Catherine Abbo

Prevalence and risk factors of depression in childhood and adolescence as seen in 4 districts of north-eastern Uganda

BackgroundMillions of African children are having to grow up under harsh and adverse psychosocial conditions but it’s not fully understood how this negative psychosocial environment is affecting their mental health. This paper examines the prevalence and risk factors of depression in childhood and adolescence as seen in a community sample derived from four disadvantaged districts in north-eastern Uganda.Methods1587 children were assessed using a structured instrument administered by trained psychiatric nurses to collect data on psychiatric disorders (DSM IV criteria), adverse psychosocial factors and socio-demographic factors.ResultsThe point prevalence of depressive disorder syndromes (DDS) in this study was 8.6% (95% CI 7.2%–10.1%) with a point prevalence for major depressive episode of 7.6% (95% CI 6.3%–9.0%) and dysthymia of 2.1% (95% CI 1.5%–3.0%). At multiple logistic regression, the factors that were independently significantly associated with DDS were: district (representing ecological factors), nature of living arrangements, domestic violence and psychiatric co-morbidities/psychiatric problems of emotional distress (assessed by the SDQ), suicidality and marginally, anxiety disorder syndromes, eating disorder syndromes, motor disorder syndromes and behavioral and developmental disorder syndromes (the later being protective against depression).ConclusionDisadvantaged north-eastern Uganda had a high prevalence of childhood depressive disorders. Ecological factors, markers of the quality of the child-principal caregiver relationship (nature of living arrangements and domestic violence) and the presence of psychiatric co-morbidities/psychiatric problems were the important independent determinants of childhood depression in this study.

Is nodding syndrome an Onchocerca volvulus-induced neuroinflammatory disorder? Uganda's story of research in understanding the disease.

Nodding syndrome is a devastating neurological disorder, mostly affecting children in eastern Africa. An estimated 10000 children are affected. Uganda, one of the most affected countries, set out to systematically investigate the disease and develop interventions for it. On December 21, 2015, the Ministry of Health held a meeting with community leaders from the affected areas to disseminate the results of the investigations made to date. This article summarizes the presentation and shares the story of studies into this peculiar disease. It also shares the results of preliminary studies on its pathogenesis and puts into perspective an upcoming treatment intervention. Clinical and electrophysiological studies have demonstrated nodding syndrome to be a complex epilepsy disorder. A definitive aetiological agent has not been established, but in agreement with other affected countries, a consistent epidemiological association has been demonstrated with infection by Onchocerca volvulus. Preliminary studies of its pathogenesis suggest that nodding syndrome may be a neuroinflammatory disorder, possibly induced by antibodies to O. volvulus cross-reacting with neuron proteins. Histological examination of post-mortem brains has shown some yet to be characterized polarizable material in the majority of specimens. Studies to confirm these observations and a clinical trial are planned for 2016.

Patients with nodding syndrome in Uganda improve with symptomatic treatment: a cross-sectional study

Objectives Nodding syndrome (NS) is a poorly understood neurological disorder affecting thousands of children in Africa. In March 2012, we introduced a treatment intervention that aimed to provide symptomatic relief. This intervention included sodium valproate for seizures, management of behaviour and emotional difficulties, nutritional therapy and physical rehabilitation. We assessed the clinical and functional outcomes of this intervention after 12 months of implementation. Design This was a cross-sectional study of a cohort of patients with NS receiving the specified intervention. We abstracted preintervention features from records and compared these with the current clinical status. We performed similar assessments on a cohort of patients with other convulsive epilepsies (OCE) and compared the outcomes of the two groups. Participants Participants were patients with WHO-defined NS and patients with OCE attending the same centres. Outcome measures The primary outcome was the proportion of patients with seizure freedom (≥1 month without seizures). Secondary outcome measures included a reduction in seizure frequency, resolution of behaviour and emotional difficulties, and independence in basic self-care. Results Patients with NS had had a longer duration of symptoms (median 5 (IQR 3, 6) years) compared with those with OCE (4 (IQR 2, 6) years), p<0.001. The intervention resulted in marked improvements in both groups; compared to the preintervention state, 121/484 (25%) patients with NS achieved seizure freedom and there was a >70% reduction in seizure frequency; behaviour and emotional difficulties resolved in 194/327 (59%) patients; 193/484 (40%) patients had enrolled in school including 17.7% who had earlier withdrawn due to severe seizures, and over 80% had achieved independence in basic self-care. These improvements were, however, less than that in patients with OCE of whom 243/476 (51.1%) patients were seizure free and in whom the seizure frequency had reduced by 86%. Conclusions Ugandan children with NS show substantial clinical and functional improvements with symptomatic treatments suggesting that NS is probably a reversible encephalopathy.

Prevalence, comorbidity and predictors of anxiety disorders in children and adolescents in rural north-eastern Uganda

BackgroundChild and adolescent anxiety disorders are the most prevalent form of childhood psychopathology. Research on child and adolescent anxiety disorders has predominantly been done in westernized societies. There is a paucity of data on the prevalence, comorbidity, and predictors of anxiety disorders in children and adolescents in non-western societies including those in sub-Saharan Africa. This paper investigates the prevalence, comorbidity, and predictors of anxiety disorders in children and adolescents in north-eastern Uganda.ObjectiveTo determine the prevalence of DSM-IV anxiety disorders, as well as comorbidity patterns and predictors in children and adolescents aged 3 to 19 years in north-eastern Uganda.MethodsFour districts (Lira, Tororo, Kaberamaido and Gulu) in rural north-eastern Uganda participated in this study. Using a multi-stage sampling procedure, a sample of 420 households with children aged 3–19 years from each district was enrolled into the study. The MINI International Neuropsychiatric Interview for children and adolescents (MINI KID) was used to assess for psychiatric disorders in 1587 of 1680 respondents.ResultsThe prevalence of anxiety disorders was 26.6%, with rates higher in females (29.7%) than in males (23.1%). The most common disorders in both males and females were specific phobia (15.8%), posttraumatic stress disorder (PTSD) (6.6%) and separation anxiety disorder (5.8%). Children below 5 years of age were significantly more likely to have separation anxiety disorder and specific phobias, while those aged between 14–19 were significantly more likely to have PTSD. Anxiety disorders were more prevalent among respondents with other psychiatric disorders; in respondents with two or more co-morbid psychiatric disorders the prevalence of anxiety disorders was 62.1%. Predictors of anxiety disorders were experience of war trauma (OR = 1.93, p < 0.001) and a higher score on the emotional symptom scale of the SDQ (OR = 2.58, p < 0.001). Significant socio-demograghic associations of anxiety disorders were found for female gender, guardian unemployment, living in permanent housing, living without parents, and having parents without education.ConclusionThe prevalence of anxiety disorders in children and adolescents in rural north-eastern Uganda is high, but consistent in terms of gender ratio and progression over time with a range of prior work in other contexts. Patterns of comorbidity and predictors of anxiety disorders in this setting are also broadly consistent with previous findings from western community studies. Both psychosocial stressors and exposure to war trauma are significant predictors of anxiety disorders.Prevention and treatment strategies need to be put in place to address the high prevalence rates of anxiety disorders in children and adolescents in Uganda.

Adolescent Suicidality as Seen in Rural Northeastern Uganda

BACKGROUND Suicidal behavior in adolescence is a public health concern and has serious consequences for adolescents and their families. There is, however, a paucity of data on this subject from sub-Saharan Africa, hence the need for this study. AIMS A cross-sectional multistage survey to investigate adolescent suicidality among other things was undertaken in rural northeastern Uganda. METHODS A structured protocol administered by trained psychiatric nurses collected information on sociodemographics, mental disorders (DSM-IV criteria), and psychological and psychosocial risk factors for children aged 3-19 years (N = 1492). For the purposes of this paper, an analysis of a subsample of adolescents (aged 10-19 years; n = 897) was undertaken. RESULTS Lifetime suicidality in this study was 6.1% (95% CI, 4.6%-7.9%). CONCLUSIONS Factors significantly associated with suicidality included mental disorder, the ecological factor district of residence, factors suggestive of low socioeconomic status, and disadvantaged childhood experiences.

Neuropsychiatric perspectives on nodding syndrome in northern Uganda: a case series study and a review of the literature

BACKGROUND Nodding Syndrome (NS), previously called Nodding Disease, is a chronic and debilitating illness affecting thousands of children aged 3-18 years in post-conflict Northern Uganda and South Sudan. Characterised by malnutrition, stunted growth, mental retardation and seizures, some researchers have designated it as epilepsy. With reports appearing in Northern Uganda in1997, NS reached epidemic proportions around 2000-2003 when people were moved into Internally Displaced Peoples (IDP) camps. Investigations for infections (onchocerciasis) and toxins have been inconclusive as to cause, treatment or outcome. No study has addressed the possible relationship of NS to childhood war-trauma experiences. OBJECTIVE To explore a possible relationship of exposure to prolonged war-trauma and the emergence of epidemic NS in Northern Uganda. METHOD This study was a case-series descriptive psychiatric naturalistic field observations of NS cases from homesteads in Northern Uganda and psychiatric investigations and treatment of NS cases referred to Mulago National Referral and Teaching Hospital. RESULTS Detailed Psychiatric clinical evaluations and field observations revealed that NS children had been exposed to severe war-related psychological and physical trauma as well as non-specific CNS insults including untreated CNS infections/infestations and malnutrition possibly causing seizures. Many children suffered post-traumatic stress disorder (PTSD) and depression. CONCLUSION NS could present as an association of childhood complex PTSD, (called Developmental Trauma Disorder), occurring in the chronically war-traumatised children of Northern Uganda, complicated by severe prolonged depression with its characteristic symptoms of psychomotor retardation, anxiety, anhedonia and anorexia. This, coupled with food shortages, resulted in malnutrition, wasting and stunted growth with severe avitaminoses. Many children had seizures. All this calls for multi-disciplinary treatment approaches.

Naturalistic outcome of treatment of psychosis by traditional healers in Jinja and Iganga districts, Eastern Uganda – a 3- and 6 months follow up

ObjectiveTo determine the naturalistic outcome of treatment of psychosis by traditional healers in Jinja and Iganga districts of Eastern Uganda.MethodA cohort of patients with psychosis receiving treatment from traditional healers’ shrines were recruited between January and March 2008 and followed up at three and six months. The Mini International Neuropsychiatry Interview (MINI Plus) was used for making specific diagnosis at the point of contact. For specific symptoms, Positive and Negative Symptom Scale (PANSS), Young Mania Rating Scale (YMRS) and Montgomery Asberg Depression Rating Scale (MADRS) were used to measure severity of schizophrenia, mania and psychotic depression, respectively. The Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) were used for objective assessments. The Compass Mental Health Index measured well being. Mean scores of the scales were computed using one way ANOVA for independent samples. Associations between outcome and categorical variables were examined at bivariate and multivariate levels.ResultsAll the symptom scales had a percentage reduction of more than 20% at three and six months follow up. The differences between the mean scores of the scales at baseline and 3 months, baseline and 6 months, and 3 and 6 months were all significant (P < 0.0001). The post test for pair wise comparisons, the Tukey HSD (Honestly Significant Difference) test was also all significant at P < 0.01 except for MADRS where there was no significant difference between 3 and 6 months for depression severity. Over 80% of the participants used biomedical services for the same symptoms in the study period. At 3 months follow up, patients who combined treatment were less likely to be cases (P = 0.002; OR 0.26 [0.15-0.58]), but more likely to be cases at 6 months follow up (P = 0.020; OR 2.05 [1.10-3.189]). Being in debt was associated with caseness both at 3 and 6 months.ConclusionThis study suggests that there may be some positive effects for patients with psychosis who combine both biomedical services and traditional healing. Further research in the area of naturalistic outcome of traditional healing is necessary.

Cytochrome P450 2C19 genetic polymorphisms in Ugandans

Sir, Cytochrome P450 (CYP) 2C19 metabolizes a wide variety of drugs [1–6]. A marked inter-individual difference in CYP2C19 enzyme activity has been reported, which can be explained—at least in part—by genetic polymorphisms causing defective (e.g. CYP2C19*2, CYP2C19*3) or increased (CYP2C19*17) activity [1–3, 5–8]. The CYP2C19*2 and CYP2C19*3 alleles account for 100% of the Japanese poor metabolizers (PMs), 83% of Caucasian PMs [7] and 96% of Ethiopian PMs [9]. The impact of the CYP2C19*17 allele on drug metabolism is also well-established [1, 3, 5, 10]. Therefore, the genotyping of CYP2C19 is a useful tool for evaluating individual drug response to its substrates. Since data on genetic polymorphisms among African populations are limited [1, 9, 11, 12], we have investigated the frequency of CYP2C19 genetic polymorphisms in Ugandans. Healthy adult ethnic Ugandans were recruited among students of the Butabika School of Psychiatric Nursing, Uganda. The health status of the participants was confirmed by clinical history and examination. Subjects suffering from any acute or chronic illnesses or taking any medications were excluded from participating in the study. All participants gave their written informed consent on the basis of verbal and written information provided in English, the official language of Uganda. A venous blood sample was obtained from each participant, and DNA was prepared using a QIAamp DNA Blood Midi kit (Qiagen, Tokyo, Japan). The CYP2C19*2 (rs4244285) and CYP2C19*3 (rs4986893) alleles were identified using the PCR–restriction fragment length polymorphism (RFLP) assay [7], the CYP2C19*17 allele was analyzed by PCR-RFLP (-3402C>T) and allele-specific amplification methods (-806C>T) (rs12248560) [1] and the CYP2C19*1 allele was assumed when none of these three other alleles were detected. This study was approved by the ethics committees of the Hirosaki University Graduate School of Medicine and Makerere University Faculty of Medicine, respectively. Permission to conduct the study was given by the Uganda National Council for Science and Technology. A total of 99 unrelated subjects (22 females and 77 males) were enrolled. All were black Ugandans from various regions of the country. The genotypes and predicted phenotypes are shown in Table 1. The genotype frequency distribution was in concordance with Hardy–Weinberg equilibrium. In the subjects with the CYP2C19*17 allelic polymorphism, complete linkage was found between the – 3402C>T and –806C>T mutations. The frequency of PMs (subjects with two defective alleles) and ultra-rapid metabEur J Clin Pharmacol (2009) 65:319–320 DOI 10.1007/s00228-008-0583-6

Stereotypes on Nodding syndrome: responses of health workers in the affected region of northern Uganda.

BACKGROUND Nodding Syndrome is a debilitating disorder of yet unknown etiology that has affected children and adolescents aged 3 - 18 years in parts of sub Saharan African countries including Uganda, South Sudan, Tanzania and Liberia. OBJECTIVE To identify stereotypes and negative attitudes held by primary care health workers about nodding syndrome. METHOD Of one hundred health workers invited by the Uganda Ministry of Health for training on nodding syndrome from the three most affected districts of Pader, Lamwo and Kitgum forty were interviewed using a predesigned tool. Content and thematic analysis was applied. RESULTS There were 22 females. The median age was 33 years (range 23-54 years). The participants included Psychiatric Clinical Officers, Medical Clinical Officers, Laboratory Technicians, Midwives, Registered and Enrolled Nurses. Overall, four broad categories of negative stereotypes were identified; Nodding syndrome is 1) an incurable disease, 2) is associated with evil spirits and curses, 3) is disabling, making the patient a burden to society and 4) is a fatal illness. CONCLUSION Primary health care workers who lead the care of patients with nodding syndrome have several negative stereotypes that may potentially impact negatively on the quality of care they provide.

Is the glass half full or half empty? A qualitative exploration on treatment practices and perceived barriers to biomedical care for patients with nodding syndrome in post-conflict northern Uganda.

BackgroundNodding syndrome has increasingly become an issue of public health concern internationally. The etiology of the disorder is still unknown and there are yet no curative treatments. We explored perceptions about treatment practices and barriers to health seeking for nodding syndrome in Pader and Kitgum districts in northern Uganda in order to provide data necessary for informing policy on treatment adherence and rehabilitations.MethodsWe used focus group discussions and individual interviews to gain deep insights into help-seeking and treatment practices for nodding syndrome. Purposive sampling was used to identify information-rich participants that included village health teams, community members not directly affected with nodding syndrome, district leaders, healthcare professionals, and caregivers of children affected with nodding syndrome. We used qualitative content analysis to analyze data and presented findings under distinct categories and themes.ResultsCaregivers and communities sought care from multiple sources including biomedical facilities, traditional healers, traditional rituals from shrines, and spiritual healing. Nodding syndrome affected children reportedly have showed no enduring improvement with traditional medicines, traditional rituals, and prayers. A substantial minority of participants reported minimal improvements in symptoms of convulsions with use of western medicines. Challenges involved in health seeking included; (1) health system factors e.g. long distances to facilities, frequent unavailability of medicines, few healthcare providers, and long waiting times; (2) contextual and societal challenges e.g. lack of money for transport and medical bills, overburdening nature of the illness that does not allow time for other activities, and practical difficulties involved in transporting the physically deformed and mentally retarded children to the health facilities.ConclusionsHelp-seeking for nodding syndrome is pluralistic and include use of traditional and biomedical practices. Western medicines admittedly showed at least short term control on nodding syndrome symptoms, especially convulsions and led in a few cases to regain of functional abilities. However, multiple barriers hinder health seeking and interfere with adherence to biomedical treatments. Regarding cure, there are hitherto no treatments participants perceive cure nodding syndrome.