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.

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.

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.