Suvira Ramlall

Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile

OBJECTIVE To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting. METHOD One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain. RESULTS The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis. CONCLUSION The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.

Forensic telepsychiatry: a possible solution for South Africa?

OBJECTIVE South Africa has a shortage of facilities and psychiatrists to assess adjudicative competence of prisoners awaiting assessment under sections 77 to 79 of the Criminal Procedures Act of 1977. Various solutions have been proposed by the Department of Health. The recent linking of a Magistrates court and a prison by videoconferencing offers the opportunity to implement a forensic telepsychiatry service. The literature on forensic telepsychiatry for assessment of adjudicative competence was reviewed. METHOD The electronic databases, PubMed, Scopus, Cinahl and Google Scholar were searched for papers on forensic telepsychiatry. The inclusion criterion was papers reporting the use of videoconferencing for assessment of adjudicative competence or for assessment for referral out of the judicial system, by psychiatrists or psychologists. RESULTS 411 papers were found of which 13, published between 1997 and 2008 were relevant. The use of videoconferencing for forensic psychiatric assessment was reported from four countries. The courts in those jurisdictions have accepted the use of videoconferencing for assessment and no successful appeals have been mounted on the basis of the use of videoconferencing for assessment. User satisfaction has not been reported for assessing adjudicative competence. Forensic telepsychiatry has been found to be cost effective, improve access to scarce specialist skills and reduce transport of prisoners under guard to hospitals or psychiatrists to prisons. CONCLUSION There is nothing in the literature to suggest that a forensic telepsychiatry service is not feasible in South Africa and a pilot project is being planned.

Practice guidelines for videoconference-based telepsychiatry in South Africa

Telepsychiatry, the practice of psychiatry over distance using information and communication technologies is, after teleradiology, the most practiced form of telemedicine in the world. As with any new technology, clinical service, or intervention in medicine, it is prudent to have guidelines for the safe and efficacious use of the technology in clinical practice. Guidelines facilitate best practice and provide both clinicians and patients with a set of standards and procedures that serve to protect their interests. Protection is particularly important when dealing with vulnerable groups.

Videoconference-based education for psychiatry registrars at the University of KwaZulu-Natal, South Africa

OBJECTIVE Psychiatry registrars form the backbone of specialized psychiatric service provision in South Africa. Medical schools are centralized while clinical services need to be widespread and accessible. Video-conferencing has the potential to link registrars at satellite hospitals with academic centers. The study thus evaluated of the use of videoconferencing in a Psychiatry Education Program delivered via videoconferencing. METHOD To evaluate the implementation of the videoconference-based psychiatry registrar program, a pre- and post evaluative design was used. This involved all registrars in the 2008 and 2009 academic education program at the University of KwaZulu-Natal, South Africa. Access to education, satisfaction, suitability and costs of the psychiatry registrar education were studied. RESULTS In the evaluation of the Registrar Program, general satisfaction with the videoconferencing program was reported, though concerns were expressed about the level of interaction using this mode, the quality of the transmitted pictures of the anatomy specimens and the quality of the sound. Access to education was improved with potential cost savings identified. CONCLUSION Well supported and planned videoconference-based teaching is a feasible, cost-effective and acceptable method of supporting registrars at sites distant from academic centers.

The Mental Health Care Act No 17 – South Africa. Trials and triumphs: 2002-2012

The Mental Health Care Act 17 of 2002 (MHCA) was promulgated in 2004. It has been hailed as one of the most progressive pieces of mental health legislation. A true measure of its merit is the degree to which it has transformed mental health services and in particular improved the quality of care. This paper will describe the impact of the Act on mental health care service delivery in the country. Literature pertaining to the MHCA published from 2006-2012, a report compiled by the South African Society of Psychiatrists and the results of a national survey conducted among Heads of Departments of Psychiatry, Mental Health Review Boards and Provincial Directors of Mental Health was reviewed. The MHCA has been successful in shifting the emphasis of care from psychiatric institutions to general hospitals. However, the integration of services has been hampered by infrastructure constraints and shortages of mental health personnel. It has been less successful in integrating mental health care into primary health services where the focus remains largely on the pharmacological maintenance treatment of the chronically mentally ill. Little attention has been given to the health promotion, disease prevention and rehabilitation aspects of care. Mental health review boards contend with limited resources, administrative challenges and limited political support. Isolated pockets of success characterised the implementation of the MHCA across the country. Greater investment of resources is needed to ensure the comprehensive implementation of the Act.

Screening a heterogeneous elderly South African population for cognitive impairment: the utility and performance of the Mini- Mental State Examination, Six Item Screener, Subjective Memory Rating Scale and Deterioration Cognitive Observee.

OBJECTIVE The aim of this study was to report on the prevalence of cognitive impairment, and to assess the performance and utility of subjective, objective and informant screening tools in a heterogeneous community sample. METHOD A sample of 302 elderly participants (>60 years) living in residential homes in a large city in South Africa were screened for the presence of cognitive impairment using objective (Mini-Mental State Examination [MMSE] and Six Item Screener-[SIS]), subjective (Subjective Memory Complaint [SMC]and Subjective Memory Rating Scale [SMRS]) and informant (Deterioration Cognitive Observee [DECO]) screening tools. All tools were compared to the MMSE and the influence of demographic variables on the performance on these tools was considered. RESULTS Significantly lower MMSE scores were found in participants aged 80-89 years (p=.023) and those who had 8-11 years of education (p=.002). For every one additional year of education, participants were 0.71 times less likely to screen positive on the MMSE. Differential item functioning on various components of the MMSE was demonstrated due to the effects of education, race and gender. There was significant differential performance between the recommended and alternate attention/concentration items (p<.001) with the alternate item favouring better performance. Based on the MMSE cutoff score of < 23, the prevalence of cognitive impairment was 16.9%; the prevalence yielded by the remaining tools ranged from 10.5% using the DECO to 46% as determined by the presence of a SMC. Using the MMSE as the reference standard for the presence of cognitive impairment, the SIS, SMC, SMRS and DECO had sensitivities of 82.3%, 54.6%, 17.0% and 37.5%, and specificities of 71.3%, 57.6%, 87.4% and 96.7% respectively. Age and race influenced performance on the MMSE, SIS and SMRS. CONCLUSION Different types of cognitive screening tools yielded varying sensitivities and specificities for identifying cognitive impairment when compared to the MMSE. The influence of race, age and education on test performance highlights the need for suitable, culture-fair screening tools. Locally, the alternate item for attention/concentration should be preferred.

Developing telepsychiatry services in KwaZulu-Natal – an action research study

OBJECTIVE In 2009, the Departments of Psychiatry and Telehealth of the University of KwaZulu-Natal (UKZN) initiated a three year project to develop telepsychiatry services in KwaZulu-Natal. This paper describes the challenges and opportunities of this project. METHOD This was a collaborative, in situ health service project and an action research framework was adopted. Over the three years, following a needs assessment and an e-health Readiness Assessment, two action research cycles were completed. Cycle 1: The preparation, implementation and evaluation of educational material, technical requirements and clinical guidelines and clinical support materials. Cycle 2: Preparation and evaluation of educational and clinical outreach sessions. RESULTS Videoconference education sessions were beneficial to health staff without post-qualification psychiatry training. A flexible format for education improved knowledge outcomes. Clinical sessions are feasible, but require administration and technical support for facilitation. With facilitator training, 128Kbps is a suitable bandwidth for education but 384Kbps is preferred for clinical consultation. CONCLUSION Telepsychiatry offers tremendous potential to facilitate the three strategies suggested by the World Psychiatric Association to address the treatment gap, save time and costs and improve access to the small pool of specialist psychiatrists in resource constrained environments.

Spirituality, depression and quality of life in medical students in KwaZulu-Natal

Background The majority of studies on spirituality demonstrate its positive association with mental health. Despite the increasing number of studies, there remains a dearth of studies emanating from African countries looking at the relationship between mental illness, quality of life and measures of spirituality. The present study evaluates the role of spirituality in relation to current depression and quality of life in medical students, who are known to be at high risk for depression. Objectives The aim of this study was to determine the prevalence of moderate and severe depressive symptoms in this population and explore potential correlations between spirituality, depression and quality of life. Methods 230 medical students were surveyed at the University of KwaZulu-Natal Medical School, using the Zung Self-Rating Depression Scale (Zung SDS), Spiritual Involvement and Beliefs Scale (SIBS), WHO Quality of Life Scale (WHOQOL) and a demographic data sheet. Results There was a high prevalence of depressive symptoms in the medical students, with a significant proportion (15.6%) showing evidence of severe depressive symptoms (indicating likely depressive illness). Those with a history of mental illness or of having attended traditional, complementary or alternate medical practitioners showed higher levels of depression. Lower spirituality was associated with non-adherence to a major religion and a history of mental illness. Quality of life was better in second and fifth year students and poorer in those with a history of mental illness. Conclusion Medical students’ experiences of depression (most probably due to stress) and its relationship with spirituality and quality of life merit further investigation with a view to establishing policy guidelines for dealing with this issue.

Depression in older adults: prevalence and risk factors in a primary health care sample

Background: Depression in the geriatric population has been identified as a significant problem in view of the associated negative outcomes regarding poor functioning, increased perception of poor health and increased utilisation of medical services. Significantly associated with increased morbidity and mortality, depression has been found to be an independent cause of disability as well as adding to disability due to primary physical illnesses. Early identification and treatment of depression reduces medical costs and lessens caregiver burden. Epidemiological data and prevalence rates of geriatric depression in Africa are limited, although such data are vital to mobilise and plan government mental health initiatives aimed at screening and early intervention. Objective: To determine the prevalence of depression and associated clinical and socio-demographic factors amongst older adult patients attending a primary health care clinic in the Ethekwini District in Kwa-Zulu Natal, South Africa. Methods: The 15-item Geriatric Depression Scale and a socio-demographic questionnaire were administered in English to 255 geriatric outpatients, randomly selected, at a local community clinic in Durban. Data analysis: Data were analysed using SPSS version 23®. Descriptive statistics were used to summarise the sample demographics and response rate and non-parametric statistics were used to test for associations and differences. Results: A Cronbach’s alpha for the GDS was calculated (p = 0.793). Some 40% of participants screened positive for depression. Female gender, widowhood and a negative subjective health status rating were significantly associated with depression and marriage appeared to be protective (p < 0.001). Participants with a poor subjective health rating were 21 times more likely to be depressed and widowhood conferred an almost fourfold increased risk of being depressed, with widows at greater risk than widowers. No association between depression and specific medical conditions was identified. Conclusion: There is a high rate of undetected depression among the elderly attending a local primary health care clinic with widowhood and poor subjective health being strong predictors of mood disorders. The findings warrant replication in bigger samples.

A Nationwide Panel Study on Religious Involvement and Depression in South Africa: Evidence from the South African National Income Dynamics Study

Panel data from the South African National Income Dynamics Study, a nationally representative sample of households (years 2008, 2010 and 2012), were used to examine the longitudinal association between religious involvement and depression risk. Approximately 89.6–91.8% identified themselves as religiously affiliated, while 88.0–90.3% perceived religion to be important in South Africa during the observed study periods. A short-term association between religious involvement and significant depressive symptomatology was not detected, but logistic regression models that accounted for the clustering of repeated observations within participants indicated that, over time, those with religious affiliations (aOR 0.85, 95% CI 0.76–0.96) were at a lower risk than those not affiliated. Furthermore, individuals who reported religious activity as being important (aOR 0.81; 95% CI 0.73–0.91) were at less risk of significant depressive symptomatology over time than those rating religious activity as not important. Our study points to the potentially important role of religious involvement as an emerging area of investigation toward improving mental health at a population level in resource-limited settings.