Chronic substance use and self-harm in a primary health care setting

Background: Chronic substance use (CSU) is associated with health problems, including selfharm, placing a significant burden on health care resources and emergency departments (EDs). This is problematic in low- and middle-income countries like South Africa (SA), where primary care facilitates and emergency departments (EDs) are often poorly resourced. Aim: To investigate the epidemiology of CSU and self-harm and to consider the implications for primary health care service delivery and suicide prevention in SA. Methods: Data were collected from 238 consecutive self-harm patients treated at the emergency department (ED) of an urban hospital in SA. The data were analysed using bivariate and multivariate analyses. Results: Approximately 37% of self-harm patients reported CSU. The patients in the CSU subgroup, compared to other self-harm patients, were more likely to be men (odds ratio[OR] = 8.33, 95% confidence interval [CI] = 3.19–20.9, p < 0.001), to have self-harmed by inflicting damage to their body tissue OR = 4.45, 95% CI = 1.77–11.2, p < 0.01) and to have a history of self-harm (OR = 3.71, 95% CI = 1.44–9.54, p = 0.007). A significantly smaller proportion of CSU patients, compared to other self-harm patients, were referred for psychiatric assessment (OR = 8.05, 95% CI = 4.16–15.7, p < 0.001). Conclusion: The findings of this study confirm that CSU is associated with greater service utilisation and repetition of self-harm among patients in primary health care settings. Treating self-harm as the presenting problem within primary care settings does not necessarily ensure that patients receive the care that they need. It might be helpful to include psychiatric assessments and screening for CSU as an integral component of care for self-harm patients who present in primary health care settings

Substance use and self-harm: a cross-sectional study of the prevalence, correlates and patterns of medical service utilisation among patients admitted to a South African hospital

Abstract Background Substance use is a potentially modifiable risk factor for suicidal behaviour. Little is known about the epidemiology of substance use among self-harm patients in South Africa. This study set out to collect epidemiological data about the prevalence, correlates, and patterns of medical service utilisation among self-harm patients who used substances at the time of self-injury. Methods Data from 238 consecutive self-harm patients treated at an urban hospital in South Africa were analysed using bivariate and multivariate statistics. Results Approximately 20% of patients reported substance use at the time of self-harm. When compared to other self-harm patients, higher rates of patients who had used substances: had depressed levels of consciousness on admission; utilised more medical resources and required longer hospital admissions; cited relationship difficulties and financial concerns as reasons for their self-harm; reported a previous episode of self-harm; and intended to die as a result of their injuries. Although the observed differences were not statistically significant (p > 0.05), the proportional differences were congruent with international literature. Conclusion Acute use of substances among self-harm patients warrants more focused research and clinical attention particularly in the context of reducing utilisation of scarce medical resources

South African university students’ experiences of online group cognitive behavioural therapy: Implications for delivering digital mental health interventions to young people

Mental disorders are common among university students. In the face of a large treatment gap, resource constraints and low uptake of traditional in-person psychotherapy services by students, there has been interest in the role that digital mental health solutions could play in meeting students’ mental health needs. This study is a cross-sectional, qualitative inquiry into university students’ experiences of an online group cognitive behavioural therapy (GCBT) intervention. A total of 125 respondents who had participated in an online GCBT intervention completed a qualitative questionnaire, and 12 participated in in-depth interviews. The findings provide insights into how the context in which the intervention took place, students’ need for and expectations about the intervention; and the online format impacted their engagement and perception of its utility. The findings of this study also suggest that, while online GCBT can capitalise on some of the strengths of both digital and in-person approaches to mental health programming, it also suffers from some of the weaknesses of both digital delivery and those associated with in-person therapies

Methods of deliberate self-harm in a tertiary hospital in South Africa

CITATION: Pieterse, D. et al. 2020. Methods of deliberate self-harm in a tertiary hospital in South Africa. South African Journal of Psychiatry, 26:a1399, doi:10.4102/sajpsychiatry.v26i0.1399.The original publication is available at https://sajp.org.zaBackground: Little is known about the methods of deliberate self-harm (DSH) in South Africa (SA), despite the importance of means restriction as a public health strategy to reduce the morbidity and mortality associated with self-harm. Aim: The aim of this study was to investigate the range of methods used in DSH and identify the socio-demographic and clinical factors associated with violent and non-violent methods of DSH among patients treated at a tertiary hospital in SA. Setting: The study was conducted at an urban, tertiary level emergency department at Groote Schuur hospital in Cape Town, South Africa. Method: Data were collected from 238 consecutive DSH patients who presented for emergency department treatment at the hospital. Logistic regression models were used to explore the factors associated with violent and non-violent methods of DSH. Results: Self-poisoning was the most common method of self-harm (80.3%). Prescription medication was the most common form of self-poison (57.6%), while a large number of patients used non-prescription paracetamol (40.9%). In the 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: Improved monitoring of prescription medications commonly used in DSH is integral to public health suicide prevention strategies in SA. This study underscores the need for substance use interventions in the healthcare setting.South African Medical Research Councilhttps://sajp.org.za/index.php/sajp/article/view/1399Publisher's versio

The prevalence of mental health problems in sub-saharan adolescents : a systematic review

Background and purpose Most research regarding child and adolescent mental health prevention and promotion in low-and middle-income countries is undertaken in high-income countries. This systematic review set out to synthesise findings from epidemiological studies, published between 2008 and 2020, documenting the prevalence of mental health problems in adolescents from across sub-Saharan Africa. Methods A systematic search of multiple databases (MEDLINE, PsycINFO, Scopus) and Google Scholar was conducted guided by the Joanna Briggs Institute (JBI) Reviewer's manual for systematic reviews of observational epidemiological studies. Studies included reported prevalence outcomes for adolescents aged 10-19 using either clinical interviews or standardized questionnaires to assess psychopathology. Clinical samples were excluded. Results The search yielded 1 549 records of which 316 studies were assessed for eligibility and 51 met the inclusion criteria. We present a qualitative synthesis of 37 of these 51 included articles. The other 14 studies reporting prevalence rates for adolescents living with HIV are published elsewhere. The prevalence of depression, anxiety disorders, emotional and behavioural difficulties, posttraumatic stress and suicidal behaviour in the general adolescent population and selected at-risk groups in 16 sub-Saharan countries (with a total population of 97 616 adolescents) are reported.Hochschule für Angewandte Wissenschaften HamburgPeerReviewe

Design and development process of a youth depression screening m-health application for primary health care workers in South Africa and Zambia : an overview of the MEGA project

Literature indicates a high prevalence and burden of mental illness in youths world-wide, which may be even higher in low- and middle-income countries (LMIC), such as South Africa and Zambia. Additionally, there is a lack of knowledge regarding youth depression amongst many primary health care (PHC) practitioners. The principal goal of the MEGA project is to provide youth with better access to mental health services and appropriate care, by developing a mental health screening mobile application tool to be used in PHC settings in South Africa and Zambia. In this study, we will use a mixed methods multi-center study design. In phase one, we will investigate the mental health literacy of PHC practitioners to identify areas in need of development. Based on the needs identified, we will develop and test a mobile health application to screen for common youth mental health problems in phase two. In phase three, we will implement and evaluate a tiered education and training program in the use of the m-health application. In the final phase, we will evaluate the acceptability and feasibility of the m-health application in PHC centres across South Africa and Zambia. Evidence suggests that PHC practitioners should routinely consider mental illness when assessing youth. However, common psychiatric disorders remain largely undetected and untreated in PHC settings. By identifying limitations in PHC workers knowledge with regard to youth mental health, we aspire to improve the depression care provided to youth in Southern Africa and Zambia by developing and implementing a locally relevant m-health application.http://www.tandfonline.com/loi/imhn20hj2020Psychiatr

Substance use and self-harm at an urban South African hospital: implications for suicide prevention, service delivery and future research

Thesis (PhD)--Stellenbosch University, 2018.ENGLISH SUMMARY: Self-harm is a form of suicidal behaviour which constitutes a serious public health problem in low-income and middle-income countries (LMICs). The World Health Organization identifies substance use as a potentially modifiable risk factor for suicidal behaviour, including self-harm. Little is known about the prevalence, correlates, nature, and context of substance use among self-harm patients in South Africa. In this thesis, I explored the relationship between substance use and self-harm among patients who presented for treatment at an urban hospital in the Western Cape, South Africa. I employed a mixed methods research design and present my findings in the form of four journal articles. In the first article, I report on the results of a systematic review to investigate what is known, and what remains unknown, about the relationship between substance use and suicidal behaviour in LMICs. From the review results, I argue that: (1) the assessment and management of substance use should be integral to the care of at-risk patients; (2) suicide prevention research in LMICs should focus on reducing hazardous use of alcohol, tobacco, cannabis, opioids, sedatives, stimulants and non-medical use of medications; and (3) more research is required to understand the nature of the relationship between substance use and suicidal behaviour. In articles two and three, I report on two quantitative studies, consisting of a retrospective review of patient files to establish the demographic characteristics, patterns of medical service utilisation, and sociocultural differences between self-harm patients who report substance use and other self-harm patients (i.e. those who reported no substance use) among 238 self-harm patients. I focused on acute use of substances (i.e. substance intoxication) (AUS) in article two and chronic substance use (i.e. recurrent substance use over an extended period) (CSU) in article three. In article two, bivariate and multivariate statistical analysis showed that one in five selfharm patients reported AUS. Compared to other self-harm patients, the AUS sub-group were more inclined to: have depressed levels of consciousness on admission; utilise more medical resources; report previous acts of self-harm; and state an intention to die as a result of their injuries. In article three, 37% of self-harm patients reported CSU. Compared to other self-harm patients, the CSU sub-group were more likely to be male; to inflict damage to their body tissue; and to have a history of self-harm. A significantly smaller proportion of CSU patients, compared to other self-harm patients, were referred for psychiatric assessment (p<0.001). For article four, I conducted a qualitative study by analysing semi-structured interviews of 80 self-harm patients who were admitted to the hospital. I made use of a multiple-case study methodology and identified seven ways in which patients understood their substance use was implicated in their self-harm: impulsivity, poor judgment, and aggression; auditory hallucinations or paranoia related to substance use; substance use to facilitate self-harm; substance use as a method of self-harm; unsuccessful treatment for substance use disorder; the breakdown of substance use as a means of coping; and third-party substance use. I conclude this thesis by, reflecting on the broad aim and offering recommendations for future research and suicide prevention at the hospital where data were collected.AFRIKAANSE OPSOMMING: Selfbeskadiging is ‘n vorm van selfmoordgedrag wat 'n ernstige openbare gesondheidsprobleem is in lae-inkomste- en middelinkomste-lande (LMIL). Die Wêreldgesondheidsorganisasie (WGO) identifiseer substansgebruik as 'n potensieel veranderbare risikofaktor vir sekere uitkomste onder individue wat selfbeskadig. Min is bekend oor die voorkoms en korrelate, aard, en konteks van substansgebruik onder selfbeskadigingpasiënte in Suid-Afrika. In hierdie proefskrif, ondersoek ek die verhouding tussen substansgebruik en selfbeskadiging, asook die sosiokulturele konteks waarin hierdie gedrag plaasgevind het, onder pasiënte wat behandeling ontvang in 'n stedelike hospitaal in die Wes-Kaap, Suid-Afrika. Ek het 'n gemengde metode navorsingsontwerp onderneem en my gevolgtrekkings in vier tydskrif artikels aangebied. In die eerste artikel rapporteer ek die resultate van 'n sistematieseoorsig om ondersoek in te stel oor wat bekend is, en wat nog onbekend is, van die verhouding tussen substansgebruik en selfmoordgedrag in LMIL. Vanuit die resultate argumenteer ek dat: (1) die assessering en bestuur van substansgebruik ʼn integrale deel moet wees van die versorging van risiko-pasiënte; (2) selfmoordvoorkomingsnavorsing in LMIL moet fokus op die vermindering van die gevaarlike gebruik van alkohol, tabak, cannabis, opioïede, kalmeermiddels, stimulante en die nie-mediese gebruik van medisyne; en (3) meer navorsing benodig word om die aard van die verhouding tussen substansgebruik en selfmoordgedrag te verstaan. In artikels twee en drie, rapporteer ek oor twee kwantitatiewe studies wat behels die retrospektiewe hersiening van pasiëntlêers om die demografiese eienskappe, patrone van mediese diensbenutting en sosiokulturele verskille te identifiseer tussen selfbeskadigingpasiënte wat substansgebruik rapporteer en ander selfbeskadigingpasiënte (diegene wat geen substansgebruik rapporteer het nie) onder 'n kohort van 238 selfbeskadigingpasiënte. In artikel twee het ek gefokus op die akute gebruik van substanse (d.w.s. substansinname) (AGS) terwyl ek in artikel drie gefokus het op chroniese substansgebruik (d.w.s. herhalende substansgebruik oor 'n verlengde tydperk) (CSG). In artikel twee het bivariate en multivariate statistiese analise getoon dat een uit vyf selfbeskadigingpasiënte AGS gerapporteer het. In vergelyking met ander selfbeskadigingpasiënte was die AGS-subgroep meer geneig om depressiewe vlakke van bewussyn te toon by opname in die hospitaal; gebruik te maak van meer mediesehulpbronne; langer hospitaalopnames te vereis; vorige selfbeskadigings dade te noem; en te beoog om te sterf as gevolg van hul beserings. In artikel drie het 37% van die selfbeskadigingpasiënte CSG geraporteer. In vergelyking met ander selfbeskadigingpasiënte was die CSG-subgroep meer geneig om manlik te wees; skade aan hul liggaamsweefsel te veroorsaak; en 'n geskiedenis van selfbeskadiging te hê. 'n Statistiesebeduidende kleiner persentasie CSG-pasiënte, in vergelyking met ander selfbeskadigingpasiënte, is verwys vir psigiatriese assessering (p<0.001). In artikel vier het ek 'n kwalitatiewe studie gedoen deur semi-gestruktureerde onderhoude te analiseer van 80 selfbeskadigingpasiënte wat in die hospitaal opgeneem is. Ek het gebruik gemaak van 'n meervoudige gevallestudie-metodologie en het sewe maniere geïdentifiseer waarop pasiënte verstaan hulle substansgebruik betrokke was in hul selfbeskadiging: impulsiwiteit, swak oordeel, en aggressie; ouditiewe hallusinasies of paranoia wat verband hou met substansgebruik; substansgebruik om selfbeskadiging te fasiliteer; substansgebruik as 'n metode van selfbeskadiging; onsuksesvolle behandeling vir substansgebruiksversteuring; die ineenstorting van substansgebruik as 'n manier om moeilikhede te hanteer; en derdepartysubstansgebruik

The relationship between intimate partner violence, HIV-related stigma, social support, and mental health among people living with HIV

Thesis (MSc)--Stellenbosch University, 2012.ENGLISH ABSTRACT: Global estimates show that sub-Saharan Africa has the largest portion of HIV cases with South Africa having more people living with HIV than any other country in the world. Moreover, studies have shown a high incidence of intimate partner violence (IPV) among people living with HIV. IPV has been shown to be associated with mental health problems. Considerable empirical studies have demonstrated that HIV is a highly stigmatized disease. In addition, HIV-related stigma has also been shown to be a risk factor for mental health problems among persons living with HIV. However, no empirical studies have examined the combined effect of IPV and HIV-related stigma on mental health. This thesis builds on the existing body of research by examining to what extent the linear combination of IPV (timing and frequency) and HIV related stigma explained variation in symptoms of common mental health disorders in both men and women living with HIV. In addition, theoretical and empirical studies have suggested that social support may serve as a protective factor in the relationship between IPV, HIV-related stigma, and mental health. Yet, despite the increasing attention, no known studies have focused on the mediating or moderating role of social support in the relationship between IPV or HIV-related stigma, and mental health. This thesis examined the extent to which social support played a mediating or moderating role in these relationships. The study used a cross-sectional research design to study a convenience sample of 210 people living with HIV in three peri-urban areas in the Western Cape, South Africa. Participants completed a battery of self-report questionnaires that assessed IPV (timing and frequency), HIV-related stigma, social support, and symptoms of common mental health. The results from the hierarchical multiple regression analysis demonstrated that the linear combination of psychological aggression frequency and HIV related stigma explained a significant portion of the variance in symptoms of depression. Likewise, both physical assault timing and psychological aggression timing combined with HIV-related stigma explained a significant portion of variance in symptoms of depression. Psychological aggression timing combined with HIV-related stigma significantly explained variance in symptoms of posttraumatic stress disorder (PTSD). The results from the product-term regression analyses indicated that social support played a mediating role in the relationship between HIV-related stigma and symptoms of PTSD, but not depression. Social support did not moderate the relationship between HIV-related stigma and symptoms of common mental health disorders. In conclusion, the combination of IPV (physical assault and psychological aggression) and HIV-related stigma explained a significant portion of the variance in symptoms of common mental health disorders. Future research is needed for a better understanding of these relationships. A longitudinal experimental design is recommended in order to explore the direction of these relationships and to examine the context in which the IPV, HIV-related stigma, and social support is experienced.AFRIKAANSE OPSOMMING: Wêreldwye beramings toon dat sub-Sahara Afrika die grootste gedeelte van HIV gevalle te wêreld het, terwyl Suid-Afrika meer mense het wat met MIV leef as enige ander land in die wêreld. Verder het studies getoon dat daar 'n hoë voorkoms van intiemepaargeweld (IPV) is onder mense wat met MIV leef. Daar is al getoon dat IPV verband hou met geestelike probleme. Aansienlike empiriese studies het getoon dat MIV 'n hoogs gestigmatiseer siekte is. Daarbenewens, is daar getoon dat MIV-verwante stigma 'n risiko faktor is vir geestelike probleme onder persone wat leef met MIV. Daar is egter geen empiriese studies wat die gekombineerde effek van IPV en MIV-verwante stigma op geestesgesondheid ondersoek nie. Hierdie tesis bou voort op die bestaande navorsing deur te ondersoek tot watter mate die lineêre kombinasie van IPV (tydsberekening en frekwensie) en MIV-verwante stigma variasie in die simptome van algemene geestesgesondheid afwykings verduidelik in beide mans en vroue wat met MIV leef. Daarbenewens, het teoretiese en empiriese studies voorgestel dat sosiale ondersteuning kan dien as 'n beskermende faktor in die verhouding tussen IPV, MIV-verwante stigma, en geestesgesondheid. Tog, ten spyte van die toenemende aandag, het daar al geen studies gefokus op die bemiddelende of modererende rol van sosiale ondersteuning in die verhouding tussen IPV of MIV-verwante stigma, en geestesgesondheid. Hierdie tesis ondersoek die mate waarin sosiale ondersteuning 'n bemiddelende of modererende rol speel in hierdie verhoudings. Die studie het 'n deursnee-navorsing ontwerp gebruik om 'n gerieflikheidsteekproef van 210 mense wat met MIV leef in drie peri-stedelike gebiede in die Wes-Kaap, Suid-Afrika te bestudeer. Deelnemers het 'n battery van self-verslag vraelyste voltooi wat IPV (tydsberekening en frekwensie), MIV-verwante stigma, sosiale ondersteuning, en simptome van algemene geestesgesondheid geassesseer het. Die resultate van die hiërargiese meervoudige regressie-analise het getoon dat die lineêre kombinasie van sielkundige aggressie frekwensie en MIV-verwante stigma 'n beduidende deel van die variansie in simptome van depressie verduidelik. Net so, het beide fisiese aanranding tydsberekening en sielkundige aggressie tydsberekening gekombineer met MIV-verwante stigma 'n beduidende deel van die variansie in simptome van depressie verduidelik. Sielkundige aggressie tydsberekening gekombineer met MIV-verwante stigma het „n beduidende variansie in simptome van post-traumatiese stresversteuring (PTSV) verduidelik. Die resultate van die produk-term regressie-analises het aangedui dat sosiale ondersteuning 'n bemiddelende rol speel in die verhouding tussen MIV-verwante stigma en simptome van PTSV, maar nie depressie nie. Sosiale ondersteuning het nie die verhouding tussen MIV-verwante stigma en simptome van algemene geestesgesondheid versteurings modereer nie. Ten slotte, die kombinasie van IPV (fisiese aanranding en sielkundige aggressie) en MIV-verwante stigma het 'n beduidende deel van die variansie in simptome van algemene geestesgesondheid versteurings verduidelik. Toekomstige navorsing is nodig vir 'n beter begrip van hierdie verhoudings. 'n Longitudinale eksperimentele ontwerp word aanbeveel om die rigting van hierdie verhoudings te verken en die konteks waarin die IPV, MIV-verwante stigma en sosiale ondersteuning ervaar is te ondersoek

Substance use and suicidal ideation and behaviour in low- and middle-income countries : a systematic review

CITATION: Breet, E., Goldstone, D. & Bantjes, J. 2018. Substance use and suicidal ideation and behaviour in low- and middle-income countries : a systematic review. BMC Public Health, 18:549, doi:10.1186/s12889-018-5425-6.The original publication is available at https://bmcpublichealth.biomedcentral.comPublication of this article was funded by the Stellenbosch University Open Access Fund.Background: Understanding relationships between substance use and suicidal ideation and behaviour (SIB) has important public health implications for suicide prevention in low- and middle-income countries (LMICs), where 75% of suicides occur. This systematic review explored the associations between substance use and SIB in LMICs. Methods: We searched five databases using a combination of keywords for substance use, SIB and LMICs to identify English-written quantitative studies published between January 2006 and February 2016. Data were extracted to provide an overview of what is known about the topic, highlight gaps in the literature, and explore the implications of current knowledge for suicide prevention. Studies included in the review were assessed for methodological quality using the Scottish Intercollegiate Guidelines Network checklist. Results: Analysis of included studies (N = 108) demonstrated a consistent positive association between substance use and SIB across all substances (i.e. alcohol, tobacco, cannabis, illicit drugs, non-medical use of prescription drugs), all substance use dimensions (i.e. intoxication, use, and pathological use) and all SIB dimensions (i.e. suicidal ideation, nonfatal suicidal behaviour, and suicide). Most of the available research evidence comes from upper-middle-income countries, only 22% comes from lower-middle-income and low-income countries. Most studies focused on alcohol and tobacco, while neglecting substances such as cannabis, opioids, sedatives, stimulants, misuse of prescription medication, inhalants, and hallucinogens. Most of the studies employed a cross-sectional design, were conducted within a risk-factor paradigm, and provided little information about the potential interaction between variables. Conclusions: Public health suicide prevention policy and research in LMICs should take account of the fact that: substance use is a potentially modifiable risk factor; assessment and management of substance use is integral to the care of at-risk patients; reducing consumption and hazardous use of substances in LMICs is important for suicide prevention; and research needs to be expanded to include more theory driven research that focuses on all substance use dimensions and SIB dimensions, while employing more sophisticated statistical methods.Medical Research CouncilNational Research Foundation (NRF)https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5425-6Publisher's versio

Systematic review and narrative synthesis of suicide prevention in high-schools and universities: a research agenda for evidence-based practice

Abstract Background Youth suicide prevention in high-schools and universities is a public health priority. Our aim was to propose a research agenda to advance evidence-based suicide prevention in high-schools and universities by synthesizing and critically reviewing the research focus and methodologies used in existing intervention studies. Methods Fourteen databases were systematically searched to identify studies which evaluate suicide prevention interventions delivered on high-school or university campuses, with before and after measures. Data from included studies (n = 43) were extracted to identify what, where, how and for whom interventions have been tested. Narrative synthesis was used to critically evaluate research focus and methodology. Study quality was assessed. Results Research has focused primarily on selective interventions, with less attention on indicated and universal interventions. Most evidence comes from North America and high-income countries. The target of interventions has been: non-fatal suicidal behaviour; confidence and ability of staff/students to intervene in a suicidal crisis; suicide-related knowledge and attitudes; and suicide-related stigma. No studies included suicide deaths as an outcome, evaluated eco-systemic interventions, explored how context influences implementation, used multisite study designs, or focused explicitly on LGBTQ+ youth. Two studies evaluated digital interventions. Quality of the majority of studies was compromised by lack of methodological rigour, small samples, and moderate/high risk of bias. Interventions often assume the existence of an external well-functioning referral pathway, which may not be true in low-resource settings. Conclusion To advance evidence-based suicide prevention in educational settings we need to: conduct more high-quality clinical and pragmatic trials; promote research in low- and middle-income countries; test targeted interventions for vulnerable populations (like LGBTQ+ youth), evaluate interventions where death by suicide is the primary outcome; include translational studies and use implementation science to promote intervention uptake; evaluate the potential use of digital and eco-systemic interventions; and conduct multisite studies in diverse cultural settings