Practice guidelines for videoconference-based telepsychiatry in South Africa

Telepsychiatry, the practice of psychiatry over distance using information and communication technologies is, after teleradiology, the most practiced form of telemedicine in the world. As with any new technology, clinical service, or intervention in medicine, it is prudent to have guidelines for the safe and efficacious use of the technology in clinical practice. Guidelines facilitate best practice and provide both clinicians and patients with a set of standards and procedures that serve to protect their interests. Protection is particularly important when dealing with vulnerable groups.Web of Scienc

Doctorates by thesis and publication in clinical medicine: an analysis of examiners' reports

National and institutional policies to escalate the production of doctorates have raised concerns about the quality of PhDs in South Africa. This study evaluates examiner reports of doctorates by thesis and publication in clinical medicine to ascertain the criteria that examiners used to define a successful doctoral thesis. A qualitative hermeneutic approach through document analysis was taken, involving 54 national and international examiner reports of 18 doctoral theses, half of which were by publication. The examiners rated the majority (81%) of these theses to be of a high quality. Our results show a scatter of positive and negative aspects distributed across all 18 theses, with corresponding commendations and criticisms. Notably, almost equal emphasis was placed on conceptual and communication issues. Ratings per thesis were not always concordant, with five theses each given widely divergent ratings by three respective examiners. The study also found differences in ratings between examiners, based on whether they were medical or non- medical, international or national, and with or without PhDs themselves. While no single criterion was identifiable as being diagnostic of doctoral quality, the identified strengths and shortcomings of these theses serve as a useful platform for supervisors and students aspiring to cross the doctoral threshold

Sensitivity and specificity of neuropsychological tests for dementia and mild cognitive impairment in a sample of residential elderly in South Africa

BACKGROUND. Neuropsychological tests can successfully distinguish between healthy elderly persons and those with clinically significant cognitive impairment. Objectives. A battery of neuropsychological tests was evaluated for their discrimination validity of cognitive impairment in a group of elderly persons in Durban, South Africa. METHOD. A sample of 117 English-speaking participants of different race groups (9 with dementia, 30 with mild cognitive impairment (MCI) and 78 controls) from a group of residential homes for the elderly was administered a battery of 11 neuropsychological tests. Kruskal-Wallis independent sample tests were used to compare performance of tests in the groups. Sensitivity and specificity of the tests for dementia and MCI were determined using random operating curve (ROC) analysis. RESULTS. Most tests were able to discriminate between participants with dementia or MCI, and controls (p<0.05). Area under the curve (AUC) values for dementia v. non-dementia participants ranged from 0.519 for the digit span (forward) to 0.828 for the digit symbol (90 s), with 14 of the 29 test scores achieving significance (p<0.05). AUC values for MCI participants ranged from 0.754 for controlled oral word association test (COWAT) (Animal) to 0.507 for the Rey complex figure test copy, with 17 of the 29 scores achieving significance (p<0.05). CONCLUSION. Several measures from the neuropsychological battery had discrimination validity for the differential diagnosis of cognitive disturbances in the elderly. Further studies are needed to assess the effect of culture and language on the appropriateness of the tests for different populations.Web of Scienc

The association of depressive symptoms in patients with acute myocardial infarction in a regional hospital in Durban, South Africa

Objective: To examine the association of depressive symptoms and contributing psychosocial factors during hospitalisation and 1-month post discharge in patients with acute myocardial infarction (MI).Methods and results: The study population comprised consecutive patients from a multi-ethnic background, admitted June 2015 - November 2015 to the Coronary Care Unit at R. K. Khan Hospital, Durban, South Africa, with a diagnosis of MI. Demographic and clinical data stored in a specialised electronic cardiac database were extracted for all patients. Patients were screened for depressive symptoms using the Cardiac Depression Scale (CDS). Levels of perceived stress were evaluated using the 4-item Perceived Stress Scale (4-PSS). The study cohort consisted of 117 patients with a mean age of 58.16 ± 11.12 years, the majority of whom were males (70%, mean age 56.54 ± 1.23 years) and 30% females (mean age 61.97 ± 1.75 years). Forty-nine percent of the participants were diagnosed with depressive symptoms with a significantly greater number of females experiencing depressive symptoms compared to males (p &lt;0.01). Patients with depressive symptoms were more likely to have a previous history of depression (p=0.02), positive family history of depression (p=0.04), greater non-adherence to their medication (p &lt;0.01) and lower levels of physical activity (p &lt;0.01). Depressed patients also reported higher levels of stress on voluntary (p &lt;0.01) and subjective rating (p &lt;0.01), experienced greater financial stress (p &lt;0.01), major life events (p &lt;0.01) and had higher 4–PSS scores (p &lt;0.01). Thirteen percent of patients experienced major adverse cardiac events (MACE) with a significantly greater number of events found in those with depressive symptoms (p &lt;0.01).Conclusion: Depressive symptoms are a common finding in a South African population presenting with MI. They are linked to higher rates of MACE, a previous history and/or family history of depression, greater stress levels and major life events. Females with MI are significantly more likely to present with depressive symptoms. These findings suggest that patients with MI should be screened for depressive symptoms and psychosocial factors as this may serve as an important arena for research and therapeutic intervention

The sensitivity and specificity of subjective memory complaints and the subjective memory rating scale, deterioration cognitive observee, mini-mental state examination, six-item screener and clock drawing test in Dementia Screening.

Background: The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aim of this study was to evaluate the discriminant validity of 7 screening measures for dementia. Methods: A sample of 140 participants aged ≥60 years living in a residential facility for the aged were assessed clinically and assigned caseness for dementia using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised diagnostic criteria. Sensitivity and specificity of a selection of the following screening measures were tested using receiver operating characteristic (ROC) analysis for individual and combined tests: the Mini-Mental State Examination (MMSE), Six-Item Screener (SIS), Subjective Memory Complaint, Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO) and the Clock Drawing Test (CDT). Results: Using ROC analyses, the SMCC, MMSE and CDT were found to be ‘moderately accurate' in screening for dementia with an area under the curve (AUC) >0.70. The AUCs for the SIS (0.526), SMRS (0.661) and DECO (0.687) classified these measures as being ‘less accurate'. At recommended cutoff scores, the SMCC had a sensitivity of 90.9% and specificity of 45.7%; the MMSE had a sensitivity of 63.6% and a specificity of 76.0%, and the CDT had a sensitivity of 44.4% and a specificity of 88.9%. Combining the SMCC and MMSE did not improve their predictive power except for a modest increase when using the sequential rule. Conclusion: The SMCC is composed of valid screening questions that have high sensitivity, are simple to administer and ideal for administration at the community or primary health care level as a first level of ‘rule-out' screening. The MMSE can be included at a second stage of screening at the general hospital level and the CDT in specialist clinical settings. Sequential use of the SMCC and MMSE will improve the specificity of the former and the sensitivity of the latter.Department of HE and Training approved lis

Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile

OBJECTIVE: To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting. METHOD: One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain. RESULTS: The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis. CONCLUSION: The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.Web of Scienc

Screening a heterogeneous elderly South African population for cognitive impairment: the utility and performance of the Mini-Mental State Examination, Six Item Screener, Subjective Memory Rating Scale and Deterioration Cognitive Observee

OBJECTIVE: The aim of this study was to report on the prevalence of cognitive impairment, and to assess the performance and utility of subjective, objective and informant screening tools in a heterogeneous community sample. METHOD: A sample of 302 elderly participants (>60 years) living in residential homes in a large city in South Africa were screened for the presence of cognitive impairment using objective (Mini-Mental State Examination [MMSE] and Six Item Screener-[SIS]), subjective (Subjective Memory Complaint [SMC]and Subjective Memory Rating Scale [SMRS]) and informant (Deterioration Cognitive Observee [DECO]) screening tools. All tools were compared to the MMSE and the influence of demographic variables on the performance on these tools was considered. RESULTS: Significantly lower MMSE scores were found in participants aged 80-89 years (p=.023) and those who had 8-11 years of education (p=.002). For every one additional year of education, participants were 0.71 times less likely to screen positive on the MMSE. Differential item functioning on various components of the MMSE was demonstrated due to the effects of education, race and gender. There was significant differential performance between the recommended and alternate attention/concentration items (p<.001) with the alternate item favouring better performance. Based on the MMSE cutoff score of < 23, the prevalence of cognitive impairment was 16.9%; the prevalence yielded by the remaining tools ranged from 10.5% using the DECO to 46% as determined by the presence of a SMC. Using the MMSE as the reference standard for the presence of cognitive impairment, the SIS, SMC, SMRS and DECO had sensitivities of 82.3%, 54.6%, 17.0% and 37.5%, and specificities of 71.3%, 57.6%, 87.4% and 96.7% respectively. Age and race influenced performance on the MMSE, SIS and SMRS. CONCLUSION: Different types of cognitive screening tools yielded varying sensitivities and specificities for identifying cognitive impairment when compared to the MMSE. The influence of race, age and education on test performance highlights the need for suitable, culture-fair screening tools. Locally, the alternate item for attention/concentration should be preferred.Web of Scienc

Developing telepsychiatry services in KwaZulu-Natal - an action research study

OBJECTIVE: In 2009, the Departments of Psychiatry and Telehealth of the University of KwaZulu-Natal (UKZN) initiated a three year project to develop telepsychiatry services in KwaZulu-Natal. This paper describes the challenges and opportunities of this project. METHOD:This was a collaborative, in situ health service project and an action research framework was adopted. Over the three years, following a needs assessment and an e-health Readiness Assessment, two action research cycles were completed. Cycle 1: The preparation, implementation and evaluation of educational material, technical requirements and clinical guidelines and clinical support materials. Cycle 2: Preparation and evaluation of educational and clinical outreach sessions. RESULTS: Videoconference education sessions were beneficial to health staff without post-qualification psychiatry training. A flexible format for education improved knowledge outcomes. Clinical sessions are feasible, but require administration and technical support for facilitation. With facilitator training, 128Kbps is a suitable bandwidth for education but 384Kbps is preferred for clinical consultation. CONCLUSION: Telepsychiatry offers tremendous potential to facilitate the three strategies suggested by the World Psychiatric Association to address the treatment gap, save time and costs and improve access to the small pool of specialist psychiatrists in resource constrained environments.Web of Scienc

The role of ‘micro-decisions’ in involuntary admissions decision-making for inpatient psychiatric care in general hospitals in South Africa

While the ethics of involuntary admission for psychiatric inpatient care is widely contested, the practice is legally permissible across most jurisdictions. In many countries, laws governing the use of involuntary admission set out core criteria under which involuntary admission is permitted; these parameters broadly related to either risk of harm to self or others, need for treatment, or both. In South Africa, the use of involuntary admission is governed by the Mental Health Care Act no. 17 of 2002 (MHCA 2002), which sets out clear criteria to direct mental healthcare practitioners' decision-making and delineates a process by which decision-making should occur. However, recent research suggests that, in practice, the process of decision-making differs from the procedure prescribed in the MHCA 2002. To further explore how decision-making for involuntary admission occurs in practice, we interviewed 20 mental healthcare practitioners, all with extensive experience of making involuntary admission decisions, working in district, regional, and tertiary hospitals across five provinces. We also interviewed four mental health advocates to explore patient-centered insights. Our analysis suggests that the final decision to involuntarily admit individuals for a 72-h assessment period under the MHCA 2002 was preceded by a series of ‘micro-decisions’ made by a range of stakeholders: 1) the family's or police's decision to bring the individual into hospital, 2) a triage nurse's decision to prioritise the individual along a mental healthcare pathway in the emergency centre, and 3) a medical officer's decision to sedate the individual. Practitioners reported that the outcomes of each of these ‘micro-decisions’ informed aspects of their final decision to admit an individual involuntarily. Our analysis therefore suggests that the final decision to admit involuntarily cannot be understood in isolation because practitioners draw on a range of additional information, gleaned from these prior ‘micro-decisions’, to inform the final decision to admit