Heroin detoxification during pregnancy: A systematic review and retrospective study of the management of heroin addiction in pregnancy

Background. There is general consensus that methadone maintenance is the gold standard in the management of pregnant heroin users. However, in South African state hospitals, methadone withdrawal is the routine procedure offered to these patients, as methadone maintenance programmes are unavailable in the public sector.Objectives. To conduct a systematic review of the literature on heroin detoxification in pregnancy, and to document pregnancy outcomes in heroin users detoxified with methadone at Groote Schuur Hospital (GSH), Cape Town, from 2006 to 2010.Methods. A literature search was undertaken to identify key publications on the management of heroin addiction in pregnancy. Patients for the study were identified from the GSH methadone registry, and data were collected from the clinical files.Results. A total of 20 relevant publications were identified and reviewed. Early case reports described an increased risk of stillbirths and fetal distress after methadone detoxification, but more recent case series involving larger numbers of patients showed positive outcomes. In our study, six pregnant patients received methadone withdrawal over a 5-year period at GSH, and all the neonates had good Apgar scores and were discharged home within 3 days of delivery.Conclusions. There is limited evidence on the management of heroin addiction during pregnancy, and the only two guidelines identified suggest that methadone maintenance is preferable to methadone withdrawal. The favourable pregnancy outcomes in this small sample of patients managed with methadone withdrawal suggest that it may be safe and deserves further study

Adjunctive quetiapine for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: A meta-analysis of randomised controlled treatment trials

Small studies have shown positive effects from adding a variety of antipsychotic agents in patients with obsessive–compulsive disorder who are unresponsive to treatment with serotonin reuptake inhibitors. The evidence, however, is contradictory. This paper reports a meta-analysis of existing double-blind randomized placebo-controlled studies looking at the addition of the second-generation antipsychotic quetiapine in such cases. Three studies fulfilled the inclusion criteria. Altogether 102 individuals were subjected to analysis using Review Manager (4.2.7). The results showed evidence of efficacy for adjunctive quetiapine (< 400 mg/day) on the primary efficacy criterion, measured as changes from baseline in total Yale–Brown Obsessive Compulsive Scale scores (P = 0.008), the clinical significance of which was limited by between-study heterogeneity. The mechanism underlying the effect may involve serotonin and/or dopamine neurotransmission

Predictors of distress and anxiety during pregnancy

Objective: There is a high incidence of distressing psychological symptoms including anxiety in pregnancy. Nevertheless, predictors of distress and anxiety during pregnancy have not been well characterized. We determined whether temperament and character, trait anxiety, resilience, and social support predicted distress and anxiety symptoms in pregnancy.Method: Pregnant women (n=105) with low risk singleton pregnancies were recruited from Midwife Obstetric Units. Assessments of distress (usingthe K-10) and anxiety (using the Spielberger State Inventory) were undertaken in trimester 2 and 3. Measures of temperament and character, trait anxiety, resilience and social support were undertaken at the same time points. Regression analyses were used to determine predictors of distress and anxiety at each trimester.Results: Predictors of distress and anxiety were lower selfdirectedness,higher harm avoidance, higher trait anxiety, lower resilience, and lower social support, at each time point.Conclusion: Understanding predictors of distress and anxiety in pregnancy may be useful in developing interventions for addressing such symptoms, as well as perhaps in preventing potential sequelae such as anxiety and mood disorders.Keywords: Distress; Anxiety; Self-directedness; Harm avoidance; Resilience; Social suppor

The neural correlates of intimate partner violence in women

Objective: To examine hippocampal volume and white matter tracts in women with and without intimate partner violence (IPV). Method: Nineteen women with IPV exposure in the last year, and 21 women without IPV exposure in the last year underwent structural magnetic resonance imaging (MRI) including diffusion tensor imaging (DTI) sequences. Additional data on alcohol use and presence of psychiatric disorder was collected. Differences in fractional anisotropy (FA) between the two groups were examined, using a statistical model that included demographic measures, alcohol use and psychiatric disorder. Results: IPV subjects did not demonstrate significantly different hippocampal volumes compared to subjects without recent IPV. FA was, however, significantly reduced in the body of the corpus callosum of IPV subjects. Adjusting for age, alcohol use, smoking and psychiatric diagnosis did not change the significance of the result. Conclusion: Data on hippocampal volume in IPV are inconsistent, perhaps reflecting the fact that multiple factors influence this measure. Reduced FA in the body of the corpus callosum in IPV suggests altered integrity of this white matter tract; additional work is needed to address the underlying mechanisms and clinical correlates of this finding.Key Words: Corpus callosum; Hippocampal volume; Intimate partner violence; Neuroimagin

The neural correlates of intimate partner violence in women

Objective: To examine hippocampal volume and white matter tracts in women with and without intimate partner violence (IPV). Method: Nineteen women with IPV exposure in the last year, and 21 women without IPV exposure in the last year underwent structural magnetic resonance imaging (MRI) including diffusion tensor imaging (DTI) sequences. Additional data on alcohol use and presence of psychiatric disorder was collected. Differences in fractional anisotropy (FA) between the two groups were examined, using a statistical model that included demographic measures, alcohol use and psychiatric disorder. Results: IPV subjects did not demonstrate significantly different hippocampal volumes compared to subjects without recent IPV. FA was, however, significantly reduced in the body of the corpus callosum of IPV subjects. Adjusting for age, alcohol use, smoking and psychiatric diagnosis did not change the significance of the result. Conclusion: Data on hippocampal volume in IPV are inconsistent, perhaps reflecting the fact that multiple factors influence this measure. Reduced FA in the body of the corpus callosum in IPV suggests altered integrity of this white matter tract; additional work is needed to address the underlying mechanisms and clinical correlates of this finding

Olfactory reference syndrome in DSM-V

LetterThe original publication is available at http://www.samj.org.zaTo the Editor: We read with interest Dr A Lawrence’s recent SAMJ case report of a young man who presented with persistent preoccupation with personal body odour in the absence of any physical abnormalitiesPublishers’ Versio

Heroin detoxification during pregnancy: A systematic review and retrospective study of the management of heroin addiction in pregnancy

Background. There is general consensus that methadone maintenance is the gold standard in the management of pregnant heroin users. However, in South African state hospitals, methadone withdrawal is the routine procedure offered to these patients, as methadone maintenance programmes are unavailable in the public sector.Objectives. To conduct a systematic review of the literature on heroin detoxification in pregnancy, and to document pregnancy outcomes in heroin users detoxified with methadone at Groote Schuur Hospital (GSH), Cape Town, from 2006 to 2010.Methods. A literature search was undertaken to identify key publications on the management of heroin addiction in pregnancy. Patients for the study were identified from the GSH methadone registry, and data were collected from the clinical files.Results. A total of 20 relevant publications were identified and reviewed. Early case reports described an increased risk of stillbirths and fetal distress after methadone detoxification, but more recent case series involving larger numbers of patients showed positive outcomes. In our study, six pregnant patients received methadone withdrawal over a 5-year period at GSH, and all the neonates had good Apgar scores and were discharged home within 3 days of delivery.Conclusions. There is limited evidence on the management of heroin addiction during pregnancy, and the only two guidelines identified suggest that methadone maintenance is preferable to methadone withdrawal. The favourable pregnancy outcomes in this small sample of patients managed with methadone withdrawal suggest that it may be safe and deserves further study.

Collaborative care for the detection and management of depression among adults with hypertension in South Africa: study protocol for the PRIME-SA randomised controlled trial

Background: The high co-morbidity of mental disorders, particularly depression, with non-communicable diseases (NCDs) such as cardiovascular disease (CVD), is concerning given the rising burden of NCDs globally, and the role depression plays in confounding prevention and treatment of NCDs. The objective of this randomised control trial (RCT) is to determine the real-world effectiveness of strengthened depression identification and management on depression outcomes in hypertensive patients attending primary health care (PHC) facilities in South Africa (SA). Methods/design: The study design is a pragmatic, two-arm, parallel-cluster RCT, the unit of randomisation being the clinics, with outcomes being measured for individual participants. The 20 largest eligible clinics from one district in the North West Province are enrolled in the trial. Equal numbers of hypertensive patients (n = 50) identified as having depression using the Patient Health Questionnaire (PHQ-9) are enrolled from each clinic, making up a total of 1000 participants with 500 in each arm. The nurse clinicians in the control facilities receive the standard training in Primary Care 101 (PC101), a clinical decision support tool for integrated chronic care that includes guidelines for hypertension and depression care. Referral pathways available include referrals to PHC physicians, clinical or counselling psychologists and outpatient psychiatric and psychological services. In the intervention clinics, this training is supplemented with strengthened training in the depression components of PC101 as well as training in clinical communication skills for nurse-led chronic care. Referral pathways are strengthened through the introduction of a facility-based behavioural health counsellor, trained to provide structured manualised counselling for depression and adherence counselling for all chronic conditions. The primary outcome is defined as at least 50% reduction in PHQ-9 score measured at 6 months. Discussion: This trial should provide evidence of the real world effectiveness of strengtheneddepression identification and collaborative management on health outcomes of hypertensive patients withcomorbid depression attending PHC facilities in South Africa