South African Journal of Psychiatry - Volume 20, Issue 3, 2014
Volume 20, Issue 3, 2014
Author J.K. BurnsSource: South African Journal of Psychiatry 20, pp 66 –71 (2014) http://dx.doi.org/10.7196/SAJP.589More Less
With the publication of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and the ongoing revision of the International Classification of Diseases, currently 10th edition, it is timely to consider the wider societal implications of evolving psychiatric classification, especially within low- and middle-income countries (LMICs).
The author reviewed developments in psychiatric classification, especially the move from categorical to dimensional approaches based on biobehavioural phenotypes. While research supports this move, there are several important associated ethical challenges. Dimensional classification runs the risk of 'medicalising' a range of normality; the broadening of some definitions and the introduction of new disorders means more people are likely to attract psychiatric diagnoses. Many LMICs do not have the political, social, legal and economic systems to protect individuals in society from the excesses of medicalisation, thus potentially rendering more citizens vulnerable to forms of stigma, exploitation and abuse, conducted in the name of medicine and psychiatry. Excessive medicalisation within such contexts is also likely to worsen existing disparities in healthcare and widen the treatment gap, as inappropriate diagnosis and treatment of mildly ill or essentially normal people has an impact on health budgets and resources, leading to relative neglect of those with genuine, severe psychiatric disorders.
In an era of evolving psychiatric classification, those concerned for, and involved in, global mental health should be critically self-reflective of all aspects of the modern psychiatric paradigm, especially changes in classification systems, and should alert the global profession to the sociopolitical, economic and cultural implications of changing nosology for LMIC regions of the world.
Comparative efficacy and acceptability of seven augmentation agents for treatment-resistant depression : a multiple-treatments meta-analysisSource: South African Journal of Psychiatry 20, pp 71 –76 (2014) http://dx.doi.org/10.7196/SAJP.530More Less
Background. Treatment-resistant depression (TRD) is a therapeutic challenge for clinicians. Augmentation pharmacotherapy is effective for TRD, but it is still unclear which augmentation agent is most efficacious.
Objective. To assess the effects of seven augmentation agents on TRD.
Methods. We did a multiple-treatments meta-analysis, accounting for both direct and indirect comparisons. PubMed, the Center for Clinical and Translational Research, Web of Science, Embase, CBM-disc, the Chinese National Knowledge Infrastructure and relevant websites (up to August 2013) were searched for randomised controlled trials (RCTs) about augmentation agents. The following terms were used: 'potentiation', 'augmentation', and 'adjunct' paired with 'depression' and 'resistant depression'. No language limitation was imposed.
Results. We systematically reviewed 12 RCTs (1 936 participants), which included seven augmentation agents: lithium, tricyclic antidepressants (TCAs), atypical antipsychotics (AAPs), antiepileptic drugs (AEDs), buspirone, cognitive behaviour therapy (CBT) and tri-iodothyronine (T3). The results revealed that T3 was more efficacious than lithium, TCAs, AAPs, AEDs, buspirone and CBT with odds ratios (ORs) of 1.58, 1.56, 1.51, 1.47, 1.77 and 1.25, respectively. ORs favoured CBT compared with lithium, TCAs, AAPs, AEDs and buspirone. Buspirone was the least efficacious of all the other augmentation agents tested. AAPs were significantly more acceptable than lithium, and CBT more than buspirone. T3 was slightly more acceptable than lithium, and CBT more than AAPs.
Conclusion. T3 as an augmentation agent should be a clinician's first consideration instead of lithium in acute treatment for TRD. CBT might be a good augmentation agent in some communities. Buspirone should be a final option as an augmentation agent. Further research is needed, such as a well-designed, large-scale controlled trial, to support and draw definite conclusions.
Frequency and correlates of comorbid psychiatric illness in patients with heroin use disorder admitted to Stikland Opioid Detoxification Unit, South AfricaSource: South African Journal of Psychiatry 20, pp 77 –82 (2014) http://dx.doi.org/10.7196/SAJP.540More Less
Background. There is a lack of studies addressing the frequency and correlates of comorbidities among heroin users admitted for treatment in South Africa (SA).
Objective. To assess the frequency and correlates of psychiatric comorbidity among patients with heroin use disorder admitted to the Opioid Detoxification Unit at Stikland Hospital in the Western Cape, SA.
Method. Participants (N=141) were assessed for psychiatric illness (Mini International Neuropsychiatric Interview), comorbid substance use disorders (World Health Organization's Alcohol Smoking Substance Involvement Screening Tool), and legal and social problems (Maudsley Addiction Profile). Demographic, personal, psychiatric and substance-use history, in addition to mental state examination on admission, were collected from the case notes.
Results. The largest group of patients (n=56, 40%) had not been abstinent from heroin use since drug debut, and most had been arrested for drug-related activities (n=117, 83%) and had family conflicts related to use (n=135, 96%). Nicotine was the most common comorbid substance of dependence (n=137, 97%) and methamphetamine was the most common comorbid substance abused (n=73, 52%). The most common comorbid psychiatric illness was previous substance-induced psychosis (n=42, 30%) and current major depressive disorder (n=37, 26%). Current major depressive disorder was significantly associated with females (p=0.03), intravenous drug use (p=0.03), alcohol use (p=0.02), and a higher number of previous rehabilitation attempts (p=0.008).
Conclusion. Patients with heroin use disorders present with high rates of psychiatric comorbidities, which underscores the need for substance treatment services with the capacity to diagnose and manage these comorbidities.
Outcomes of adult heroin users v. abstinent users four years after presenting for heroin detoxification treatmentSource: South African Journal of Psychiatry 20, pp 82 –87 (2014) http://dx.doi.org/10.7196/SAJP.541More Less
Background. There are no studies in South Africa (SA) on the outcomes following detoxification and psychosocial rehabilitation of heroin-dependent patients.
Objective. To compare the demographic, clinical, forensic and treatment data of active heroin users v. users who were abstinent at the time of interview 4 years after attending the Opioid Detoxification Unit at Stikland Hospital in the Western Cape Province, SA.
Method. Participants included patients above the age of 16 years who had been admitted to the Opioid Detoxification Unit at Stikland Hospital for heroin detoxification between July 2006 and June 2007. Participants were individually interviewed (either in person or telephonically) using a structured self-report questionnaire to collect demographic, clinical, forensic and treatment data 4 years following heroin detoxification treatment at this unit.
Results. Of the participants, 60% were abstinent and a large portion (34%) attributed this to social support. Furthermore, there was a significant (p=0.04) difference in the longest period of abstinence between the past user group and active users, with more participants in the past user group being abstinent for 18 months or longer (n=24, 57%) than in the active users group (n=8, 29%). Active users (n=18, 64%) had significantly (p=0.03) more legal problems than abstinent users (n=14, 33%). Most participants (n=38, 54%) relapsed within 3 months after index detoxification and rehabilitation.
Conclusion. Active users had more legal problems than abstinent users, with social support structures playing a pivotal role in abstinence. Future research should assess the impact of interventions such as post-discharge social support programmes on criminality and heroin use in those that relapse following treatment.
Source: South African Journal of Psychiatry 20, pp 88 –93 (2014) http://dx.doi.org/10.7196/SAJP.498More Less
Background. For most low- and middle-income countries, mental health remains a neglected area, despite the recognised burden associated with neuropsychiatric conditions and the inextricable link to other public health priorities.
Objectives. To describe the results of a free outpatient mental health programme delivered by non-specialist health workers in Makeni, Sierra Leone between July 2008 and May 2012.
Methods. A nurse and two counsellors completed an 8-week training course focused on the identification and management of seven priority conditions: psychosis, bipolar disorder, depression, mental disorders due to medical conditions, developmental and behavioural disorders, alcohol and drug use disorders, and dementia. The World Health Organization recommendations on basic mental healthcare packages were followed to establish treatment for each condition.
Results. A total of 549 patients was assessed and diagnosed as suffering from psychotic disorders (n=295, 53.7%), manic episodes (n=69, 12.5%), depressive episodes (n=53, 9.6%), drug use disorders (n=182, 33.1%), dementia (n=30, 5.4%), mental disorders due to medical conditions (n=39, 7.1%), and developmental disorders (n=46, 8.3%). Of these, 417 patients received pharmacological therapy and 70.7% were rated as much or very much improved. Of those who could not be offered medication, 93.4% dropped out of the programme after the first visit.
Conclusions. The identification and treatment of mental disorders must be considered an urgent public health priority in low- and middle-income countries. Trained primary health workers can deliver safe and effective treatment for mental disorders as a feasible alternative to ease the scarcity of mental health specialists in developing countries.
Source: South African Journal of Psychiatry 20, pp 94 –95 (2014) http://dx.doi.org/10.7196/SAJP.518More Less
Childhood disintegrative disorder (CDD) is a rare pervasive developmental disorder, which is often misdiagnosed as schizophrenia, probably due to the resultant severe social impairment and withdrawn behaviour with stereotypes that could be mistaken for psychosis. We report a case of CDD that was misdiagnosed by a psychiatrist as childhood-onset schizophrenia and treated with high doses of antipsychotics. The patient did not show any improvement. This highlights ethical issues that arise from treatment modalities, with polypharmacy being the biggest culprit, and also points to the need to continue medical education at the level of primary health services and among practising rural doctors where tertiary centres with child guidance facilities and a multidisciplinary team are not available.