Provider-initiated HIV counselling and testing (PICT) in the mentally ill

The prevalence of HIV infection is substantially higher in mentally ill individuals than in the general population. Despite this, HIV testing is not yet standard practice among the mentally ill population, and many mental health settings do not encourage HIV testing. This paper discusses provider-initiated HIV counselling and testing (PICT) and some of the ethical dilemmas associated with it, on the basis that PICT may be used to increase the number of mentally ill persons tested for HIV. The authors conclude that PICT should be promoted to all psychiatric admissions and mentally ill individuals receiving outpatient services, and that this is within the parameters of existing policies and legislations in South Africa

Strengthening of district mental health services in Gauteng Province, South Africa

In response to the Life Esidimeni tragedy, the Gauteng Department of Health established a task team to advise on the implementation of the Health Ombud’s recommendations and to develop a mental health recovery plan. Consistent with international human rights and South African legislation and policy, the plan focused on making mental healthcare more accessible, incorporating a strategy to strengthen district mental health services to deliver community-based care for people with any type and severity of mental illness. The strategy included an organogram with three new human resource teams integrated into the district health system: a district specialist mental health team to develop a public mental health approach, a clinical community psychiatry team for service delivery, and a team to support non-governmental organisation governance. This article discusses the strategy in terms of guiding policies and legislation, the roles and responsibilities of the various teams in the proposed organogram, and its sustainability

The South African society of psychiatrists (SASOP) and SASOP State Employed Special Interest Group (SESIG) position statements on psychiatric care in the public sector

Executive summary. National mental health policy: SASOP extends its support for the process of formalising a national mental health policy as well as for the principles and content of the current draft policy. Psychiatry and mental health: psychiatrists should play a central role, along with the other mental health disciplines, in the strategic and operational planning of mental health services at local, provincial and national level. Infrastructure and human resources: it is essential that the state takes up its responsibility to provide adequate structures, systems and funds for the specified services and facilities on national, provincial and facility level, as a matter of urgency. Standard treatment guidelines (STGs) and essential drug lists (EDLs): close collaboration and co-ordination should occur between the processes of establishing SASOP and national treatment guidelines, as well as the related decisions on EDLs for different levels. HIV/AIDS in children: national HIV programmes have to promote awareness of the neurocognitive problems and psychiatric morbidity associated with HIV in children. HIV/AIDS in adults: the need for routine screening of all HIV-positive individuals for mental health and cognitive impairments should also be emphasised as many adult patients have a mental illness, either before or as a consequence of HIV infection, constituting a ‘special needs’ group. Substance abuse and addiction: the adequate diagnosis and management of related substance abuse and addiction problems should fall within the domain of the health sector and, in particular, that of mental health and psychiatry. Community psychiatry and referral levels: the rendering of ambulatory specialist psychiatric services on a community-centred basis should be regarded as a key strategy to make these services more accessible to users closer to where they live. Recovery and re-integration: a recovery framework such that personal recovery outcomes, among others, become the universal goals by which we measure service provision, should be adopted as soon as possible. Culture, mental health and psychiatry: culture, religion and spirituality should be considered in the current approach to the local practice and training of specialist psychiatry, within the professional and ethical scope of the discipline. Forensic psychiatry: an important and significant field within the scope of state-employed psychiatrists, with 3 recognised groups of patients (persons referred for forensic psychiatric observation, state patients, and mentally ill prisoners), each with specific needs, problems and possible solutions. Security in psychiatric hospitals and units: it is necessary to protect public sector mental healthcare practitioners from assault and injury as a result of performing their clinical duties by, among others, ensuring that adequate security procedures are implemented, appropriate for the level of care required, and that appointed security staff members are appropriately trained and equipped.Dr Reddy’s Laboratorieshttp://www.sajp.org.za/index.php/sajpam2013ay201

Community psychiatry: An audit of the services in southern Gauteng

Aim. To audit the community psychiatric services in southern Gauteng with a view to determining whether the objectives of the country’s mental health legislation and policies are being achieved. Results. Although southern Gauteng’s community psychiatric clinics are situated in a primary health setting, primary health clinicians play no active role in the management of mentally ill patients. Care is supplied mainly by specialist psychiatrists, psychiatric registrars (in training) and psychiatric nurses. For first appointments, a mean of 2 patients are seen per doctor per clinic day for a mean duration of 30 minutes. For follow- up appointments, a mean of 17 patients are seen per doctor per clinic day for a mean duration of 8 minutes. The waiting time for new patient appointments is a mean of 6 months. Follow-up patients are seen once a month by nursing staff and approximately once every 4 months by doctors. An average of 1 in 5 patients is treated with oral atypical antipsychotics; in the majority of clinics, this is the total extent of care. However, where psychologists, social workers and occupational therapists are present, only 0.2% of all users have access to them. Conclusion. The community psychiatric services, although better than those in some other countries, fall short of what is required by South African legislation and policies. General community health services ought to play an active role in the structure and delivery of psychiatric services by developing and strengthening the current limited services, with an emphasis on cost-effective and preventive approaches. Existing community psychiatric services, if so transformed, could serve as a model for other countries in Africa

Antidepressants versus interpersonal psychotherapy in treating depression in HIV-positive patients.

Aim. Despite the prevalence of HIV and AIDS in South Africa reaching pandemic proportions, very few studies have been published on co-morbid depression. This study at Chris Hani Baragwanath Hospital was conducted on a group of HIV-positive patients with depression who were receiving antiretroviral treatment. The aim of the study was to describe their response to treatment with either an antidepressant or psychotherapy. Method. The study was prospective, randomised and controlled. The sampling was a convenience sampling, as it included patients attending the HIV clinic. At entry to the study, a clinical diagnostic evaluation and the Hamilton Depression Rating Scale (HAMD) were performed on all subjects by the investigator. The depressed patients were randomly assigned to receive either an antidepressant (citalopram) or psychotherapy (interpersonal psychotherapy, IPT). The HAMD was repeated at the study endpoint of 8 weeks. Results. Sixty-two HIV-positive persons on antiretrovirals participated in this study. Thirty of them were not depressed and served as controls, and 32 were depressed. There were no significant differences between the controls and the patients (either receiving pharmacotherapy or psychotherapy) in respect of any of the socio-demographic characteristics evaluated (p>0.05). Approximately 60% (n=19) of the depressed patients were, randomised to receive pharmacotherapy, while 40.6% (n=13) received IPT. The mean HAMD scores of the patients on pharmacotherapy decreased from 25.7 to 6.2 from entry to completion of the study, and those for patients receiving psychotherapy decreased from 22.5 to 8.2. The decreases in HAMD scores in patient groups receiving either pharmacotherapy or psychotherapy were not significantly associated with any socio-demographic variables (p>0.05). Conclusion. Both pharmacotherapy and psychotherapy may be equally effective in the treatment of depression in HIV-positive patients. The choice of treatment will be influenced by factors such as adverse effects of antidepressants and adding another medication to an already complex antiretroviral regimen. In such cases, IPT may be particularly beneficial

Orexin - does it have a role in mental illness?

Orexin-A and Orexin-B (also known as hypocretin 1 and 2) are, respectively, 33- and 28-amino acid residue peptides that activate a G-protein-coupled ‘orphan’ receptor, i.e. which has no known ligand.  Immuno-cytochemical studies show that orexin-positive neurons are located in the lateral hypothalamic area and arcuate and perifornical nuclei. They are also found in various sites beyond the hypothalamus such as the thalamic paraventricular and reuniens nuclei, locus coeruleus, nucleus of the solitary tract, raphe and septal nuclei. The hypothalamus has a major role in regulating various behaviours that contribute to homeostasis (such as arousal, feeding, and thermoregulation) by integrating external and internal stimuli.  It is involved in the regulation of nutritional status via the co-ordination of many neurotransmitter systems implicated in food intake and energy expenditure. The hypothalamic orexin system directly and strongly innervates and potently excites noradrenergic, dopaminergic, serotonergic, histaminergic and cholinergic neurons. Orexin also has a major role in modulating the release of glutamate and other amino acid transmitters. This widespread distribution and effect of orexin on multiple neurotransmitters suggests that it may be implicated in functions other than feeding, viz. other vegetative and neuroendocrine regulations or those related to general arousal states

The use of restraints in psychiatric patients

Restraints are usually used for the protection of patients and others when medication and verbal therapies are insufficient to control potentially violent patients. Many fear the abuse of restraints as well as their psychological, physical and emotional consequences. In South Africa, according to the Mental Health Care Act No. 17 of 2002, the use of restraints is permissible but subject to certain regulations. Restraint may not be used any longer than is necessary to prevent serious bodily harm to the patient or others. When restraint has the desired effect of settling the patient’s behaviour to the point where control is regained, its further imposition is illegal. Restraints may be classified into three main categories: ( i ) environmental restraints; ( ii ) physical restraints; and ( iii ) chemical restraints. There is much debate over what types of restraint are superior. There may be differences in cost, risk of serious staff injury, requirements of staff time for monitoring and implementation, and impacts on staff and patient attitudes. It is hoped that the use of environmental and physical restraint will be rendered obsolete by advances in the field of psychiatry such psychopharmacology and the therapeutic milieu. In order to reach this goal more research needs to be done on restraint practices across a wide range of psychiatric treatment settings

Feelings of hopelessness in stable HIV-positive patients on antiretrovirals

Aim. The coping skills and styles individuals utilise to deal with the stress of HIV infection greatly influence the psychological impact of this illness and potential consequent feelings of hopelessness. The aim of this study was to describe levels of hopelessness in a group of stable, non-depressed HIV-positive patients receiving antiretroviral therapy, and factors associated with hopelessness. Method. Thirty randomly selected non-depressed patients (according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria) were included in this study. Demographic and other data were obtained from all subjects, who also completed the Beck’s Hopelessness Scale (BHS). The 20 true-false items of the BHS (29) measured three major aspects of hopelessness, which was interpreted on the total scale score as follows: ≤3 minimal, and >3 significant. Results. The study population comprised 30 patients with a mean age of 37.9 years (standard error (SE) 1.18) ( range 28 - 51 years). The mean BHS score was 4.03 (SE 0.55), with a range from 0 to 12. There were no statistically significant correlations between BHS scores of the study population and gender, marital status, employment status, level of education, years since the diagnosis of HIV, or number of children (p>0.05). Eighteen subjects (60%) scored 3 or less on the BHS, considered minimal levels of hopelessness. However, 12 (40%) scored more than 3, which is considered significant; of these 23% had scores of 7 or more. There was no statistically significant association between BHS scores and gender, employment status, level of education, number of children or number of years since diagnosis (p>0.05). However, patients who were married or living with partners were statistically more likely to score higher on the hopelessness scale compared with those who were single (

A review of the applications for involuntary admissions made to the Mental Health Review Boards by institutions in Gauteng in 2008

Aim. To review applications for involuntary admissions made to the Mental Health Review Boards (MHRBs) by institutions in Gauteng. Method. A retrospective review of the register/database of the two review boards in Gauteng for the period January - December 2008. All applications for admissions (involuntary and assisted inpatient) and outpatient care (involuntary and assisted), and periodic reports for continued care (inpatient or outpatient care) were included. Results. During the study period the two MHRBs received a total of 3 803 applications for inpatient care, of which 2 526 were for assisted inpatient care (48.1% regional hospitals, 29.6% specialised psychiatric hospitals, 22.2% tertiary academic hospitals). Of the applications for involuntary inpatient care, 73.1% were from the specialised psychiatric hospitals (65.2% from Sterkfontein Hospital). Applications for outpatient care, treatment and rehabilitation (CTR) numbered 1 226 (92% assisted outpatient CTR). Although the health establishments in northern Gauteng applied for more outpatient CTR compared with those in southern Gauteng (879 v. 347, respectively), the ratios of assisted to involuntary outpatient applications for CTR for each region were similar (approximately 12:1 and 9:1, respectively). The boards received 3 805 periodic reports for prolonged CTR (93.5% inpatient, 6.5% outpatient), in the majority of cases for assisted CTR. Conclusion. The study suggests that in the 4 years since the promulgation of the MHCA in 2004 , there have been significant strides towards implementation of the procedures relating to involuntary admission and CTR by all stakeholders. Differences in levels of implementation by the various stakeholders may result from differences in knowledge, perceptions, attitudes and understanding of their roles and therefore indicate the need for education of mental health care professionals and the public on a massive scale. The Department of Health also needs to invest more funds to improve mental health human resources and infrastructure at all health establishments

Treating depression in HIV/AIDS

The prevalence of HIV/AIDS has reached alarming proportions in South Africa. Although it is strongly associated with depressive moods, there are very few published studies on its treatment in patients with HIV/AIDS. This article reviews the prevalence, treatment and potential effects of depressive disorders on immunity and adherence to antiretroviral therapy (ART).The studied prevalence of depressive disorders in HIV-positive patients varies widely, ranging from 0% to 47.8%. However, these patients have nearly twice the likelihood of having had a recent episode of major depressive disorder compared with HIV-negative individuals. Currently available antidepressant medications are equally effective in treating HIV/AIDS patients and the general population. Furthermore, intervention studies have shown that psychotherapy reduces depressive symptoms and is well tolerated. Interpersonal psychotherapy is more successful than supportive psychotherapy in lessening depression, and patients experience improved functioning physically and emotionally. Untreated depression may be associated with reduced adherence to ART, immunosuppression, and more rapid HIV illness progression. In South Africa, HIV/AIDS patients may be at greater risk for psychiatric disorder given the potentially stressful living conditions including high rates of unemployment and poverty, poor and unstable housing, inadequate social services, and high rates of crime and domestic violence. A lack of data on depression in South Africa underscores the need for further research