Clinical practice guideline adaptation methods in resource-constrained settings : four case studies from South Africa

CITATION: McCaul, Michael et al. 2020. Clinical practice guideline adaptation methods in resource-constrained settings : four case studies from South Africa. BMJ Evidence-Based Medicine, 25(6):193-198, doi:10.1136/bmjebm-2019-111192.The original publication is available at: https://ebm.bmj.comDeveloping a clinical practice guideline (CPG) is expensive and time-consuming and therefore often unrealistic in settings with limited funding or resources. Although CPGs form the cornerstone of providing synthesised, systematic, evidence-based guidance to patients, healthcare practitioners and managers, there is no added benefit in developing new CPGs when there are accessible, good-quality, up-to-date CPGs available that can be adapted to fit local needs. Different approaches to CPG development have been proposed, including adopting, adapting or contextualising existing high-quality CPGs to make recommendations relevant to local contexts. These approaches are attractive where technical and financial resources are limited and high-quality guidance already exists. However, few examples exist to showcase such alternative approaches to CPG development. The South African Guidelines Excellence project held a workshop in 2017 to provide an opportunity for dialogue regarding different approaches to guideline development with key examples and case studies from the South African setting. Four CPGs represented the topics: mental health, health promotion, chronic musculoskeletal pain and prehospital emergency care. Each CPG used a different approach, however, using transparent, reportable methods. They included advisory groups with representation from content experts, CPG users and methodologists. They assessed CPGs and systematic reviews for adopting or adapting. Each team considered local context issues through qualitative research or stakeholder engagement. Lessons learnt include that South Africa needs fit-for-purpose guidelines and that existing appropriate, high-quality guidelines must be taken into account. Approaches for adapting guidelines are not clear globally and there are lessons to be learnt from existing descriptions of approaches from South Africa.Publisher's versio

Prevalence and clinical correlates of substance use disorders in South African Xhosa patients with schizophrenia

Purpose: To determine the prevalence of substance use disorders (SUDs) in patients with schizophrenia in a sample from South Africa and compare the clinical and demographic correlates in those with and without co-occurring SUDs. Methods: Patients with schizophrenia were interviewed using the Xhosa version SCID-I for DSM-IV. We used logistic regression to determine the predictors of SUDs. Results: In the total sample of 1420 participants, SUDs occurred in 47.8%, with the most prevalent SUD being cannabis use disorders (39.6%), followed by alcohol (20.5%), methaqualone (6.2%), methamphetamine (4.8%) and other SUDs (cocaine, ecstasy, opioids, 0.6%). Polydrug use occurred in 40%, abuse occurred in 13.5%, and 39.6% had at least one substance dependence diagnosis. Signifcant predictors of any SUD were younger age (41–55 vs. 21–30: OR=0.7, 95% CI=0.5–0.9), male sex (OR=8.6, 95% CI=5.1–14.6), inpatient status (OR=1.7, 95% CI=1.3–2.1), post-traumatic stress symptoms (OR=4.6, 95% CI=1.6–13.3), legal (OR=3.4, 95% CI=2.0–5.5) and economic problems (OR=1.4, 95% CI=1.0–2.0). Methamphetamine use disorders occurred signifcantly less often in the Eastern compared to the Western Cape provinces. Inpatient status and higher levels of prior admissions were signifcantly associated with cannabis and methamphetamine use disorders. Post-traumatic stress symptoms were signifcantly associated with alcohol use disorders. Anxiety disorders were associated with other SUDs. Conclusion: SUDs occurred in almost half of the sample. It is important for clinicians to identify the presence of SUDs as their presence is associated with characteristics, such as male sex, younger age, inpatient status, more prior hospitalisations, legal and economic problems, PTSD symptoms and anxiety

The relationship between childhood trauma and schizophrenia in the Genomics of Schizophrenia in the Xhosa people (SAX) study in South Africa

Background. Evidence from high-income countries suggests that childhood trauma is associated with schizophrenia. Studies of childhood trauma and schizophrenia in low and middle income (LMIC) countries are limited. This study examined the prevalence of childhood traumatic experiences among cases and controls and the relationship between specific and cumulative childhood traumatic experiences and schizophrenia in a sample in South Africa. Methods. Data were from the Genomics of Schizophrenia in the South African Xhosa people study. Cases with schizophrenia and matched controls were recruited from provincial hospitals and clinics in the Western and Eastern Cape regions in South Africa. Childhood traumatic experiences were measured using the Childhood Trauma Questionnaire (CTQ). Adjusted logistic regression models estimated associations between individual and cumulative childhood traumatic experiences and schizophrenia. Results. Traumatic experiences were more prevalent among cases than controls. The odds of schizophrenia were 2.44 times higher among those who experienced any trauma than those who reported no traumatic experiences (95% CI 1.77–3.37). The odds of schizophrenia were elevated among those who experienced physical/emotional abuse (OR 1.59, CI 1.28–1.97), neglect (OR 1.39, CI 1.16–1.68), and sexual abuse (OR 1.22, CI 1.03–1.45) compared to those who did not. Cumulative physical/emotional abuse and neglect experiences increased the odds of schizophrenia as a dose–response relationship. Conclusion. Childhood trauma is common in this population. Among many other benefits, interventions to prevent childhood trauma may contribute to a decreasing occurrence of schizophrenia

Reply to: New Meta- and Mega-analyses of Magnetic Resonance Imaging Findings in Schizophrenia: Do They Really Increase Our Knowledge About the Nature of the Disease Process?

This work was supported by National Institute of Biomedical Imaging and Bioengineering Grant No. U54EB020403 (to the ENIGMA consortium)

Textbook of Psychiatry First Edition, Draft 2

This multi-authored collaborative textbook on psychiatry, originally created on Wikibooks, discusses a range of psychiatric disorders, including psychotic, mood and and anxiety disorders, amongst many others. It covers other aspects of psychiatric care such as diagnosis, neurobiology, psychopharmacology, treatment methods, and dealing with agitated or violent patients

In vivo hippocampal subfield volumes in bipolar disorder—A mega-analysis from The Enhancing Neuro Imaging Genetics through Meta-Analysis Bipolar Disorder Working Group

The hippocampus consists of anatomically and functionally distinct subfields that may be differentially involved in the pathophysiology of bipolar disorder (BD). Here we, the Enhancing NeuroImaging Genetics through Meta‐Analysis Bipolar Disorder workinggroup, study hippocampal subfield volumetry in BD. T1‐weighted magnetic resonance imaging scans from 4,698 individuals (BD = 1,472, healthy controls [HC] = 3,226) from 23 sites worldwide were processed with FreeSurfer. We used linear mixed‐effects models and mega‐analysis to investigate differences in hippocampal subfield volumes between BD and HC, followed by analyses of clinical characteristics and medication use. BD showed significantly smaller volumes of the whole hippocampus (Cohen's d = −0.20), cornu ammonis (CA)1 (d = −0.18), CA2/3 (d = −0.11), CA4 (d = −0.19), molecular layer (d = −0.21), granule cell layer of dentate gyrus (d = −0.21), hippocampal tail (d = −0.10), subiculum (d = −0.15), presubiculum (d = −0.18), and hippocampal amygdala transition area (d = −0.17) compared to HC. Lithium users did not show volume differences compared to HC, while non‐users did. Antipsychotics or antiepileptic use was associated with smaller volumes. In this largest study of hippocampal subfields in BD to date, we show widespread reductions in nine of 12 subfields studied. The associations were modulated by medication use and specifically the lack of differences between lithium users and HC supports a possible protective role of lithium in BD