Mental health care - a public health priority in South Africa

Mental health is an integral part of health and it includes an individual's emotional, psychological and social well-being. Mental illness remains underreported and underdiagnosed, particularly in low- and middle-income countries, including South Africa. South Africa carries a huge burden of mental illnesses with the most prevalent being anxiety disorders, substance abuse disorders, mood disorders and depression. People with mental health conditions often face neglect in the health system as well as stigma and discrimination. This has resulted in poor health outcomes, isolation and high suicide rates, including amongst adolescents. The South African National Mental Health Policy Framework and Strategic Plan (2013­2020) aims to integrate mental health into the health system to provide quality mental health services that are accessible, equitable and comprehensive, particularly for community-based mental health. This article provides an overview of mental health care in South Africa, highlighting its public health importance

Suicide attempts during pregnancy in South Africa

Background: Research on suicide attempts during pregnancy is limited as these are considered to be rare in the perinatal period. Aim: A retrospective pilot study was undertaken to establish what percentage of suicide attempters admitted to a hospital were pregnant and to identify their clinical and sociodemographic characteristics. Setting: The study was conducted at a tertiary hospital in Durban, South Africa. Methods: A retrospective chart review was undertaken of all female patients admitted following suicide attempts over a period of 1 year. Clinical and sociodemographic data of pregnant suicide attempters were extracted. Results: Of 27 charts reviewed, 33% ( n = 9) patients were pregnant at the time of the attempt. V Code diagnoses predominated, followed by major depressive disorder. Past psychiatric diagnoses and suicide attempts were also present. Conclusion: Suicide attempts during pregnancy are not rare. Pregnant women should be routinely screened for prior suicide attempts, depression and stressors as part of perinatal assessments

Sociodemographic characteristics of persons committing suicide in Durban, South Africa: 2006­2007

Background: Suicidal behaviour is a leading contributor to the burden of disease worldwide and varies widely between countries. South African figures are amongst the highest in the world; with recent trends indicating a disturbing rise; especially amongst the younger age groups; across all races. Aim: This study analysed sociodemographic characteristics and trends relating to suicides committed in Durban; South Africa during the period of 2006-2007. Method: A retrospective analysis of suicidal deaths (during 2006-2007); extracted from autopsy registers at all three government-run mortuaries in Durban; was conducted. Results: The total number of suicides in Durban increased by 6.68 from 2006 to 2007. Suicide accounted for an average of 8.8 of all non-natural deaths per year of the study. The overall suicide rates of 14.53 (2006) and 15.53 (2007) per 100 000 population are comparable with national and global figures. The majority of suicides occurred in single unemployed persons; men and younger age groups. The largest number of suicides per year was recorded in black people; followed by Indian; white and mixed-race people. Hanging was the preferred method in the majority of victims; followed by self-poisoning; shooting and jumping. Conclusions: The findings indicate a disturbingly high suicide rate amongst the various population and age groups in Durban. The dominant methods used may be influenced by ease of access. The reported trends may worsen unless there is a swift and decisive public health response and cohesive community-based programmes which include a supportive multidisciplinary network

Psychiatric features in perpetrators of homicide-unsuccessfulsuicide at Weskoppies Hospital in a 5-year period

Background. In the absence of medical literature reporting on homicide-unsuccessful-suicide (HUS) cases in which the perpetrator is referred for forensic psychiatric observation present an opportunity to explore psychiatric features pertaining to the event.Objective. To identify possible contributing psychiatric features in HUS cases.Method. A retrospective; single-centre; descriptive study was conducted; in which were reviewed clinical records of HUS subjects referred for observation to Weskoppies Hospital from December 2005 to January 2011. Socio-demographic and psychiatric information was obtained. Results. Nine cases were reviewed. The median age of the subjects was 29 years and 7 subjects were male. Five cases involved family members. Cases involving couples demonstrated male subjects and cases involving filicide demonstrated female subjects. Only 1 case involved the use of a firearm. At the time of the incident; 4 of the cases had no psychiatric diagnosis but notable interpersonal difficulties. Psychotic disorders were diagnosed in 3 subjects; a depressive disorder in 1 subject and a depressive and anxiety disorder in 1 subject.Conclusion. Subjects commonly used less lethal methods than shooting. The high rate of psychiatric disorders diagnosed is in keeping with court referrals occurring when a mental illness is suspected. Some cases may require specialised probing before psychosis becomes apparent. Identification of psychosocial stressors and failure of coping mechanisms during periods of strife within an intimate relationship may be a focus of future research in homicide-suicide cases. Separation should possibly be investigated as an independent factor which promotes the interpersonal difficulty associated with homicide-suicide

Effectiveness of psycho-education on depression, hopelessness, suicidality, anxiety and substance use among basic diploma students at Kenya Medical Training College

Objective. To determine the effectiveness of psycho-education on symptom severity in depression; hopelessness; suicidality; anxiety and risk of substance abuse among para-medical students at Kenya Medical Training College (KMTC).Methodology. A clinical trial drew experimental (N=1 181) and control (N=1 926) groups from different KMTC campuses. Self-administered questionnaires were used to collect data: the researcher-designed social demographic questionnaire was used at baseline only; while Beck's Depression Inventory; Beck's Hopelessness Scale; Beck's Suicide Ideation Scale; Beck's Anxiety Inventory and World Health Organization alcohol; smoking and substance involvement screening test (ASSIST) (for drug abuse) were used for baseline; mid-point and end-point assessments at 3-month intervals. The experimental group received a total of 16 hours of structured psycho-education. All study participants gave informed consent.Results. Overall; there was no significant reduction in symptom severity between the experimental and control groups at 3 months (p0.05) but there was a significant difference at 6 months (p0.05).Conclusion. Psycho-education was effective in reducing the severity of symptoms of depression; hopelessness; suicidality; anxiety and risk of substance abuse at 6 months

A 20 Year Retrospective Analysis of Medicolegal Deaths in a Tertiary Hospital Setting in Nigeria

Objective: To determine and classify the various types of medicolegal deaths as seen at University of Benin Teaching Hospital (UBTH); Benin City; Nigeria.Materials and Methods: This is a retrospective study of all the medicolegal deaths seen in the Department of Histopathology; (UBTH; Benin City over a 20 year period (January 1990-December 2009) as recorded in the autopsy registers of the department.Result: A total of 5035 autopsies were done during the period; 89 of which were coroner cases. Four thousand; four hundred and eighty-one coroner cases representing 12.5 of all bodies received by the mortuary during the period were studied. The male to female ratio was 1.9:1; with an overall mean age of 38.3 years. The ages ranged from 1 day to 101 years with a peak incidence in the 25-44 years age group. A total of 553 children and 3928 adults were involved. The commonest indication for coroner's autopsy was sudden unexpected natural deaths (SUNDs) which accounted for 65.5 of the cases. Other causes of death were accidents; homicide; suicide; and undetermined causes representing 28.6; 5.0; 0.5; and 0.4; respectively. Commonest cause of SUND was cardiovascular diseases with complications of hypertension being the most common CVS disease (26.9). Road traffic accident was the commonest form of accident causing death (88.7). Public enlightenment and health education about routine medical screening will help to reduce causes of natural deaths.Conclusion: This study shows the pattern of medicolegal autopsies in UBTH and this preliminary data will provide a baseline for future research and help in formulating policies to help in reduction of preventable causes of death

Social dynamics of suicide in South Africa: A theoretical perspective

Suicide rates in South Africa are on the increase; particularly amongst the youth. What are the complexities of modern life which are driving the increase? The suicidal act of self-destruction signals society's failure to provide good support systems and meaningful psycho-social well-being for its members. With its impressive Reconstruction and Developmental Programme (RDP); South Africa has not yet succeeded in extending the equivalent reconstruction of people's minds and thought processes. In some instances the art of negotiating one's existence on a daily basis is compromised by hostile socio-economic and political realities. The collective consciousness that once glued society has lost its bonding effect. Traditional systems of social support need to be revisited. The aim of this study is therefore to give a theoretical view of social dynamics of suicide in South Africa

Associations between Family Suicide and Personal Suicidal Behaviour among Youth in Kwazulu-Natal; South Africa

Background: For every suicide; a minimum of six people are affected. Given the increasing number of suicide deaths in South Africa; the associations between the suicide of a family member and personal suicidal behaviour were explored in grade 8 students.Method: Grade 8 students were asked to participate with parental consent and child assent. Demographic questionnaires were completed and formal psychometric assessment instruments were used.Results: Thirty-five (15.98) students reported knowing that a family member had committed suicide. The mean age was 13.3 years (range 13-15 years). There were significant associations between family suicide and students' self-reported involvement in physical fights; use of alcohol and concerns about physical health. Family suicide was associated with personal suicidal ideation; suicidal plans and suicide attempts. Higher scores were reported on the scales assessing depression; perceived stress and feelings of hopelessness by those having had a family member commit suicide. There were low scores for having a sense of mastery; self-esteem and perceived social support among those who had experienced a family member commit suicide.Conclusion: Significant associations were found between the suicide of a family member and personal suicidal behaviour among the participants. There appear to be negative associations at a psychological level for the youth in a family in which a family member has committed suicide. Family practitioners play an important role in the identification and management of suicidal behaviour. While there are organisations in South Africa that offer help to the family and friends of those who have committed suicide; specific programmes directed towards child/adolescent survivors appear to be limited; and this needs to be addressed. The limitations of the study are discussed

Suicide in Urban Kampala; Uganda: a Preliminary Exploration

Background: Suicide was investigated in the urban setting of Kampala; Uganda. Objectives: Firstly; to explore the use of two research methodologies; a retrospective review of patient records and the psychological autopsy methodology in suicide research in Uganda. Secondly to investigate the characteristics and correlates of urban suicide in Uganda. Results: A male to female ratio of suicide of 3.4:1 and a peak age of suicide in the 20-39 years age group were found. The main methods of suicide were hanging and ingestion of poison (organophosphates). Problems with social networks; negative life events; higher psychological distress and lower quality of life were associated with suicide at univariate analysis. It was only psychological distress that retained significance at multivariate analysis. Conclusion: The retrospective review of records at Mulago hospital was beset by incomplete records whereas a pilot psychological autopsy study was well accepted and might contribute valuable data in African settings

Lifetime mental disorders and suicidal behaviour in South Africa

There is relatively little data on the relationship between lifetime mental disorders and suicidal behaviour in low and middle income countries. This study examines the relationship between lifetime mental disorders; and subsequent suicide ideation; plans; and suicide attempts in South Africa. Method: A national survey of 4185 South African adults was conducted using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate psychiatric diagnoses and suicidal behaviour. Bivariate; multivariate and discrete-time survival analyses were employed to investigate the associations between mental disorders and subsequent suicide ideation; plans; and attempts. Results: Sixty-one percent of people who seriously considered killing themselves at some point in their lifetime reported having a prior DSM-IV disorder. Mental disorders predict the onset of suicidal ideation; but have weaker effects in predicting suicide plans or attempts. After controlling for comorbid mental disorders; PTSD was the strongest predictor of suicidal ideation and attempts. There is a relationship between number of mental disorders and suicidal behaviour; with comorbidity having significantly sub-additive effects. Conclusion: Consistent with data from the developed world; mental disorders are strong predictors of suicidal behaviour; and these associations are more often explained by the prediction of ideation; rather than the prediction of attempts amongst ideators. This suggests some universality of the relevant mechanisms underlying the genesis of suicidal thoughts; and the progression to suicide attempts

The Lived Experiences of Late-Adolescent Female Suicide Survivors: 'A Part of Me Died'

People's thoughts often focus on the suicide victim immediately after a completed suicide. Yet; the real victims of such an event are those individuals who are left behind to cope with the aftermath of the suicide. This phenomenological psychological study explored the lived experiences of lateadolescent suicide survivors; particularly those negative experiences that seemed to worsen in the weeks and months after a significant other's completed suicide. The research participants were five female late-adolescents (aged 17-22 years) who were recruited by means of purposive sampling at a South African tertiary institution and at youth camps. Data collection consisted of collagefacilitated; face-to-face phenomenological interviews. In addition; some participants provided documentary material in the form of personal diaries; letters and poems. The data analysis was conducted according to Giorgi's phenomenological method. The following salient experiences emerged during the data analysis: guilt; self-blame; blaming others or God; anger; loss or restriction of 'self'; depression; suboptimal behavioural coping patterns; changes in relationship dynamics; and suicidality. The results of this study can be used by mental health professionals and caregivers to support adolescent suicide survivors effectively; in the midst of their mourning

HIV-infection as a self-reported risk factor for attempted suicide in South Africa

Objective: The aim of this study was to examine variables associated with recently diagnosed HIV-infection as a self-reported attempted suicide risk factor. Method: The study cohort consisted of 112 general hospital in-patients who attempted suicide because of HIV-infection. All the patients were subject to a comprehensive mental state examination and administration of a semi-structured questionnaire to obtain biographical; sociodemographic and other relevant information. Pearson uncorrected Chi-square (X2) or Fisher's Exact Probability Test were used to analyze data utilising Epicalc 2000; version 1.02. Results: Most patients expressed a heterosexual preference. The average age was 34.9 years. Females predominated and in both genders depression and substance abuse (mainly alcohol-related) accounted for the most common psychiatric diagnoses. Less than half of the patients were married. Partner relational problems was a statistically significant variable. The most prevalent co-morbid stressors were poor social support; fear of disclosure/stigmatization and socio-economic pressures. Cognitive deficits included problems with cognitive flexibility; concentration and memory. Based on estimated national suicidal behaviour prevalence rates; a descriptive HIV-related attempted suicide rate of 67.2 per 100 000 and an increased risk for attempted suicide of 13.33to 18.87were calculated. Conclusion: HIVinfection can be an underestimated suicide risk factor. Effective management and prevention programmes should include as imperatives early diagnosis of HIV-related suicidal behaviour; recognition of underlying psychopathology; neurocognitive deficits; associated stressors; the dynamics of partner relationship problems; as well as cultural awareness and sensitivity. Potential neurocognitive complications that can act as additional risk factors require further research

Suicide Cases Investigated at the State Mortuary in Bloemfontein; 2003-2007

Background: Up to 8 000 South Africans commit suicide annually. This study aimed to investigate the profile of suicide cases in Bloemfontein and the southern Free State province. Methods: A cross-sectional descriptive study was performed. Suicides in the Bloemfontein and southern Free State areas (Xhariep and Motheo districts) investigated at the state mortuary in Bloemfontein in 2003 to 2007 were included. Data were collected retrospectively by using a specially designed data-capturing form. Results: A total of 469 suicide cases were included in the study. The estimated suicide rate for this part of the Free State province was 10.9/100 000 of the population per year. The majority (82.1) of the victims were men. In total; 338 (72.1) of the victims were black; 122 (26.0) were white; five (1.1) were coloured and three (0.6) were Indian. The most common methods were hanging (262; 55.9); shooting (99; 21.1) and overdosing on pills (43; 9.2). Most cases (57.8) occurred in victims 21 to 40 years of age. Five (1.1) victims were children younger than 11 years of age; while 12 (2.6) were older than 65 years. More than half (267 cases; 56.9) of the suicide victims were unemployed. The majority (43.1) of suicides occurred in January to April of each year; with the highest incidence (67 cases; 14.3) in January. Conclusion: The rate of suicide and the profile of victims with regard to the variables investigated corresponded to findings reported from other studies. The information obtained could make a meaningful contribution to suicide-prevention programmes

A hundred cases of parasuicide: V. validation of the amharic version of hopelessness scale at St. Paul's General specialized referral hospital, AA, Ethiopia

Background: Hopelessness is an important variable in parasuicide and suicide. The need for a valid and reliable Amharic version (AV) of Hopelessness Scale (HS) for clinical screening is obvious. Objective: To test the validity and the reliability of the AV of HS. Methods: 100 consecutive parasuicide cases arriving at the OPD were included in this `retrospective descriptive clinical case study'. Self-rated AV of HS and interviewer-rated Expanded BPRS was administered. The AV of HS was validated against the corres- ponding item/items on the Expanded BPRS. Reliability test was also performed. Results: Concurrent validity: Yule's Q; between AV of HS and Expanded BPRS depression and suicidality items were 0.66265; p=0.00052 and 0.55585; p=0.04144 respectively. Construct validity: It was shown that cases with the intention `to die' had significantly higher (p=0.0028) HS scores than those without the intention. The association between the dichotomous measures of AV of HS and intention `to die' was very highly positive and significant (Yule's Q=0.89563; P=0.00011). No such relationships between the AV of HS scores and other 9 endorsed intentions/`reasons' for parasuicidal act with different themes. These findings indicate that the AV of HS has an acceptable construct validity to measure Hopelessness. Reliability: in item-total correlation test; only item no. 5 was eliminated due to low correlation coefficient (0.0370; p=0.715). Three more items were eliminated in factor analysis which yielded 3 factors similar to Beck's finding. Conclusion: The AV of HS has acceptable validity; reliability and factor loading. Items recommended to be discarded have to be re-translated/re-written to keep the meaning as close to the original (eng version) as possible. Further validation studies are advisable to be done. In the meantime; the AV of HS has to be applied clinically in vulnerable groups

A hundred cases of parasuicide: IV validation of the Amharic Version of IDA-Scale at St. Paul's General Specialised Referral Hospital; AA; Ethiopia

Background: There is a need for a valid and reliable Amharic version (AV) of IDA-Scale whose sub-scales measure irritability (inward and outward directed); depression and anxiety. Irritability which had emerged to be an important distinguishing characteristic of parasuicide cases can be easily tapped with IDA- Scale which is cost-effective andquickly administered. Objective: To test the validity and the reliability of each sub-scale. Methods: Retrospective and prospective data were collected from a cohort of 100 consecutive parasuicide cases and each followed for a period of five years. Self-rated AV of IDA-Scale and interviewer-rated Expanded BPRS (Brief Psychiatric Rating Scale) were administered. Each sub-scale was validated against the corresponding item/items on the Expanded BPRS. ROC curves were plotted for sub-scales to select the efficient cut-off scores. Reliability and validity tests were performed for each sub-scale. Results: The coefficient of association (Yule's Q) between depression; anxiety; extropunitiveness and intropunitiveness sub-scales and the corresponding item/items on Expanded BPRS were 0.83333 (p=0.0000); 0.72680 (p=0.00021); 0.49116 (p=0.01702) and 0.61821 (p=0.00029) respectively (all 2-tailed). One of the items of extropunitiveness sub-scale; IDA12; has low item-total correlation. This sub-scale; at its cut-off point; lacks the desired discriminating ability and could not manifest the expected relationship between PV+; specificity or positivity criterion. Its factor loading was also insignificant. Conclusion : Depression; anxiety and intropunitiveness sub-scales showed acceptable validity and reliability. IDA12 has to be re-translated/re-written to keep the meaning as close to the original (eng version) as possible and to ensure that terms are understood. Further validation of extropunitiveness sub-scale is advisable. In the meantime; the AV of IDA-Scale has to be applied clinically in vulnerable groups

Incidence of suicide among teenagers and young adolescent in Transkei, South Africa

Background: Transkei is the least developed of the former black homelands in South Africa and has a population of about 4 million. People in this area are poor and depend mainly on the income from migratory workers to the gold mines. Suicide is a complex problem; with no definitive causative agent that has been identified as yet. Suicide among teenagers and young adults is now emerging as an important mental health issue. Suicidal behaviour in the population is under- researched; and therefore under-reported.Method: This is a retrospective record review from 1993 to 2003; carried out in the Umtata General Hospital mortuary. About 1 000 medico-legal autopsies are conducted annually; and the mortuary caters for a population of about 400 000. Results: Of the 10 340 medico-legal autopsies; 398 (3.84) suicide cases were due to hanging. The number has increased from 5.2 per 100 000 of the population in 1993 to 16.2 in 2003. More than a half (55) of the hangings were of people less than 30 years of age; and less than one-quarter (23) of these victims were younger than 20 years. The rate in males has increased from 4.5 (1993) to 14 per 100 000; and in females from 0.7 to 2.2 per 100 000. The male/female ratio is recorded highest (9 : 1) in the 20- and 29-year age group. Conclusion: There is an increasing incidence of suicides among young adults. Suicidal tendency among teenagers and young adults is emerging as an important health issue that needs to be addressed

Preliminary Validation of the Multi-Attitude Suicide Tendency (MAST) Scale Using a South African Adolescent Sample

Objective:The factor structure of the Multi-Attitude Suicide Tendency (MAST) scale was examined using a sample of non-white South African adolescents. Method: The MAST scale was administered to 205 secondary school students between 13 and 20 years of age. Results: The scale demonstrated satisfactory internal consistency with alpha values being in line with previous studies using the instrument. Factor analysis confirmed the original four-factor structure of the scale. Strong support was found for the Repulsion by Death (RD) and Attraction to Life (AL) subscales of the instrument; with moderate support for the Atttraction to Death (AD) and Repulsion by Life (RL) subscales. Conclusion: The authors conclude that the generalisability of the MAST can be improved by the inclusion of more culturally relevant items

The profile analysis of attempted-suicide patients referred to Pelonomi Hospital for psychological evaluation and treatment from 1 May 2005 to 30 April 2006

Background. Suicide is an increasing phenomenon worldwide. A suicide occurs every 40 seconds; and there is 1 attempt every 1 to 3 seconds. By 2020; these figures may have doubled. No accurate statistics regarding the occurrence of attempted suicide (or non-fatal suicidal behaviour) in South Africa exist; because there has been no systematic data collection. Aim. The aim of the study was to determine the profile of patients who had attempted suicide and were referred to Pelonomi Hospital; Bloemfontein; for psychologicalevaluation and treatment during the period 1 May 2005 to 30 April 2006. Method. A descriptive; retrospective study was conducted. The study population comprised 258 attempted-suicide patients referred to Pelonomi Hospital for psychological evaluation and treatment. A data form was compiled to transfer the relevant information from patients' clinical files. Results. The majority of patients were female (68.9). The median age was 22 years. The most common method used in suicide attempts was drug overdose (66) - mostly antidepressants (19.7)) and analgesics (8.2). More females than males overdosed on drugs (p=0.0103). The main precipitating factors included problematic relationships (55.4); financial problems (22.9); psychiatric problems (22.1); arguments (19.8); abuse (emotional; sexual; physical - 18.2); low self-esteem/ worthlessness/hopelessness/humiliation (16.7); and recent life changes (13.2). Conclusion. The aim of the study was to determine the profile of patients who had attempted suicide. Possible factors associated with suicide attempts in our sample were identified and summarised in the form of a screening checklist. The value of the checklist is that it can be used as a screening method to identify possible suicide risk in patients

Subjective experience of depressed mood among medical students at the University of Pretoria

Introduction. Following the suicide of a 4th-year medical student, questions were raised as to whether medical students are more vulnerable to depression and suicide than their counterparts studying other courses at the University of Pretoria. A literature search revealed that medical students and doctors run a higher risk for suicide than other students and professions. Method. A questionnaire was devised and distributed to medical students and a control group of other students, asking about feelings of despair/hopelessness, suicide ideation and previous attempts, knowledge regarding support structures provided by the university, and willingness to use these structures. Results. Both groups of students responded similarly to all questions. Frequency of diagnosed psychiatric illness, use of medication, and suicidal thoughts and attempts did not differ significantly. Both groups of students were unaware of support services offered by the university, and both were unwilling to utilise such services. The students seemed to have high rates of depression in comparison with prevalence data from other countries. Conclusion. Attempts to improve support for medical students should address students' awareness of available support structures and their willingness to utilise them

Family Functioning and Suicidal Ideation/Behaviour in Adolescents: a Pilot Study

Objective: The main aim of this study was to explore the associations between specific aspects of family functioning and adolescent suicidal ideation/behaviour. Method: Participants were 87 high school students (43 male and 44 female) aged between 14 and 16 years of age. They completed a questionnaire measuring various aspects of family functioning and suicidal ideation/behaviour. The specific dimensions of family functioning assessed were: connection; psychological control and behavioural regulation in the parent-adolescent relationship; family conflict and family structure. Results: The results of t-test and chi-square analyses indicated that adolescents who reported suicidal ideation or behaviour in the previous year experienced lower levels of connection and regulation and higher levels of conflict and psychological control in the parent-child relationship than non-suicidal adolescents. Family structure and interparental conflict were not significantly associated with suicidal ideation/behaviour. Conclusions: The quality of relationships between adolescents and both of their parents may be important in distinguishing South African adolescents with recent suicidal ideation/behaviour from non-suicidal