Catatonia a manifestation of serious mental Illness: prevalence, presentation, management, and outcomes in a mental health unit

Catatonia is a psychomotor abnormality that may be caused by severe physical or mental illness or by substances. It has a wide-ranging prevalence from less than 10% to just over 60%, worldwide. This thesis investigated multiple aspects of catatonia in an acute mental health unit setting. Critical aspects examined include the psychological experience of catatonia and assessment, prevalence, presentation, management, and treatment outcomes of catatonia. The research design was a prospective descriptive triangulation study that used a mixed quantitative and qualitative approach. The theoretical framework applied in this thesis was a positivist paradigm approach to explore the quantitative data collected, with application of deductive reasoning, supported by statistical analysis to detect correlations between catatonia and demographic and clinical data. The research explored the experience of a person with catatonia from the beginning to the end of the catatonic episode, inclusive of neglected areas such as the patient’s psychological and experiences. Sources of information included participant reports, clinical notes, and assessments conducted using screening tools for catatonia. Key knowledge gaps on catatonia were identified as target areas for this thesis. These are the prevalence of catatonia in a South African setting; the use of assessment tools like the Bush Francis Catatonia Screening Instrument (BFCSI), the Bush Francis Catatonia Rating Scale (BFCRS), and the Diagnostic and Statistical Manual (5th Edition; DSM-5) in this setting; interventions for catatonia; treatment outcomes; and the subjective experiences of catatonia, as described by patients. To date, there have been five publications produced from this thesis. The first paper was on the protocol for the research and was published in the British Medical Journal (BMJ) Open and presented the literature review, research design, and methodology for the planned Abstract ii research on catatonia (which has ultimately been presented in this current thesis). This paper also identified the aforementioned critical knowledge gaps. The second paper was published in the Biomedicine Central (BMC) International Journal of Mental Health Systems. This paper described a 6-month prevalence rate of catatonia of 11.9%, and concluded that the BFCSI and BFCRS had the highest inter-rater reliability (IRR) and pick-up rate when screening for catatonia, while the DMS-5 had low IRR, and the lowest correlation with the BFCSI and BFCRS. The 12-month prevalence rate was found to be 18.3% and was described in the third paper which was published in the PLOS One Psychiatry. Both lorazepam and electroconvulsive therapy (ECT) were found to be the most widely used treatment at the study site, with good response rates and outcomes. The results were published in the 4th paper in SAGE Open. The fifth paper was on the subjective and psychological experience and published in the BMC Psychology journal. It described the psychological and subjective experience of catatonia as narrated by participants which is characterised by intense experiences of fear, anxiety, and sadness that manifested as extreme withdrawal, combined with obedience or submission. This research has yielded new knowledge with potential applications at a regional, national, and global level. New knowledge yielded includes the need for screening of patients for catatonia across all acute settings, the need for training of both medical and nursing personnel in the assessment of catatonia, the effectiveness of screening and assessment tools, effective interventions for catatonia and outcomes. The descriptions of catatonia at an emotional, cognitive, and behavioural level also highlight the need to develop psychological strategies and targeted psychological interventions to complement the current management strategies.Thesis (PhD) -- Faculty of Health Sciences, 202

Catatonia a manifestation of serious mental Illness: prevalence, presentation, management, and outcomes in a mental health unit

Catatonia is a psychomotor abnormality that may be caused by severe physical or mental illness or by substances. It has a wide-ranging prevalence from less than 10% to just over 60%, worldwide. This thesis investigated multiple aspects of catatonia in an acute mental health unit setting. Critical aspects examined include the psychological experience of catatonia and assessment, prevalence, presentation, management, and treatment outcomes of catatonia. The research design was a prospective descriptive triangulation study that used a mixed quantitative and qualitative approach. The theoretical framework applied in this thesis was a positivist paradigm approach to explore the quantitative data collected, with application of deductive reasoning, supported by statistical analysis to detect correlations between catatonia and demographic and clinical data. The research explored the experience of a person with catatonia from the beginning to the end of the catatonic episode, inclusive of neglected areas such as the patient’s psychological and experiences. Sources of information included participant reports, clinical notes, and assessments conducted using screening tools for catatonia. Key knowledge gaps on catatonia were identified as target areas for this thesis. These are the prevalence of catatonia in a South African setting; the use of assessment tools like the Bush Francis Catatonia Screening Instrument (BFCSI), the Bush Francis Catatonia Rating Scale (BFCRS), and the Diagnostic and Statistical Manual (5th Edition; DSM-5) in this setting; interventions for catatonia; treatment outcomes; and the subjective experiences of catatonia, as described by patients. To date, there have been five publications produced from this thesis. The first paper was on the protocol for the research and was published in the British Medical Journal (BMJ) Open and presented the literature review, research design, and methodology for the planned Abstract ii research on catatonia (which has ultimately been presented in this current thesis). This paper also identified the aforementioned critical knowledge gaps. The second paper was published in the Biomedicine Central (BMC) International Journal of Mental Health Systems. This paper described a 6-month prevalence rate of catatonia of 11.9%, and concluded that the BFCSI and BFCRS had the highest inter-rater reliability (IRR) and pick-up rate when screening for catatonia, while the DMS-5 had low IRR, and the lowest correlation with the BFCSI and BFCRS. The 12-month prevalence rate was found to be 18.3% and was described in the third paper which was published in the PLOS One Psychiatry. Both lorazepam and electroconvulsive therapy (ECT) were found to be the most widely used treatment at the study site, with good response rates and outcomes. The results were published in the 4th paper in SAGE Open. The fifth paper was on the subjective and psychological experience and published in the BMC Psychology journal. It described the psychological and subjective experience of catatonia as narrated by participants which is characterised by intense experiences of fear, anxiety, and sadness that manifested as extreme withdrawal, combined with obedience or submission. This research has yielded new knowledge with potential applications at a regional, national, and global level. New knowledge yielded includes the need for screening of patients for catatonia across all acute settings, the need for training of both medical and nursing personnel in the assessment of catatonia, the effectiveness of screening and assessment tools, effective interventions for catatonia and outcomes. The descriptions of catatonia at an emotional, cognitive, and behavioural level also highlight the need to develop psychological strategies and targeted psychological interventions to complement the current management strategies.Thesis (PhD) -- Faculty of Health Sciences, 202

Fatal nevirapine-induced Stevens-Johnson syndrome with HIV-associated mania

Mania with psychotic features is one of the common presenting clusters of psychiatric symptoms in HIV-infected patients. Commonly, patients with HIV-associated mania receive antiretroviral treatment, mood stabilisers and antipsychotics. This case of Stevens-Johnson syndrome highlights the dilemmas and complications that may arise when prescribing multiple medications in HIV-associated psychiatric disorders

South Africa’s Psychiatric training capacity in 2008 and in 2018. Has training capacity improved?

Background: There is a deficit of psychiatrists in South Africa, and to our knowledge, there is no situational analysis of training posts for psychiatrists in the country. Aim: To compare the number of specialists and subspecialists in training and training posts available in 2008 and 2018. Setting: South African medical schools with departments of psychiatry. Methods: A situational analysis involving data collection through a survey completed by eight heads of academic psychiatric departments followed by a comparative analysis of the two aforementioned years. Results: Data shows an 11% increase in funded and unfunded posts combined and a 9.3% increase in funded posts. The occupancy of funded posts decreased (92% in 2008 to 82% in 2018). When considering both funded and unfunded posts, only three more psychiatrists were being trained in 2018. Supernumeraries appointed in unfunded posts can be expected to return to their countries of origin. As such, a decrease in filled funded posts likely reflects a decrease in training psychiatrists destined to work in South Africa. While child and adolescent psychiatry was the only sub-speciality with accredited training posts in 2008, all sub-specialities included on the questionnaire had accredited training posts in 2018, and the number of accredited training posts in child and adolescent psychiatry doubled. That said, many of the posts were unfunded and vacant. Conclusion: While there was an increase in posts from 2008 to 2018, many posts remained unfilled. As such, not only are additional funded training posts required but also strategies to increase post-occupancy and successful completion of training. Contribution: This study is the first situational analysis of specialist and subspecialist training posts in Psychiatry in South Africa, at two time points over a 10 year period, that draws on academic heads of departments of psychiatry as respondents. The study highlights the nominal increase in funded training posts over this period, especially subspecialist training posts. The majority of Health Professions Council of South Africa (HPCSA) accredited subspecialities in Psychiatry have no funded training posts which is particularly concerning

Factors affecting specialist psychiatry training in South Africa: Bullying during specialist psychiatric training?

CITATION: Beath, N. et al. 2021. Factors affecting specialist psychiatry training in South Africa : bullying during specialist psychiatric training? South African Medical Journal, 111(4):280, doi:10.7196/SAMJ.2021.v111i4.15518.The original publication is available at http://www.samj.org.zaAs many of us served as members of the Council of Psychiatrists, Colleges of Medicine of South Africa, for the triennium 2017 - 2020, we were keen to understand how workplace experiences and supervision could affect training and examination outcomes in South African (SA) centres. We conducted a cross-sectional, descriptive study of registrar trainees in psychiatry at the University of the Witwatersrand, the University of Cape Town, the University of KwaZulu-Natal, the University of Pretoria, the University of the Free State, Stellenbosch University, the University of Limpopo, and Walter Sisulu University between 1 June and 30 November 2019. We made use of an online survey that included questions on bullying/discrimination. All questions were closed-ended.Publisher's versio

Construct validity and factor structure of the Kessler-10 in South Africa

Background The Kessler Psychological Distress Scale (K-10) is a short screening tool developed to identify, with good sensitivity, non-specific psychological distress in the general population. Sensitivity and specificity of the K-10 have been examined in various clinical populations in South Africa; however, other psychometric properties, such as construct validity and factor structure, have not been evaluated. We present evidence of the prevalence and severity of psychological distress in an outpatient setting in South Africa and evaluate the internal reliability, construct validity, and factor structure of the K-10 in this population. Methods We explored prevalence estimates of psychological distress using previously established cutoffs and assessed the reliability (consistency) of the K-10 by calculating Cronbach’s alpha, item-total correlations and omega total and hierarchical coefficients. Construct validity and factor structure of the K-10 were examined through split-sample exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA), comparing several theoretical models and the EFA. Results Overall, there was low prevalence of psychological distress in our sample of 2591 adults, the majority of whom were between the ages of 18–44 (77.7%). The K-10 showed good construct validity and reliability, with a Cronbach’s alpha of 0.84 and omega total of 0.88. EFA yielded a four-factor solution with likely measurement artifacts. CFA showed that the four-factor model from EFA displayed the best comparative fit indices, but was likely overfitted. The unidimensional model with correlated errors was deemed the best fitting model based on fit indices, prior theory, and previous studies. Conclusion The K-10 displays adequate psychometric properties, good internal reliability, and good fit with a unidimensional-factor structure with correlated errors. Further work is required to determine appropriate cutoff values in different populations and clinical subgroups within South Africa to aid in determining the K-10’s clinical utility

Using iterative learning to improve understanding during the informed consent process in a South African psychiatric genomics study

Obtaining informed consent is a great challenge in global health research. There is a need for tools that can screen for and improve potential research participants’ understanding of the research study at the time of recruitment. Limited empirical research has been conducted in low and middle income countries, evaluating informed consent processes in genomics research. We sought to investigate the quality of informed consent obtained in a South African psychiatric genomics study. A Xhosa language version of the University of California, San Diego Brief Assessment of Capacity to Consent Questionnaire (UBACC) was used to screen for capacity to consent and improve understanding through iterative learning in a sample of 528 Xhosa people with schizophrenia and 528 controls. We address two questions: firstly, whether research participants’ understanding of the research study improved through iterative learning; and secondly, what were predictors for better understanding of the research study at the initial screening? During screening 290 (55%) cases and 172 (33%) controls scored below the 14.5 cut-off for acceptable understanding of the research study elements, however after iterative learning only 38 (7%) cases and 13 (2.5%) controls continued to score below this cut-off. Significant variables associated with increased understanding of the consent included the psychiatric nurse recruiter conducting the consent screening, higher participant level of education, and being a control. The UBACC proved an effective tool to improve understanding of research study elements during consent, for both cases and controls. The tool holds utility for complex studies such as those involving genomics, where iterative learning can be used to make significant improvements in understanding of research study elements. The UBACC may be particularly important in groups with severe mental illness and lower education levels. Study recruiters play a significant role in managing the quality of the informed consent process