Sleep problems and mortality in rural South Africa: novel evidence from a low-resource setting

ObjectiveSleep problems are associated with mortality in Western populations. In low-resource settings, evidence of sleep problems and their potential association with mortality is lacking. Our study aimed to fill this gap by examining the prospective association of sleep problems with mortality among older adults in rural South Africa, as well as potential sex differences in this association.MethodsThe study was conducted in 2006 in Agincourt (South Africa), as part of the Health and Demographic Surveillance System. A community-wide sample of 4044 men and women aged 50 years or older participated in the survey. Two measures of sleep quality over the last 30 days were assessed alongside sociodemographic variables, measures of quality of life (QoL), and functional ability. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for mortality risk over time associated with the two sleep measures at baseline, while allowing adjustment for other covariates.ResultsOverall, 394 deaths occurred during 3 years of follow-up. Both men and women reporting severe/extreme nocturnal sleep problems (vs none/mild/moderate) experienced a significantly greater mortality risk in models adjusted for sociodemographic variables only (HR, 1.65 [95% CI, 1.18–2.31] and HR, 1.42 [95% CI, 1.07–1.88], respectively). However, these associations were nonsignificant in fully adjusted models (HR, 1.23 [95% CI, 0.85–1.79] and HR, 1.07 [95% CI, 0.78–1.47], respectively).Men who reported severe/extreme difficulty related to daytime function (vs none/mild/moderate) experienced a 2-fold increased mortality risk (HR, 2.01 [95% CI, 1.32–3.07]) in fully adjusted models, whereas no significant association was observed for women (1.16 [95% CI, 0.80–1.67]).ConclusionsIn this population, nocturnal sleep problems were not associated with mortality once analyses were adjusted for QoL, functional ability, and psychologic comorbidities. By contrast, severe or extreme problems with feeling unrested or unrefreshed during the day were associated with a 2-fold increased mortality risk, but this association was only significant in men.     

Mental health care providers talk about their experiences preventing suicide in people with substance use disorders in South Africa: implications for clinical practice

Objective: This study explored mental health care providers’ experiences of preventing suicide in people with substance use disorders and their perceptions of factors related to clinical practice that contributed to these experiences.

Methods: In-depth, semistructured interviews were conducted with 18 mental health care providers working in South Africa. Thematic analysis was used to analyse the data inductively with Atlas.ti software.

Results: Participants described feeling hopeless, helpless, powerless and guilty and needed to debrief from their experiences of preventing suicide. They perceived their experiences to be related to the difficulties of treating substance use disorders, the difficulties of assessing and managing suicide risk and how treating substance use might increase suicide risk.

Conclusions: The ways in which mental health care providers think about suicide and make sense of their experiences affects their perceived abilities to prevent suicide. Educating mental health care providers to transcend the limitations of risk factor approaches to suicide prevention and utilise evidence-based strategies for treating substance use disorders and associated problems, may be important to empower them and make them feel competent in suicide prevention. Empowering people with substance use disorders may help prevent suicide and may require collaboration between mental health care providers and allied professionals.     

Common mental health problems in historically disadvantaged urban and rural communities in South Africa: prevalence and risk factors

This paper reports on an epidemiological study of common mental health and substance abuse problems in a historically disadvantaged urban and rural community in South Africa. In the rural Limpopo Province of South Africa, and in a peri-urban township near Cape Town, self-report instruments were used in two random population samples and among respondents at primary care and traditional healer settings, to assess common mental health problems, substance abuse problems and associated problems in social functioning. A high prevalence of mental health and substance abuse problems was observed in both communities, with highest rates in the peri-urban township. Even higher prevalences were found among respondents at primary health care or traditional healers. The study shows that mental health and substance abuse problems constitute a considerable burden of disease among disadvantaged communities in South Africa. The study further underscores the integral role of traditional healers in the mental health care system.     

The effects of memory, attention, and executive dysfunction on outcomes of depression in a primary care intervention trial: the PROSPECT study

OBJECTIVE: To describe the influence of domains of cognition on remission and response of depression in an intervention trial among older primary care patients. METHODS: Twenty primary care practices were randomly assigned to Usual Care or to an Intervention consisting of a depression care manager offering algorithm-based care for depression. In all, 599 adults 60 years and older with a depression diagnosis were included in these analyses. Depression severity and remission of depression were assessed by the 24-item Hamilton Depression Rating Scale. The Mini-Mental State Examination (MMSE) was our global measure of cognitive function. Verbal memory was assessed with the memory subscale of the Dementia Rating Scale. Attention was measured with the digit span from the Weschler Adult Intelligence Test. Response inhibition, one of the executive functions, was assessed with the Stroop Color-Word test. RESULTS: The intervention was associated with improved remission and response rates regardless of cognitive impairment. Response inhibition as measured by the Stroop Color-Word test appeared to significantly modify the intervention versus usual care difference in remission and response at 4 months. Patients in the poorest performance quartile at baseline on the Stroop Color-Word test in the Intervention Condition were more likely to achieve remission of depression at 4 months than comparable patients in Usual Care [odds ratio (OR) = 17.76, 95% Confidence Interval (CI), 3.06, 103.1]. CONCLUSIONS: Depressed older adults in primary care with executive dysfunction have low remission and response rates when receiving usual care but benefit from depression care management.     

Persistence of psychiatric disorders in a cohort of HIV/AIDS patients in South Africa: a 6-month follow-up study

BACKGROUND: Psychiatric disorders in HIV/AIDS are common, emerging soon after diagnosis or during the subsequent course of illness. However, there are few prospective studies on the rates of psychiatric disorders in HIV/AIDS, particularly in the context of the developing world. METHODS: Sixty-five patients with recently diagnosed HIV were interviewed on presentation to a hospital-based HIV clinic and then 6 months later. On both interviews, the patients were assessed using the MINI International Neuropsychiatric Interview, the Carver Brief COPE, and the Sheehan Disability Scale. Exposure to negative life events and risk behaviors was also evaluated. RESULTS: The overall prevalence of psychiatric disorders in the follow-up period remained high (56% of patients had at least one psychiatric disorder at baseline, and 48% of patients had at least one psychiatric disorder at 6 months). Depression and posttraumatic stress disorder (PTSD) were the most prevalent disorders at both baseline (34.9% and 14.8%) and follow-up (26% and 20%), respectively. More than half of all patients with depression at baseline improved (16 of 29; 55.1%). However, there was a new onset of both depression (4 of 49; 8.1%) and PTSD (12 of 17; 70.5%) on follow-up. In univariate analysis, depression on follow-up was significantly associated with: (a) disability in work/social/family functioning, (b) greater number of negative life events, and (c) a decline in CD4 lymphocyte count. Univariate analysis also revealed that a diagnosis of PTSD on follow-up was significantly associated with (a) a longer duration of infection and (b) baseline disability in work/social/family functioning. However, in multivariate analysis, only disability scores predicted the diagnoses of major depression and PTSD on follow-up assessment. Persistence of risky sexual behaviour was also noted, with a significantly higher number of participants reporting nonuse of condom on follow-up. There appeared to be a shift from maladaptive coping behaviors to more adaptive coping behaviors over the 6-month period. CONCLUSION: The rate of psychiatric disorders in HIV/AIDS patients was consistent over time. These findings emphasize the importance of regular evaluation for psychiatric disorders in HIV/AIDS patients, not only at the commencement of treatment but also during subsequent follow-up visits.     

Characteristics of double care demanding patients in a mental health care setting and a nursing home setting: results from the SpeCIMeN study

Background: Older patients suffering from a combination of psychiatric disorders and physical illnesses and/or dementia are called Double Care Demanding patients (DCDs). Special wards for DCDs within Dutch nursing homes (NHs) and mental health care institutions (MHCIs) offer a unique opportunity to obtain insight into the characteristics and needs of this challenging population.

Methods: This observational cross-sectional study collected data from 163 DCDs admitted to either a NH or a MHCI providing specialized care for DCDs. Similarities and differences between both DCD groups are described.

Results: Neuropsychiatric symptoms were highly prevalent in all DCDs but significantly more in MHCI-DCDs. Cognitive disorders were far more present in NH-DCDs, while MHCI-DCDs often suffered from multiple psychiatric disorders. The severity of comorbidities and care dependency were equally high among all DCDs. NH-DCDs expressed more satisfaction in overall quality of life.

Conclusions: The institutionalized elderly DCD population is very heterogeneous. Specific care arrangements are necessary because the severity of a patient's physical illness and the level of functional impairment seem to be equally important as the patient's behavioural, psychiatric and social problems. Further research should assess the adequacy of the setting assignment and the professional skills needed to provide adequate care for elderly DCDs.     

Organization of services and pattern of psychiatric care in Nicaragua: result of a survey in 1986

Organization of services and patterns of psychiatric care were studied in Nicaragua in 1986, 7 years after the substantial changes in health policy launched after the revolution. The overall re-organization of the system is indicated by the progressive abandoning of the mental hospital as the center of psychiatric care and the creation of 15 community-based mental health centers now functioning throughout the country. Quality of care judged through analysis of a consecutive sample of 342 patients seen by services over a month confirmed the positive orientation of the system which seemed able to deliver good care following the new perspective of "de-institutionalization". Some problems emerged to a large extent common to psychiatric care in industrialized countries looking at psychotropic drug use and at the relationship between primary health care and the psychiatric system especially when care delivered in urban and rural areas was compared.     

Integrated care in schizophrenia: a 2-year randomized controlled study of two community-based treatment programs

OBJECTIVE: To evaluate the efficacy of two community-based programs that combined antipsychotic medication, family interventions and social skills training. METHOD: A randomized controlled trial with 2 years follow-up. The study included 84 patients with schizophrenic disorders, continuously managed in terms of care and treatment, and regularly assessed. Analysis was by intention-to-treat. RESULTS: Between-program comparisons showed significantly improved social function and consumer satisfaction in favour of the program 'Integrated Care' (IC) at the 2-year follow-up. The main clinically important differences between the two treatment programs studied were the procedures for shared decision making and patient empowerment in IC. CONCLUSION: The implementation of IC in clinical practice can improve social recovery and increase consumer satisfaction for patients with schizophrenic disorders. We identified specific procedures that might be added to improve the effectiveness of any program for severely mental ill people.     

Beliefs,knowledge and attitudes towards Parkinson's disease among a Xhosa speaking black population in South Africa: A cross-sectional study

IntroductionMany patients with Parkinson's disease (PD) in sub-Saharan Africa (SSA) are thought to be undiagnosed and untreated, leading to poor health outcomes. Increasing rates of diagnosis and treatment, with consequent improvements in the quality of life of people with PD in SSA requires an understanding of how PD is perceived and conceptualized within communities.MethodsA cross-sectional survey was conducted among a group of Xhosa speaking black South Africans. The survey involved the administration of questionnaires on beliefs, knowledge and attitudes about PD to the public, people with PD (PwPD) and traditional healers (THs).Results18% of the participants could identify PD through its symptoms. Mental illness, other diseases, stress, expressing strong emotions, consumption of certain foods or drinks and witchcraft were identified as possible causes of PD. PwPD and THs had a greater knowledge of PD than the public and greater age was a significant predictor of greater knowledge. The public and THs had a greater degree of concern about a range of symptoms of PD compared to PwPD.ConclusionThere is a striking lack of knowledge about PD amongst black South Africans. Almost half the members of the general public interviewed felt that PwPD should not live amongst their community, and a third considered that witchcraft could be a cause of PD. Finding ways to effectively educate members of a community about PD would make it easier for PwPD to adapt to their condition within their communities.     

Innovations in Practice: Child and adolescent psychiatrists and primary care – innovative models of consultation in the United States

Background: There is a severe shortage of child and adolescent psychiatrists (CAPs) in the United States, an increasingly recognized high prevalence of mental disorders in young people, and widely supported goals to provide more mental health services in the primary care setting. Method: A number of innovative, state‐wide or more local, publically funded programs have been developed in the United States over the last several years to respond to these challenges and to provide CAP consultation to primary care physicians (PCPs) who wish to address the mental health disorders of their patients in the primary care setting. Results: A number of these programs and their approaches to consultation are described. An example of a clinical scenario that might be addressed using this model of CAP/PCP collaboration is offered. Conclusions: An innovative model of consultation to PCPs from CAPs appears able to facilitate the treatment of many young people with mental health disorders in the primary care setting.     

Examining the feasibility and effectiveness of a culturally adapted participation-focused stroke self-management program in a day-rehabilitation setting: A randomized pilot study

ABSTRACT

Background: Stroke survivors find it difficult to participate in daily activities, despite their improvement throughout the rehabilitation process. Thus, it has been questioned whether day-rehabilitation services provide adequate preparation for participation and reintegration into the community. Self-management programs can improve survivors’ self-efficacy to manage their condition and participation. Improving Participation After Stroke Self-Management program (IPASS) is an occupational therapy-based group intervention developed in the United States, which has been effective in improving participation outcomes.

Objective: To evaluate the feasibility and effectiveness of the IPASS adapted for an Israeli population of individuals admitted to a day-rehabilitation center after stroke.

Methods: A single-center, randomized, assessor-blind study was conducted. Eligible participants were randomized to receive the IPASS (intervention group), in addition to standard individual therapy or standard care only (control group). Feasibility was based on attendance rate and a feedback questionnaire. Effectiveness was evaluated with the Functional Independence Measure (FIM), the Reintegration to Normal Living Index (RNLI) and self-efficacy questionnaires.

Results: Sixty participants were included, of which 39 completed baseline and post-intervention evaluations. The intervention group improved significantly in the FIM scores (p < .01), as compared to the control group (p > .05). Moderate effect sizes (≥0.35) were found for the FIM and RNLI, and large effect sizes (≥0.65) for two subcategories in the participation self-efficacy questionnaire.

Conclusions: The results support the feasibility of the adapted IPASS, and show a trend for positive effects in improving participation and self-efficacy in managing participation in home and community activities, for an Israeli post-stroke population.     

The role of subjective cognitive complaints and depressive symptoms in social re-integration following stroke: a mediation explanation in a cross-sectional sample

Background: For long-term stroke survivors, objective neuropsychological impairments and subjective cognitive difficulties are common, and may contribute to ongoing difficulties in community reintegration. However, subjective cognitive complaints have been as much associated with low mood as with actual cognitive performance.

Objective: The objective of our study was to investigate the extent to which subjective cognitive complaints predicted community reintegration following a stroke, and whether this relationship would be mediated by emotional status.

Methods: Using a cross-sectional design, patients with a primary diagnosis of stroke (n = 102; age range 25–89 years) were recruited from the register of a neurological rehabilitation service if they were at least 6 months post-stroke and had been discharged home following the stroke. Exclusions included history of dementia, co-morbid psychiatric or neurological disorder, or significant aphasia. Assessments included the Subjective Cognitive Complaints Questionnaire, the Community Integration Questionnaire, and the Depression Anxiety and Stress Scale.

Results: Subjective cognitive complaints were common, with moderate to high levels of complaint most frequent for working memory (58.9%), and information processing speed (53%). Subjective cognitive complaints were significantly associated with social integration (r = ?.23, p < .05). However, examination of relationships using statistical mediation revealed that depressive symptoms fully mediated the relationship between subjective cognitive complaints and social integration.

Conclusions: Subjective cognitive complaints are common in long-term outcome following stroke and predict difficulty in community reintegration. However, this relationship is mediated by variation in emotional status. Therefore, addressing cognitive complaints through cognitive rehabilitation programs that include components to improve mood (for example, building self-efficacy or confidence) may also improve community reintegration post-stroke.     

Neuropsychology in South Africa: confronting the challenges of specialist practice in a culturally diverse developing country

Objective: This was an invited paper on the history and current status of neuropsychology in South Africa. Method: Information was gathered from literature searches, personal communication, and the authors’ experiences while occupying relevant professional and academic positions for over 30 years. Results: Since its origins in the 1950s, the development of neuropsychology in South Africa has faced numerous challenges, against a background of extreme sociocultural and socioeconomic disparity in the country that is on-going. The creation of the South African Clinical Neuropsychological Society in the 1980s, a credentialing and training body, gave impetus to the discipline. In the absence of a neuropsychology category within the South African professional framework, university instruction has been ad hoc with vastly different levels of competency depending on the institution involved. The small number of practitioners and/or academics involved in neuropsychology includes mainly masters, and some doctoral level psychologists registered in clinical, counseling or educational categories. A prime emphasis of neuropsychological research has been local norming of psychometric tests to facilitate valid assessment practices in the country. South Africa is on the cusp of achieving a hard-won neuropsychology professional register. It is anticipated that this development will provide impetus to the discipline by promoting training programs, the creation of neuropsychology posts, wider service delivery, and increased research funding. Conclusions: Despite significant challenges in a culturally diverse, developing country, neuropsychology has evolved sufficiently to warrant the creation of a separate category in the professional framework. This development will facilitate training, research, and services in the country.     

Managing late-life depression in primary care practice: a case study of the Health Specialist's role.

Complexities in the diagnosis and treatment of late-life depression have stimulated various strategies for assisting the primary care physician to fulfil these tasks more effectively. The role of Health Specialist was developed for this purpose in a study to reduce suicidality among older depressed patients. This role includes clinical and case management tasks which aim to provide the physician with timely, patient-specific information and recommendations. Evolution of this role and its rewards/stressors during the study's first year are described.     

Needs for care and effectiveness of mental health care provision for schizophrenic patients in two European regions: a comparison between Granada (Spain) and Mannheim (Germany)

OBJECTIVE: The aims of this study were to develop an indicator for comparing the effectiveness of community mental health care across different areas, and to compare the effectiveness of care for schizophrenic patients in two European regions. METHOD: In a long-term follow-up, service utilization, needs for care and met needs of schizophrenic patients were assessed. An indicator of effectiveness of care was calculated for each region and compared. RESULTS: Patients in Mannheim received much more intervention in all types of mental health care. Despite differing utilization patterns, the indicator of effectiveness of care revealed no differences in the area of symptoms and behaviour problems between the two regions, while significant differences in the area of skills and abilities of patients were detected. CONCLUSION: We succeeded in defining a measure that describes effectiveness of mental health care in terms of the long-term relationship between needs and unmet needs of patients. Our results contribute to an evidence-based discussion of the improvement of community mental health care networks.     

Impact of transitional care for discharged elderly stroke patients in China: an application of the Integrated Behavioral Model

Background: Transitional care (TC) has been shown to improve stroke rehabilitation in discharged stroke patients. Previous TC interventions did not report satisfactory stroke rehabilitation outcomes or risk management. Incorporating a health behavior theory in interventions can effectively improve health behaviors and metabolic indicators.

Objectives: This study was a clinical controlled trial to investigate the impact of the Integrated Behavioral Model (IBM)-based 3-month TC on health behaviors, clinical outcomes, and stroke knowledge in discharged elderly stroke patients.

Methods: Sixty elderly patients were recruited from two wards of a public teaching hospital in China. To prevent potential treatment contamination, patients were allocated into either a control or intervention group depending on which wards they were admitted to. The TC intervention considered all the IBM constructs to provide patients assistance in implementing health behaviors as recommended by the Chinese stroke guidelines. The TC intervention commenced one day before discharge and lasted three months after discharge. A linear mixed model was used to measure the impact of the intervention.

Results: The TC intervention improved the discharged elderly stroke patients’ health behaviors, activities of daily living, quality of life, and stroke knowledge. The intervention also controlled the patients’ systolic blood pressure, body mass index, total cholesterol, triglycerides, and low-density lipoprotein cholesterol.

Conclusions: This study provided evidence of concurrent self-reported and objective clinical indicators in discharged elderly stroke patients for the impact of the IBM-based 3-month TC intervention, which can be recommended for clinical practice.     

Health professionals’ perceptions of developing dementia services in primary care settings in China: a qualitative study

Objectives: Primary care plays a crucial role in the timely diagnosis and proper management of dementia. Evidence from low and middle income countries is much needed to inform service development in primary care and to address the dementia burden in these countries. The aim of this study was to explore community health professionals’ perceptions of dementia service development using China as a case.

Method: An interpretive study design was utilized and focus groups were used for data collection guided by a semi-structured interview guide. Each focus group lasted between 90–120 min. Thematic analysis was applied for data analysis.

Results: Twenty-one community health professionals participated in this study and three major themes were identified. These themes are: incorporating dementia components in the government-subsidized primary care services; an under-prepared workforce to meet the demand for dementia care; and an enabling environment to sustain dementia care.

Conclusion: Government policies, regulations, standards and guidelines need to be established for dementia service development in primary care to improve the home care for people with dementia and to create a dementia-friendly society. Regular education and training activities for health professionals are a way to build dementia care service capacity in primary care.     

Background,experience of abuse,and mental health among adolescents in out-of-home care: a cross-sectional study of a Swedish high school national sample

Purpose: To compare experiences for adverse events, especially sexual abuse, and mental health in a group of high school students in out-of-home care with a representative sample of peers of the same age and similar educational attainment living with their parents.

Materials and methods: A sample of 5839 students in the third year of Swedish high school, corresponding to a response rate of 59.7%, answered a study specific questionnaire. Data from 41 students living in out-of-home care were compared with data from peers not in out-of-home care in a cross-sectional analyze.

Results: Students in out-of-home care had more often an immigrant background and a non-heterosexual orientation, had more often experienced physical and penetrative sexual abuse, and more often sought healthcare for mental problems. Disclosure of sexual abuse was less common, and acts of persuasion or adults' use of their social position was more common among students in out-of-home care.

Conclusions: Even where the protective factor ‘senior educational attainment’ is present, risks for abuse and poor mental health are evident for adolescents in out-of-home care. Disclosure of adversity, when it has occurred, ought to be higher among these adolescents with regular contact with social services, but our findings indicate tendencies for the opposite. We therefore suggest routines to be established to screen for adverse life events and mental health actively, along with general and systematic assessments of adversity and mental health during care.