African Journal of Psychiatry - Volume 11, Issue 3, August 2008

The August 2008 edition marks 1 year of the existence of the Journal, and our 5th edition. To this end, a vehicle for African psychiatry appears to have consolidated itself as a viable publication, for the discipline, for the continent.

"A welcome from the editor"

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AAPAP update

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Mental health care in Uganda

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Africa Network for Research on suicide

In this review article, the issues related to provision of psychotropic drugs in services in sub-Saharan Africa are explored. Problems encountered in procurement of drugs, their safe prescription and practical supply systems are discussed, with possible solutions suggested. The evidence-base for the preferential use of first-generation drugs is presented, with the practical implications for cost-effective service delivery shown. Options for sourcing of quality drugs are outlined with practical examples. An argument is made for a wider range of medical personnel to be allowed to prescribe than is often currently the case. This is so as to allow for the scale up of community based psychiatric services which will otherwise fail to meet the needs of the majority of persons with mental illnesses, particularly in rural communities. Drug Revolving Funds are proposed as a means of managing supplies by local projects in a context of a lack of an alternative supply. Some suggestions are made for practical solutions to the problem of those cannot afford even cheaper medications.

Objective : To document the prevalence of obsessive-compulsive disorders (OCD) among patients admitted at Mathari Psychiatric Hospital, Nairobi, Kenya. Method : This was a descriptive cross-sectional study conducted at the Mathari Hospital. Results : Out of 691 patients interviewed, 84 (12.2%) had symptoms which met the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for OCD, which started early in life. The clinicians had not recognized the OC symptoms / disorder. There were high co-morbidities between OCD and other Structured Clinical Interview for DSM-IV (SCID) core syndromes as well as psychotic symptoms often associated with schizophrenia. Conclusion : OC symptoms are common in psychiatric patients admitted at Mathari Hospital although such symptoms were clinically undetected and therefore not managed. The high co-morbidities between OCD, other psychiatric disorders and other psychiatric symptoms pose clinical challenges in differentiating between psychotic symptoms perceived by the patients to have an external locus and OC symptoms perceived to have an internal locus. A more systematic clinical procedure for assessing all DSM-IV symptoms should be adapted as standard quality control practice in all patients, particularly those with psychotic symptoms.

Objective : Little is known about predictors of readmission of psychiatric patients in the study environment. Knowledge of this, we believe could aid effective management of psychiatric patients, as well as judicious and equitable utilization of the limited mental health facilities in the North-central zone. The aim was to identify factors that may be predictive of readmissions to an in-patient psychiatric facility of a Nigerian University Teaching Hospital. Method : A retrospective record review of all admissions and discharges to / from the psychiatric inpatient ward of University of Ilorin Teaching Hospital, (UITH) between May 2000 and April 2005. Patients and clinical characteristics were recorded and all the data were characterized according to age, gender, marital status, occupational status, length of stay on admission, number of admissions, and medication compliance. Data were analyzed with SPSS version 11 to derive the chi square figures, Pearson's correlation, and logistic regression. The level of statistical significance was set at 5%. Results : Within the study period, 41.4% of cases were readmissions. Young age, longer length of stay, multiple admissions and the diagnosis of schizophrenia were predictive of readmission while medication non-compliance was not predictive. Conclusion : Provision of psycho-education to both the patients and their families, identification of early symptoms of relapse, application of immediate and appropriate measures, and adequate record-keeping by health institutions are advocated.

Objective : to explain comparatively how economic and family caregiver burden in families with bipolar disorder patients change overtime. Method : one year follow-up of economic and family caregiver burden was carried out on family caregivers of 190 bipolar, 55 diabetes, hypertension and asthma patients and 659 sick controls in the community. Population average generalized estimating equation was used to make longitudinal comparative analysis. Results : bipolar patient family caregivers were found to be more burdened, for about 8 to 10 months of the year of study, than family caregivers of diabetes, hypertension and asthma and sick controls in the community. The average difference in family caregiver burden score between bipolar and diabetes, hypertension and asthma patient family caregivers was 4.36 (z = -8.75, P > |z| = 0.001); while the difference due to time between the two groups was 3.42 (z = -4.27, P > |z| = 0.001). Similarly, the average difference in family caregiver burden score between family caregivers of bipolar patient and sick controls in the community was 3.7 (z = -4.88, P > |z| 0.001). In terms of longitudinal caregiver burden difference, bipolar patients family caregivers were found to be more burdened than family caregivers of sick controls in the community with a burden score difference of 2.97 (z = -5.17, P > |z| = 0.001). Conclusion : more should be done to lessen the economic and family caregiver burden due to bipolar disorder.

Objective : As there are no data on burnout in staff in Kenyan psychiatric hospitals, this study sought to document the level of burnout among the staff at the Mathari Psychiatric Hospital. Method : This was a cross sectional descriptive study of staff working at Mathari Psychiatric Hospital. The hospital staff completed self-administered questionnaires on socio-demographic characteristics and work environment and the Maslach Burnout Inventory - Human Services and General Survey. Analysis of the data was undertaken using the Statistical Package for the Social Sciences (SPSS) version 11.5. Results : Ninety-five percent of the respondents reported low to high emotional exhaustion while 87.8% reported depersonalization. Low accomplishment was reported by only 38.6% while 61.4% reported average to high personal accomplishment. Several work- and non-work-related factors including young age, number of own children, number of years worked, heavy workload and low morale were positively associated with various syndromes of burnout. Relationships at work, with family and society were generally rated as average. The staff made recommendations on how to improve the social support system and work performance. Conclusion : High levels of burnout were reported. These should be addressed at individual, collective and institutional levels.

Objective : Although a dysfunctional prefrontal-striatal system is presupposed in obsessive-compulsive disorder (OCD), this is not unequivocally supported by neuropsychological studies. This study aims to study the neurocognitive dysfunctions in OCD patients, compared to controls; to study the variations in neurocognitive deficits with the duration of illness, as well as, the severity of the disease. Method : Thirty OCD patients were compared with thirty, age and education matched control subjects on computer based tests measuring executive functions, vigilance and spatial working memory. Results : OCD patients performed poorly on all the neuro-cognitive parameters as compared to controls. The severity of illness had a positive correlation with poorer performance on CPT. There were no significant correlations between duration of illness and any parameters of cognition. Conclusion : The results suggest that OCD patients perform significantly worse on cognitive measures than controls. This is consistent with their poorer functional outcome. The results further indicate that on the basis of severity OCD patients are qualitatively distinguishable in neuropsychological terms, given their difference in the profiles of cognitive impairment.

Constitution for the African Association of Psychiatrists and Allied Professions.

This is a short AACAMH newsletter to provide feedback on the meetings in Istanbul, Turkey, in April / May.

Draft Constitution

No, your eyes are not deceiving you, and yes, you did read correctly! The film I am reviewing for this edition of the journal is the musically remastered edition of the original 1992 Disney Studios animation-adventure release Aladdin. As I took to the recliner, determined and on my way to review the film Stephanie Daley (Redbone Films / Silverwood Films / Pathé Production) a small but significant tingle of excitement stirred inside me as I saw the 'new' Aladdin being advertised on television. And these were my thoughts behind changing the film to be reviewed : with our current national climate of political tension, economic uncertainty and brilliant fuel costs, the foreign political developments (or lack thereof), and a general feeling amongst the people of tension and stress, I felt it high time to take a step or two back and revert, maybe 'regress' to times when things were easier and less pressured, when Aladdin followed a series of animation-adventure films such as Little Mermaid, Beauty and the Beast, Sinbad, the Lion King and the like to the enjoyment of millions of people all over the world - children AND adults.

Cognitive impairment is common in patients with depression. Verbal learning, memory tests, working memory, focussed attention and decision making may all be impaired. In the elderly, major depressive disorder is common, but in addition to its association with depression, the aetiology of cognitive impairment is complex and includes cerebrovascular and Alzheimer's-type neurodegenerative changes. Cognitive impairment may precede depression, and some elderly patients with depression may have neurodegenerative changes that are precursors to dementia.

A comprehensive treatment programme for ADHD should include measures other than medicines, such as psychological, educational and social interventions. The diagnosis of ADHD should be made in accordance with the DSM-IV-TR criteria or the guidelines in ICD-10. An assessment should be based on a full history and evaluation of the patient. This assessment should include quality of life measurements, not only initially but also with follow-up treatment. According to the European Treatment Guidelines (Banaschewski, 2006), Quality of Life (QoL) measurements should also be part of clinical trials but have not often been applied sufficiently in the past.

12 years ago, Peter from Siyabuswa called SADAG in a panic. He desperately needed help for severe panic associated particularly with taxis. His fear and panic almost caused him to lose his job. He now runs a highly successful Support Group for fellow panic sufferers in Siyabuswa. "I would not have got through this if it wasn't for SADAG. I have gained confidence in myself and have learned how to cope. I won't let panic get the better of me."

As I write this article I recall one of my patients very aptly describing her experience of suffering with depression as similar to having a broken rib. From the outside one looks fine, but every time you breathe in or out, the pain and suffering is excruciating. For those never having experienced this, it is very difficult to fully comprehend and to empathize.