Risk factors for substance use in pregnant women in South Africa.

OBJECTIVES: To study the prevalence of alcohol and substance use in a South African antenatal population and its correlates with socio-demographic factors, depression and perceived stress. METHODS: A prospective self-report study on all women presenting for their first antenatal visit who consented to the study at a midwife obstetric unit (MOU) in the East Metropole district, Cape Town, using the Alcohol Use Disorders Identification Test (AUDIT), Drug Use Disorders Identification Test (DUDIT), Edinburgh Depression Scale (EDS) and Perceived Stress Scale (PSS). Statistical analyses using the chi-square test, separate one-way analyses of variance (ANOVA) and logistic regression analyses were performed as appropriate. Outcome measures were depression, alcohol use and substance use. RESULTS: The questionnaire was completed by 323 women. During pregnancy 36.8% of women smoked, 20.2% used alcohol and 4% used substances. Using EDS cut-off scores of 12 and 15, respectively, 48.9% and 33.6% of the sample had scores consistent with major depression. An EDS cut-off score of 12 was significantly associated with both alcohol use (25.9% v. 15.2%, p=0.019) and risky drinking (76.9% v. 36.8%, p=0.04), while an EDS cut-off score of 15 was significantly associated with substance use (8.2% v. 1.4%, p=0.004) as well as alcohol dependence (23.1% v. 3.1%). CONCLUSIONS: We found high rates of both alcohol abuse and antenatal depression, and a significant association between depression, substance use and alcohol abuse; EDS scores greater than 12 could be used to identify women at risk of alcohol dependence and/or substance abuse.

Rising diabetes prevalence among urban-dwelling black South Africans.

OBJECTIVE: To examine the prevalence of and the association of psychosocial risk factors with diabetes in 25-74-year-old black Africans in Cape Town in 2008/09 and to compare the prevalence with a 1990 study. RESEARCH DESIGN AND METHODS: A randomly selected cross-sectional sample had oral glucose tolerance tests. The prevalence of diabetes (1998 WHO criteria), other cardiovascular risk factors and psychosocial measures, including sense of coherence (SOC), locus of control and adverse life events, were determined. The comparison of diabetes prevalence between this and a 1990 study used the 1985 WHO diabetes criteria. RESULTS: There were 1099 participants, 392 men and 707 women (response rate 86%). The age-standardised (SEGI) prevalence of diabetes was 13.1% (95% confidence interval (CI) 11.0-15.1), impaired glucose tolerance (IGT) 11.2% (9.2-13.1) and impaired fasting glycaemia 1.2% (0.6-1.9). Diabetes prevalence peaked in 65-74-year-olds (38.6%). Among diabetic participants, 57.9% were known and 38.6% treated. Using 1985 WHO criteria, age-standardised diabetes prevalence was higher by 53% in 2008/09 (12.2% (10.2-14.2)) compared to 1990 (8.0% (5.8-10.3)) and IGT by 67% (2008/09: 11.7% (9.8-13.7); 1990: 7.0% (4.9-9.1)). In women, older age (OR: 1.05, 95%CI: 1.03-1.08, p<0.001), diabetes family history (OR: 3.13, 95%CI: 1.92-5.12, p<0.001), higher BMI (OR: 1.44, 95%CI: 1.20-1.82, p = 0.001), better quality housing (OR: 2.08, 95%CI: 1.01-3.04, p = 0.047) and a lower SOC score (≤ 40) was positively associated with diabetes (OR: 2.57, 95%CI: 1.37-4.80, p = 0.003). Diabetes was not associated with the other psychosocial measures in women or with any psychosocial measure in men. Only older age (OR: 1.05, 95%CI: 1.02-1.08, p = 0.002) and higher BMI (OR: 1.10, 95%CI: 1.04-1.18, p = 0.003) were significantly associated with diabetes in men. CONCLUSIONS: The current high prevalence of diabetes in urban-dwelling South Africans, and the likelihood of further rises given the high rates of IGT and obesity, is concerning. Multi-facetted diabetes prevention strategies are essential to address this burden.

A screening tool for social anxiety disorder in primary care: data from South Africa.

There is little research from low- and middle-income countries examining the psychometric properties of a screening tool for social anxiety disorder. The sensitivity and specificity of the Social Anxiety Screening Questionnaire against the Mini-International Neuropsychiatric Interview as a gold standard in social phobia diagnosis were investigated using analyses of receiver operating characteristics. The "best subsets" selection procedure was conducted to determine the best three to five questions. Three questions on the screening questionnaire that best discriminate between a positive and negative diagnosis of social anxiety disorder on the MINI module were identified. Answering yes to all three of these questions gives a false-positive rate of 0.44 and a false negative rate of 0.11. For this combination, the sensitivity was 0.84, and specificity was 0.67. Additional work is needed to develop a more accurate scale that could help increase the percentage of people who receive appropriate treatment of this debilitating disorder.

Selective attention to fearful faces during pregnancy.

BACKGROUND: There is some evidence that pregnancy may be associated with cognitive affective changes, including increased ability to encode emotional faces signaling threat and increased anxiety. Nevertheless, findings to date are inconsistent, and there are few data on correlations with endocrine and hormonal measures. The aim of this study was to investigate danger sensitivity, as measured by selective attention to fearful and angry faces during pregnancy, and to correlate findings with distress and anxiety levels, glucocorticoid (cortisol) and gonadal hormones (estrogen, progesterone and testosterone). METHODS: Selective attention to fearful, angry and happy faces was assessed in pregnant women (n=44) and non-pregnant controls (n=25) using a modified version of an emotional Stroop task. General distress was assessed using the K-10, and state and trait anxiety using the Spielberger State-Trait Inventory. Levels of cortisol, estrogen, progesterone and testosterone were determined at trimester 2 and 3. Analyses of variance, regression and correlational analyses were used to investigate associations between variables. RESULTS: Pregnant women showed altered attentional responses to fearful faces, in comparison to controls. When analyzed according to different levels of distress (K-10>20 or K-10≤20), distressed pregnant women had significantly increased selective attention to fearful faces compared to distressed non-pregnant controls. Attention to fear was significantly associated with increased levels of estrogen and progesterone at trimester 2, and decreased levels of cortisol at trimester 3 of pregnancy. CONCLUSION: Heightened sensitivity to danger cues during pregnancy is consistent with a perspective that emphasizes the importance of parental precaution and the adaptive significance of responding to potentially hazardous stimuli during this period. Such changes may be particularly apparent in distressed women, and may be mediated by changes in glucocorticoid and gonadal hormone systems during pregnancy.

Altered prefrontal cortical function during processing of fear-relevant stimuli in pregnancy.

In non-pregnant individuals, the prefrontal cortex (PFC) is involved in the regulation of emotion, and appears to play a role in anxiety. Near-infrared spectroscopy (NIRS) detects cortical neural activation without harmful radiation making it safe for use in pregnancy. The aims of this study were to assess neural circuitry involved in processing fear-relevant stimuli during pregnancy using NIRS, and to determine associations between activation of this circuitry, distress and anxiety symptoms, attention to threat, cortisol, estrogen, progesterone and testosterone levels. There was significant activation of the PFC in response to fearful faces compared to rest in both pregnant and control groups. Within pregnancy, the activation was most pronounced at trimester 2, compared to the other trimesters. In pregnant women only (all trimesters), PFC activation was significantly associated with increased distress and anxiety, but with decreased selective attention to masked fear. PFC activation was also significantly associated with increased levels of cortisol and testosterone in pregnancy. PFC function appears to be altered during processing of fear-relevant stimuli in pregnancy. Changes in hormone levels may lead to changes in PFC function, and in turn to changes in cognitive-affective processing and anxiety. Further work is needed, however, to explore precisely how PFC function is altered in pregnancy; it is possible that certain changes reflect altered processing of threat stimuli, while others reflect attempts to compensate for distressing and anxious symptoms that emerge during pregnancy.

Association between antenatal distress and uterine artery pulsatility index.

Although studies have found associations between maternal distress/anxiety and alterations in blood flow, data across different trimesters are inconsistent. We, therefore, sought to determine the association between measures of distress and uterine blood flow in all three trimesters. Healthy women with low-risk singleton pregnancies were recruited from antenatal clinics. Women were assessed at 13-14 weeks (T1), 21-22 weeks (T2), and 32-33 weeks (T3) of gestation with measures of distress and anxiety (the K10, Perceived Stress Scale, and the State Subscale of the Spielberger State-Trait Anxiety Inventory [STAI]) and with uterine Doppler flow velocity studies. The Trait Subscale of the STAI was done either at T1 or T2. Thirty women were seen at T1, 79 women were seen at T2, and 59 women were seen at T3. No significant correlations were found between measures of distress and anxiety and umbilical artery pulsatility index (PI) or middle cerebral artery PI at any time-point. Small positive correlations between trait anxiety and uterine artery PI were found, but these were not significant after adjustment for alcohol and nicotine use (any use as well as problem drinking/nicotine dependence). At T3 but not T1 or T2, women scoring above 20 on the K10 (a standardized cutoff for the presence of axis I psychiatric disorders) had higher uterine artery PI than those scoring below 20.This was significant after adjusting for alcohol and nicotine use, as well as when nicotine dependence was considered. This work highlights the complexities of the relationship between increased measures of distress and anxiety and changes in the placental circulation. Further work in this area is needed to explore the underlying mechanisms which account for this relationship and to delineate fully the extent to which the relationship is determined by the presence of psychiatric and substance use disorders.

Love and attachment: the psychobiology of social bonding.

Basic animal studies and human imaging studies have contributed to our understanding of the psychobiology of love and attachment. There are overlaps and distinctions in the neuronal circuitry of maternal love, romantic love, and long-term attachment. In these circuits, important molecules, which have been demonstrated to play a role in the psychobiology of social bonding include dopamine, serotonin, opioids, oxytocin, and vasopressin. Particular genetic and environmental variations contribute to social-bonding phenotypes, consistent with an evolutionary perspective on the value of these behaviors. Advances in the psychobiology of social bonds have led to hypotheses about the pharmacotherapy of disorders of attachment.

Anxiety disorders in pregnancy.

There is now growing realization that many women suffer from new onset or worsening of anxiety disorders during pregnancy. Studies of anxiety symptoms in pregnancy show that a significant portion of women are affected. Anxiety symptoms in pregnancy have been associated with adverse fetal and infant outcomes. Furthermore, having an anxiety disorder during pregnancy is one of the strongest risk factors for postnatal depression. Although the literature on treating anxiety disorders in pregnancy per se is sparse, response to standard treatment is good. The risk of teratogenicity with pharmacotherapy must be considered, but it can be minimized by judicious tapering and cessation of medication during high-risk periods.

Social anxiety disorder: psychobiological and evolutionary underpinnings.

Social anxiety disorder (SAD) also know as social phobia is increasingly recognized as a highly prevalent and disabling psychiatric disorder. SAD patients demonstrate cognitive-affective distortions in relation to social situations and abnormal activation patterns in limbic structures during functional imaging. Behavioral inhibition is an endophenotype that may be useful in understanding vulnerability to SAD, and that has specific imaging and genetic correlates. From an evolutionary perspective, it has been speculated that SAD represents a false appeasement alarm. It is notable that SAD responds to selective serotonin reuptake inhibitors and monoamine oxidase inhibitors, but not to most tricyclic antidepressants; this finding is consistent with the importance of serotonin and dopamine in mediating this disorder.

Adjunctive quetiapine for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: a meta-analysis of randomized controlled treatment trials.

Small studies have shown positive effects from adding a variety of antipsychotic agents in patients with obsessive-compulsive disorder who are unresponsive to treatment with serotonin reuptake inhibitors. The evidence, however, is contradictory. This paper reports a meta-analysis of existing double-blind randomized placebo-controlled studies looking at the addition of the second-generation antipsychotic quetiapine in such cases. Three studies fulfilled the inclusion criteria. Altogether 102 individuals were subjected to analysis using Review Manager (4.2.7). The results showed evidence of efficacy for adjunctive quetiapine (<400 mg/day) on the primary efficacy criterion, measured as changes from baseline in total Yale-Brown Obsessive Compulsive Scale scores (P=0.008), the clinical significance of which was limited by between-study heterogeneity. The mechanism underlying the effect may involve serotonin and/or dopamine neurotransmission.

Disability and quality of life in post-traumatic stress disorder: impact of drug treatment.

The degree of functional disability and quality of life (QOL) impairment in patients with post-traumatic stress disorder (PTSD) is at least comparable with, and in many instances greater than, that of patients with other anxiety and mood disorders. Multidimensional QOL assessments in PTSD have utility in capturing aspects of individual patient experience and satisfaction related to health and treatment, and have fairly robust sensitivity to treatment effects. Despite the growing number of epidemiological and clinical studies detailing QOL in PTSD, there are few studies of the impact of pharmacological agents on QOL outcomes, and none that have included an economic component to evaluate the resource consequences of the disorder. To date, the selective serotonin reuptake inhibitors have been shown to confer significant acute (and longer term) QOL and psychosocial benefits. Further investigation of the relationship of QOL to PTSD symptom severity, disability, treatment outcome and cost, among the different drug treatment modalities, is clearly needed.

A brain-behaviour initiative for South Africa: the time is right.

BACKGROUND: Many have advocated for science and health research in developing world settings. However, there has been less focus on the value of basic and clinical neuroscience research in this context. The current paper focuses on the relevance of a brain-behaviour research initiative in South Africa. METHODS: Workshops sponsored by the University of Cape Town Research Office and by the National Research Foundation have recently focused on the state of South African basic and clinical neuroscience, and on how to strengthen research in these areas. The context of the discussion included national science and health priorities, as well as local research opportunities. RESULTS: Neuropsychiatric disorders account for the second largest proportion of the burden of disease in South Africa, but receive relatively little research funding. There is a critical need for research, and there are unique research opportunities, in areas such as trauma and resilience, impulsive behaviour (eg violence, sexual risk taking, and substance abuse), and neuroAIDS. Basic, clinical, and systems research can all make important contributions. CONCLUSION: There is a need to apprise policy-makers in developing world countries such as South Africa of the need for increased expenditure on basic and clinical neuroscience research. Local and international collaboration may be useful in increasing research capacity in South Africa, and ultimately in improving mental health services.

Pharmacological challenge with a serotonin 1D agonist in alcohol dependence.

BACKGROUND: Both animal and clinical studies have implicated serotonergic dysfunction in the pathogenesis of alcohol abuse and dependence. However the exact mechanisms involved remain unknown. Theoretically, low serotonin promotes alcohol seeking behavior. Sumatriptan is a serotonin1D agonist. It is postulated that sumatriptan's agonism at this terminal autoreceptor increases negative feedback, creating a net effect of decreased serotonergic neurotransmission. Administration of sumatriptan should therefore produce a craving for alcohol and the desire to drink. METHODS: Fifteen patients with alcohol dependence who had undergone detoxification were recruited. Sumatriptan (100 mg) and placebo was administered in cross-over fashion on 2 separate days 72 hours apart. Both patients and raters were blind to all treatments. Patients were assessed on the following scales at -30, 0, 30, 90, 150 and 210 minutes: A 6-item scale designed to rate the patient's intention to drink; The Sensation Scale; a 13-item affect analog scale designed to rate the pattern and extent of emotional changes; and an 8-item scale designed to rate the patient's craving for alcohol. RESULTS: No significant differences were found between the placebo and sumatriptan groups and no significant cross over effects were found. CONCLUSION: The general lack of efficacy of sumatriptan in producing alcohol-like symptoms or a desire to drink alcohol may suggest that the 5HT1D receptor plays little role in the pathophysiology of alcoholism.

Obsessive-compulsive disorders and dermatologic disease.

Obsessive-compulsive disorder and obsessive-compulsive spectrum disorders are often associated with dermatologic manifestations. The phenomenology is discussed and possible animal models explored. Treatment involves both pharmacotherapy and cognitive behavior therapy. Many of these patients experience considerable shame over their behavior and may be reluctant to acknowledge the existence of a psychiatric disorder. The dermatologist's approach to this patient is discussed.

Quetiapine augmentation of SRIs in treatment refractory obsessive-compulsive disorder: a double-blind, randomised, placebo-controlled study [ISRCTN83050762].

BACKGROUND: Although serotonin reuptake inhibitors are effective in the treatment of OCD, many patients fail to respond to these agents. Growing evidence from open-label and placebo-controlled trials suggests a role for augmentation of SRIs with atypical antipsychotics in OCD. Quetiapine is generally well tolerated and previous open-label data has produced mixed results in OCD and additional controlled data is needed. METHODS: We undertook a double-blind, randomised, parallel-group, flexible-dose, placebo-controlled study of quetiapine augmentation in subjects who had responded inadequately to open-label treatment with an SRI for 12 weeks. Following informed consent and screening, forty-two subjects were randomised to either placebo or quetiapine for six weeks. RESULTS: There was significant improvement from baseline to endpoint on the Yale-Brown Obsessive-Compulsive Scale in both the quetiapine and placebo groups (quetiapine, n = 20, p < 0.0001; placebo, n = 21, p = 0.001) with 40% (n = 8) of quetiapine and 47.6% (n = 10) of placebo treated subjects being classified as responders. Quetiapine did not demonstrate a significant benefit over placebo at the end of the six-week treatment period (p = .636). Similarly quetiapine failed to separate from placebo in the subgroup of subjects (n = 10) with co-morbid tics. Quetiapine was generally well tolerated. CONCLUSIONS: In this study, quetiapine augmentation was no more effective than placebo augmentation of SRIs. A number of limitations in study design make comparisons with previous studies in this area difficult and probably contributed to our negative findings. Future work in this important clinical area should address these limitations.

Is "shy bladder syndrome" a subtype of social anxiety disorder? A survey of people with paruresis.

Paruresis is characterized by the fear of not being able to urinate in public bathrooms and has been classified by some to be a sub-type of social anxiety disorder (social phobia). Despite the existence of a consumer advocacy organization, the "Intentional Paruresis Association (www.paruresis.org)," there is sparse literature on this condition. A survey of people affiliated with the "International Paruresis Association" was undertaken using a self-report questionnaire with items that addressed demographic variables, the phenomenology of paruresis, comorbid disorders, and the impact of symptoms on quality of life. Sixty-three patients (59 M, 4 F) completed the questionnaire. The mean age of the subjects was 38.1+/-12 years, with the mean duration of symptoms being 24.5+/-13 years. Paruresis impacts significantly on sufferers' lives, with approximately one third limiting or avoiding parties, sports events, or dating and just over half of the sample limiting the job they choose to do. Social anxiety disorder (SAD) and depression are the most common comorbid disorders and the most common disorders in family members. Analysis of Liebowitz Social Anxiety Scale (LSAS) scores showed higher performance than social interaction subscale scores across the whole sample (whether suffering from SAD or not.) However, compared to subjects without co-morbid SAD, those with comorbidity had higher total, performance, and social interaction scores. Thus, paruresis can be a chronic and disabling symptom, and there seems to be an association between paruresis and other performance anxieties. Further research to characterize paruresis and to determine effective treatments is needed.

SPECT scans in identical twins with trichotillomania.

SPECT scans of a set of twins with trichotillomania showed that the twin with more severe disease had larger perfusion defects, involving more areas on the scan. Prospective brain imaging studies of twins may provide useful information about the neurobiology of trichotillomania and other obsessive-compulsive spectrum disorders.