Jonathan K. Burns

Symptomatology and social inference: A theory of mind study of schizophrenia and psychotic affective disorder

Introduction. There is evidence that certain patients with schizophrenia have deficits in theory of mind (ToM) capabilities. It is, however, unclear whether these are symptom or diagnosis-specific. Methods. A ToM hinting task was given to 15 patients with a DSM-IV diagnosis of schizophrenia, 15 patients with affective disorder and 15 healthy controls. Severity of the current psychopathology was measured using the Krawiecka standardised scale of psychotic symptoms (Krawiecka, Goldberg, & Vaughan, 1977); IQ was estimated via the Ammons and Ammons Quick Test (Ammons & Ammons, 1962). Results. The group with schizophrenia performed significantly worse than the affective and control groups. Poor performance on the hinting task was found to be significantly related to the presence of positive symptoms (instead of negative ones) and specifically related to delusions and hallucinations. These findings remained when covariance for potentially confounding variables was applied. Conclusions. Individuals with high levels of delusions and hallucinations performed significantly worse on this ToM task, regardless of diagnosis, implying ToM impairment is not exclusive to schizophrenia but is evident in other forms of psychosis. Between-group analyses showed the schizophrenia group had a significicantly poorer performance on this task than the others.

A multilevel analysis of association between neighborhood social capital and depression: evidence from the first South African National Income Dynamics Study.

BACKGROUND As neuropsychiatric disorders account for a great proportion of the total burden of disease in sub-Saharan Africa, depression is rapidly emerging as a public health issue in South Africa. Given the divisions enforced by a legacy of the apartheid spatial and economic policies, features of communities such as neighborhood-level social capital may play a critical role in depression. However, the extent to which neighborhood-level social capital is associated with depression in South Africa at the population-level is unknown. METHODS Data from the first wave of the South African National Income Dynamics Study (SA-NIDS) was used to examine the association between the neighborhood-level social capital and individual depression using multilevel regression models. RESULTS There was a negative association between neighborhood-level social capital and depression score with social trust and neighborhood preference accounting for this association. Structural social capital, namely civic participation, was not related to depression. Individual predictors, including social class, self-rated health status and education, were strong covariates of depression. LIMITATIONS The cross-sectional design of the study limits our understanding of the temporal order of social capital and depression. CONCLUSIONS In post-apartheid South Africa, low social capital remains an important social determinant of health, including depression outcome. This is in addition to individual determinants related to class such as unemployment, education and social class which play an important role in influencing depression. Further research utilizing a longitudinal study design is warranted to examine the association between social capital and depression in South Africa.

Pathways from Cannabis to Psychosis: A Review of the Evidence

The nature of the relationship between cannabis use (CU) and psychosis is complex and remains unclear. Researchers and clinicians remain divided regarding key issues such as whether or not cannabis is an independent cause of psychosis and schizophrenia. This paper reviews the field in detail, examining questions of causality, the neurobiological basis for such causality and for differential inter-individual risk, the clinical and cognitive features of psychosis in cannabis users, and patterns of course and outcome of psychosis in the context of CU. The author proposes two major pathways from cannabis to psychosis based on a differentiation between early-initiated lifelong CU and a scenario where vulnerable individuals without a lifelong pattern of use consume cannabis over a relatively brief period of time just prior to psychosis onset. Additional key factors determining the clinical and neurobiological manifestation of psychosis as well as course and outcome in cannabis users include: underlying genetic and developmental vulnerability to schizophrenia-spectrum disorders; and whether or not CU ceases or continues after the onset of psychosis. Finally, methodological guidelines are presented for future research aimed at both elucidating the pathways that lead from cannabis to psychosis and clarifying the long-term outcome of the disorder in those who have a history of using cannabis.

Causal attributions, pathway to care and clinical features of first-episode psychosis: A South African perspective

Background: Causal belief systems and help-seeking practices may impact on pathway to care and features of first-episode psychosis (FEP) that have prognostic value. This is particularly relevant in South Africa where many people subscribe to traditional belief systems and consult traditional healers. Aim: To evaluate the relationship between causal attributions and pathway to care and features of FEP that have prognostic value. Method: We tested associations between causal attributions and pathway to care and duration of untreated psychosis (DUP), age of onset, PANSS-rated positive, negative and general symptoms and depressive symptoms (Calgary Depression Scale) in a sample of 54 FEP patients. Results: Spiritual attribution of cause (49% of patients) was associated with long DUP, while consultation with a traditional healer (39% of patients) was associated with long DUP and high negative symptoms. Only 19% had consulted a psychiatrist. Seventy nine per cent (79%) were referred to hospital by family, police were involved in 44% of admissions, and 81% were admitted involuntarily. Conclusions: Spiritual attributions of cause and previous consultation with traditional healers may delay entry to psychiatric care and thereby negatively impact on prognosis of FEP. This highlights the importance of mental health education and developing a positive collaborative relationship with traditional healers, especially in low- and middle-income countries.

Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.

The ecosystem service of sense of place: benefits for human well-being and biodiversity conservation

Assessing the cultural benefits provided by non-market ecosystem services can contribute previously unknown information to supplement conservation decision-making. The concept of sense of place embeds all dimensions of peoples’ perceptions and interpretations of the environment, such as attachment, identity or symbolic meaning, and has the potential to link social and ecological issues. This review contains: (1) an evaluation of the importance of sense of place as an ecosystem service; and (2) comprehensive discussion as to how incorporating sense of place in an evaluation can uncover potential benefits for both biodiversity conservation and human well-being. Sense of place provides physical and psychological benefits to people, and has neglected economic value. The biodiversity-related experiences are essential components of the service that need to be further explored. A conceptual framework was used to explore how the existing knowledge on sense of place derived from other fields can be used to inform conservation decision-making, but further research is needed to fill existing gaps in knowledge. This review contributes to a better understanding of the role biodiversity plays in human well-being, and should inform the Intergovernmental Platform on Biodiversity and Ecosystem Services (IPBES).

Income inequality and schizophrenia: Increased schizophrenia incidence in countries with high levels of income inequality

Background: Income inequality is associated with numerous negative health outcomes. There is evidence that ecological-level socio-environmental factors may increase risk for schizophrenia. Aims: The aim was to investigate whether measures of income inequality are associated with incidence of schizophrenia at the country level. Method: We conducted a systematic review of incidence rates for schizophrenia, reported between 1975 and 2011. For each country, national measures of income inequality (Gini coefficient) along with covariate risk factors for schizophrenia were obtained. Multi-level mixed-effects Poisson regression was performed to investigate the relationship between Gini coefficients and incidence rates of schizophrenia controlling for covariates. Results: One hundred and seven incidence rates (from 26 countries) were included. Mean incidence of schizophrenia was 18.50 per 100,000 (SD = 11.9; range = 1.7–67). There was a significant positive relationship between incidence rate of schizophrenia and Gini coefficient (β = 1.02; Z = 2.28; p = .02; 95% CI = 1.00, 1.03). Conclusions: Countries characterized by a large rich–poor gap may be at increased risk of schizophrenia. We suggest that income inequality impacts negatively on social cohesion, eroding social capital, and that chronic stress associated with living in highly disparate societies places individuals at risk of schizophrenia.

Measuring social inclusion—a key outcome in global mental health

BACKGROUND Social inclusion is increasingly recognized as a key outcome for evaluating global mental health programmes and interventions. Whereas social inclusion as an outcome is not a new concept in the field of mental health, its measurement has been hampered by varying definitions, concepts and instruments. To move the field forward, this paper reviews the currently available instruments which measure social inclusion and are reported in the literature, realizing that no single measure will be appropriate for all studies or contexts. METHODS A systematic literature search of English language peer-reviewed articles published through February 2013 was undertaken to identify scales specifically developed to measure social inclusion or social/community integration among populations with mental disorders. RESULTS Five instruments were identified through the search criteria. The scales are discussed in terms of their theoretical underpinnings, domains and/or key items and their potential for use in global settings. Whereas numerous reviewed abstracts discussed mental health and social inclusion or social integration, very few were concerned with direct measurement of the construct. All identified scales were developed in high-income countries with limited attention paid to how the scale could be adapted for cross-cultural use. CONCLUSIONS Social inclusion is increasingly highlighted as a key outcome for global mental health policies and programmes, yet its measurement is underdeveloped. There is need for a global cross-cultural measure that has been developed and tested in diverse settings. However, until that need is met, some of the scales presented here may be amenable to adaptation.

Depression, disability and functional status among community-dwelling older adults in South Africa: evidence from the first South African National Income Dynamics Study

This study examined the relationship between depression and functional status among a community‐dwelling older population of 65 years and older in South Africa.

Exposure to trauma and the clinical presentation of first-episode psychosis in South Africa

OBJECTIVE To evaluate the relationship between a history of traumatic experiences and the clinical features of first-episode psychosis (FEP). METHOD We tested associations between trauma variables and duration of untreated psychosis (DUP), age of onset (AO), PANSS-rated positive and negative symptoms and depressive symptoms (Calgary Depression Scale) in a sample of 54 FEP patients. RESULTS Mean DUP was 34.4 weeks, while mean AO was 24.7 years. Witnessing a seriously violent assault (49%) was associated with high positive symptoms (p = 0.002), while a significant personal experience of racism and discrimination (39%) was associated with high depressive (p = 0.042) symptoms. Previous sexual assault (44% of females) was associated with high positive (p = 0.028) and negative (p = 0.035) symptoms with a trend association with depressive symptoms (p = 0.092). CONCLUSION Our findings suggest that previous traumatic experience is associated with positive and affective symptoms in FEP.