Browsing by Author "Stein, Dan J."
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- ItemOpen AccessAssociations between prenatal alcohol and tobacco exposure on Doppler flow velocity waveforms in pregnancy: a South African study(BioMed Central, 2023-08-23) Jonker, Deborah; Melly, Brigitte; Brink, Lucy T.; Odendaal, Hein J.; Stein, Dan J.; Donald, Kirsten A.Background The negative impact of prenatal alcohol and tobacco exposure (PAE and PTE) on fetal development and birth outcomes are well described, yet pathophysiologic mechanisms are less clear. Our aim was to investigate (1) the associations between quantity, frequency and timing (QFT) of PAE and PTE with blood flow velocities in arteries of the fetal-placental-maternal circulation and (2) the extent to which combined effect of QFT of PAE and/or PTE and Doppler flow velocity waveforms (FWV) predict infant birth weight. Methods The Safe Passage Study is a cohort based in urban Cape Town, South Africa. Recruitment occurred between 2007 and 2015. Information on QFT of PAE and PTE was collected prospectively at up to 4 occasions during pregnancy using a modified Timeline Follow-Back approach. Ultrasound examinations consisted of Doppler flow velocity waveforms of the uterine, umbilical (UA) and fetal middle cerebral arteries for the pulsatility index (PI) at 20–24 and 34–38 weeks. Exclusion criteria included: twin pregnancies, stillbirths, participants exposed to other drugs. The sample was divided into three groups (controls, PAE and PTE) and included 1396 maternal-fetal-dyads assessed during the second trimester; 1398 assessed during the third trimester. Results PTE was associated with higher UA PI values in second and third trimesters (p < 0.001), compared to the PAE and control group. The total amount of cigarettes smoked during pregnancy was positively correlated with UA PI values (r = 0.087, p < 0.001). There was a positive correlation between cigarettes smoked per day in trimester one (r = 0.091, p < 0.01), and trimester two (r = 0.075, p < 0.01) and UA PI (in trimester two), as well as cigarettes smoked per day in trimester two (r = 0.058, p < 0.05) and trimester three (r = 0.069, p < 0.05) and the UA PI in trimester three. Generalized additive models indicated that PAE in trimester two, PTE in trimester one and Doppler FWV in trimester three were significant predictors of birth weight in this sample. Conclusion In our study, PTE in trimesters two and three resulted in increased vascular resistance of the placenta. These findings highlight nuance in associations between PAE, PTE and blood flow velocities in arteries of the fetal-placental-maternal circulation and birth weight, suggesting that quantity and timing are important factors in these relationships.
- ItemOpen AccessPerceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report(2021-08-09) Stein, Dan J.; Kazdin, Alan E.; Ruscio, Ayelet M.; Chiu, Wai T.; Sampson, Nancy A.; Ziobrowski, Hannah N.; Aguilar-Gaxiola, Sergio; Al-Hamzawi, Ali; Alonso, Jordi; Altwaijri, Yasmin; Bruffaerts, Ronny; Bunting, Brendan; de Girolamo, Giovanni; de Jonge, Peter; Degenhardt, Louisa; Gureje, Oye; Haro, Josep M.; Harris, Meredith G.; Karam, Aimee; Karam, Elie G.; Kovess-Masfety, Viviane; Lee, Sing; Medina-Mora, Maria E.; Moskalewicz, Jacek; Navarro-Mateu, Fernando; Nishi, Daisuke; Posada-Villa, José; Scott, Kate M.; Viana, Maria C.; Vigo, Daniel V.; Xavier, Miguel; Zarkov, Zahari; Kessler, Ronald C.Background Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. Methods Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. Results The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness. Conclusions The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.
- ItemOpen AccessPilot testing models of task shifting for the care of severe mental illness in South Africa(2018) Sibeko, Ntokozo Goodman; Stein, Dan J.; Lund, Crick; Milligan, Peter D.Background Mental and substance use disorders cause significant disability worldwide. In spite of the availability of evidence-based treatment, non-adherence rates remain high in people with severe mental illness. Mental health services are however under-resourced, especially in low- and middle-income countries. Interventions that employ task shifting, the delegation of health care delivery tasks to less specialized health workers, have the potential to address this resource shortage. Community health workers, while an established and important delivery agent for task shifting in many forms of chronic illness, including mental illness, have lacked access to standardized structured training in mental health. Together with novel approaches such as mobile health, task-shifting interventions have the potential to improve adherence and clinical outcomes for MHSU, thus reducing the burden on stretched mental health resources. While the evidence for the effectiveness of task shifting interventions is growing, it is unclear whether the combination of a task shifting intervention with mobile health would be acceptable and feasible in low resource settings. It is also unclear to what extent a structured mental health training programme would result in improved knowledge, confidence and attitudes amongst community health workers. Methods First, I conducted an appraisal of current evidence for interventions delivered by non-specialist workers for mental illness in Sub-Saharan Africa. The aim was to characterize the types of such interventions that have been carried out in Sub-Saharan Africa, to ascertain extent of use of non-specialist workers; the outcomes explored; any acceptability and feasibility findings; as well as any efficacy outcomes. Second, I developed and piloted two task shifting interventions geared at improving care for severe mental illness in Cape Town, and evaluated their acceptability, feasibility and preliminary effectiveness. Systematic review: For the systematic review, eligible studies published prior to 21 June 2017 were identified by searching the Cochrane library, PsychInfo, and Medline databases; as well as the World Health Organization International Clinical Trials and Pan African Clinical Trials Registries. The bibliographies of study reports for all eligible trials were scanned for additional studies. Included trials were those of interventions a) delivered by non-specialist health workers for b) adult populations (18-65 years) with c) psychiatric disorders diagnosed in line with ICD or DSM classification systems in d) Sub-Saharan Africa. No restriction was placed on the nature of the psychiatric disorder. Pilot randomized controlled trial: A pilot randomized controlled trial was conducted, in which 77 participants with severe mental illness were recruited from Valkenberg psychiatric hospital in Cape Town, with 42 randomized to receive the intervention and 37 to receive treatment as usual. In the intervention arm, a treatment-partner selected by the participating MHSU underwent a psychoeducation and treatment-partner contracting session. The intervention pair then received two text message reminders of clinic visit appointments monthly. The primary outcomes were acceptability and feasibility of the intervention, measured through qualitative interview and process evaluation at 3 months post-discharge. Secondary outcomes for efficacy were 1) adherence to the first clinic visit; 2) any readmission in the 9 months following discharge; 3) quality of life; 4) symptomatic relief; and 5) medication adherence. These efficacy measures were conducted at baseline and again at 3-month study review. Between-group comparisons were done using an intention to-treat ANOVA analysis for efficacy outcomes. Community Health Worker Training Intervention: My second task shifting intervention was a quasi-experiment evaluating whether structured mental health training would improve the knowledge and skill of community health workers while improving their confidence and attitudes towards mental illness. A training programme was developed in partnership with the Western Cape Department of Health, and piloted with 58 community health workers who had not previously received mental health training. Mental health knowledge and skill were measured though the use of case vignettes and the Mental Health Knowledge Schedule (MAKS). Confidence was measured using the Mental Health Nursing Clinical Confidence Scale (MHNCCS), while attitudes were measured using the Community Attitudes towards the Mental Ill Scale (CAMI). Measures were conducted at baseline, at the end of the training, and again 3 months after the end of training for the knowledge and skill measures. Daily evaluation questionnaires were used to establish acceptability, and a training evaluation questionnaire was used to obtain further acceptability data, as well as to establish feasibility of the training intervention. T-tests and regression models were used to test changes in questionnaire scores before and after each intervention, adjusting for baseline scores. Quantitative data were entered and analysed using STATA 10.0 for the pilot randomized controlled trial and the R statistical programme for the CHW intervention, while qualitative data were managed and analysed using NVIVO 8, a qualitative analysis programme for all analyses, for which a grounded theory approach was used, followed by thematic analysis. Ethics and registration: Ethical approval was obtained from the University of Cape Town Human Research Ethics Committee, Faculty of Health Sciences for the treatment partner and mobile health intervention (HREC REF: 511/2011) and for the community health worker training intervention (HREC 913/2015). Both interventions were registered on the Pan African Clinical Trials Registry (PACTR201610001830190 and PACTR201610001834198 respectively). Finally, Health Impact Assessment Unit clearance was obtained from the Western Cape Department of Health for both trials (RP168/2011 and WC_2016RP59_635 respectively). The systematic review was registered on the International prospective register of systematic reviews (PROPSERO) (CRD42017065190)). Results Systematic Review: Due to heterogeneous methods and treatment outcomes, a meta-analysis was not possible. A narrative synthesis is thus presented. Fifteen trials of interventions delivered by non-specialist workers (5087 participants) were identified. In each of the trials, the intervention was acceptable and feasible, with preliminary efficacy findings favouring the interventions. Pilot randomized controlled trial: The treatment partner and text message intervention components were acceptable. While the treatment partner and psychoeducation components were feasible, the text message component was not, as a consequence of several socioeconomic and individual factors. While efficacy outcomes favoured the intervention, they did not reach statistical significance due to the small sample size. Community Health Worker Training Intervention: Mental health knowledge improved as demonstrated by improved diagnostic accuracy on case vignette response. Sixty-three percent of participants demonstrated improved accuracy in making a diagnosis, with a roughly two-fold increase in performance in these individuals. There was a significant increase in the average scores on the Mental HeAlth Knowledge Schedule pre- to post training (t = -4.523, df = 55, p < 0.001, N=56). This improvement was sustained at 3 months after the end of training assessment scores (t = -5.0, df = 53, p < 0.001, N = 54). There was a significant increase in the average Confidence scores pre-intervention (mean SD): 45.25 (9.97) to post-intervention 61.75 (7.42), t-test: t = -8.749, df = 54, p < 0.001, N=58). Attitude scores (n=45) indicated no change in authoritarian attitudes [mean (SD): Pre 27.87 (2.97); Post 26.38 (4.1), t = 2.720, p-value = 0.995], while benevolence [mean (SD): Pre 37.67 (4.46); Post 38.82 (3.79), t = -1.818, p-value = 0.038] and social restrictiveness [mean (SD): Pre 24.73 (4.28); Post 22.4 (5.3), t = -2.960, p-value = 0.002] attitudes showed improvement pre- and post-training, as did tolerance to rehabilitation of the mentally ill in the community (t = 2.176, p-value = 0.018). Participants responded well to training, appraising it as acceptable and appropriate to their work. They expressed a need for a longer training programme with further training on substance use and geriatric disorders. Stakeholder participation was consistent and contributed to the feasibility of the intervention. Conclusions A review of task shifting interventions by non-specialist health workers indicates that these have yielded positive outcomes for mental health service users in published trials. Such interventions have the potential for reducing the mental health treatment gap in low and middle income countries in a cost-efficient way. Further work is however required to develop specific treatment approaches for particular disorders, and to assess the outcomes of such interventions, including cost-efficiency measures. The measures of outcome used in this field remains somewhat disparate; the development of a common research agenda may assist in developing and replicating further investigations and generalising findings. A treatment-partner intervention is acceptable and feasible in a low- and middle-income setting such as ours. Careful work is, however, needed to ensure that any additional components of such an intervention, such as mobile health, are tailored to the local context. Appropriately powered studies are needed to assess efficacy. Structured training in mental health is acceptable and feasible in our setting. The training intervention led to an improvement in knowledge and skill amongst community health workers while improving confidence and attitudes. Participation of policy stakeholders was key in ensuring the success of the intervention. There is a need for interventions evaluating the outcomes of community health worker training to provide more detailed descriptions of their training interventions. More focus must be placed on measuring service and end-user outcomes to improve the rigor and quality of such investigations, with well-powered randomized controlled trials being best placed to answer questions regarding efficacy and cost-effectiveness. In summary, my systematic review, and my pilot task-shifting interventions in the South African context indicate that task shifting interventions such as these are acceptable and feasible, offering a promising solution to addressing the under-resourcing of mental health care. However, interventions should ideally be tailored to the specific communities they target, taking into account specific individual, community, technological, and sociodemographic factors. Future training interventions should provide more detailed descriptions of programme components and focus on measuring patient outcomes, while all task shifting interventions may benefit from incorporating an evaluation of cost effectiveness. Task shifting presents a viable and accessible opportunity for creative innovation and as we work towards achieving mental health for all.
- ItemOpen AccessPrevalence of lifestyle cardiovascular risk factors and estimated framingham 10-year risk scores of adults with psychotic disorders compared to controls at a referral hospital in Eldoret, Kenya(2023-12-05) Kwobah, Edith; Koen, Nastassja; Mwangi, Ann; Atwoli, Lukoye; Stein, Dan J.Abstract Introduction Lifestyle factors such as smoking, alcohol use, suboptimal diet, and inadequate physical activity have been associated with increased risk of cardiovascular diseases. There are limited data on these risk factors among patients with psychosis in low- and middle-income countries. Objectives This study aimed to establish the prevalence of lifestyle cardiovascular risk factors, and the 10-year cardiovascular risk scores and associated factors in patients with psychosis compared to controls at Moi Teaching and Referral Hospital in Eldoret, Kenya. Methods A sample of 297 patients with schizophrenia, schizoaffective disorder, or bipolar mood disorder; and 300 controls matched for age and sex were included in this analysis. A study specific researcher-administered questionnaire was used to collect data on demographics, antipsychotic medication use, smoking, alcohol intake, diet, and physical activity. Weight, height, abdominal circumference, and blood pressure were also collected to calculate the Framingham 10-year Cardiovascular Risk Score (FRS), while blood was drawn for measurement of glucose level and lipid profile. Pearson’s chi-squared tests and t-tests were employed to assess differences in cardiovascular risk profiles between patients and controls, and a linear regression model was used to determine predictors of 10-year cardiovascular risk in patients. Results Compared to controls, patients with psychosis were more likely to have smoked in their lifetimes (9.9% vs. 3.3%, p = 0.006) or to be current smokers (13.8% vs. 7%, p = 0.001). Over 97% of patients with psychosis consumed fewer than five servings of fruits and vegetables per week; 78% engaged in fewer than three days of vigorous exercise per week; and 48% sat for more than three hours daily. The estimated 10-year risk of CVD was relatively low in this study: the FRS in patients was 3.16, compared to 2.93 in controls. The estimated 10-year cardiovascular risk in patients was significantly associated with female sex (p = 0.007), older patients (p < 0.001), current tobacco smoking (p < 0.001), and metabolic syndrome (p < 0.001). Conclusion In the setting of Eldoret, there is suboptimal physical exercise and intake of healthy diet among patients with psychosis and controls. While the estimated risk score among patients is relatively low in our study, these data may be useful for informing future studies geared towards informing interventions to promote healthy lifestyles in this population.