any other first-rank symptoms as measured by the SCID-I and a diagnosis of schizophrenia or methamphetamine psychosis. Conclusion: The symptom of thought broadcasting was significantly more likely to occur in patients diagnosed with schizophrenia than in patients diagnosed with methamphetamine psychosis. Auditory hallucinations of voices heard conversing was significantly less likely to occur in patients with schizophrenia than in those with methamphetamine psychosis. Overall, there was a significant overlap of first-rank symptoms and a diagnosis of either schizophrenia or methamphetamine psychosis, but this study did not show that patients with a diagnosis of schizophrenia are more likely to have first-rank symptoms when compared to those with methamphetamine psychosis.

Background: Enquiring about and documenting care arrangements for children of inpatient mothers with mental illness is paramount. Failure to do so could have a negative impact on the well-being of their children. Documenting care arrangements on admission signals good practice on the part of the admitting medical staff and ensures compliance with the requirements of the South African Children’s Act of 2004. This study explores the current practice at a large government run tertiary female inpatient psychiatric unit in Cape Town, regarding the enquiring and documenting practice within the first 24 hours of admission, of these care arrangements. Methods: The study is a cross sectional study using a mixed methods approach including: i) a case note audit of 100 consecutive patient folders examining the documentation of care arrangements within the first 24 hours of admission and ii) a structured self-administered questionnaire to professional staff working on the unit. Results: A total of 87 clinical folders were audited. Ninety nine percent of these folders had written down in them whether the women had children or not. Fifty eight percent of women had minor children and had 87 children between them. Fifteen percent of women had no care arrangements documented and 20% of women had unclear documentation of care arrangements. Fifteen completed staff questionnaires were returned. All staff agreed that it was important to ask the mothers about care arrangements. Conclusion: Significant more women that those identified on admission may have children who may have been in unsafe care arrangements at the time of their admission. There is room for improving the clarity of documenting of care arrangements and the enquiring into the specific care arrangements.

Includes abstract. / Includes bibliographical references. / Myasthenia gravis (MG) is an acetylcholine receptor antibody- mediated disease targeting the neuromuscular junction resulting in fatigable muscle weakness. A number of reports have suggested a high prevalence of psychiatric symptoms amongst MG patients. Approximately 10% of MG subjects are found to have an associated thymoma and despite thymomectomy, the MG persists. The presence of thymoma may lead to other antibody-mediated neuropsychiatric manifestations including limbic encephalitis. We hypothesized that the prevalence of neuropsychiatric symptoms may be higher in MG subjects with thymoma-associated MG when compared with those who have non-thymoma MG. This study aims to compare the prevalence of neuropsychiatric symptoms in a South African population of non-thymoma MG and thymoma-associated MG.

Includes bibliographical references. / The aim of this study was to review the available published structural magnetic resonance imaging (MRI) data in bipolar type I disorder, looking for any evidence of a change in size of the structures in lateral orbitofrontal circuits relative to the conceptually unaffected motor circuit. Structures in the motor circuit will thus act as an internal control. We will additionally look at healthy controls as an external control.

Bibliography: leaves 221-270. / Serotonin neurones have been implicated in the pathophysiology and treatment of clinical depression to a greater degree than any other neurotransmitter. Additionally, serotonin pathways may playa role in the pathophysiology and treatment of eating disorders, anxiety states and schizophrenia. Molecular biological studies have confirmed pharmacological evidence suggesting the existence of multiple serotonin receptor subtypes and the genes for these receptors, as well as that of the serotonin transporter, have common polymorphic variants. To investigate the effect of repeated treatment with selective serotonin fe-uptake inhibitors (SSRI's) on the function of central 5-HT2C receptors. To assess the effect of polymorphic variation in the 5-HT2c receptor and serotonin transporter on functional responses to selective pharmacological challenge. To determine whether polymorphic variation in the 5-HT receptor and serotonin transporter influence the clinical response of patients with major depression to treatment with serotonergic antidepressants. To assess the effect of repeated treatment with selective serotonin re-uptake inhibitors (SSRI's) on the function of central 5-HT2c receptors I used the 5-HT2C receptor agonist, m-chlorophenylpiperazine (m-CPP) as a 5-HT2c probe in a neuroendocrine challenge paradigm. I used the same approach to assess whether polymorphic variation in the 5-HT2c receptor (serine vs cysteine substitution) was associated with differences in functional response to 5-HT2C receptor challenge. I then studied whether polymorphic variation in the serotonin transporter promotor region (long versus short form) was associated with differing functional responses to acute challenge with clomipramine, a tricyclic antidepressant with a high affinity for the serotonin transporter. Finally, I studied whether either of these polymorphic variants influenced the clinical response of patients with major depression to treatment with SSRI's and clomipramine. SSRI treatment significantly lowered the sensitivity of 5-HT2c receptors as predicted from animal experimental studies. However polymorphic variation in the 5-HTzc receptor did not significantly influence functional responses to m-CPP challenge. In contrast polymorphic variation in the serotonin transporter was associated with differing neuroendocrine responses to acute clomipramine challenge with greater prolactin release being seen in subjects with the long polymorphic variant. Neither the 5-HTzc nor the transporter polymorphisms correlated with clinical response to SSRI and clomipramine treatment in patients with major depression. The ability of SSRI's to produce a functional down-regulation of 5-HTzc receptors may be relevant to certain of their therapeutic effects. Polymorphic variation in the 5-HT2c receptor (serine vs cysteine) seems unlikely to explain functional differences in responses to 5-HTzc receptor challenge or antidepressant responses to SSRI treatment. In contrast variation in the serotonin transporter promotor is associated with differing functional responses to acute serotonin re-uptake blockade. However, this did not correlate with clinical response to longer-term SSRI treatment.

The mental health needs of patients entering the program at ward one, Valkenberg Hospital, are not routinely measured. Their presenting problems are frequently complicated by basic and social needs, which impact on recovery and re-integration into the community. The Camberwell Assessment of Need is a valid and reliable instrument used to measure the mental health needs of psychiatric patients. In this study, this instrument was used with some modifications to assess the needs of patients on admission to ward one. At discharge, these needs were explored to measure the extent to which services and interventions were useful in meeting those needs. Where not, questions aimed at elucidating impediments to care were asked. All 60 patients completing the program agreed to participate. The average number of total needs on admission was 9.2, which included an average of 6.7 unmet needs. Psychiatric needs were the most commonly reported, with a need in the area of "depression" being declared in 59 patients. Help received prior to admission was scant, and patients had high expectations of ward one. Help received from ward one was highest in areas of psychiatric needs, with 89.8% of patients receiving moderate or high help in the area of depression. More than two-thirds of patients reported receiving low help in basic areas such as accommodation, self-care, and sexual expression. The services most often regarded as useful were organised group activities and therapies. Paired t-tests revealed that the patients without borderline personality had more unmet needs on admission. Regression analysis suggests that younger age and lower level of education confer a greater risk of unmet needs on admission and discharge. The routine use of a needs assessment instrument is recommended as an aid to guide clinicians. Attention needs to be given to basic and social needs, such as accommodation, daily activities and company, prior to admission to hospital. Where these needs persist, the active involvement of a social worker and occupational therapist is suggested. The high numbers of unmet needs in domains other than psychiatric problems, requires the input of the multidisciplinary team.

Background. HIV infection increases the risk for mental illness. Neuroimaging is an important part of the diagnostic workup in HIV+ psychiatric patients; CT is the primary neuroimaging modality available in resource limited settings. Despite advances in neuroimaging no clear guidelines exist for the use of CT in psychiatric settings. Objective. To determine the diagnostic yield of CT brain (CTB) scans in HIV+ psychiatric patients and to describe these abnormalities as well as demographic and clinical variables associated with abnormal CT scans. Methods. A retrospective study was conducted at the Department of Psychiatry and Mental illness at Groote Schuur Hospital, Cape Town, South Africa. Clinical and radiological data for HIV+ psychiatric patients who received a CTB scan during admission were analysed for the period January 2013 - June 2015. Results. A total of 65 patients met the inclusion criteria. The mean age of the participants in this study was 36.2 years (range 18 - 64). The most common presenting psychiatric symptoms were psychosis (81.54%), cognitive deficits (72.41%) and mood symptoms (69.23%). CT scans results consisted of 29 (44.62%) normal scans and 36 (55.38%) abnormal scans. Atrophy was the most common (72%) radiological finding in abnormal CT scans. No associations were found between current proposed CT guidelines in psychiatric patients, although a history of previous traumatic brain injury (TBI) approached significance (p = 0.054). There was a significant correlation between abnormal CT scans and past or current substance use (X² = 5.9508 P = .015). Abnormal CT findings increased with the Centers for Disease Control and Prevention (CDC) HIV immunological stage progression. The management of 9 patients changed; 7 of these CT scans were abnormal. Conclusion. In this study of CTB scans in HIV+ psychiatric inpatients, previously suggested criteria proposed in guidelines for imaging were not associated with significantly higher rates of abnormal CT findings. Current or previous substance use correlated with significant higher rates of abnormal CT findings. Due to the high yield of abnormal CT scans in this study, it is suggested that HIV+ psychiatric inpatients with previous or current substance use, a history of TBI or HIV immunological stages B or C, are considered for imaging. It is recommended that further studies with larger sample sizes, consisting of inpatient and outpatient populations, with control groups be conducted to investigate current or previous substance use as an indication in guidelines for CTB scan in HIV+ psychiatric patients.