Sanja Kilian

A systematic review of genetic variants associated with metabolic syndrome in patients with schizophrenia

Metabolic syndrome (MetS) is a cluster of factors that increases the risk of cardiovascular disease (CVD), one of the leading causes of mortality in patients with schizophrenia. Incidence rates of MetS are significantly higher in patients with schizophrenia compared to the general population. Several factors contribute to this high comorbidity. This systematic review focuses on genetic factors and interrogates data from association studies of genes implicated in the development of MetS in patients with schizophrenia. We aimed to identify variants that potentially contribute to the high comorbidity between these disorders. PubMed, Web of Science and Scopus databases were accessed and a systematic review of published studies was conducted. Several genes showed strong evidence for an association with MetS in patients with schizophrenia, including the fat mass and obesity associated gene (FTO), leptin and leptin receptor genes (LEP, LEPR), methylenetetrahydrofolate reductase (MTHFR) gene and the serotonin receptor 2C gene (HTR2C). Genetic association studies in complex disorders are convoluted by the multifactorial nature of these disorders, further complicating investigations of comorbidity. Recommendations for future studies include assessment of larger samples, inclusion of healthy controls, longitudinal rather than cross-sectional study designs, detailed capturing of data on confounding variables for both disorders and verification of significant findings in other populations. In future, big genomic datasets may allow for the calculation of polygenic risk scores in risk prediction of MetS in patients with schizophrenia. This could ultimately facilitate early, precise, and patient-specific pharmacological and non-pharmacological interventions to minimise CVD associated morbidity and mortality.

Language, culture, and task shifting – an emerging challenge for global mental health

Language is at the heart of mental health care. Many high-income countries have sophisticated interpreter services, but in low- and middle-income countries there are not sufficient professional services, let alone interpreter services, and task shifting is used. In this article, we discuss this neglected issue in the context of low- and middle-income countries, where task shifting has been suggested as a solution to the problem of scarce mental health resources. The large diversity of languages in low- and middle-income countries, exacerbated by wide-scale migration, has implications for the scale-up of services. We suggest that it would be useful for those who are working innovatively to develop locally delivered mental health programmes in low- and middle-income countries to explore and report on issues of language and how these have been addressed. We need to know more about local challenges, but also about local solutions which seem to work, and for this we need more information from the field than is currently available.Language is at the heart of mental health care. Many high-income countries have sophisticated interpreter services, but in low- and middle-income countries there are not sufficient professional services, let alone interpreter services, and task shifting is used. In this article, we discuss this neglected issue in the context of low- and middle-income countries, where task shifting has been suggested as a solution to the problem of scarce mental health resources. The large diversity of languages in low- and middle-income countries, exacerbated by wide-scale migration, has implications for the scale-up of services. We suggest that it would be useful for those who are working innovatively to develop locally delivered mental health programmes in low- and middle-income countries to explore and report on issues of language and how these have been addressed. We need to know more about local challenges, but also about local solutions which seem to work, and for this we need more information from the field than is currently available.

Competence of Interpreters in a South African Psychiatric Hospital in Translating Key Psychiatric Terms

OBJECTIVE Provision of good-quality interpreting services in mental health practice is essential, but little is known about interpreting psychiatric terms in low-and middle-income countries. This study examined the basic translation competencies of interpreters in a South African psychiatric hospital. METHODS In the context of a larger study, six individuals who interpreted from English into Xhosa were asked to translate key psychiatric terms into Xhosa. These translations were back-translated by translators unfamiliar with psychiatric terminology, and back-translations were compared with the original English. RESULTS Some interpreters had a very limited command of English. None had formal training in interpreting. Not all were familiar with core psychiatric concepts. Incorrect translations were often made. CONCLUSIONS The competence level of the interpreters was not conducive to optimal care. The lack of formally trained interpreters in South Africas public health services could lead to misdiagnosis and could compromise interventions.

Rate and predictors of non-response to first-line antipsychotic treatment in first-episode schizophrenia†

The goals of this study were to (i) estimate the rate of non‐response to first‐line treatment in first‐episode schizophrenia, (ii) evaluate other outcomes associated with symptom non‐response and (iii) identify demographic, baseline clinical and early treatment response predictors of non‐response.

Mediating words, mediating worlds: Interpreting as hidden care work in a South African psychiatric institution

Many mental health clinicians in South Africa use informal interpreters, who are employed to perform other functions, such as cleaners and security guards; there are no formally trained interpreters. Drawing on qualitative semistructured interviews, this paper examines the experiences of informal interpreters working within a psychiatric setting. Furthermore, this paper explores how working in this invisible capacity affects informal interpreters’ views of themselves and the contribution they feel they are making by acting as interpreters. An interpretative phenomenological approach enabled an in-depth analysis of the experiences of the ad hoc interpreters. The results of this study reveal a dilemma. On the one hand, informal interpreters interviewed jeopardize ethical principles by breaching confidentiality and reporting on patient behaviour without their consent. On the other hand, they report fulfilling an additional beneficial role in terms of the overall care of patients which goes beyond the ambit of the interpreting session. The impact and extent of the informal interpreters’ involvement in care could not be ascertained solely from the data obtained in this study, but it is clear that informal interpreting may usefully be viewed as a form of hidden care work. A detailed ethnographic study aimed at exploring this further is therefore recommended.

The accuracy of interpreting key psychiatric terms by ad hoc interpreters at a South African psychiatric hospital

OBJECTIVE This study examined the competence and accuracy of ad hoc interpreters in interpreting key psychiatric terms at a South African psychiatric hospital METHODS Nine individuals were asked to translate key psychiatric terms from English to Xhosa. These translations were then back-translated by independent translators, who do not have knowledge of psychiatric terminology. These back-translations were then compared with the original English. RESULTS It was clear that not all the participants were fully competent in English. None had formal training in interpreting or psychiatric terminology. Not all of the participants were familiar with the psychiatric concepts that clinicians use and they often made mistakes while interpreting. CONCLUSION The competency levels of interpreters are unsatisfactory to ensure the optimal delivery of mental health care. It is clear that there is a need for trained interpreters in South Africa, as the continuous use of untrained interpreters compromises the effectiveness of mental health care and could lead to adverse health outcomes.

The Invisibility of Informal Interpreting in Mental Health Care in South Africa: Notes Towards a Contextual Understanding

Despite South Africa’s constitutional commitment to equality, represented by 11 official languages and the promotion of South African Sign Language, many users of the public health system receive treatment from people who cannot speak their language, and there are no formal interpreting services. This is a legacy of service provision from the apartheid era, and interpreting is currently undertaken by nurses, cleaners, security guards, and family members of patients, amongst others. We provide a preliminary outline of proximal and distal issues which may bear upon this situation. Changing understandings of the nature of careers in the health field, international trends in mental health theory and practice toward crude biologism, and ongoing patterns of social exclusion and stigma all contribute not only to a continuing state of compromised linguistic access to mental health care, but also to processes of rendering invisible the actual work of care in the mental health field.

Symptom attribution and frontal cortical thickness in first-episode schizophrenia

Misattribution of symptoms is a common feature of schizophrenia, and likely involves impairment of metacognitive function that may be mediated by the frontal cortex. We aimed to compare frontal cortical thickness in first‐episode schizophrenia (FES) patients with matched controls, and investigate its relationship with the symptom attribution dimension of insight in FES patients.

Brain volume changes over the first year of treatment in schizophrenia: relationships to antipsychotic treatment

BACKGROUND Progressive brain volume reductions have been described in schizophrenia, and an association with antipsychotic exposure has been reported. METHODS We compared percentage changes in grey and white matter volume from baseline to month 12 in 23 previously antipsychotic-naïve patients with a first episode of schizophrenia or schizophreniform disorder who were treated with the lowest effective dose of flupenthixol decanoate depot formulation, with 53 matched healthy individuals. Total antipsychotic dose was precisely calculated and its relationship with brain volume changes investigated. Relationships between volumetric changes and treatment were further investigated in terms of treatment response (changes in psychopathology and functionality) and treatment-related adverse-events (extrapyramidal symptoms and weight gain). RESULTS Excessive cortical volume reductions were observed in patients [-4.6 (6.6)%] v. controls [-1.12 (4.0)%] (p = 0.009), with no significant group differences for changes in subcortical grey matter and white matter volumes. In a multiple regression model, the only significant predictor of cortical volume change was total antipsychotic dose received (p = 0.04). Cortical volume change was not significantly associated with the changes in psychopathology, functionality, extrapyramidal symptoms and body mass index or age, gender and duration of untreated psychosis. CONCLUSIONS Brain volume reductions associated with antipsychotic treatment are not restricted to poor outcome patients and occur even with the lowest effective dose of antipsychotic. The lack of an association with poor treatment response or treatment-related adverse effects counts against cortical volume reductions reflecting neurotoxicity, at least in the short term. On the other hand, the volume reductions were not linked to the therapeutic benefits of antipsychotics.

How long should antipsychotic treatment be continued after a single episode of schizophrenia

Purpose of review In this article, recent publications addressing the pros and cons of antipsychotic maintenance treatment are reviewed and some recommendations formulated. Recent findings On one hand, relapse rates are extremely high when antipsychotic treatment is discontinued, even after a single episode of psychosis; there are no reliable predictors of relapse; and there are serious psychosocial and biological consequences of relapse. On the other hand, in addition to the well recognised side-effect burden of antipsychotics, a few recent publications suggest an association between greater exposure to antipsychotic treatment and poorer long-term outcome. Summary There is more evidence in favour of maintaining patients on antipsychotics than on stopping them. There is an urgent need for more and better research before the question of duration of maintenance after a single episode of schizophrenia can be answered with confidence. Until such studies have been conducted, clinicians should prioritize relapse prevention, particularly in the early years of illness, by encouraging indefinite, continuous antipsychotic treatment, and avoid unnecessary side-effects by using the lowest possible effective dose and selecting the best tolerated antipsychotic.