Doctoral Degrees (Psychiatry)
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Item The development and feasibility of a community mental health education and detection (CMED) tool in the Amajuba District, KwaZulu-Natal, South Africa.(2022) Grant, Merridy.; Petersen, Inge.; Luvuno, Zamasomi.Background Poor mental health literacy, misinformation about treatment and stigma result in low demand for mental health services in low-and middle-income countries. Community-based interventions that raise mental health awareness and facilitate detection of mental health conditions, are instrumental in increasing demand of available mental health services. The CMED tool was developed to provide psychoeducation on mental health conditions and identify people with potential mental health problems at a household level who may benefit from available mental health interventions. Aims/Objectives Objectives of the study were 1) To develop the CMED Tool for adults for use by Ward-based Primary Health Care Outreach Teams (WBPHCOTs) in South Africa aligned with their roles of health promotion, screening and linkage to care; 2) To assess the accuracy of the CMED in identifying patients with a mental health problem and 3) to assess the feasibility of the CMED for use by WBPHCOTs and community members. Methods The research was made up of three sub-studies 1) Formative study, 2) an Accuracy study 3) and a Feasibility study. The Formative study (Objective 1) involved engagement with the KwaZulu-Natal Department of Health (KZN DoH) to ensure co-creation of the CMED tool and alignment with routine WBPHCOT activities; adaptation of the CMED tool; review of the CMED vignettes and illustrations by a panel of local and international mental health care experts to establish contextual and cultural relevance; and process mapping and focus group discussions with WBPHCOTs in one district to establish cultural and contextual appropriateness as well as coherence and compatibility with existing community-based services. The Accuracy study (Objective 2) involved assessing the accuracy of the newly developed CMED against the validated Brief Mental Health screening tool as the gold standard in identifying individuals in households with possible mental health conditions at a community level. The Feasibility study (Objective 3) was assessed using Bowen et al.’s (2009) framework which informed the study design, interview tools and analysis. The feasibility study involved four phases: (1) observations of the CMED consultation to evaluate the administration of the tool; (2) semi-structured interviews with household member/s after the CMED was administered to explore experiences of the visit; (3) follow-up interviews of household members referred using the CMED tool to assess uptake of referrals; (4) and weekly focus group discussions with the community health team to explore experiences of using the tool. Framework analysis was used to inform a priori themes and allow inductive themes to emerge from the data. Results The formative study resulted in a co-produced CMED tool consisting of five case vignettes and related illustrations to facilitate psychoeducation and detection of possible depression, anxiety, psychosis, harmful alcohol and drug use by WBPHCOTs. The tool was found to be culturally and contextually appropriate and aligned to the services provided by WBPHCOTs. The accuracy study found the CMED to perform at an acceptable level having a 79% sensitivity and 67% specificity. The feasibility study found the CMED to be acceptable to both community health teams and household members, demand for the tool was evident, implementation, practicality and integration within the existing health system were also indicated. Conclusion Collectively, the formative, accuracy and feasibility studies that make up this thesis, provide a valid and feasible tool that enables community health workers to perform their functions at a household level of health promotion, screening and linkage to care in relation to mental health. It enables mental health to be practically integrated at a community level as part of primary health care services through a people-centered, task sharing approach. This approach is aligned to international guidelines (Sustainable Development Goals) and National policy (South African Mental Health Act and the National Mental Health Framework and Strategic Plan) which call for the integration of mental health into primary health care), as well as the South African District Health System model through the PHC re-engineering strategy and the community-oriented primary care model where care extends from primary health care facilities into the community.Item Exploring movement of embodied, enacted, and inscribed knowledge through policy consultation: a case study of a mental health policy consultation process in South Africa.(2018) Marais, Debra Leigh.; Petersen, Inge.; Quayle, Michael Frank.This study is concerned with the intersection of knowledge and policy in the context of mental health system challenges in a developing country. Its focus is specifically on the way in which different forms of knowledge, from multiple sources, move through a policy consultation process to inform mental health policy. Policymakers tasked with developing mental health policies must balance a number of competing demands, including the need to develop policies that are applicable on a national level, while simultaneously addressing the idiosyncratic and contextual particularities associated with mental ill health at individual and local levels. Marrying the principles of evidence-based policymaking, with its focus on what works, with the principles of consultative policymaking, with its focus on what works for whom, means finding ways to integrate multiple knowledge inputs to incorporate these into policy decisions. In this sense, policymaking represents something of a knowledge problem for policymakers. In the South African legislative context, public participation in policymaking is taken as a given, with little guidance specifying how such processes should be conducted, nor whether or how the inputs from such processes are used in policy decisions. The consultation process around first mental health policy was the focus of this case study. The aim was to trace the movement of knowledge inputs through the consultation summits into policy outputs. Research suggests that certain forms of experiential knowledge may not be amenable to being captured in policy consultation processes. This study thus used a) conceptual schema of knowledge functions in policy as its analytical framework. This schema distinguishes between three phases of knowledge embodied, enacted, and inscribed that can be transformed between phases through various kinds of action. It provided a lens through which to trace the enactment and movement of embodied (experiential and evidence-based) knowledge through the consultation process, to determine the extent to which this form of knowledge was transferred into the inscribed knowledge of consultation recommendations and policy outputs. Data included mental health policy documents, reports and audio recordings from the provincial and national consultation summits, and key informant interviews. Thematic framework and thematic content analyses were conducted using the embodied-enacted-inscribed analytical framework. Findings revealed that no substantive changes were made to the mental health policy following the consultation summits, and suggest that the consultation summits had minimal impact on policy. In particular, there do not seem to have been systematic processes for facilitating and capturing knowledge inputs, or for transferring these inputs through increasing levels of summarisation during the consultation process. knowledge was not followed through to be incorporated into consultation and policy outputs. The implications of the findings for mental health policy consultation in South Africa are discussed. This is the first study to document, in depth, a significant part of the consultation process around mental health policy in South Africa, using the embodied-enacted-inscribed framework to explore how knowledge inputs informed policy. In doing so, it draws attention to the unique challenges in reconciling the contextual detail of embodied knowledge with the abstract generalisability of inscribed (policy) knowledge an undertaking that has particular relevance for mental health policy consultation. The study highlights the importance of designing participatory processes that enable optimal use of knowledge inputs in these enacted spaces, in order to align assumptions about the value of policy consultation with consultation practice, as well as to strengthen the policy development-consultation implementation link.Item Screening for and diagnosing dementia in an elderly residential home population : a validation study.(2014) Ramlall, Suvira.; Pillay, Basil Joseph.; Bhigjee, Ahmed Iqbal.Background: With the projected increase in the elderly population and expected rise in the prevalence of dementia, particularly in low-and-middle-income countries, early case identification is necessary for planning and delivering clinical services. The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aims of this research study were to report on the prevalence of cognitive impairment (dementia and Mild Cognitive Impairment-MCI), and to assess the performance of selected screening tools and a neuropsychological battery of tests in a heterogeneous local population. Methodology A cross-sectional study was conducted in a heterogeneous elderly South African population and consisted of three stages of data collection. In the first stage, cognitive screening measures were administered to a group of 302 participants, aged +60 years, living in a residential facility for the aged. The second stage consisted of a sub-sample of 140 participants who were assessed for cognitive impairment based on the Diagnostic and Statistical Manual of Mental Disorders 4th Edition-Text Revised criteria (DSM-IV-TR). Criteria A and B for Alzheimer’s and Vascular dementia were applied to assign a diagnosis of dementia without reference to aetiology. The participants were also assessed for Mild Cognitive Impairment (MCI), based on the criteria of the International Working Group on Mild Cognitive Impairment. Of the 140 participants in stage two, 117 were administered a neuropsychological battery of tests in the third stage. The influence of demographic variables and the sensitivity, specificity and optimum cut-off scores were determined for the following seven selected screening measures, individually and in combination: the Mini- Mental State Examination (MMSE), Subjective Memory Complaint (SMC), Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO), Subjective Memory Complaint Clinical (SMCC) and the Clock Drawing Test (CDT). The sensitivity and specificity of the neuropsychological tests in the detection of dementia were also determined. Results Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Performance on the screening measures was influenced by race, age and education. Using ROC analyses, the SMCC, MMSE and CDT were found to be moderately accurate in screening for dementia with AUC >.70. Neuropsychological test performance was influenced by the age, gender, race and education level of participants. With the exception of the Digit Span (forward), Digit Span (total), COWAT-A, Narrative Memory Test (delayed recall), Token Test and the Luria Hand Sequence Test, all the neuropsychological test measures displayed significance in distinguishing between the three classification groups (controls, MCI, dementia). Conclusion SMCC’s are valid screening questions as a first level of ‘rule-out’ screening. The MMSE can be included at a second stage of screening at general hospital level and the CDT in specialist clinical settings. Several measures from the neuropsychological battery of tests evaluated have discriminant validity and diagnostic accuracy for the differential diagnosis of cognitive disturbances in an elderly heterogeneous South African population .Item The distinction between malingering and mental illness in black forensic patients(1997) Buntting, Basil,Gregory.; Wessels, Wessel Hendrik.; Van Rensburg, P. H. J. J.One of the main problems facing the psychiatrist in forensic psychiatry is the distinction between malingering and mental illness especially in Zulu speaking patients. This study identified twenty items from the literature and clinical practice that separate malingering from mental illness. The validity of these items was assessed through an experimental, cross -sectional study design which compared two groups. These were a sample of fifty malingering African patients, male and female and a control group of fifty mentally-ill African forensic patients who were classified as State Patients. Since the data was categorical, that is, the outcome was either positive (that is malingering) or negative (that is mentally ill) the groups were compared by employing such methods as the chi-square test and Fisher's exact test. Seventeen items we re found to be statistically significant and were regarded as valid items that separate malingering from mental illness. Then the effectiveness of these seventeen items in separating malingering from mental illness was determined by calculating their sensitivity, specificity, their false positive rate and their false negative rate. The items fell into Group four categories or groups. Group I are those three items with a high sensitivity, a high specificity, a few false positives, a few false negatives, high positive predictive values and high negative predictive values. They were able to diagnose both malingering and sickness with a high degree of accuracy. Group 11 consisted of eight items with a high specificity, a few false negatives and high positive predictive values. i1 These items are good at diagnosing malingering patients directly. Group III consisted of six items with a high sensitivity, a few false positives and high negative predictive values. These items are good at diagnosing sick patients and therefore diagnose malingering indirectly by excluding mental illness. Group IV consisted of three items which did not show statistical significance between malingering and mentally ill patients. This study proved that seventeen items were able to separate malingering from mental illness to a statistically significant extent and are effective for the use in the diagnostic assessment of Zulu speaking forensic patients.Item Structural violence and schizophrenia : psychosocial, economic and cultural impacts on the onset of psychoses.(2010) Burns, Jonathan Kenneth.; Emsley, Robin A.Schizophrenia is a common and serious mental disorder affecting approximately 1% of the population (WHO, 1973). That genetic and other developmental factors give rise to a predisposition or vulnerability to schizophrenia is well recognized. However, the role of the environment in conferring risk for the disorder is now indisputable. Psychosocial, economic and cultural factors all impact on risk as evidenced by recent epidemiological studies reporting variable incidence in relation to factors including unemployment, urbanicity, migration and trauma. Complex gene-gene and gene-environment (GxE) interactions lie at the origin of this common human disorder and account for the diversity of epidemiological findings and clinical presentations that we encounter in research and clinical practice. This thesis comprises of six research papers and includes data from two separate studies of first-episode psychosis (FEP) conducted in KwaZulu-Natal, South Africa. The first study (Chapter 2) explored the impact of income inequality and poverty on the incidence of FEP and the results provide the first evidence for an association between increasing income inequality and increased incidence of FEP. The second study (Chapter 3) investigated the impact of a number of psychosocial, economic and cultural factors on the clinical presentation of FEP. Previous experiences of trauma were associated with positive and affective symptoms at psychosis onset, while cannabis use was associated with clinical features of FEP that previously have been associated with better outcome. Cultural factors such as spiritual attributions of cause and previous consultation with traditional healers may delay entry to psychiatric care and thereby negatively impact on prognosis of FEP. Chapter 4 addresses the issue of how the environment acts through GxE interactions to modify risk and alter the clinical presentation and course of schizophrenia. In this paper, new epidemiological findings are integrated with an evolutionary genetic theory of schizophrenia. In Chapter 5, I present a human rights perspective on the inequities and inequalities that characterize the lives of those with serious mental disorders such as schizophrenia, resulting from psychosocial, political, economic and cultural forces in the environment. The concluding chapter draws all of the data together, highlights key findings and conclusions from the thesis, addresses weaknesses and limitations of these conclusions and identifies priority areas for future research in this field.Item An Investigation into dopamine function in bipolar and unipolar primary affective disorders measuring prolactin when challenged by chlorpromazine and L-Dihydroxyphenylalanine.(1986) Hart, George Allan Desmond.; Wessels, Wessel Hendrik.This work is the result of an investigation into aspects of prolactin and dopamine in primary affective disorders. It is introduced by a discussion on the need for obtaining good scientific data on the organic and psychosocial aspects of psychiatric illness, and in particular, primary affective disorders. A short perspective of the history of depressive illness preceeds the review of relevant scientific literature on primary affective disorder. The literature survey covers aspects which indicate organic causal factors as well as viewing numerous organic studies which are thought to be relevant to this investigation. The role of dopamine in motor behaviour is considered in some detail. Psychopharmacological evidence that the mesolimbic and nigrostriatal dopaminergic systems are involved in motor regulation is reviewed. The role of dopamine receptors in motor behaviour is important to the conceptual framework of this thesis. Dopamine D 2 and D 1 receptors are considered and the opposing roles of these receptors is thought to be significant. Drugs affecting manic and depressive phases of primary affective disorders are reviewed. Emphasis is placed on dopaminergic aspects of various drugs in primary affective disorders as with pimozide as an antimanic agent, and nomifensine as an antidepressant. The possible role of noradrenaline in learning and mood regulation and in the dialogue with dopamine is looked at from an experimental and clinical point of view. Dopaminergic control of prolactin is reviewed and in particular the nature of the D4 receptor. The fact that these receptors which are on the pituitary mammotrophs have similarities to the D2 receptors is relevant. Thus considerable commonality exists between the dopaminergic regulation of motor behaviour and regulation of prolactin. Prolactin is used as an index of dopamine function in patients with primary affective disorders. Motor behaviour is strongly influenced by affective disorders.The central theme of the study itself was to indirectly evaluate dopamine function in primary affective disorder by measuring prolactin levels. As strong tonic inhibition is exerted by dopamine on prolactin, a series of challenges to the dopamine system was decided upon in order to generate a number of serum prolactin values. A dopamine agonist L-dihydroxyphenylalanine (indirect) and an antagonist, chlorpromazine, were used to stress the system mildly. The procedure was carried out under standard conditions both in the illness phase and upon significant recovery. Both these investigations were conducted in a drug-free state. The data generated was subjected to statistical analysis. The results of the analysis suggests that prolactin levels are low in depressed patients, and increase upon recovery, while manic patients have elevated levels which decrease with recovery. The pattern of the curves obtained from the challenge procedure suggests a possible supersensitivity of dopamine receptors in the manic patients. Blunting of responses of depressed patients remains a possibility but a study against normal controls is required to further assess this aspect. Evidence is therefore found for altered prolactin levels in illness phases of primary affective disorders. This is thought to be due to an abnormality in the dopamine regulation of prolactin. A discussion on the possible mechanisms and significance of these changes involves Beta-endorphin in an attempt to tie motor changes to mood regulation. Shortcomings of the study and future implications and developments are considered.Item A study of the relation between health attitudes, values and beliefs and help-seeking behaviour with special reference to a representative sample of black patients attending a general hospital.(1993) Pillay, Basil Joseph.; Schlebusch, Lourens.There is strong evidence supporting the view that beliefs and attitudes influence health behaviour. Furthermore, cultural and social beliefs also have been shown to influence the way health care facilities are used. Although western medicine plays a dominant role in the mass control of disease, traditional or folk medicine continues to play an important role in the health care of black communities. They therefore, possess unique attitudes, values and beliefs about health and illness which integrally influence their health behaviour. This study aims therefore to: understand phenomenologically the urban African’s perception of illness, disease and health; identify attitudes that directly influence health behaviour: identify “trigger factors” that precipitate health action and isolate factors that contribute to “negative” health behaviour. The sample in this study consisted of 3 groups of urban Africans who were 20 years and older. Group 1 comprised first time attenders to a medical outpatients department Group 2 and Group 3 were sample groups drawn from the Umlazi Township and the Kwa Mashu Township respectively. The Health and Illness Battery in the language of the participants were administered by trained interviewers. This study has demonstrated the following: urban Africans have a personal conception of illness, health and disease that influences their manner of help‐seeking; there are certain attitudes and beliefs that directly influence both positive and negative health behaviour;. there are several health beliefs which interact in a complex way and may lead to medical help‐seeking. Health action was found to be influenced by significant individuals in the subject's environment; demographic variables, such as, age, sex, education and urbanisation strongly influence the health and illness beliefs; these results validated some of the fundamental aspects of the common western health and illness models; the use of services and facilities are determined by the location, accessibility and the quality of services; financial costs, time, transport, lack of community supports, negatively affected helpseeking; symptoms have been identified as a “trigger factor” of help‐seeking. Individuals use other forms of treatments independent of medical treatments. A model of help‐seeking for urban Africans is proposed.