Schizophrenia: management and family burden.

OBJECTIVE: To explore schizophrenia with respect to its management, causes, risk factors as well as the impact it has in families regarding the burden and social networks support. METHODS: Desk literature reviews. RESULTS: The findings are that patients with schizophrenia typically have great difficulty following a medication regimen, but they also have the greatest potential for benefiting from adherence. As with other chronic diseases that lack a definitive cure, the individual's service/recovery plan must include treatment interventions directed towards decreasing manifestations of the illness, rehabilitative services, enhancing adaptive skills, and social support mobilization aimed at optimizing function and quality of life. CONCLUSION: Finally, this paper is not exhaustive, but a pointer for further readings.

Epilepsy in sub-Saharan Africa: its socio-demography, aetiology, diagnosis and EEG characteristics in Harare, Zimbabwe.

OBJECTIVE: To assess epileptics with regard to socio-demographic characteristics, aetiology, EEG results and classification. DESIGN: A descriptive cohort study from 1997 to 2001. SETTING: Parirenyatwa Group of Hospitals in Harare, Zimbabwe. SUBJECTS: A total of 229 consecutive epileptic subjects. RESULTS: The mean (s.d.) follow-up was 3.2 (1.14) years. The mean (s.d.) age of subjects was 23.4(11.8) years and 56% of them were males, over one third (43.1%) were unemployed and had secondary education (48%). Over one fourth (26.6%) of the subjects were first borns and had a family history of epilepsy (25.8%). Most of the subjects had Generalised Tonic Clonic Seizures (TCS). Over half (51.5%) of the subjects had their first onset of seizures after the age of 20 years. Lack of sleep (7.9%) and emotional disturbance (5.4%) were described by subjects as the frequent provoking factors for epileptic attacks. One hundred and fourteen subjects had electroencephalogram (EEG) results. Of these, 96 (41.9%) subjects had abnormal EEG results and only 18 (7.9%) had normal EEG results a majority (43.8%) of whom were of generalised slow waves. Majority of the subjects (52.8%) sought treatments from biomedical drugs, but some started with traditional herbs (20.5%) and then biomedical drugs, whereas others sought biomedical drugs then resorted to traditional herbs (20.1%). Phenobarbital and carbamazepine were taken by over 40% of the subjects. CONCLUSION: The findings of this study seem to suggest that these referrals to a specialised epilepsy outpatient clinic for further management may be attributed to socio cultural issues in our African settings about the actual nature of the condition, hence the delay in treatments and diagnosis of seizures as well as under diagnoses of non-epileptic seizure disorders that may lead to the condition becomes uncontrollable. Inexpensive drugs such as phenobarbital and phenytoin can be able to control most of the epileptic seizures, if they can be made available in primary health care centres.

Prevalence of HIV/AIDS and psychiatric disorders and their related risk factors among adults in Epworth, Zimbabwe.

OBJECTIVES: To examine the prevalence of HIV infection, neuropsychiatric disorders, psychiatric symptoms/signs, alcohol use/misuse, CD4 cell counts and risk factors in adult patients. DESIGN: Cross-sectional study. SETTING: Epworth, which is about 15 km on the southeastern part of Harare, Zimbabwe. SUBJECTS: Two hundred subjects were included in the study out of which six were excluded beacause of HIV-1 indeterminate results. MATERIALS AND METHODS: A convenience sample of 200 subjects recruited in a cross-sectional study in Epworth, Zimbabwe. Six subjects had indeterminate HIV-1 antibody results and were excluded from the study. The remaining 194 subjects of whom 101 (52.1%) knew about their sero-status and were consecutively recruited, whereas, 93 (47.9%) did not know about their sero-status and were recruited by a systematic random sampling method (1-in-3). They were then interviewed about neuropsychiatric disorders using BPRS, MADRS, AUDIT and MINI Mental State Test, including the risk factors related to HIV infection. After ELISA tests' results, the two groups were combined and then categorised into HIV positive (n=115) and HIV negative (n=79) subjects. MAIN OUTCOME MEASURES: Prevalence, neuropsychiatric disorders, increased CD4 cell counts and risk factors associated with HIV infection. RESULTS: The findings were that the overall point prevalence of the HIV infection was 59.3% (115/194). Comparative analyses between seropositive and seronegative HIV/AIDS subjects showed: over two thirds (71.3%) of the HIV positive subjects suffered from psychiatric disorders, more than those with HIV negative 44.3% (OR=3.12, 95% CI=1.64-5.95, P=0.0002), and subjects aged 35 years and less were mostly HIV seronegatives (n=77.2%, OR=2.34, 95% CI=1.18-4.75, P=0.014). The overall prevalence of alcohol use/misuse was 41 (21.1%), with higher prevalence rate among HIV positive subjects, 28 (24.3%) than those who were HIV negative, 13 (16.5%). The commonest psychiatric symptoms/signs (P<0.05) were emotional withdrawal, depressed mood, suspiciousness, apparent sadness, reduced sleep and suicidal thoughts (especially among women). CONCLUSION: There is very high point prevalence of HIV/AIDS and psychiatric disorders, including a moderate prevalence rate of alcohol use/misuse in this less affluent community that warranted intervention.

Burden of mental illness on family members, care-givers and the community.

OBJECTIVE: To determine the burden of mental illness in the family/caregiver and the community. DESIGN: A cross-sectional descriptive study. SETTING: Rehabilitation centres, community day centres, resettlement villages and in the community in three provinces (Harare, Bulawayo and Masvingo), Zimbabwe. SUBJECTS: A sample size comprising sixty six care-givers and 126 patients were consecutively interviewed for the study. RESULTS: The care-givers had a mean +/- s.d. age of 48.8 +/- 15.7 years. The majority were females (80.3%), married males, 76.9% (p=0.073), unemployed females, 94.3% (p=0.0004) and parents of the patients accounted for 51.5%. Many respondents believed that the cause of mental illness was witchcraft (31%), they experienced financial constraints (63.6%), and spent a lot of money on food (56.1%). Patients were younger than their caregivers, with a mean +/- s.d. age of 37.7 +/- 12.8 years and mostly on medications (91.3%). CONCLUSION: The caregivers were mainly women and unemployed, whereas patients were mostly male. Caregivers were faced with multiple problems, but they were more tolerant to patients' behaviour than the community at large.

Prevalence of major depression in deliberate self-harm individuals in Harare, Zimbabwe.

OBJECTIVE: To investigate the prevalence of major depression in deliberate self-harm individuals. DESIGN: A cross sectional descriptive study. SETTING: Three tertiary health care centres in Harare, Zimbabwe. SUBJECTS: Three hundred and eighty seven deliberate self-harm consecutive subjects were recruited from July 1, 1997 to December 31, 1997 for this study. Diagnostic procedures included complete medical history, physical and neurological examinations. The DSM-IV criterion for major depression was used for the diagnostic purpose. MAIN OUTCOME MEASURES: The prevalence of major depression, number of attempts and recent life events, methods used, feeling in deliberate self-harm individuals. RESULTS: The prevalence of major depression was 20.7% (n=80, 95% CI=16.7-24.2) according to the DSM-IV criterion. Sixty-two percent (95% CI=57.2-66.8) of the subjects with DSH were aged < or = 30 years. Significant differences (P<0.05) were found between DSH subjects with and without major depression related to age, education, life events and number of previous attempts. CONCLUSION: The most predictive factors associated with DSH risks are age, depression, recent loss, divorced, loss of job and history of previous attempts. Further studies are needed to address some causes of DSH.

Quality of life evaluation in patients with HIV-I infection: the impact of traditional medicine in Zimbabwe.

OBJECTIVES: To evaluate the impact of phytotherapy (traditional medicine) in persons with HIV infection and to assess the quality of life of those persons with respect to HIV disease progression, including sociodemographic characteristics. DESIGN: A community based open label non-intervention and uncontrolled cohort study. SETTING: Blair Research Institute Clinic. SUBJECTS: A total of 105 HIV infected persons at various stages of HIV infection. Seventy-nine percent were on phytotherapy (PT) and 21% on conventional medical care (CMC). MAIN OUTCOME MEASURES: (a) Assessment of quality of life of HIV infected persons on phytotherapy using the WHOQol instrument, and (b) assessment of quality of life of those persons in relation to the HIV disease progression using CD4 cell counts and viral load as measure of disease progression. METHODS: We interviewed 105 patients with various stages of HIV-I infection in a community based cohort study from June 1996 to May 1998, in Harare. The 96 (91.4%) asymptomatic and six (8.6%) symptomatic patients underwent regular physical examinations and had blood drawn for laboratory tests at the baseline afterwards at three month intervals over a period of two years. RESULTS: The mean (s.d.) age was 34.9 (7.3) years; 64.4% were women and 60.3% were married. In multi variate analyses, age was significantly correlated with the level of independence domains (p = 0.032), whereas, gender was significantly correlated with social relationships' domains (p = 0.034). The type of treatment received was significantly correlated with spiritual domains (p = 0.045). Proportions of scores on five domains measuring different aspects of quality of life for patients on phytotherapy were much lower than those on conventional therapy (p < 0.0001, for all variables). CONCLUSION: Our data support the role of phytotherapy in improving the quality of life of HIV-I infected patients, yet its pharmacological basis is unknown. The WHOQol instrument is a good measure of quality of life for patients with HIV infection.

Alcohol consumption in HIV-I infected persons: a study of immunological markers, Harare, Zimbabwe.

OBJECTIVE: To examine the effect of alcohol use in relation to the age, gender and plasma levels of HIV-I RNA and CD4 cells count in HIV-I infected persons as a prognostic indicator for the disease progression to AIDS. DESIGN: A community based cohort study. SETTING: The study was conducted at the Blair Research Institute Clinic from June 1996 to May 1998. SUBJECT: We interviewed 105 volunteers, at a baseline and then followed them up on a three monthly basis. They underwent physical examinations and had blood drawn for laboratory tests. AUDIT Core was used to gain an indication of how much dependence there was on alcohol by patients in relation to demographic and immunological variables. MAIN OUTCOME MEASURES: Frequency of alcohol use and HIV-I disease progression to AIDS using viral loads and CD4 cells counts as measures of immune impairment. RESULTS: The volunteers had a mean (s d) age of 34.9 (7.3) years. Prevalence of alcohol use was 30.5% (n = 34.95% CI = 21.7 to 39.3). Most of the patients with CD4 cells count less than 200 mm3 did not use alcohol (p = 0.023) by the six months follow ups. There were no significant mean differences between users and nonusers of alcohol regarding the levels of both plasma viremia and CD4 cells count. CONCLUSION: Our finding is consistent with previous findings that found no relationship between alcohol use in persons with HIV-I infection and progression of disease to AIDS.

A case of gelastic seizures in Harare, Zimbabwe.

We describe a very rare case of a frontal lobe epilepsy that presented with gelastic seizures. It occurred in a 19 year old male and the gelastic seizures were controlled by carbamazepine 400 mg/day.

Study of psychiatric consequences of closed head injury at the Kenyatta National Hospital.

This was a study to compare the psychiatric consequences of closed head injury (CHI) in 37 patients with 39 demographically similar patients with fractured lower limb injury (FLLI), aged 16-55 years. The outcome measures were the Clinical Interview Schedule-Revised, the Bender Gestalt Test and the WHO AUDIT Core for alcohol abuse. The final diagnoses were made according to DSM-III-R diagnostic criteria. The findings indicated that CHI patients suffered more psychiatric consequences than FLLI controls (OR = 4.07; 95% CI = 1.30:13.14; p = 0.013). Depression and anxiety disorders were the most common problems encountered in these subjects.

Use of seclusion and restraint in psychiatric patients in Harare Hospital Psychiatric Unit, Zimbabwe: gender differences.

OBJECTIVE: To examine the frequency and indications for use of seclusion and restraint of psychiatric patients in relation to gender differences and risk factors in Harare Hospital Psychiatric Unit. DESIGN: Descriptive study. SETTING: Harare Central Hospital Psychiatric Unit, Harare, Zimbabwe. SUBJECTS: 95 consecutively secluded/restrained patients were recruited for the study. MAIN OUTCOME MEASURES: The frequency of seclusion and the characteristics of patients secluded/restrained. RESULTS: 54 (56.8%) patients were males and 41 were females. They had a median (Q1, Q3) age of 30 (Q1, = 24, Q3 = 36) years. Over two thirds (70.5%) of them were aged 35 years or less. The frequency of seclusion and restraint was 8.5% (95% CI 6.9 to 10.1) of the population of 1,115 patients admitted during the study period. The groups (male versus female) differed significantly with respect to marital status; single patients being 4.66 (95% CI 1.17 to 19.96) times more likely to be males when compared to the divorced/separated patients. Male patients were more likely to have been brought by police than by their relatives or friends (OR 3.30; CI 1.19 to 9.73; p = 0.020). CONCLUSION: Seclusion/restraints of psychiatric patients were common in a psychiatric unit. Male patients were more likely to be brought by police. Female patients resorted more to physically assaulting staff/other patients than did male patients.

Prevalence of psychoactive substance use among psychiatric in-patients in Harare, Zimbabwe.

OBJECTIVE: To determine the prevalence of psychoactive substance use among psychiatric in-patients in Harare. DESIGN: A cross sectional study that was conducted in 1994. SETTING: Harare Central Hospital Psychiatric Unit. SUBJECTS: A total of 194 consecutively admitted patients to Harare Central Hospital Psychiatric Unit, aged from 16 to 55 years with a mean (SD) age of 33.5 (11.4) years. MAIN OUTCOME MEASURES: The psychiatric diagnoses were made according to the ICD10 diagnostic criteria, while the substance abuse was evaluated by the modified WHO AUDIT core questionnaire, which was translated into the Shona language. RESULTS: The point prevalence rate of psychoactive substance abuse among the psychiatric in-patients were alcohol 28.4% (95% CI = 22.1, 34.7), tobacco 27.6% (95% CI = 18.7, 36.5) and cannabis 14.3% (95% CI = 7.4, 21.2). CONCLUSION: The data have provided scientific evidence on the moderate prevalence and pattern of substance abuse among psychiatric patients in Zimbabwe.

Prevalence of psychiatric disorders in general practice in Nairobi.

This study was designed to examine the point prevalence rate of psychiatric disorders among adult patients at primary care attenders in Nairobi A total sample of 186 of the 295 consecutive patients, aged 16-75 years (mean of 32.3 +/- 11.1) were studied within the period January 1990 and December 1993. Using a cross-sectional design study, they were assessed for psychiatric disorders by the Self Rating Questionnaire (SRQ), the Clinical Interview Schedule/revised (CIS-R), and the W.H.O Audit Instrument for Alcohol abuse. The final diagnosis of a psychiatric disorder was made according to DSM-111-R criteria. A matched gender analysis using Chi-squared (chi 2) test was carried out. The findings were that the overall prevalence rate of psychiatric disorder was 0.43% with an incidence of 0.43% per 1000 persons. This information can be used to provide a framework for the formulation of a more effective mental health policy.

Serostatus surveillance testing of HIV-I infection among Zimbabwean psychiatric inpatients, in Zimbabwe.

OBJECTIVE: To investigate seroprevalence rates of HIV infection among Zimbabwean psychiatric inpatients. DESIGN: An identity-unlinked procedure, for ELISA and Western blot HIV testing of consecutively admitted psychiatric patients, was used during the four month period of the study. The seropositive groups were further categorized along the WHO case definition of HIV/AIDS infection criteria. The blood results were coded and linked to various demographic variables and risk factors. All data were measured at either nominal or ordinal levels. Comparisons between variables were made by chi-square test for proportion and independence. SETTING: Harare Central Hospital Psychiatric Unit, Harare, Zimbabwe. SUBJECTS: A total of 143 inpatients (60.8 pc males and 39.2 pc females), mean(SD) age 32.5 (10.5) years and the mean(SD) duration of psychiatric illness of 4.21 (1.7) years. MAIN OUTCOME MEASURE: Prevalence of HIV/AIDS infection among psychiatric patients. RESULTS: The seroprevalence rate of HIV infection was 23.8pc and was significantly related to high education attainment (p < 0.03) and unemployment status of the patients (p < 0.03). CONCLUSION: There is an urgent need to develop and apply preventive interventions for HIV infected psychiatric patients.

PIP: Psychiatric patients, like any other medical patients, are vulnerable to HIV infection and those infected with HIV could transmit the virus to others. Some studies have found that the severely mentally ill as a group are more vulnerable to HIV infection because of comorbidity with substance abuse. Unsafe sexual behavior has also been reported among the severely mentally ill. Blood samples from 87 male and 56 female patients consecutively admitted to Harare Central Hospital's Psychiatric Unit were tested with ELISA and Western blot for infection with HIV. The subjects were 17-70 years old of mean age 32.5 years with a mean 4.21 years of psychiatric illness. 23.8% were infected with HIV and HIV infection was significantly related to high education attainment and being unemployed. Preventive interventions are urgently needed for HIV-infected psychiatric patients in Zimbabwe.

Tension headache in a primary health care setting.

Twenty-two of the 295 consecutive patients referred to primary care clinic for psychiatric assessment and management had headache as the predominant complaint. Of these, 95.5% suffered from tension headache and 4.5% had a common migraine headache (without aura).

A case of the frontal lobe syndrome following head injury in Harare, Zimbabwe.

A 51 year old male, presented with recurrent outbursts of aggression, hypersexuality, sexual indiscretion and hoarding litter following a head injury sustained in a road traffic accident. His premorbid personality was described as energetic but quick tempered. He had no delusions or perceptual disturbances and cognitive functions were intact. Physical and detailed neurological examination were essentially normal, with the exception of disuse atrophy of the lower limb muscles. He lacked insight into his problems. This case illustrates the need for a multidisciplinary approach to assessment, management and rehabilitation of such cases.

Sexual dysfunction in African males in Nairobi, Kenya.

Out of a total of 295 subjects referred to the Pangani Clinic for psychiatric assessment, between January 1990 and December 1993, 49 were studied. All were males and aged between 16 and 55 years. Using a cross-sectional design study, they were consecutively assessed for sexual dysfunction. Each subject was studied using, the Self Rating Questionnaire, the Standardized Psychiatric Interview and WHO Audit Instrument for Alcohol abuse. The final diagnoses of sexual dysfunction were made according to DSM-R categories. A matched analysis using Chi-squared (X2) test were carried out. The finding was that erectile disorder was the major disorder seen in 57.1% of the subjects. The peak age for sexual dysfunction was between 26 and 36 years. In an African setting, questions pertinent to bewitchment and age (husband versus wife) are very important with regard to sexual dysfunction.

Neuropsychiatric HIV-1 infection study: in Kenya and Zaire cross-sectional phase I and II.

The objective of the study was to determine the prevalence and natural history of human immunodeficiency virus type 1 (HIV-1) associated psychiatric, neuropsychological and neurological abnormalities. A total of 408 subjects were recruited in Nairobi and Kinshasa. The study consisted of a cross sectional phase and a longitudinal follow up. Assessment was made by a data collection instrument including six modules. The intercentre and intracentre reliability in the use of the each module have been formally evaluated. The mean global score on the Montgomery-Asberg Depression Rating Scale was significantly higher in symptomatic seropositive individuals than in matched seronegative controls. In conclusion, these data suggest that the risk of subtle cognitive deficits may be increased in asymptomatic stages of HIV-1 infection.

PIP: Studies have shown an increased vulnerability to psychological distress and a significant prevalence of psychiatric disorders associated with HIV-1 infection, in the range of 30-63%. Infection with HIV-1 may also lead to a number of neurological complications, including AIDS dementia complex. The incidence of HIV-1 dementia is approximately 7 per 100 patients per year following the development of AIDS, with up to 20% of HIV-1-infected individuals receiving a diagnosis of HIV-1 dementia before death. A recent study, however, found no significant decline in cognitive functions before AIDS, unless overt dementia is present. To learn more about the prevalence and natural history of psychiatric, neuropsychological, and neurological complications of HIV-1 infection, the World Health Organization (WHO) conducted the WHO Neuropsychiatric AIDS Study. Findings are based upon the cross-sectional study and longitudinal follow-up of 203 subjects recruited in Nairobi, Kenya, and 205 in Kinshasa, Zaire. The author reports finding a significantly higher mean global score on the Montgomery-Asberg Depression Rating Scale in symptomatic HIV-seropositive individuals compared to in matched seronegative controls. Overall, the study data suggest that the risk of subtle cognitive deficits may be increased during the asymptomatic stages of HIV-1 infection.