Forensic telepsychiatry: a possible solution for South Africa?

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

Patients with Severe Mental Illness : a New Approach for Testing for HIV

Background :The prevalence of infection with the Human Immuno-deficiency Virus (HIV) in South Africa is approaching 20of young adults. In severely mentally ill people; it is probably higher. Testing for infection is subject to stringent ethical principles. Undiagnosed HIV infection in people with severe mental illness increases costs and morbidity. Since effective treatments are available; it is imperative to diagnose HIV infection early in this high risk population. Methods : a literature review established the prevalence of HIV infection in in-patient populations with HIV infection. The pattern of testing for HIV over three years at a major psychiatric hospital was investigated. We surveyed public sector psychiatrists in the Western Cape to establish their attitudes to HIV in their patients. Results The HIV reported seroprevalence in psychiatric in-patients ranges from 0-59.3; with a mean of 10. Data show a clear trend towards an increase in prevalence: Pre 1996 the mean HIV seroprevalence was 7.4; while post 1996 the mean was 15. State psychiatrists in the Western Cape do not test routinely for HIV infection; mainly due to ethical constraints: 14.6of patients at Lentegeur Hospital were tested in 2006. Conclusions The high prevalence of HIV infection in South Africa; that is probably higher in patients with severe mental illness (most of whom are not competent to provide informed consent) and the availability of effective treatment; requires debate and a clear policy regarding testing for HIV infection to be implemented. We recommend a new approach to HIV testing in these patients

A comparison of risk factors for habitual violence in pre-trial subjects.

OBJECTIVE: Pre-trial referrals to the Valkenberg Hospital forensic unit over a 6-month period were studied. Habitually violent offenders were compared with those with no history of violence. METHODS: Risk factors known to be associated with violent behaviour were elicited, i.e. demographics, behaviour during index offence (such as impulsivity, identity of victim, use of weapon, accomplices, intoxication, psychotic symptoms), psychiatric and family histories, history of suicide attempts, past child abuse, head injury, criminal record, psychiatric diagnosis and presence of medical disorders. EEG's, Barratt's Impulsivity, Zuckerman's Sensation Seeking and Mini-Mental Scales were administered. Behaviour in the ward during the 30 days was also appraised. Logistic regression models were used to determine relative risks. RESULTS: There were 155 subjects; 89.7% were male, 71.6% were single and 58.7% were unemployed. For 44.5% the index offence was violent, and 9.7% had committed sexual offences; 61.9% had histories of habitual violence. A psychotic disorder was diagnosed in 32.3% and a personality disorder in 48.4%. Habitually violent subjects were distin- guished by a history of issuing threats (OR=3.68; CI=3.19-4.16; P=0.000), delusions of persecution (OR=3.43; CI=2.67-4.17; P=0.001), history of conduct disorder (OR=1.95; CI=1.70-2.19; P=0.006), alcohol/substance abuse (OR=2.08; CI=1.53-2.61; P=0.008) and violent index offence (OR=1.66; CI=1.54-2.61; P=0.035). CONCLUSION: This seems to confirm the relationship between threats, feeling threatened, psychosis, a history of antisocial behaviour and alcohol abuse.

[Rheumatoid arthritis among mapuche aborigines. A 16 years experience in the IX Region of the Chile]. / Artritis reumatoidea en población mapuche. Una experiencia de 16 años en la IX región de Chile.

BACKGROUND: Mapuche, Chilean natives, represent approximately 9.8% of Chilean population and in the IX region of the country, they account for 18.4% of population over 15 years old. They preserve some socio-cultural characteristics that make them different to the rest of the population. AIM: To describe the epidemiological characteristics rheumatoid arthritis among Mapuche natives. SUBJECTS AND METHODS: Retrospective review of patients of Mapuche origin with rheumatoid arthritis, seen at Temuco Hospital between 1980 and 1996. RESULTS: Among 308 cases gathered, only 106 (93 women, aged 55 +/- 10 years old) complied with 1987 American College of Rheumatology (ACR) criteria for rheumatoid arthritis. The disease began between 29 and 52 years old in 73% of patients and the mean delay in diagnosis was 4.4 years. At diagnosis, 99% had symmetric poliarthritis, 28.3% had either fatigue, fever or weight loss, and 46.9% were in class III or in class IV of ACR-1991. Fifty three percent of patients developed Sicca syndrome, 36% developed nodules, 23% developed Raynaud phenomenon, 11% developed pulmonary involvement, 7% developed vasculitis, 5% developed neurological manifestations and 19% developed ophthalmologic involvement. Rheumatoid factor was positive in 78% and 73% had erosions. HLA DR4 was (+) in 60% of 30 patients. Thirty percent required 3 or more disease modifying drugs and prednisone over 10 mg/day. There was no correlation between functional capacity and several other features of the disease. CONCLUSIONS: Mapuche rheumatoid arthritis patients are detected late and have a poor functional capacity at the time of diagnosis. They also have a higher proportion of extraarticular manifestations, more erosions and require more aggressive treatments.

Defendants are clueless--the 30-day psychiatric observation.

OBJECTIVE: To investigate the understanding and expectations of defendants referred to Valkenberg Hospital for 30-day observation. DESIGN: Defendants referred for 30 days of psychiatric assessment were surveyed by means of a semi-structured interview within 3 days of admission. PARTICIPANTS: One hundred consecutive referrals from the Western, Northern and Eastern Cape were considered; 88 were eventually entered into the study. RESULTS: All defendants were generally ignorant of the reasons for referral, but had a good understanding of court procedure and wrongfulness. Mentally ill subjects differed only in their not being able to distinguish between a guilty/not guilty plea. Most did not have legal representation, did not personally request the assessment and denied guilt of the alleged offence. CONCLUSIONS: Mental illness affects triability but not necessarily criminal responsibility. Disturbingly, most defendants were without legal representation and were unaware of the purpose, implications and possible outcomes of psychiatric observation. It is imperative that the legislation governing these aspects be reviewed.

Violence, sensation seeking, and impulsivity in schizophrenics found unfit to stand trial.

Many studies have confirmed an association between violent behavior, impulsivity, and sensation seeking in nonpsychotic subjects. Schizophrenic patients (n = 49) who had been found unfit to stand trial were investigated for violence, according to index offenses and longitudinal histories (before and after admission) for violence. Those charged with violent offenses were significantly more often married with children, and were equally likely to direct their assaultiveness to strangers, acquaintances, and family members. The nature of the index offense seemed to be a good indicator of general violent propensity. No significant differences were found on Barratt's Impulsivity Scale and Zuckerman's Sensation Seeking Scale, except that schizophrenic patients with negative histories of violence scored higher on the thrill and adventure subscale. No pattern of substance abuse differentiated the groups. Patients charged with violent offenses more often presented with persecutory delusions, but this did not extend to those whose histories were positive for repetitive violence. Although impulsivity and sensation seeking do not seem to cause violent behavior in this group, psychopathology can also only be regarded as a necessary but not sufficient determinant.

[Anticardiolipin antibodies in rheumatic autoimmune diseases. Correlation with clinical and laboratory findings]. / Anticuerpos anticardiolipina en enfermedades reumatologicas autoimmunes. Correlacion con hallazgos clinicos y de laboratorio.

The prevalence of anticardiolipin antibodies (ACA) was determined using an Elisa method in sera of 60 patients with autoimmune diseases. ACA were correlated with clinical manifestations of the antiphospholipid syndrome and other serological markers of autoimmunity. Sixty three percent of sera had ACA IgG (+) and 50% ACA IgM (+). Nine patients, five of them with systemic lupus erythematosus, had a history of arterial or venous thrombosis and all had positive ACA (IgG (+) in 7 and IgM (+) in 2). In patients with rheumatoid arthritis, no association was found between the presence of ACA and thrombosis. Patients with a history of spontaneous abortion had non significantly higher levels of ACA. There was a significant correlation between ACA levels and rheumatoid factor (ACA IgG r = 0.374, ACA IgM r = 0.676), no other association was found between ACA and other autoantibodies. It is concluded that ACA are found frequently in patients with autoimmune diseases and its clinical significance may be different in patients with lupus than in patients with rheumatoid arthritis or other connective tissue diseases.

Radiologic progression during intramuscular methotrexate treatment of rheumatoid arthritis.

The radiographic evolution of joint lesions in 41 patients with severe and longstanding rheumatoid arthritis (RA) (mean duration: 12.9 years) treated with methotrexate (MTX) for more than 24 months (mean 31.2 months) was studied in a double blind manner by 2 rheumatologists using Larsen's score. All the patients were clinically improved. The radiological study of hands and wrists was possible in only 37 of 41 patients for surgical reasons. We found a deterioration of joint lesions in 31 cases (83.8%), a stabilization in 6 cases (16.2%). MTX does not appear to be able to slow down the radiographic evolution of RA. Whether it could prevent the radiologic progression in early RA remains to be elucidated.

Survey of certification practices for patients admitted to Sterkfontein Hospital.

The involuntary hospitalisation of psychiatric patients continues to be a controversial issue. All patients certified and admitted to Sterkfontein Hospital under Sections 9 and 12 of the Mental Health Act, No. 18 of 1973, over a 4-week period were surveyed. Almost 40% were admitted as urgent certifications. The majority of the patients in the sample were black, single, urban and had either primary or limited high school education. Most patients had been referred from academic/teaching and provincial hospitals. The average duration of hospital stay was 7.2 weeks, with only 1 patient eventually being transferred to a ward for chronic patients within the hospital, which suggests that Sterkfontein Hospital functions largely as an acute psychiatric facility. There was a discrepancy of approximately 30% between the assessments of the certifying and ward doctors, probably as a result of differing uses of terminology. Not only are more community psychiatric services needed, but communication between psychiatry and the other medical disciplines should be improved.