Risk-based lung cancer screening performance in a universal healthcare setting

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

Biological Psychiatry Congress 2015

<p><strong>List of Abstract Titles and authors:<br /></strong></p><p><strong>1. Psychosis: A matter of mental effort?</strong></p><p>M Borg, Y Y van der Zee, J H Hsieh, H Temmingh, D J Stein, F M Howells</p><p><strong>2.In search of an affordable, effective post-discharge intervention: A randomised control trial assessing the influence of a telephone-based intervention on readmissions for patients with severe mental illness in a developing country</strong></p><p><strong></strong>U A Botha, L Koen, M Mazinu, E Jordaan, D J H Niehaus</p><p><strong>3. The effect of early abstinence from long-term methamphetamine use on brain metabolism using 1H-magnetic resonance spectro-scopy (1H-MRS)</strong></p><p>A Burger, S Brooks, D J Stein, F M Howells</p><p><strong>4. The effect of <em>in utero exposure </em>to methamphetamine on brain metabolism in childhood using 1H-magnetic resonance spectroscopy (1H-MRS)</strong></p><p>A Burger, A Roos, M Kwiatkowski, D J Stein, K A Donald, F M Howells</p><p><strong>5. A prospective study of clinical, biological and functional aspects of outcome in first-episode psychosis: The EONKCS Study</strong></p><p><strong></strong>B Chiliza, L Asmal, R Emsley</p><p><strong>6. Stimulants as cognitive enhancers - perceptions v. evidence in a very real world</strong></p><p><strong></strong>H M Clark</p><p><strong>7. Pharmacogenomics in antipsychotic drugs</strong></p><p><strong></strong>Ilse du Plessis</p><p><strong>8. Serotonin in anxiety disorders and beyond</strong></p><p><strong></strong>Ilse du Plessis</p><p><strong>9. HIV infection results in ventral-striatal reward system hypo-activation during cue processing</strong></p><p><strong></strong>S du Plessis, M Vink, J A Joska, E Koutsilieri, A Bagadia, D J Stein, R Emsley</p><p><strong>10. Disease progression in schizophrenia: Is the illness or the treatment to blame?</strong></p><p>R Emsley, M J Sian</p><p><strong>11. Serotonin transporter variants play a role in anxiety sensitivity in South African adolescents</strong></p><p> S M J Hemmings, L I Martin, L van der Merwe, R Benecke, K Domschke, S Seedat</p><p><strong>12. Iron deficiency in two children diagnosed with multiple sclerosis: Report on whole exom sequencing</strong></p><p><strong></strong>S Janse van Rensburg, R van Toorn, J F Schoeman, A Peeters, L R Fisher, K Moremi, M J Kotze</p><p><strong>13. Benzodiazepines: Practical pharmacokinetics</strong></p><p><strong></strong>P Joubert</p><p><strong>14. What to consider when prescribing psychotropic medications</strong></p><p><strong></strong>G Lippi</p><p><strong>15. Current prescribing practices for obsessive-compulsive disorder in South Africa: Controversies and consensus</strong></p><p><strong></strong>C Lochner, L Taljaard, D J Stein</p><p><strong>16. Correlates of emotional and behavioural problems in children with preinatally acquired HIV in Cape Town, South Africa</strong></p><p><strong></strong>K-A Louw, N Phillips, JIpser, J Hoare</p><p><strong>17. The role of non-coding RNAs in fear extinction</strong></p><p><strong></strong>S Malan-Muller, L Fairbairn, W M U Daniels, M J S Dashti, E J Oakleley, M Altorfer, J Harvey, S Seedat, J Gamieldien, S M J Hemmings</p><p><strong>18. An analysis of the management og HIV-mental illness comorbidity at the psychiatric unit of the Dr George Mukhari Academic Hospital</strong></p><p><strong></strong>M L Maodi, S T Rataemane, T Kyaw</p><p><strong>19. The identification of novel genes in anxiety disorders: A gene X environment correlation and interaction study</strong></p><p><strong></strong>N W McGregor, J Dimatelis, S M J Hemmings, C J Kinnear, D J Stein, V Russel, C Lochner</p><p><strong>20. Collaborations between conventional medicine and traditional healers: Obstacles and possibilities</strong></p><p><strong></strong>G Nortje, S Seedat, O Gureje</p><p><strong>21. Thought disorder and form perception: Relationships with symptoms and cognitive function in first-episode schizophrenia</strong></p><p>M R Olivier, R Emsley</p><p><strong>22. Investigating the functional significance of genome-wide variants associated with antipsychotic treatment response</strong></p><p><strong></strong>E Ovenden, B Drogemoller, L van der Merwe, R Emsley, L Warnich</p><p><strong>23. The moral and bioethical determinants of "futility" in psychiatry</strong></p><p><strong></strong>W P Pienaar</p><p><strong>24. Single voxel proton magnetic resonance spectroscopy (1H-MRS) and volumetry of the amylgdala in social anxiety disorder in the context of early developmental trauma</strong></p><p>D Rosenstein, A T Hess, J Zwart, F Ahmed-Leitao, E Meintjies, S Seedat</p><p><strong>25. Schizoaffective disorder in an acute psychiatric unit: Profile of users and agreement with Operational Criteria (OPCRIT)</strong></p><p><strong></strong>R R Singh, U Subramaney</p><p><strong>26. The right to privacy and confidentiality: The ethics of expert diagnosis in the public media and the Oscar Pistorius trial</strong></p><p><strong></strong>C Smith</p><p><strong>27. A birth cohort study in South Africa: A psychiatric perspective</strong></p><p>D J Stein</p><p><strong>28. 'Womb Raiders': Women referred for observation in terms of the Criminal Procedures Act (CPA) charged with fetal abduction and murder</strong></p><p><strong></strong>U Subramaney</p><p><strong>29. Psycho-pharmacology of sleep wake disorders: An update</strong></p><p>R Sykes</p><p><strong>30. Refugee post-settlement in South Africa: Role of adjustment challenges and family in mental health outcomes</strong></p><p><strong></strong>L Thela, A Tomita, V Maharaj, M Mhlongo, K Jonathan</p><p><strong>31. Dstinguishing ADHD symptoms in psychotic disorders: A new insight in the adult ADHD questionnaire</strong></p><p>Y van der Zee, M Borg, J H Hsieh, H Temmingh, D J Stein, F M Howells</p><p><strong>32. Oscar Pistorius ethical dilemmas in a trial by media: Does this include psychiatric evaluation by media?</strong></p><p>M Vorster</p><p><strong>33. Genetic investigation of apetite aggression in South African former young offenders: The involvement of serotonin transporter gene</strong></p><p>K Xulu, J Somer, M Hinsberger, R Weierstall, T Elbert, S Seedat, S Hemmings</p><p><strong>34. Effects of HIV and childhood trauma on brain morphemtry and neurocognitive function</strong></p><p>G Spies, F Ahmed-Leitao, C Fennema-Notestine, M Cherner, S Seedat</p><p><strong>35. Measuring intentional behaviour normative data of a newly developed motor task battery</strong></p><p><strong></strong>S Bakelaar, J Blampain, S Seedat, J van Hoof, Y Delevoye-Turrel</p><p><strong>36. Resilience in social anxiety disorder and post-traumatic stress disorder in the context of childhood trauma</strong></p><p>M Bship, S Bakelaar, D Rosenstein, S Seedat</p><p><strong>37. The ethical dilemma of seclusion practices in psychiatry</strong></p><p>G Chiba, U Subramaney</p><p><strong>38. Physical activity and neurological soft signs in patients with schizophrenia</strong></p><p>O Esan, C Osunbote, I Oladele, S Fakunle, C Ehindero</p><p><strong>39. A retrospective study of completed suicides in the Nelson Mandela Bay Metropolitan Area from 2008 to 2013 - preliminary results</strong></p><p><strong></strong>C Grobler, J Strumpher, R Jacobs</p><p><strong>40. Serotonin transporter variants play a role in anxiety sensitivity in South African adolescents</strong></p><p><strong></strong>S M J Hemmings, L I Martin, L van der Merwe, R Benecke, K Domschke, S Seedat</p><p><strong>41. Investigation of variants within antipsychotic candidate pharmacogenes associated with treatment outcome</strong></p><p>F Higgins, B Drogmoller, G Wright, L van der Merwe, N McGregor, B Chiliza, L Asmal, L Koen, D Niehaus, R Emsley, L Warnich</p><p><strong>42. Effects of diet, smoking and alcohol consumption on disability (EDSS) in people diagnosed with multiple sclerosis</strong></p><p>S Janse van Rensburg, W Davis, D Geiger, F J Cronje, L Whati, M Kidd, M J Kotze</p><p><strong>43. The clinical utility of neuroimaging in an acute adolescnet psychiatric inpatient population</strong></p><p><strong></strong>Z Khan, A Lachman, J Harvey</p><p><strong>44. Relationships between childhood trauma (CT) and premorbid adjustment (PA) in a highly traumatised sample of patients with first-episode schizophrenia (FES</strong>)</p><p>S Kilian, J Burns, S Seedat, L Asmal, B Chiliza, S du Plessis, R Olivier, R Emsley</p><p><strong>45. Functional and cognitive outcomes using an mTOR inhibitor in an adolescent with TSC</strong></p><p>A Lachman, C van der Merwe, P Boyes, P de Vries</p><p><strong>46. Perceptions about adolescent body image and eating behaviour</strong></p><p><strong></strong>K Laxton, A B R Janse van Rensburg</p><p><strong>47. Clinical relevance of FTO rs9939609 as a determinant of cardio-metabolic risk in South African patients with major depressive disorder</strong></p><p>H K Luckhoff, M J Kotze</p><p><strong>48. Childhood abuse and neglect as predictors of deficits in verbal auditory memory in non-clinical adolescents with low anxiety proneness</strong></p><p>L Martin, K Martin, S Seedat</p><p><strong>49. The changes of pro-inflammatory cytokines in a prenatally stressed febrile seizure animal model and whether <em>Rhus chirindensis</em> may attenuate these changes</strong></p><p><strong></strong>A Mohamed, M V Mabandla, L Qulu</p><p><strong>50. Influence of TMPRSS6 A736v and HFE C282y on serum iron parameters and age of onset in patients with multiple sclerosis</strong></p><p><strong></strong>K E Moremi, M J Kotze, H K Luckhoff, L R Fisher, M Kidd, R van Toorn, S Janse van Rensburg</p><p><strong>51. Polypharmacy in pregnant women with serious mental illness</strong></p><p>E Thomas, E du Toit, L Koen, D Niehaus</p><p><strong>52. Infant attachment and maternal depression as predictors of neurodevelopmental and behavioural outcomes at follow-up</strong></p><p>J Nothling, B Laughton, S Seedat</p><p><strong>53. Differences in abuse, neglect and exposure to community violence in adolescents with and without PTSD</strong></p><p><strong></strong>J Nothling, S Suliman, L Martin, C Simmons, S Seedat</p><p><strong>54. Assessment of oxidative stress markers in children with autistic spectrum disorders in Lagos, Nigeria</strong></p><p><strong></strong>Y Oshodi, O Ojewunmi, T A Oshodi, T Ijarogbe, O F Aina, J Okpuzor, O C F E A Lesi</p><p><strong>55. Change in diagnosis and management of 'gender identity disorder' in pre-adolescent children</strong></p><p>S Pickstone-Taylor</p><p><strong>56. Brain network connectivity in women exposed to intimate partner violence</strong></p><p>A Roos, J-P Fouche, B Vythilingum, D J Stein</p><p><strong>57. Prolonged exposure treatment for PTSD in a Third-World, task-shifting, community-based environment</strong></p><p>J Rossouw, E Yadin, I Mbanga, T Jacobs, W Rossouw, D Alexander, S Seedat</p><p><strong>58. Contrasting effects of early0life stress on mitochondrial energy-related proteins in striatum and hippocampus of a rat model of attention-deficit/ hyperactivity disorder</strong></p><p><strong></strong>V Russell, J Dimatelis, J Womersley, T-L Sterley</p><p><strong>59. Attention-deficit hyperactivity disorder in adults: A South African perspective</strong></p><p>R Schoeman, M de Klerk, M Kidd</p><p><strong>60. Cognitive function in women with HIV infection and early-life stress</strong></p><p>G Spies, C Fennema-Notestine, M Cherner, S Seedat</p><p><strong>61. Changes in functional connectivity networks in bipolar disorder patients after mindfulness-based cognitic therapy</strong></p><p>J A Starke, C F Beckmann, N Horn</p><p><strong>62. Post-traumatic stress disorder, overweight and obesity: A systematic review and meta-analysis</strong></p><p><strong></strong>S Suliman, L Anthonissen, J Carr, S du Plessis, R Emsley, S M J Hemmings, C Lochner, N McGregor L van den Heuvel, S Seedat</p><p><strong>63. The brain and behaviour in a third-trimester equivalent animal model of fetal alcohol spectrum disorders</strong></p><p>P C Swart, C B Currin, J J Dimatelis, V A Russell</p><p><strong>64. Irritability Assessment Model (IAM) to monitor irritability in child and adolescent psychiatric disorders.</strong></p><p>D van der Westhuizen</p><p><strong>65. Outcome of parent-adolescent training in chilhood victimisation: Adaptive functioning, psychosocial and physiological variables</strong></p><p>D van der Westhuizen</p><p><strong>66. The effect of ketamine in the Wistar-Kyoto and Sprague Dawley rat models of depression</strong></p><p>P J van Zyl, J J Dimatelis, V A Russell</p><p><strong>67. Investigating COMT variants in anxiety sensitivity in South African adolescents</strong></p><p>L J Zass, L Martin, S Seedat, S M J Hemmings</p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p><strong><br /></strong></p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p>

Undiagnosed metabolic syndrome and other adverse effects among clozapine users of Xhosa descent

<p><strong>Background.</strong> Clozapine use is known to be associated with significant side-effects, including prolongation of the QT-interval, agranulocytosis and metabolic syndrome. However, few data exist on the prevalence of clozapine side-effects in patients of Xhosa descent. </p><p><strong>Objective. </strong>To gather data from Xhosa patients with schizophrenia to establish the prevalence of clozapine side-effects in this population. </p><p><strong>Methods.</strong> Twenty-nine Xhosa patients with schizophrenia (as per the <em>Diagnostic and Statistical Manual of Mental Disorders</em> (DSM-IV-TR)) who had been receiving clozapine treatment for &gt;1 year on an outpatient basis were selected for inclusion. All patients were participating in a genetics study in the Cape Metropolitan area. The participants were evaluated for the presence of side-effects (tests including an electrocardiogram, white blood cell count (WCC) and fasting blood glucose). </p><p><span><strong>Results. </strong>The prevalence of metabolic syndrome was 44.8% (95% confidence interval (CI) 26.7 - 62.9) and of undiagnosed diabetes mellitus 13.8% (95% CI 1.24 - 26.34). There was a significant association between metabolic syndrome and body mass index (BMI) (<em>p</em>&lt;0.01). The mean (SD) WCC was 7.8 × 10⁹/L (2.8), with 3.4% of the subjects having a WCC &lt;3.5 × 10⁹/L. Sedation (82.8%; 95% CI 69.0 - 96.5), hypersalivation (79.3%; 95% CI 64.6 - 94.1) and constipation (44.8%; 95% CI 26.7 - 62.9) were common. The mean QT-interval was 373.8 (35.9) ms and 10% had a corrected QT-interval &gt;440 ms. There was an association between the duration of clozapine treatment and QT-interval (with Bazett’s correction).  </span></p><p><strong>Conclusion. </strong>The high prevalence of metabolic syndrome and undiagnosed diabetes mellitus in this sample points to a need to monitor glucose levels and BMI on a regular basis. A larger study should be done to accurately quantify the differences in prevalence of side-effects between population groups.</p>

Retrospective review of trends in assaults and seclusion at an acute psychiatric ward over a 5-year period

In developing countries such as South Africa, not much is known about the prevalence of assaults and seclusion occurring in mental health wards over time. Here, we describe a 5-year trend in assaults and seclusions, stratified by gender, at Stikland Hospital, South Africa. A retrospective review of clinical records of patients admitted to the acute psychiatric admission wards at Stikland and involved in assault and secluded was undertaken between 1 January 2005 and 31 December 2010. Data on the number of patient and staff assaults as well as seclusions, gender, age, marital status, level of education, level of income, duration of hospital admission and primary psychiatric diagnosis were collected. Significantly (P < 0.01) more men than women engaged in patient assaults, while significantly (P < 0.01) more men were secluded than women. On a monthly basis, the number of gender-stratified patient assaults and seclusions significantly increased (P < 0.01) throughout the study period. In conclusion, we show here that gender had a significant effect on both patient assault and seclusion numbers, which increased towards the end of the study period. Monitoring of these events is therefore important to continuously improve quality of care.

Neurological soft signs as an endophenotype in an African schizophrenia population - a pilot study

OBJECTIVE

The use of endophenotypes, such as neurological soft signs (NSS), is advocated as one possible method to elucidate the heterogeneity of schizophrenia. Exploring the associations between NSS and specific illness symptoms has revealed some trends, although results have been conflicting. To date, such studies have been conducted largely on Caucasian populations and our pilot study represents the first attempt to gather such data in a homogenous African population.

METHOD

Fifty-one patients, all of Xhosa ethnicity and participating in a larger schizophrenia genetic study were recruited. NSS were evaluated using a modified Neurological Evaluation Scale. Data were analysed using SPSS with the strength of the overall relationships between NES groups and SANS and SAPS components analyzed by means of canonical correlation analysis.

RESULTS

The canonical correlation of SANS domains (excluding asociality) with the NES conceptual groups was 0.53 (SE=0.11, p=0.024) and of the SAPS domains 0.38 (SE=0.13, p=0.943).

CONCLUSION

Our results suggest a correlation between negative symptoms of schizophrenia and the presence of NSS, supporting the recruitment of a larger sample to more comprehensively evaluate a possible role for NSS as an endophenotype in the Xhosa schizophrenia population. Taking into account that NSS evaluations allow for inexpensive, relatively easy-to-do objective evaluations, this method presents us with a valuable research tool that can be used effectively within our under-resourced environment to help inform on the neurobiological substrate of schizophrenia.

Applicability and fairness of the oral examination in undergraduate psychiatry training in South Africa

OBJECTIVE

There are several methods of evaluating medical students' performance, such as written examination, oral examination and objective structured clinical examination (OSCE). Many studies have focused on the reliability and validity of these methods but few studies have explored comparison between these methods. Psychiatry is the only subject at the University of Stellenbosch where the final assessment consists of solely an oral component. The aim of the study was to compare students' final overall and discipline specific examination marks (i.e. in the other subjects) with the examination marks in psychiatry, and to determine if content or structure (e,g. oral, written or OSCE format) of examination impacts more on the student performance in the examination.

METHOD

343 final year medical students were included. All undertook their psychiatry rotation at the University of Stellenbosch, South Africa during 2008 and 2009. Data of marks obtained in all the disciplines during 2008 and 2009 were collected and class marks were compared with their final examination marks across all disciplines. Bland-Altman plots were used to assess the level of agreement between the class and examination marks. Cases below the lower threshold were compared to all other cases across all disciplines. The odds ratio for group status was calculated for gender distribution of examiners.

RESULTS

The psychiatry class mark and final oral examination mark provided similar measures within a width of 31.5. Cases below the threshold had poorer performance in two other disciplines. The gender distribution of the examiners (female-female) significantly increased the odds ratio for poorer performance in the oral examination.

CONCLUSION

The results suggest that a group of students underperform in their final examination independent of method of evaluation and that the gender of examiners impacts on examination marks. Therefore future research should focus on identifying and modifying factors (including choice of examiner combinations) that contribute to the poor performance of medical students in their final examination, in order to help students perform better. Gender distribution of examiners should also be considered when examinations are structured and designed.

Psychiatric genetics in South Africa: cutting a rough diamond

Psychiatric disorders place a considerable healthcare burden on South African society. Incorporating genetic technologies into future treatment plans offers a potential mechanism to reduce this burden. This review focuses on psychiatric genetic research that has been performed in South African populations with regards to obsessive-compulsive disorder, schizophrenia and bipolar disorder. Preliminary findings from these studies suggest that data obtained in developed countries cannot necessarily be extrapolated to South African population groups. Psychiatric genetic studies in South Africa seem to involve relatively low-cost methodologies and only a limited number of large national collaborative studies. Future research in South Africa should therefore aim to incorporate high-throughput technologies into large scale psychiatric studies through the development of collaborations. On a global level, the vast majority of psychiatric genetic studies have been performed in non-African populations. South Africa, as the leading contributor to scientific research in Africa, may provide a foundation for addressing this disparity and strengthening psychiatric genetic research on the continent. Although the elucidation of the genetic architecture of psychiatric disorders has proved challenging, examining the unique genetic profiles found in South African populations could provide valuable insight into the genetics of psychiatric disorders.

An audit of non-urgent general adult referrals to Stikland State Psychiatric Facility

<p><strong>Objectives.</strong> The national Department of Health strongly advocates the strengthening of primary health care systems, and recommendations for appropriate level of care referrals exist. Very few published data on the scope of current ambulatory specialised psychiatric hospital services in South Africa are currently available, making it difficult to assess whether these recommendations are being followed. As a starting point, an audit was conducted to obtain a profile of new non-urgent general adult patients seen at Stikland Hospital with a view to evaluating system needs and demands. <strong></strong></p><p><strong>Methods.</strong> The folders of 103 consecutively seen patients were selected for retrospective review. Patient demographic, referral and assessment information was entered into a single database. Descriptive statistics were compiled with reference to the above variables using SPSS.</p><p><strong>Results.</strong> Overall 58.3% of referrals were from the private sector. More than a third (36.7%) of referral letters stated no clear reason for referral and 41.7% no psychiatric diagnosis, and 29.1% of patients were referred without psychotropic medication being started. On assessment 62.1% of patients were found to have a single Axis I diagnosis. Despite virtually no referral letters making any mention of them, substance use disorders (30.1%), personality traits/disorders (35.9%) and co-morbid medical illness (36.7%) were commonly found on assessment.</p><p><strong>Conclusions.</strong> A significant portion of the patients in our sample could have been managed at primary care level and were referred prematurely. The overall quality of referral letters was poor, and they lacked vital information required for appropriate pre-assessment decision making. Undergraduate training focusing on these skills should be intensified, and consideration should be given to incorporating aspects of our findings into primary health care updates.</p>

Subjective awareness of tardive dyskinesia and insight in schizophrenia

BACKGROUND

Lack of awareness of tardive dyskinesia (TD) and poor insight into mental illness are common in schizophrenia, raising the possibility that these phenomena are manifestations of a common underlying dysfunction.

METHODS

We investigated relationships between low awareness of TD and poor insight into mental illness in 130 patients with schizophrenia and TD. We also examined selected demographic and clinical correlates of these two phenomena.

RESULTS

Sixty-six (51%) patients had no or low awareness of TD and 94 (72%) had at least mild impairment of insight into their mental illness. Low awareness of TD was not significantly correlated with greater impairment of insight into mental illness. Regression analyses indicated that the Positive and Negative Syndrome Scale (PANSS) disorganised factor (β=0.72, t=11.88, p<0.01) accounted for 52% of the variance in insight into mental illness (adjusted R(2)=0.55) (F[2, 127]=81.00, p<0.01) and the Extrapyramidal Symptom Rating Scale (ESRS) dyskinesia subscale score (β=0.47, t=6.80, p<0.01), PANSS disorganised factor (β=-0.26, t=-3.73, p<0.01), and ESRS parkinsonism subscale score (β=0.31, t=4.55, p<0.01) together accounted for 37% of the variance in awareness of TD (adjusted R(2)=0.37) (F[3, 126]=26.87, p<0.01).

CONCLUSION

The two phenomena appear to be dissociated, and may be domain-specific.

Schizophrenia-Window-of-Hope.com: Development of a psycho-educational Internet resource for the South African setting

Psycho-educational programmes for families of persons with schizophrenia have been shown to reduce relapse rates, subsequently reducing the burden on the family as well as health care systems. Although various South African helplines and psycho-educational websites exist, none of these focused specifically on schizophrenia. The South African Depression and Anxiety Group SADAG was approached for assistance to enable us to develop a piggy-back schizophrenia service on their already established helpline. A multidisciplinary mental health team compiled a manual for use by SADAG helpline operators, but owing to the huge amount of information it was realised that the resource would be more efficient if both a helpline and an Internet resource could be created. The website (www.schizophrenia-window-of-hope.com) was then developed with the help of an IT professional. This site represents the first attempt to create an internet-based schizophrenia-specific educational resource for the South African setting. The next step will be to obtain formal feedback from helpline and website users in order to inform the ongoing development of the site.

Combining ECT and clozapine in the treatment of clozapine-refractory schizophrenia and schizoaffective disorder – a pilot study

<p><strong>Objective.</strong> Clozapine is the current gold standard treatment for severe treatment-refractory schizophrenia, but even so 40 - 70% of these patients will continue to experience disabling symptoms when treated with clozapine monotherapy. Current clinical practice at Stikland Hospital holds that known clozapine-refractory schizophrenia patients who relapse due to non-compliance are treated with an initial combination of clozapine and ECT (if able to consent) when readmitted. The purpose of this study was to evaluate the validity of this practice. <strong></strong></p><p><strong>Methods.</strong> Patients were divided into an ECT (EG) and non-ECT (CG) group. Clozapine was started and ECT administered as per protocol. Demographic data, psychiatric and medication history and data concerning adverse events were collected. Positive and Negative Symptom Scale (PANSS) scores were done at baseline and at days 21 and 42.<strong> </strong></p><p><strong>Results.</strong> At discharge, although numerically the average increase in clozapine dose was lower and the reduction in length of stay was greater in the EG, none of the variables measured were statistically significantly different between groups. More concomitants were also used in the EG. <strong></strong></p><p><strong>Conclusions.</strong> This pilot study represents the first controlled trial of ECT-clozapine bitherapy in a population with clozapine- refractory schizophrenia and schizoaffective disorder reported in the literature. The validity of our choice of current clinical practice in this population was not supported by our results. However, the study did provide us with preliminary evidence for the safety and efficacy of this combination. It would therefore be reasonable to continue to use this strategy in selected cases, at least until other clozapine-refractory treatment strategies become more available in our setting.</p>

Assertive community treatment in the South African context

Although the integration of psychiatric services into the community has potentially been beneficial to many patients, this transition has not been without problems. A major obstacle to establishing successful community-based treatment in South Africa has been that the reduction in number of inpatients beds did not coincide with the development of adequate community resources. This, in combination with our patients' poor socio-economic circumstances, has contributed to a substantial increase in the so-called "revolving door" or high frequency use phenomenon in state psychiatric facilities. Clearly, there is need for a renewed approach to address this problem in our setting. With this in mind the APH in the Western Cape appointed three community treatment teams in January 2007. This publication serves to give an overview of the Stikland Psychiatric Hospital team's experiences in the first 12 months since establishment. To date, we have been confronted by several challenges that complicate the successful implementation of an "assertive" outreach service in the South African context. However, there seems to be some hope as early findings demonstrate a reduction in number of admissions as well as inpatient days. Furthermore there has been a very positive response from service users, their families and other staff members leaving us to conclude that this initiative seems to be a much needed step in the right direction.

The multidimensional assessment of psychopathology in mood and psychotic disorders. A proposal for Axis II in DSM-V/ICD-11

The inclusion of dimensional elements in the psychiatric diagnostic systems have been advocated for many years, however it has been resisted due to concerns about clinical utility. Recent suggestions have been for a combination of categorical and dimensional data in future diagnostic classification systems. In this paper we discuss the overlap in symptom complexes between mood disorders and schizophrenia and a multi-dimensional model of the mood-psychosis interface. We propose that the personality diagnoses should be included in Axis I and suggest the inclusion of a five factor dimensional diagnosis of mood and psychotic disorders on Axis II of DSM-V/ICD-11.

Antipsychotic prescription patterns in Xhosa patients with schizophrenia or schizoaffective disorder

OBJECTIVE

To examine the degree to which South African physicians use similar treatment guidelines in their prescription of antipsychotic medication.

METHOD

Data on the prescriptions for Xhosa patients with schizophrenia and schizoaffective disorder were retrospectively examined to investigate differences between three catchment areas in the Western Cape, especially in terms of clozapine use.

RESULTS

There was an overall low rate (10.0%) of clozapine use and a relatively high occurrence of polypharmacy (28.6% of 510 patients). There were statistically significant differences between the three catchment areas in terms of clozapine (p=0.002) and haloperidol (p=0.001) use. Valkenberg hospital had the highest number of clozapine prescriptions and the lowest of haloperidol. Prescriptions of depot antipsychotics did not differ between catchment areas.

CONCLUSION

Discrepancies in antipsychotic medicine prescription patterns were evident between the examined hospitals. It is becoming paramount for practical implementation of guidelines to be improved in South Africa to address, e.g., low clozapine use and the high frequency of polypharmacy.

Hoarding behaviour in Xhosa patients with schizophrenia - prevalence and clinical presentation

<div style="left: 81.816px; top: 554.304px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.945404);" data-canvas-width="64.96499999999999"><strong>Objective:</strong></div><div style="left: 146.781px; top: 554.304px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.916953);" data-canvas-width="327.78">Hoarding is commonly defined as the acquisition of</div><div style="left: 81.816px; top: 577.634px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.925405);" data-canvas-width="392.8499999999999">and failure to discard possessions of little use or value, and is</div><div style="left: 81.816px; top: 600.963px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.925516);" data-canvas-width="392.82">included as a symptom in the diagnostic criteria for obsessive</div><div style="left: 81.816px; top: 624.293px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.921474);" data-canvas-width="392.63999999999976">compulsive personality disorder (OCPD) and obsessive</div><div style="left: 81.816px; top: 647.622px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.966516);" data-canvas-width="392.76">compulsive disorder (OCD). However, it has also been</div><div style="left: 81.816px; top: 670.952px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.927338);" data-canvas-width="392.80500000000006">observed in other clinical syndromes including schizophrenia.</div><div style="left: 81.816px; top: 694.281px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.877386);" data-canvas-width="392.8349999999999">This study was conducted to investigate the prevalence and</div><div style="left: 81.816px; top: 717.611px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.901411);" data-canvas-width="392.79">clinical presentation of hoarding behaviour in schizophrenia</div><div style="left: 81.816px; top: 740.94px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.896676);" data-canvas-width="145.65">among Xhosa patients.</div><div style="left: 81.816px; top: 778.453px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.945913);" data-canvas-width="52.845000000000006"><strong>Method:</strong></div><div style="left: 134.661px; top: 778.453px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.875209);" data-canvas-width="339.975">The sample consisted of 102 patients, recruited as</div><div style="left: 81.816px; top: 801.782px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.892501);" data-canvas-width="392.7749999999999">part of a larger genetic study in the Cape Town metropole</div><div style="left: 81.816px; top: 825.112px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.942281);" data-canvas-width="392.7900000000001">between November 2004 and January 2005, diagnosed with</div><div style="left: 81.816px; top: 848.441px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.911274);" data-canvas-width="392.82">schizophrenia or schizoaffective disorders according to the</div><div style="left: 81.816px; top: 871.771px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.906643);" data-canvas-width="335.72999999999996">Diagnostic and Statistical Manual of Mental Disorders</div><div style="left: 417.051px; top: 871.771px; font-size: 15.45px; font-family: sans-serif;">(</div><div style="left: 420.651px; top: 871.771px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.845623);" data-canvas-width="45.720000000000006">DSM-IV</div><div style="left: 466.371px; top: 871.771px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.873016);" data-canvas-width="8.25">)</div><div style="left: 81.816px; top: 895.1px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.933064);" data-canvas-width="392.82">criteria. They were screened for clinically significant hoarding</div><div style="left: 81.816px; top: 918.43px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.903346);" data-canvas-width="392.82000000000005">symptoms. If these were present, additional information on</div><div style="left: 81.816px; top: 941.759px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.883932);" data-canvas-width="392.7750000000001">the phenomenology was obtained by means of a structured</div><div style="left: 81.816px; top: 965.089px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.892874);" data-canvas-width="392.82000000000005">questionnaire. The Mini International Neuropsychiatric Interview</div><div style="left: 81.816px; top: 988.418px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.893517);" data-canvas-width="392.79000000000013">(MINI) (screen and full version), the Yale Brown Obsessive</div><div style="left: 81.816px; top: 1011.75px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.902758);" data-canvas-width="392.82000000000005">Compulsive Scale (Y-BOCS) Checklist, Y-BOCS, Clutter Image</div><div style="left: 81.816px; top: 1035.08px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.887528);" data-canvas-width="392.80499999999995">Rating Scale (CIRS) and a structured questionnaire on hoarding</div><div style="left: 81.816px; top: 1058.41px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.907236);" data-canvas-width="118.485">were administered.</div><div style="left: 81.816px; top: 1095.92px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.789549);" data-canvas-width="44.06999999999999"><strong>Results:</strong></div><div style="left: 125.886px; top: 1095.92px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.878424);" data-canvas-width="348.7050000000001">Only four patients with schizophrenia were classified</div><div style="left: 81.816px; top: 1119.25px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.890916);" data-canvas-width="392.7899999999999">as hoarders. Although their clinical presentation resembled that</div><div style="left: 81.816px; top: 1142.58px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.912332);" data-canvas-width="392.8349999999999">of hoarders described elsewhere in the literature, they had low</div><div style="left: 81.816px; top: 1165.91px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.908464);" data-canvas-width="392.835">Y-BOCS scores and did not report other obsessive-compulsive</div><div style="left: 81.816px; top: 1189.24px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.872842);" data-canvas-width="68.94">symptoms.</div><div style="left: 81.816px; top: 1226.75px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.906502);" data-canvas-width="73.2"><strong>Conclusion:</strong></div><div style="left: 155.016px; top: 1226.75px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.900338);" data-canvas-width="319.575">Our results suggest that hoarding behaviour is</div><div style="left: 81.816px; top: 1250.08px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.908745);" data-canvas-width="392.79000000000013">not common in Xhosa patients with schizophrenia. Further</div><div style="left: 81.816px; top: 1273.41px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.912192);" data-canvas-width="392.78999999999996">investigation of protective factors for hoarding behaviour in the</div><div style="left: 81.816px; top: 1296.74px; font-size: 15.45px; font-family: sans-serif; transform: scaleX(0.907419);" data-canvas-width="192.63000000000002">Xhosa population is warranted.</div>

Changing the course of schizophrenia - predictors of treatment outcome revisited

<p>Multiple factors play a role in determining the outcome of schizophrenia. However, the role of these factors is poorly understood, and research findings so far have been inconclusive and sometimes contradictory. Various demographic and baseline clinical factors have been reported to be associated with treatment outcome. Also, early symptom reduction after initiation of antipsychotic therapy is closely related to later treatment response. However, associations as such do not necessarily imply predictive value, and none of these factors can be regarded as clinically useful in predicting treatment outcome. This article discusses selected aspects of treatment outcome and its prediction in schizophrenia, focusing particularly on early treatment response, ethnicity, neurological soft signs, and the predictive value of a discriminant functional analysis model utilising a combination of putative predictors. Such a model holds promise, and it is to be hoped that future refinements will lead to a clinically useful model for predicting outcome.</p>

HIV/AIDS risk behaviour in South African schizophrenia patients

BACKGROUND

Initially the risk of HIV in people with severe mental illness (SMI) was grossly underestimated, but comparisons with the general population have in fact revealed higher infection rates in this particular group. Not only are patients with SMI sexually active but it has also been demonstrated that this group and especially patients with schizophrenia are less knowledgeable about HIV risk behaviours than the general population. Currently no data concerning the participation in and knowledge of HIV/AIDS risk behaviours by South African schizophrenic patients is available.

METHODS

Patients with schizophrenia and a control-group were recruited from community clinics in the Western Cape, South Africa, whereafter 43 from each group were matched (race, age, sex). The patient group was subjected to a structured clinical interview and both groups completed the AIDS Risk Behaviour Assessment (ARBAQ) and Knowledge (ARBKQ) Questionnaires.

RESULTS

Comparatively, significant knowledge deficits could be demonstrated for the patient group in overall terms (p<0.001) as well as for five specific items (all p<0.05) on the ARBKQ. Furthermore, 10% of the patients believed that the depot antipsychotic injection placed individuals at risk for contracting HIV. Both groups also admitted participation in various high risk sexual behaviours.

CONCLUSION

Our results suggest that patients with schizophrenia should be a target group when developing AIDS prevention programmes. In order to identify particularly at risk individuals, a comprehensive risk behaviour assessment should form part of the psychiatric interview.

Emotional face processing deficit in schizophrenia: A replication study in a South African Xhosa population

Schizophrenia is associated with a deficit in the recognition of negative emotions from facial expressions. The present study examined the universality of this finding by studying facial expression recognition in African Xhosa population. Forty-four Xhosa patients with schizophrenia and forty healthy controls were tested with a computerized task requiring rapid perceptual discrimination of matched positive (i.e. happy), negative (i.e. angry), and neutral faces. Patients were equally accurate as controls in recognizing happy faces but showed a marked impairment in recognition of angry faces. The impairment was particularly pronounced for high-intensity (open-mouth) angry faces. Patients also exhibited more false happy and angry responses to neutral faces than controls. No correlation between level of education or illness duration and emotion recognition was found but the deficit in the recognition of negative emotions was more pronounced in familial compared to non-familial cases of schizophrenia. These findings suggest that the deficit in the recognition of negative facial expressions may constitute a universal neurocognitive marker of schizophrenia.

Clozapine-induced intestinal obstruction - a critical examination of four cases

Clozapine is an atypical antipsychotic drug indicated for the management of severely ill patients with schizophrenia who fail to respond adequately to standard antipsychotic treatment. It has demonstrated superior efficacy in treating both the positive and negative symptoms in treatment-refractory cases. It also has the added benefit of causing minimal extrapyramidal side- effects, producing no tardive dyskinesia and having little effect on prolactin levels

Management of violent behaviour in acutely relapsed schizophrenics

The management of aggressive behaviour has always been a critical issue in psychiatry. Finding measures that can be used to accurately predict the likelihood of assaultative behaviour and thus ensure timeous appropriate pharmacological management remains a dilemma. The study objective was to investigate the naturalistic, pharmacological management of inpatient aggressive behaviour in a group of 50 schizophrenic subjects with a view to determine: (1) whether a presenting history of recent violence lead to altered pharmacological management and (2) whether the NOSIE could be regarded as a useful assessment tool with regards to inpatient behaviour management. No significant difference could be demonstrated between the 2 subsets of subjects (history of violence vs none) with respect to total doses of medication administered. No statistical correlation could be found between the total NOSIE score and the dose of psychotropic medication used. The relationship between a subset of NOSIE-items and the total dose of medication was more complex and a clear linear relationship could be demonstrated for a total score of 0 to 5. In this particular ward setting a presenting history of recent violent behaviour did not influence the administration of medication and neither could the clinical judgement employed by the nursing staff to manage inpatient behaviour be captured by the NOSIE. However, a five-item subset of the NOSIE with questions relating to aggression and irritability warrants further scrutiny in this regard.

Duration of untreated psychosis and outcome in first-episode psychosis. Perspective from a developing country

OBJECTIVE

To investigate the association between duration of untreated psychosis (DUP) and treatment outcome in a sample of subjects from a developing country.

METHOD

Forty-eight subjects with a first episode of psychosis were evaluated prior to treatment and at 3-month intervals over a period of 24 months. We first examined correlations between DUP and symptom improvement as measured on the Positive and Negative Symptom Scale (PANSS), and then performed multivariate analysis to determine the validity of DUP as a predictor of outcome.

RESULTS

DUP was significantly correlated with improvement in PANSS total and negative subscale scores as well as the PANSS depression factor at 21 and 24 months. Multivariate analysis found DUP to be the only significant predictor of improvement in negative symptoms at 24 months.

CONCLUSION

DUP was a significant predictor of outcome in a cohort form a developing country. This study provides support for early detection and intervention strategies.

Suicide attempts in an African schizophrenia population: an assessment of demographic risk factors

This study investigated demographic variables, including affected sibling pair status, as risk factors for suicidal behavior in schizophrenia patients of African (Xhosa) descent. Xhosa subjects with schizophrenia were interviewed with the Diagnostic Interview for Genetic Studies (DIGS) and then stratified into two groups: those with ( n = 90) and those without ( n = 364) a history of previous suicide attempts. Demographic parameters (including gender, age, and social circumstances, sib ship) were then compared across these groups. Demographic predictors of suicide included sib ship status ( p = 0.038; OR = 1.7) and age of onset of illness ( p = 0.008; OR = 2.5). On further analysis of suicide in siblings, only a minority of sib pairs was found to be concordant for a lifetime history of suicide attempts (3%). These findings raise the possibility that affected sib pair status may be protective in nature. Given the counter-intuitive nature of this finding, further work is needed to replicate it, and to explore possible underlying mechanisms.

Violence in male patients with schizophrenia: risk markers in a South African population

OBJECTIVE

We investigate the role of functional variants in the catecholamine-O-methyl transferase gene (COMT) and the monoamine oxidase-A gene (MOA-A), as well as previously identified non-genetic risk factors in the manifestation of violent behaviour in South African male schizophrenia patients.

METHOD

A cohort of 70 acutely relapsed male schizophrenia patients was stratified into violent and non-violent subsets, based on the presence or absence of previous or current violent behaviour. Standardized violence rating scales were also applied and the COMT/NlaIII and MAO-A promoter region variable number of tandem repeats (VNTR) polymorphisms were genotyped.

RESULTS

A multiple logistic regression model based on the clinical, genetic and socio-demographic variables indicated that delusions of control (OR = 3.7, 95% CI = 1.21-11.61) and the combined use of cannabis and alcohol (OR = 6.89, 95% CI = 1.28-37.05) were two significant predictors of violent behaviour in this schizophrenia population. No association was found between the tested polymorphisms and violent behaviour.

CONCLUSIONS

Although the sample size may have limited power to exclude a minor role for these specific gene variants, such a small contribution would have limited clinical relevance given the strong significance of the non-genetic markers. These findings suggest that currently proactive management of violent behaviour in this schizophrenia population should continue to be based on clinical predictors of violence.