Bernard Janse van Rensburg

WPA Position Statement on Spirituality and Religion in Psychiatry.

The WPA and the World Health Organization (WHO) have worked hard to assure that comprehensive mental health promotion and care are scientifically based and, at the same time, compassionate and culturally sensitive1, 2. In recent decades, there has been increasing public and academic awareness of the relevance of spirituality and religion to health issues. Systematic reviews of the academic literature have identified more than 3,000 empirical studies investigating the relationship between religion/spirituality (R/S) and health3, 4. In the field of mental disorders, it has been shown that R/S has significant implications for prevalence (especially depressive and substance use disorders), diagnosis (e.g., differentiation between spiritual experiences and mental disorders), treatment (e.g., help seeking behavior, compliance, mindfulness, complementary therapies), outcomes (e.g., recovering and suicide) and prevention, as well as for quality of life and wellbeing3, 4. The WHO has now included R/S as a dimension of quality of life5. Although there is evidence to show that R/S is usually associated with better health outcomes, it may also cause harm (e.g., treatment refusal, intolerance, negative religious coping). Surveys have shown that R/S values, beliefs and practices remain relevant to most of the world population and that patients would like to have their R/S concerns addressed in health care6, 7, 8. Psychiatrists need to take into account all factors impacting on mental health. Evidence shows that R/S should be included among these, irrespective of psychiatrists’ spiritual, religious or philosophical orientation. However, few medical schools or specialist curricula provide any formal training for psychiatrists to learn about the evidence available, or how to properly address R/S in research and clinical practice7, 9. In order to fill this gap, the WPA and several national psychiatric associations (e.g., Brazil, India, South Africa, UK, and USA) have created sections on R/S. WPA has included “religion and spirituality” as a part of the “Core Training Curriculum for Psychiatry”10. Both terms, religion and spirituality, lack a universally agreed definition. Definitions of spirituality usually refer to a dimension of human experience related to the transcendent, the sacred, or to ultimate reality. Spirituality is closely related to values, meaning and purpose in life. Spirituality may develop individually or in communities and traditions. Religion is often seen as the institutional aspect of spirituality, usually defined more in terms of systems of beliefs and practices related to the sacred or divine, as held by a community or social group3, 8. Regardless of precise definitions, spirituality and religion are concerned with the core beliefs, values and experiences of human beings. A consideration of their relevance to the origins, understanding and treatment of psychiatric disorders and the patients attitude toward illness should therefore be central to clinical and academic psychiatry. Spiritual and religious considerations also have important ethical implications for the clinical practice of psychiatry11. In particular, the WPA proposes that: A tactful consideration of patients’ religious beliefs and practices as well as their spirituality should routinely be considered and will sometimes be an essential component of psychiatric history taking. An understanding of religion and spirituality and their relationship to the diagnosis, etiology and treatment of psychiatric disorders should be considered as essential components of both psychiatric training and continuing professional development. There is a need for more research on both religion and spirituality in psychiatry, especially on their clinical applications. These studies should cover a wide diversity of cultural and geographical backgrounds. The approach to religion and spirituality should be person‐centered. Psychiatrists should not use their professional position for proselytizing for spiritual or secular worldviews. Psychiatrists should be expected always to respect and be sensitive to the spiritual/religious beliefs and practices of their patients, and of the families and carers of their patients. Psychiatrists, whatever their personal beliefs, should be willing to work with leaders/members of faith communities, chaplains and pastoral workers, and others in the community, in support of the well‐being of their patients, and should encourage their multi‐disciplinary colleagues to do likewise. Psychiatrists should demonstrate awareness, respect and sensitivity to the important part that spirituality and religion play for many staff and volunteers in forming a vocation to work in the field of mental health care. Psychiatrists should be knowledgeable concerning the potential for both benefit and harm of religious, spiritual and secular worldviews and practices and be willing to share this information in a critical but impartial way with the wider community in support of the promotion of health and well‐being. Alexander Moreira‐Almeida1,2, Avdesh Sharma1,3, Bernard Janse van Rensburg1,4, Peter J. Verhagen1,5, Christopher C.H. Cook1,6 1WPA Section on Religion, Spirituality and Psychiatry; 2Research Center in Spirituality and Health, School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Brazil; 3‘Parivartan’ Center for Mental Health, New Delhi, India; 4Department of Psychiatry, University of the Witwatersrand, Johannesburg, South Africa; 5GGZ Centraal, Harderwijk, the Netherlands; 6Department of Theology and Religion, Durham University, Durham, UK

A Model for the Role of Defined Spirituality in South African Specialist Psychiatric Practice and Training

The current bio-psycho-social approach in South African psychiatry refers to Engel’s extended model of health care. It forms the basis of the existing collaboration between medicine, nursing, psychology, occupational therapy and social work. Psychiatry also has to bridge the multi-cultural, multi-religious and spiritual diverse reality of everyday practice. It has become important to establish how, within accepted boundaries, spirituality should be incorporated into the model for practice. Referring to methods described for nursing theory development, a defined core concept was used to construct a model. It may contribute to the discourse on spirituality in local psychiatry, health and mental health.

Competence of medical students and residents in psychiatry regarding spirituality, at a South African school of clinical medicine.

Objective: Elsewhere, curricula for undergraduate and postgraduate psychiatry have been extended to include the role of spirituality. It has also become important to establish how, within accepted professional boundaries, spirituality should be incorporated appropriately into the current model for South African practice and training. The objectives included exploring, analyzing, and describing the views and experience of local academic psychiatrists on this topic. Methods: This study was designed as an explorative, descriptive, phenomenological qualitative investigation. In-depth, semi-structured interviews were conducted with individual academic specialist psychiatrists as the primary data source. Results: Data saturation was achieved after 13 interviews. “Training of spirituality in psychiatry” emerged as one of six main themes from the integrated interview and literature content. All participants proposed that spirituality must be included in undergraduate medical and specialist psychiatric training. They have suggested that a mentorship model should be considered, which implies the reorientation of the teachers of psychiatry in this regard. Conclusions: This view concurred with the international medical literature, recommending that spirituality has to be incorporated into specialist psychiatric practice and training, but within professional boundaries and with all faith traditions and belief systems considered equally.

WPA-WHO Africa Mental Health Forum - recommendations and position statement

The WPA Action Plan 2017-2020 has been released by H. Herrman, new WPA President, during the recent World Congress of Psychiatry in Berlin. An agreement that could assist in achieving the objectives of that Action Plan in an African context has been produced during the WPA-World Health Organization (WHO) Africa Mental Health Forum meeting that took place in November 2016 in Cape Town, South Africa. In particular, the agreement can be helpful with regard to the Action Plan’s enabling activities, aimed at supporting psychiatrists to promote mental health and improve care capacity, and its partnership and collaboration activities, aimed to expand the reach and effectiveness of partnerships with service providers, service beneficiaries and policy makers. The Forum, co-chaired by D. Bhugra (WPA Immediate Past-President) and S. Saxena (Director of WHO Department of Mental Health and Substance Abuse), was opened by M. Moeti, WHO Director for the African Region. The following recommendations were made by the four panels (1. Leadership and governance; 2. Health and social services; 3. Prevention and promotion; 4. Information, evidence and research):

A retrospective record review and assessment of cost of quetiapine use in a community psychiatric setting in the Sedibeng district of Gauteng

Background With the revision of the National Essential Medicines List in South Africa, quetiapine is only available at the discretion of individual institutions in the public health sector. However, quetiapine is effective in managing all aspects of bipolar disorder, including preventative treatment of depressive episodes, and may be a cost-effective option in severe illness. Aim To present the first retrospective review of quetiapine use in a peri-urban health district of South Africa, describing the patient profile, clinical response and prescribing patterns. Methods The clinical files of all patients in Sedibeng District who received quetiapine over a defined 3-year period (2011–2013) were reviewed. A positive clinical response was defined as both symptomatic and functional improvement. Demographic and clinical characteristics of responders were compared with that of non-responders. Pre- and post-quetiapine scripts of the responders were audited and costed. Results Patients who received quetiapine (n = 40) had chronic disabling illness, often with multiple medication trials and hospitalisations prior to quetiapine use. Bipolar II disorder (followed by bipolar I disorder) was the most common primary psychiatric diagnosis documented. Other than improvement in functioning (p < 0.0001), responders differed significantly from non-responders in terms of a higher level of polypharmacy and a significant reduction in median number of medications from pre- to post-quetiapine (p = 0.0057). Conclusion Quetiapine use was associated with a highly significant improvement in functioning; however, it came at a 52% increase in medicine cost. Pre-quetiapine treatments, though, did not achieve an optimal level of functioning, and overall costs may be reduced by more rational prescribing habits.

Communication and adherence of patients at a South African public sector specialist psychiatric out-patient clinic

Background The impact that communication has on adherence, considering outcomes such as patient satisfaction and recall of the content of encounters with health care providers, has been extensively reported on in the literature. The South African Depression and Anxiety Group (SADAG) developed a specific communication intervention program, which was implemented in a local public sector setting. Objective To investigate the attendance and medication adherence of patients at the specialist psychiatric outpatient clinic of the Helen Joseph Hospital in Johannesburg, before and after the pilot implementation of this program. Methods Included quantitative and qualitative methodologies. The retrospective component included a review of participants’ demographic and clinical profile and medication adherence. The prospective, qualitative component included structured pre- and post-questionnaires. Results The typical participant was female (76%), older than 40 years (58.2%) and unemployed (74.2%). Comparing the study and control groups, the communication program resulted in a higher post-intervention booking ratio for the Study group, while the diagnostic category of participants were associated with their understanding of their medication. Discussion Being mindful of the noted limitations of this pilot project, the SADAG program or similar communication intervention strategy, should be a standard operational procedure in local South African state sector clinics.