Browsing by Subject "psychiatry"

Now showing 1 - 6 of 6
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    An exploration of sociodemographic and psychosocial determinants of cognitive performance in a peri-urban clinic population of people with HIV in Cape Town, South Africa
    (2023) Dreyer, Anna Jane; Joska, John A; Thomas, Kevin G F; Nightingale, Sam
    Introduction. Numerous studies, conducted in many different countries, report that cognitive impairment is highly prevalent in people with HIV (PWH). Such impairment can affect adherence to antiretroviral therapy (ART), and adherence is, in turn, essential for PWH to achieve viral suppression. The gold standard to confirm cognitive impairment is a neuropsychological assessment. However, accurate interpretation of neuropsychological test performance requires consideration of, for instance, how impairment is determined and how accurately the contribution of non-HIV factors to poor cognitive test performance is described. These non-HIV factors include sociodemographic variables (e.g., age, sex, educational attainment), psychosocial variables (e.g., socioeconomic status, food security, quality of life), psychiatric variables (e.g., depression, problematic alcohol use), and other medical co-morbidities. Because many existing studies of PWH do not account for (a) the fact that current quantitative methods for defining cognitive impairment may not accurately reflect HIV-associated brain injury, and (b) possible contributions of non-HIV factors to cognitive test performance, it is possible that the reported prevalence rates of cognitive impairment in PWH are inaccurate (or, at least, do not solely reflect the contributions of HIV disease to the impairment). Another uncertainty in the HIV neuropsychology literature concerns sex differences in the cognitive performance of PWH. Some recent studies suggest that women with HIV (WWH) may present with greater cognitive impairment than men with HIV (MWH). Such a sex difference is of potentially significant concern for South African clinicians because two-thirds of the population of PWH in this country are women. However, there is no definitive empirical evidence regarding whether this sex difference exists to a clinically significant degree (in South Africa, specifically, as well as globally) and what its underlying mechanisms might be. To address the knowledge gaps outlined above, this thesis set out to explore the following aims: (1) investigate sex differences in the cognitive performance of PWH by reviewing the current published literature; (2) determine if sex differences exist in a clinic sample of South African PWH; (3) determine how much variation in reported prevalence rates of HIV-associated cognitive impairment are due to the method used to define impairment, and which method correlates best with MRI biomarkers of HIVrelated brain injury in a South African sample of PWH; (4) investigate the contribution of sociodemographic and psychosocial variables, as well as HIV-disease factors and other medical and psychiatric comorbidities, to cognitive performance in a South African sample of PWH; and (5) investigate associations between cognitive performance and ART adherence in 10 a South African sample of PWH. Each of these aims was explored in a separate study. Hence, this thesis reports on findings from five separate journal manuscripts. Method. Study 1 was a systematic review and meta-analysis summarizing the findings of published studies investigating differences in cognitive performance between WWH and MWH. An extensive systematic search of the literature across several databases found 4062 unique articles of potential interest. After thorough screening of that pool of articles, 11 studies (total N = 3333) were included in the narrative systematic review and 6 studies (total N = 2852) were included in the meta-analysis. Effect sizes were calculated to estimate between-sex differences in cognitive performance, both globally and within discrete cognitive domains. Study 2 investigated sex differences in cognitive performance in a sample of PWH with comorbid MDD (N = 105). All participants were attending community clinics in Khayelitsha, a peri-urban community in Cape Town, South Africa, and were part of a larger research program for a randomised controlled trial of a cognitive-behavioral treatment for ART adherence and depression (CBT-AD). As part of this program, they completed baseline neuropsychological, psychiatric, and sociodemographic assessments. T-tests and multivariable regressions controlling for covariates compared baseline cognitive performance of WWH and MWH, both globally and within discrete cognitive domains. Study 3 applied 20 different quantitative methods of determining cognitive impairment to existing data from a different sample of PWH (N = 148). These individuals had also been recruited from community clinics in Khayelitsha, and had completed a comprehensive neuropsychological assessment and a 3T structural MRI and diffusion tensor imaging (DTI) session. Logistic regression models investigated the association between each method and HIV-related neuroimaging abnormalities. Study 4 again used data from the sample of PWH with comorbid MDD who participated in the larger CBT-AD research program. This study investigated which sociodemographic, psychosocial, psychiatric, and medical variables (as measured at baseline) were associated with baseline cognitive performance. Post-baseline, 33 participants were assigned to CBT-AD and 72 to standard-of-care treatment; 81 participants (nCBT-AD = 29) had a follow-up assessment 8 months post-baseline. This study also investigated whether, from baseline to follow-up, depression and cognitive performance improved significantly more in the participants who had received CBT-AD, and examined associations between post-intervention improvements in depression and cognitive performance. Study 5 assessed ART adherence in the same sample of PWH with comorbid MDD. Mixed-effects regression models estimated the relationship between ART adherence (as measured by both self-report and objective measures, and by degree of HIV viral suppression) with cognitive performance 11 and with other sociodemographic, psychosocial, and psychiatric variables at both baseline and follow-up. Results. Study 1: Analyses suggested that, in terms of overall cognitive functioning, there were no significant differences in cognitive performance between WWH and MWH. However, WWH did perform significantly more poorly than MWH in the domains of psychomotor coordination and visuospatial learning and memory. Additionally, the review suggested that cognitive differences between WWH and MWH might be accounted for by sex-based variation in educational and psychiatric characteristics among study samples. Study 2: Analyses suggested that, in our sample of PWH with comorbid MDD, there were no significant differences in cognitive performance between WWH and MWH. Study 3: Findings suggested that there was marked variation in rates of cognitive impairment (20– 97%) depending on which method was used to define impairment, and that none of these methods accurately reflected HIV-associated brain injury. Study 4: Analyses suggested that less education and greater food insecurity were the strongest predictors of global cognitive performance. Improvement in depression severity was not significantly associated with improved cognitive performance, except in the domain of Attention/Working Memory. Overall, factors associated with cognitive performance were unrelated to HIV disease and other medical factors. Study 5: Analyses identified poor global cognitive performance as a potential barrier to achieving HIV suppression. Conclusion. Taken together, the findings from the five studies contained within this thesis suggest that one oft-mooted sociodemographic influence on cognitive performance in PWH, sex, was not a consistent influence on such performance. However, non-biological (mainly psychosocial and socioeconomic) factors were stronger predictors of cognitive performance in PWH than medical factors (including HIV-disease variables). Current quantitative criteria for defining cognitive impairment in PWH also do not accurately reflect the biological effects of HIV in the brain. The implication of these findings is that research studies may be misclassifying PWH as cognitively impaired and consequently overestimating the prevalence of cognitive impairment in this population. When conducting clinical assessments of PWH, future research studies should measure and consider the strong influence of psychosocial and socioeconomic factors on cognitive test performance. Ideally, a diagnosis of impairment should only be made after a comprehensive clinical assessment that includes a detailed history taking. Overall, we need new criteria for defining cognitive impairment in diverse global populations of PWH. Ideally these criteria should be applicable to both research and clinical settings. Assessing for cognitive impairment among PWH and then providing 12 appropriate support could help achieve viral suppression in patients with non-optimal adherence to ART. At public policy levels, addressing larger psychosocial issues (e.g., food insecurity and low educational attainment) may also help improve cognitive performance in PWH.
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    How do you feel? The origins of emotions
    (2011) Lef, Julian; Lef, Joan Raphael
    This course first explores the links between emotions shown by animals and humans, by asking these questions: What is the value of empathy? Do animals show empathy? These presentations were used in the Summer School 2011 run by the Centre for Extra-Mural Studies at the University of Cape Town.
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    Medicine and the Arts Week 5 - Experiences of mental illness through music
    (2015-01-21) Baumann, Sean
    In this video, Sean Baumann, a senior specialist psychiatrist in UCT's Department of Psychiatry and Mental health, discusses the misrepresentation of mental illness in film and theater, particular misrepresentations of schizophrenia-like disorders. He makes the argument that an improved understanding of mental health by viewing it from a first-person perspective would help address this problem. He describes how music can offer rich representations of mental illness. This is the third video in Week 5 of the Medicine and the Arts Massive Open Online Course.
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    Textbook of Psychiatry First Edition, Draft 2
    (Wikibooks, 2014-09-18) Stein, Dan; Maud, Catherine; van der Merwe, Nicolina; Tasman, Allan; Fountoulakis, Konstantinos; Pies, Ronald; Simonsen, Erik; Summergrad, Paul; McDermott, Bruce; Ansari, Arash; Milev, Roumen; Kohn, Robert; Arboleda-Florez, Julio; Osser, David; Temmingh, Henk; Thomas, Stuart; Ojserkis, Rachel; Attia, Evelyn; Allgulander, Christer; Preda, Adrian; Page, Lisa; Spiegel, David; Chopra, Kapil; Jaffa, Tony; Bestha, Durga Prasad; Madeen, Vishal; Wilson, Daniel
    This multi-authored collaborative textbook on psychiatry, originally created on Wikibooks, discusses a range of psychiatric disorders, including psychotic, mood and and anxiety disorders, amongst many others. It covers other aspects of psychiatric care such as diagnosis, neurobiology, psychopharmacology, treatment methods, and dealing with agitated or violent patients.
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    The experiences of ex-offenders living with a mental disorder within three to twelve months following discharge from psychiatric prison care in Zimbabwe: a qualitative study
    (2022) Mhishi, Wellington; Sorsdahl, Katherine; Williams, Petal Petersen; Mangezi, Walter
    Background: There are significant challenges in many countries to effectively manage service needs of prisoners with a mental illness. In Zimbabwe, there is no literature on the prevalence of mental disorders among prisoners but it is likely to be as high as in other African countries. Apart from high prison populations which often under resourced, it is also reported that ex-offenders from correctional psychiatric institutions face a range of social, economic and personal challenges once released which often hamper their ability to live adaptive crime-free lifestyles. Although there is extensive literature on experiences of offenders within the criminal justice system, few studies have examined the convergence of the factors affecting those ex-offenders living with mental illness' transition from the prison environment to the community, as related to (i) their experiences upon discharge, (ii) barriers to effective community reintegration of this vulnerable population, and (iii) their service needs. The study addresses this gap. Aims & Objectives: The overall aim of the study was to explore the experiences of ex-offenders with a mental illness within a period of three to twelve months following discharge from psychiatric prison care. Specific objectives included: (1) exploring the experiences and needs of ex-offenders with severe mental illness upon discharge from psychiatric prison care; (2) exploring the key drivers and barriers to community re-integration of ex-offenders with severe mental illness after being discharged from psychiatric prison care; and explore available services and identify further service needs of ex-offenders with mental illness after being discharged from psychiatric prison care. Methods: Thirteen ex-offenders with a severe mental illness who were discharged at Chikurubi Maximum Security Prison participated in the study. There is a dedicated psychiatric facility at Chikurubi Maximum Security Prison and it was being funded externally through MSF. Key informant structured interviews were utilised. All ex-offenders were discharged within a period of three to twelve months, were over eighteen (18) years of age and they participated in the study willingly and provided informed consent. Only those based in Harare Metropolitan Province were included. The research participants were interviewed using a qualitative interview schedule which inquired about the experiences and needs of ex-offenders with severe mental illness; key drivers and barriers to community re-integration following discharge and access to mental health services. Interviews were transcribed verbatim and analysed using the framework approach to identify themes. To facilitate analysis of data, the qualitative analysis computer software NVivo 12 was utilised. Results: Findings of the study were grouped according to three main themes. Theme one highlighted how the prison infrastructure and environment negatively impacted on their mental health. This included dilapidated buildings, no running water, electricity shortages, poor ventilation in cells and overcrowding. The second theme focused on the perceived benefits of the comprehensive and integrated mental health services at Chikurubi Hospital. The third theme looked at the experiences and needs upon discharge from psychiatric prison care. Participants had mixed experiences of integration depending on the severity of the crime committed and whether or not they were integrated back into the same community where the crime was committed. Successful reintegration was challenging given the stigma and discrimination experienced as a result of committing a crime and having a mental health illness. The lack of community based services providing recovery focused interventions was also highlighted as a challenge. Conclusions: The study examined experiences of ex-offenders living with mental illness within three to twelve months following discharge from psychiatric prison care. Chikurubi Psychiatric Hospital provided comprehensive quality services through external funding. Upon discharge, community mental health services focused primarily on clinical recovery in the form of medication, impacting on the mental health of the participants as they re-integrated into the community.
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    Using Theory of Change to design and evaluate complex mental health interventions in low and middle income countries: the case of PRIME
    (2018) Breuer Erica; Lund, Crick; de Silva, Mary
    Background: Many health interventions are complex and consist of several interacting components (Medical Research Council 2008). These components include multiple causal strands, outcomes and levels of governance and may result in unexpected outcomes and non-linear change (Glouberman and Zimmerman 2002). As such they present challenges to the design and evaluation of complex health interventions. Although broad theoretical guidance has been developed by the UK Medical Research Council (MRC) (Craig, Dieppe et al. 2008), it contains little practical guidance and has been criticised for not including theory driven approaches to evaluation such as Theory of Change (ToC) (Anderson 2008). De Silva, Breuer et al. (2014) have proposed that ToC may complement the MRC guidance on complex health interventions. Methods: This study explores how ToC can strengthen the design and evaluation of complex health interventions using the example of The Programme for Improving Mental Health Care (PRIME). PRIME is a research programme which aimed to develop, implement and evaluate the integration of mental health into primary health in districts or sub-districts in Ethiopia, India, Nepal, South Africa and Uganda. A ToC approach was used in addition to other approaches to design and evaluate these complex mental health interventions. Firstly, I conducted a systematic review to determine the extent to which ToC has been used to design and evaluate public health interventions. Secondly, I compared the process of developing the ToC between all five PRIME countries and reflected on the value of ToC workshops using a framework analysis of workshop documentation and interviews with facilitators. Thirdly, I explored the development of the ToCs within the programme as a whole and the implications for the development of the intervention and the choice of evaluation methods. Fourthly, I presented a ToC for the integration of mental health care in low and middle income countries. Fifthly, I demonstrated how ToC can be used as a framework for a qualitative comparative analysis of process and outcome data using longitudinal data from 10 PRIME implementation facilities in Nepal. Lastly, I provide a set of 10 key lessons learned from PRIME in the application of ToC to complex mental health interventions. Results I found that the ToC approach has been used for the design and evaluation of public health interventions since the 1990s. However, there is a lack of clear description of the use of ToC in the literature on public health interventions and inconsistency in how it is used. In applying the ToC approach to PRIME, I found that facilitators reported that ToC workshops were a valuable way to develop ToCs and that different stakeholders at the workshop contribute different types of information to the ToC process. Hierarchies within the health system are an important consideration for ToC workshops as power dynamics are likely to influence the functioning of the group. In addition, I found that the development of a cross country ToC can result in a programme theory which is relevant for complex multilevel intervention in different contexts. This ToC can provide a framework to map contextually relevant interventions and can be used to complement other intervention development approaches. The ToC can also be used to ensure indicators for all the short-, medium- and long-term outcomes are identified. However, combining process and outcome data analysis using the ToC is not straightforward. Qualitative Comparative Analysis (QCA) can be used to analyse process and outcome data in a single analysis in health services research. Conclusion: ToC can be used to strengthen the design and evaluation of complex health interventions and can be used to complement the MRC guidance in the design and evaluation of complex health interventions.