D. J. H. Niehaus

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.

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.

The rise of assertive community interventions in South Africa: a randomized control trial assessing the impact of a modified assertive intervention on readmission rates; a three year follow-up

BackgroundMany countries have over the last few years incorporated mental health assertive interventions in an attempt to address the repercussions of deinstitutionalization. Recent publications have failed to duplicate the positive outcomes reported initially which has cast doubt on the future of these interventions. We previously reported on 29 patients from a developing country who completed 12 months in an assertive intervention which was a modified version of the international assertive community treatment model. We demonstrated reduction in readmission rates as well as improvements in social functioning compared to patients from the control group. The obvious question was, however, if these outcomes could be sustained for longer periods of time. This study aims to determine if modified assertive interventions in an under-resourced setting can successfully maintain reductions in hospitalizations.MethodsPatients suffering from schizophrenia who met a modified version of Weidens’ high frequency criteria were randomized into two groups. One group received a modified assertive intervention based on the international assertive community treatment model. The other group received standard care according to the model of service delivery in this region. Data was collected after 36 months, comparing readmissions and days spent in hospital.ResultsThe results demonstrated significant differences between the groups. Patients in the intervention group had significantly less readmissions (p = 0.007) and spent less days in hospital compared to the patients in the control group (p = 0.013).ConclusionModified assertive interventions may be successful in reducing readmissions and days spent in hospital in developing countries where standard care services are less comprehensive. These interventions can be tailored in such a way to meet service needs and still remain affordable and feasible within the context of an under-resourced setting.

Initiation Rites as a Perceived Stressor for Isixhosa Males with Schizophrenia

Although traditional initiation forms a pivotal part of Xhosa culture, it may be a stressful life event for the individual. In this study, 75 Xhosa males diagnosed with schizophrenia were interviewed to examine their perceptions of the role of initiation in the onset and course of their illness. In all, eight patients (10.7%) perceived the initiation rites as a stressful event that had triggered the onset of a psychotic episode, and six (8%) felt it precipitated a relapse. Our findings suggest that initiation rituals may be perceived as a stressful life event influencing the onset and course of schizophrenia. This underlines the importance of understanding the cultural background of patients.

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.

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

Accessible summary Research on trends in assaults and seclusion over time in developing countries such as South Africa is scant. Here, we assessed trends in assaults and seclusion, stratified by gender, at the acute admission wards in one psychiatric facility over a 5-year period. The results of this study show that continuous monitoring of assaults and seclusions is important to improve quality of care. Abstract 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.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.

Attempted Suicide in a Xhosa Schizophrenia and Schizoaffective Disorder Population

Suicide risk behavior is a significant contributor to the mortality and morbidity of schizophrenia. We previously reported affected sibship status in a Xhosa schizophrenia or schizoaffective disorder sample to be protective in nature; given the counterintuitive nature of this finding, we expanded the sample size to seek further clarification. Subjects were assessed with the Diagnostic Interview for Genetic Studies and then stratified into two groups: with (n = 137) or without (n = 837) a previous suicide attempt. The presence of lifetime bizarre behavior (OR 1.5; 95% CI 1.12-1.87) or cannabis use or abuse (OR 1.2; 95% CI 10.01-1.47) was a significant predictor of suicide attempts, while a higher global alogia score (OR 0.84; 95% CI 0.74-0.96) was a protective factor. Our data seem to support that in this population, encouraging family members to report bizarre behavior and implementing dual diagnosis interventions for cannabis use or abuse could be an appropriate starting point toward developing a targeted suicide prevention program for further research.