Psychiatry Part 1:

Introduction to Psychiatry

Ahmed Badat
2021

Ahmed Badat
 Introduction to Psychiatry
Psychiatric Emergencies
Suicide and Self-Harm
Definitions:
-Suicidal ideation: thoughts about killing oneself which may include a plan, writing or talking
about killing oneself.
-Suicide attempt: an act with a nonfatal outcome an individual deliberately initiates to cause
self-harm or death. Does not take intention into account. (According to UptoDate: attempt
implies intention to cause death).
-Suicide: self-injurious behaviour that is intended to kill oneself and is fatal.
-Suicide threat: verbalising thoughts to cause self-harm with intention to lead others to the
belief one wants to die, without the intention to do so.
-Suicide gesture: behaviour intended to lead others to believe once wants to die without
intent.
-Nonsuicidal self-injurious thoughts: thoughts of engaging in destruction to bodily tissue in
the absence of intent to die that may lead non-suicidal self-injury. Also called non-fatal
suicidal behaviour (NFSB).

Risk Factors and Risk Assessment:

Adults
-Any mood disorder or other psychiatric illness including substance use
-Physical and sexual abuse
-Parental divorce
-Previous suicide attempts (younger age)
-Physical illnesses such as cancer and HIV, with HIV (likely after test BEFORE diagnosis, 3-
6m after diagnosis, late stage), diagnosis of HIV can also cause relational problems.
-Social and contextual factors: unemployment, financial difficulties, acute perceived stress
etc.
-Family hx of psycopathology and suicidal behaviour
-Hopelessness, helplessness, anger, poor problem-solving etc.

Management:
-A thorough history and MSE
-NB to assess for suicidal intent:
1) Distinguish between active and passive suicidal ideation.
2) Assess dimensions of current suicidal thoughts:
-frequency, duration, reasons, protective factors
-specificity of plan
-availability of methods and opportunity
-preparatory behaviour of any kind

Ahmed Badat
3) Suicide attempt
-Hospitalisation for review by mental health care provider
-Strict suicide observations
-May need to admit involuntary if necessary.
-Collateral from family, psychoeducation
-Post dc plan is NB: collaborative.

Management of the Aggressive Patient:

-Aim: to contain the behaviour and exclude acute mental illness so that definitive treatment
and care can be provided.
NB exclude delirium, which is likely if:
-age >40 with no history of MI
-visual, tactile, olfactory hallucinations
-illusions and disorientation.

Step 1: Ensure the Environment is Secure:

-devise policy for mx of aggressive patient
-security to be present or nearby
-remove dangerous objects
-clinician to have easy access to exit

Step 2: De-escalation:
-Use of verbal and non-verbal techniques to diffuse situation
-Try to negotiate
-Speak clearly, firmly and slowly (do not scream at patient)
-Introduce yourself and reassure you want to help
-Provide choices if possible.

Step 3: Physical Restraint:

-Group of 5 trained staff to approach patient slowly as a show of force
-Must be coordinated by a team later
-Express intention
-One member for each limb
-Use for as short as possible

Step 4: Sedation
-Usually two classes of drugs used: antipsychotics and benzodiazepines
-Lorazapam (2-4mg IMI) or haloperidol 5mg IMI (max 10mg in 24hr)
-Avoid antipsychotic if index and antipsychotic naïve
-Monitor paradoxical aggression/disinhibition especially if medically ill/elderly
-Monitor vitals every 15 min for first hour and then hourly until patient ambulatory

-The user must be admitted as an involuntary user.

-Offer post violence counselling.

Ahmed Badat
Catatonia:
-Catatonia is a behavioural syndrome marked by an inability to move normally, which can
occur in the context of many psychiatric and medical disorders.
-Failure to recognise and properly treat catatonia can lead to poor outcomes; malignant
catatonia can be fatal.

Pathogenesis:
-Treatment used for the underlying psychiatric disorder or GMC may cause or exacerbate
catatonia.
-Association with mood disorders more than psychotic disorders.

Clinical Features:
-The disturbance can range from marked reduction to agitation of movements.
-Starting, stopping and planning movement can be impaired.
-Motor behaviour may be repetitive, purposeless, impervious to external stimuli and contrary
to intent.

Stupor: Combination of immobility and mutism

Posturing: Maintaining the same posture for long periods
Negativism: resists attempts by examiner to move parts of the body.
Waxy flexibility: Patient can be positioned into uncomfortable postures which can be
maintained for long periods of time
Verbigeration: meaningless repetition of words or phrases
Stereotypies: repetitive, regular movements that are not goal directed (e.g. rocking)
Echolalia: senseless repetition of another person’s utterances
Echopraxia: senseless repetition of another person’s movements
Staring

Management (Maudsley):
-Exclude or treat underlying physical illness
-NB rule out NMS
-Benzodiazepines are the drug of choice (lorazepam challenge)
-Lorazepam up to 4mg daily, starting with 2mg and a further 2mg if no response after three
hours
-If no response after 1-2 days: high dose lorazepam 8-24mg daily
-If no response after 1-2 days: ECT

Ahmed Badat
Delirium:

-Common among elderly

-Associated with complex underlying medical conditions

Definition and Terminology

DSM V: Lists 5 key features that characterise delirium
1. Disturbance in attention (reduced ability to direct, focus, sustain and shift attention)
and awareness.
2. Develops over a short period of time (hours to days) and represents a change from
baseline and tends to fluctuate over the course of day
3. Additional disturbance in cognition (memory deficit, disorientation, language,
visuospatial ability or perception
4. Not better explained by another pre-existing/established or evolving neurocognitive
disorder and does not occur in severely reduced levels of arousal like coma
5. Evidence from history, physical exam or labs of disturbance caused by another
medical condition, substance intoxication or withdrawal or medication side effect.

The following my accompany a delirium:

-psychomotor behavioural disturbances: hypoactivity, hyperactivity with increased SNS
activity, impairment in sleep architecture
-emotional disturbances: fear, depression, euphoria, perplexity

-acute confusional states and encephalopathy used with delirious

-confusion= depressed sensorium and reduced attention

Pathogenesis:
-Pathophysiology poorly understood
Neurobiology of attention:
Arousal and attention are disrupted by lesions involving the ascending reticular activating
system (ARAS) from mid-pontine tegmentum rostrally to anterior cingulate regions
Attention is governed by the nondominant parietal and frontal lobes
Insight and judgement depend on intact higher order integrated cortical function, usually
frontal lobe impairment as it is involved in scrutinizing incoming sensory information
Important role for subcortical (thalamus, basal ganglia and pontine reticular formation) as
well as cortical structures in the pathogenesis of delirium (NB: pts with subcortical strokes
and basal ganglia abnormalities (like Parkisons) have a higher susceptibility to delirium

Neurotransmitter and humoral mechanisms:

Actylcholine plays an important role in pathogenesis
Anticholinergic drugs-block Ach, cholinesterase inhibitors-increase amount of Ach
Anticholinergic drugs cause delirium, this can be reversed using cholinesterase inhibitors
Medical conditions like hypoxia, hypoglycaemia and thiamine def decrease Ach synthesis-->
delirium
Ahmed Badat
Alzheimers dementia which has a loss of cholinergic neurons has an increased risk for
delirium
Psychotropic drugs, especially in elderly can cause anticholinergic effects

Proinflammatory cytokines such as interleukins and tumor necrosis factor-alpha may have a
role in the pathogenesis of delirium
Cytokine activation may account for delirium (especially hyperactivre delirium) in situations
like sepsis, cardiopulmonary bypass and acute hip fractures.

Precipitating factors:

Risk Factors:
-Multifactorial disorder
-Risk factors can be classified into those that increase baseline vulnerability and those that
precipitate the disturbance
-Most common: underlying brain diseases (dementia, stroke, Parkinsons), high prevalence
with superimposed dementia and dementia is often poorly recognised prior to the onset of
delirium

Clinical Presentation:
-Disturbance in consciousness and altered cognition are essential components.
-Develops over a short period of time and fluctuates over the course of the day
Ahmed Badat
-Typically causes by a medical condition, substance intoxication or medication side effect.

Disturbance of consciousness:
-change in awareness and the ability to focus, sustain or shift attention.
-loss of clarity is initially subtle
-Distractibility is a hallmark-evident in conversation
-In more advanced stages: appear drowsy, lethargic, semicomatose
-Hypervigilance may occur in alcohol and sedative withdrawal.

Change in cognition:
-Memory loss, disorientation and difficulty with language and speech
-NB while doing mental status testing: patients overall accessibility and attentiveness when
answering questions
-NB ascertain level of functioning prior to onset of delirium from family
-Common to have perceptual disturbances: shadows represent a person, vague delusions of
harm, auditory, visual or somatosensory hallucinations
-Patients may lose the ability to write or speak a second language

Temporal course:
-Develops over hours to days and persists for days to months
-Acuteness is the most helpful feature in differentiating delirium from dementia
-Features are unstable and become severe during the night
-Often a prodromal phase: complaints of fatigue, sleep disturbance, depression, anxiety,
restlessness, irritability and hypersensitivity to light or sound.

Other features:
-psychomotor agitation
-sleep wake reversals
-irritability
-anxiety
-emotional distress
-hypersensitivity to light and sounds

Evaluation:

-Two important aspects of diagnostic evaluation: recognising the disorder is present and
uncovering the underlying cause

Clinical confirmation:
-Change in LOC is the first observable clue
-lack of accessibility when taking a history
-conversation may elicit memory difficulties, disorientation, speech is tangential,
disorganised or incoherent,
-Can do formal testing for attention: MMSE (poor scoring in serial 7s) or bedside tests of
attention (Vigilance for letter A or digit span).

Ahmed Badat
Clinical Instruments:
Confusion Assessment Method (CAM)-good sensitivity and specificity, can use CAM-ICU in
ICU setting

Differential Diagnosis:

Sundowning:
-behavioural deterioration seen in evening hours in demented patients

Focal syndromes:
-Temporal-parietal:
Patients with wernicke aphasia may appear delirious if they do not comprehend or obey or
seem confused. The problem is restricted to language

Occipital:
-anton syndrome of cortical blindness and confabulation

Frontal:
-bifrontral lesions (trauma or tumor) often show akinetic mutism, aspontaneity, lack of
judgement, problems with recent or working memory, blunted or labile emotional responses,
incontinence.

Nonconvulsive status epilepticus: needs an EEG for detection, bilateral facial twitching,
unexplained nystagmoid eye movements, hippus, automatisms.

Dementia:
-Cognitive change in Alzheimers is insidious, progressive and without fluctuation and occurs
over a much longer time. Attention and remote memories in earlier stages are intact
-Lewy body dementia: common to have fluctuation sand visual hallucinations

Diagnostic Tests:
-Lab tests
-Neuroimaging
-LP (older patients with meningitis present with delirium)
-EEG- to exclude seizures especially nonconvulsive, some metabolic enceohalopathies or
infectious incephalitides with characteristic EEG patterns

Delirium: prevention, treatment and prognosis

Prevention and therapy of delirium based on following principles:

-avoiding factors that cause or aggravate delirium: multiple medications, dehydration,
immbolisation, sensory impairment and disruption of sleep-wake cycle
-identify and treat underlying acute illness
-supportive and restorative care to prevent further physical and cognitive decline
-if appropriate: use of low dose and short acting agents
Ahmed Badat
Prevention:

Modifying risk factors:

1. Orientation protocols: clocks, calendars, outside views, verbal orientation
2. Cognitive stimulation: regular visits from family and friends
3. Facilitation of physiologic sleep: avoid procedures during sleeping hours, reduce
night time noise
4. Early mobilisation and minimised use of physical restraints for patients with limited
mobility: early physio
5. Visual and hearing aids in patients with impairments
6. Avoiding or monitoring the use of problematic medications: especially benzos,
caution with opiods and antihistamines
7. Avoid and treat medical complications: eg hypoxemia, sepsis
8. Manage pain
-Currently the evidence DOES NOT support the use of medications in preventing delirium in
high risk patients, the potential of cholinesterase inhibitors, antipsychotics and
dexmedetomidine are being investigated

Management:

1. Treat underlying conditions

2. Supportive care
3. Manage agitation:
-nonpharm: reduce noise, improve lighting, windows, avoid restraints. Restraints used as a
last resort as they increase agitation and cause additional problems like pressure ulcers,
aspiration etc

-Antipsychotic medications:
Suggest low dose haloperidol (.5 to 1mg) as needed to a max of 5mg per day, onset 5-20
mins. Evidence shows similar efficacy with new atypicals.

-Benzodiazepines:
More rapid onset of action but can worsen confusion and sedation
Used for sedative drug and alcohol withdrawal

-Cholinesterase inhibitors: no role in treatment

Ahmed Badat
Acute Dystonia (Maudsley):
-Muscle spasm in any part of the body e.g:
-Oculogyric crisis (eyes rolling upwards)
-Toritcollis (head and neck twisted to one side)
-Patient may not be able to swallow or speak
-In extreme cases back may arch and jaw dislocation
-Extremely painful and distressing to patient.
-Usually occurs within hours of starting antipsychotic
-Response to IV in 5 mins, IMI in 20mins

Management:
-Anticholinergic drugs given orally, IM or IV depending on severity.
-Biperiden IM 2-4mgm may be repeated every 30mins
-Maximum 4 doses in 24 hours
OR
-Promethazine 50mg IMI

Serotonin Syndrome:
-Characterised by a triad of neuromuscular abnormalities (myoclonus and clonus), altered
mental state and autonomic dysfunction.
-Ranges from mild agitation and tremor to extreme muscle rigidity with hyperthermia.
-Clonus, hyperreflexia and muscular rigidity are nearly always present,
-Onset is typically acute and rapidly progressive
-Most common is co-adminstration of MAOI with an SSRI

Hunter’s Criteria: ONE of the following

-spontaneous clonus
-inducible clonus PLUS agitation or diaphoresis
-Ocular clonus PLUS agitation or diaphoresis
-tremor PLUS hyperreflexia
-hypertonia PLUS temp>38 PLUS ocular clonus or inducible clonus

Management:
-Discontinue offending agent
-Supportive care
-Sedation with BZD
-Can use cyproheptadine

Ahmed Badat
Neuroleptic Malignant Syndrome:

Clinical features:
-Fever (high grade)
-Muscular rigidity: generalised, tone increased, lead-pipe
-Autonomic instability tachycardia, labile BP
-Mental status changes: agitated delirium, catatonia, stupor

Laboratory:
-Elevated CK, leucocytosis, altered LFT

Management:
-Stop causative agent
-Supportive care (may need ICU)
-cooling blankets
-Prevent DVT
-Benzodiazepine for agitation
Medical therapy:
-Lorazepam: 1-2 mg IM/IV 4-6 hours
-Dantrolene: 1-2.5mg/kg IV

Antipsychotic rechallenge:
-stop AP for at least 5 days
-Start low dose and monitor closely
-Consider drug with low dopamine affinity (quetiapine or clozapine)
-Avoid depot
-Avoid high potency FGA

Serotonin Syndrome vs NMS:

-NB distinguishing features are the hyperreflexia, clonus, ocular clonus and tremor in SS
-SS usually quicker in onset, NMS can be slower and takes 9-14 days to remit

Lithium Toxicity:

Therapeutic range: 0.8-1.2

-Anticipated toxic effects of lithium exposure will depend on renal function and hydration
status.
-Medications that cause dehydration or renal impairment can precipitate lithium toxicity e.g.
diuretics, ACE inhibitors and NSAIDS

Clinical findings:

Mild (<1.2-2.0):
GIT: nausea, vomiting, diarrhoea
CNS: ataxia, coarse tremor, muscle twitches, drowsiness

Ahmed Badat
Moderate (2.0-2.5):
GIT: persistent nausea and vomiting
CNS: blurred vision, hyperreflexia, delirium

Severe (>2.5):
Stupor, coma, convulsions
Oliguria and renal failure
-The above classification is commonly used, but it is important to note that serum levels do
not always correlate with clinical signs of toxicity.

-Patients present acutely with GIT symptoms which can lead to dehydration and
compromised renal function, further exacerbating toxicity as excretion is impaired
-Prolonged QTc intervals and bradycardia have been reported
-Neurologic findings develop later than GIT symptoms- initially sluggishness, ataxia,
confusion and neuromuscular excitability which can manifest as coarse tremors, fasiculations
and myoclonic jerks, severe is seizures, nonconvulsive status epilepticus and encephalopathy

Management:
-Medical emergency
-ABCs and supportive care
-Hydration with isotonic saline IV
-Gastrointestinal decontamination: NB activated charcoal has no role, whole bowel irrigation
may be effective
-Must be seen by renal who will decide on dialysis.

Mental Health and the Law

The Mental Health Care Act no 17 of 2002
Aims
-To provide care for those who are mentally ill
-Safeguard against exploitation and abuse of MHCU
-Protect public and property where applicable (MHCU poses danger)
-Co-ordinate services within general health services and communities
-To establish mental health review boards in respect of every establishment

Definitions:
-MHCU: diagnosis of a mental health related illness as accepted by diagnostic criteria made
by a MHCP authorised to make such a diagnosis
-Intellectual capacity: only persons with severe or profound ID are mentioned in the act
-Administrator: looks after MHCU affairs and finances
-HHE (head of health est): person who manages the health establishment (managerial,
administrative) to ensure legal and ethical practice

Ahmed Badat
Review Boards:
-Review assisted and involuntary admissions
-Review periodical reports and appeals
-Ensure protection of rights
-Must have at least 3 people: MHCPractitioner, magistrate/attorney, member of community

Emergency Care for MHCU Incapable of Making Informed Decisions:

-Form 01
-Care can be provided to a MHCU if delay will result in death, irreversible harm, danger to
others and property
-Allows urgent emergency admission without consent for a period of 24 hours
-Must be reported to review board within 24hr
-Thereafter decision must be made: assisted/invol/dc

Assisted User:
-Suffers from mental illness or severe/profound ID
-Requires treatment
-Incapable of making an informed decision but NOT REFUSING treatment
-Application is made by: spouse, next of kin, parent, associate
-If user >18 application can be made by parent/guardian only
-Applicant must have seen user in last 7 days
-Associate is defined as a person with substantial or material interest in the health of MHCU

Involuntary User:
-Presence of mental illness
-Likelihood of serious harm to self/others
-UNWILLING to receive care
-Incapable of making an informed decision
-Admitted for above reasons and to protect financial interests or reputation
-Patient must be reviewed every 24 hours for a period of 72 hrs
Rationale for 72 hr assessment:
-Exclusion and treatment of general medical conditions
-User may recover within period
-User can be treated closer to home
-Increases accessibility and availability of MHC at a community level
-After 72 hours: dc/assisted/continue involuntary care (form 08)

Appeals:
-An assisted or inv MHCU can appeal the decision of the HHE
-Must be provided with a form 14 to request appeal, which is sent to review board
-If appeal accepted: user must be dc according to accepted clinical practice
-If appeal rejected: forwarded to high court for further orders
-May be done by family who don’t believe the MHCU has a MI

Ahmed Badat
-The same categories of people who can apply for assisted care (as above) may also apply for
an appeal.
-Must be done within 30 days
-Sent to review board who informs all relevant parties of decision within 30 days
-May request a hearing where any party involved may have to appear (2 weeks notice must
be given) or written explanation.

Seclusion and Restraint:

-Only in extreme situations as a last resort
-Seclusion means isolation of user in a space where their movement is restricted
-It is done in terms of risk assessment
-Patient needs regular monitoring

Periodical Reports:
-To regulate long term admissions in order to prevent unnecessary limitations
-Done for: a person who cannot give consent, a state patient, mentally ill prisoner
-Done 6 months after being admitted and then yearly thereafter (Form 13).

Section 15: MHCU is entitled to representation including legal

Section 16: refers to a discharge report and informs all parties
Section 17: MHCU right knowledge of their rights

Confidentiality:
-Should be done in accordance to Promotion of Access to Information Act
-A MHCP may temporarily withhold information to the MHCU if disclosure will result in
prejudice against user
-Can be breached under specific conditions: court order, patient allows information to be
given to another party, cases of abuse in vulnerable populations (children and elderly- done in
accordance with Children’s Act and Old Person’s Act)
-Domestic Violence Act: allows practitioner to identify at-risk individuals by reporting abuse
with the patient’s consent
-In legal cases and for self defence issues

Informed Consent:
-The ability to give consent to procedures other than psychiatric disorders must be considered
separately.
-A loss of capacity to give informed consent in terms of MHCA does not imply a loss of
capacity to consent to other procedures.
-If user unable to give consent and urgent medical treatment needed then consent can be
given by curator, spouse, parent

Referrals under the Criminal Procedure Act:

-An accused may be sent for a 30d forensic observation (sec 79)
-Section 77: ability to follow court proceedings
-Section 78: the ability to appreciate the wrongfulness of the act and act in accordance with
such wrongfulness.
Ahmed Badat
General Health Care and Criminal Justice System:
-State patients: must be referred to designated hospital, may be attended to for general care
during LOA (form 27), must be reported if absconded or relapsed.
-Awaiting trial prisoners: if need of care may be cared for in prison hospitals, general
hospitals and the intervention will not be related to CPA.
-Mentally ill prisoners: generally treated within correctional facility, can be directed by court
order to be managed in psychiatric hospital.

The Role of SAPS:

-If a member of SAPS has reason to believe a person has mental illness and likely to inflict
serious harm to self/others they can bring the individual to a health establishment (Form 22)
-Assistance in the return of absconded patients (Form 25) and (form 26 completed on return)
-Assist with transfer of patients under exceptional circumstances (likely to abscond and very
dangerous).

Relevant Sections of Other Legislation:

The Sterilisation Act:

-Provides guidelines when an individual is incompetent to consent due to severe mental
disability
-A panel/MDT: mental health professionals (psychiatrist, social worker, psychologist, nurse)
must be appointed after an application has been made
-The panel must show: the individual is affected by mental illness to a severe degree, the
individual will not develop capacity to give informed consent, the individual won’t be able to
perform parenting responsibilities.
-Individual must be more than 18yrs old. (if less than 18 only if threat to physical wellbeing)
-There must be no safer/more effective form of contraception available.
-Sterilisation is performed in designated facilities with the consent of the parent, guardian etc
-If an individual gives full consent this is done on a voluntary basis (like any other procedure)

The Prevention and Treatment of Substance Act:

-Aims to simplify systems aimed at eliminating substance abuse.
-The act provides for the committal of individual to treatment

The Children’s Act

Ahmed Badat
-Chapter 7: reporting suspected abuse (as above)
-Age of consent to medical and surgical procedures: 12 years
-A child between 12-18 can consent to surgery without permission of parent

Research Methodology
Basic Epidemiological Principles in Psychiatry
-Epidemiology is defined as the study of distribution and determinants of health-related states
or events in specified populations and application of this to the control of health problems.
-Psychiatric epidemiology is the study and distribution of mental disorders in populations and
the risk factors associated with their onset and course
-Basics of epidemiology include: determining the distribution of mental disorders, risk factors
and interventions to prevent and treat them.
-Scientific evidence points to multiple causes of mental illness including: biological,
psychological, social, cultural, environmental and spiritual

DSM-V Definition of a Mental Disorder

-A syndrome characterised by clinically significant disturbance of an individual’s cognition,
behaviour and/or emotional regulation.
-Associated with significant stress and/or disability in social and occupational settings.
-An expected or culturally appropriate response to a common stressor is not considered to be
a mental illness.
-Socially deviant behaviour are not mental disorders unless they cause impairment as
described above.

Population: a defined collection of individuals/regions/institutions (e.g. by location, sex, age)

Measures of Morbidity and Risk

Incidence Rate:
-The number of new cases in a population per unit of person-time; the number of people who
develop a disorder during a given period in time.
-Incidence= no of new cases in a time interval divided by persons at risk in a time interval.
-It is used to describe how quickly a disease is transmitted and therefore used to guide
interventions to slow down transmission.

Ahmed Badat
Prevalence:
-The total number of cases over a defined period of time
-Point prevalence: assessed at one point in time
-Period prevalence: as above, but all cases over a defined time window (including incident
ones) are included
-Lifetime prevalence: all people who have had the disease at any point in their lives
-Depends on the incidence rate and disease duration from onset to termination
-Influenced by number of new cases and speed of recovery.
-Favours inclusion of chronic over acute cases
-Prevalence studies are cross-sectional and weak evidence for causal inference
-It is useful in determining the extent of a disease can aid in planning facilities and services.
-Prevalence= number of existing cases at a point in time divided by persons at risk at that
time.

Measures of Effect:
-Relative risk/risk ratio: ratio of the occurrence of a given outcome (e.g. disease) in person’s
exposed to a risk factor compared to the occurrence in the unexposed
-Measures the association between strength and outcome.
RR=1 (no correlation between exposure and outcome)
RR >1 the risk outcome is increased by exposure
RR<1 the risk outcome is decreased by exposure (it is a protective factor)

Measures of Morbidity:

Disability Adjusted Life Years (DALY):

-Life expectancy weighted by the amount of disability experienced.
-both premature death and time spent with the disability accounted for which can be physical
or mental

Quality Adjusted Life Years (QALY):

-Years of life weighted by utility (similar to quality of life) ranging from 0-1 assigned to a
year of life.
-a year of ‘perfect’ health = QALY 1
-The lower the value, the greater the burden of disease.

Morbid Risk (disease expectancy):

-The probability that a randomly selected member of a defined population will develop a
specific disorder if they survive to a specific age over a period of time.

Types of Research Study and Design

Ahmed Badat
 Qualitative
-Used to generate hypotheses (why?
What does it mean?)
-Bottom up approach:
Observationpatterntentative
hypothesistheory
Sampling approach to obtain
representative coverage of ideas,
concepts or experiences
Narrative: rich, contextual, detailed
information from a small number of
participants
Quantitative
-Often tests hypotheses (what? How much/many?
-Top down approach:
Theoryhypothesisobservationconfirmation
Sampling approach to obtain representative
coverage of people in a population
Numeric: frequency, severity and association
from a large number of participants

Types of Epidemiological Study Design:

1) Descriptive: cross-sectional studies
2) Analytical: cohort, case-control, ecological
3) Experimental studies: intervention studies, clinical trials
4) Secondary research: systemic reviews.
Observational Study Designs:
-Involve neither the manipulation of the exposure of interest nor randomisation of study
subjects
2 main types: descriptive and analytic
Descriptive: describes events and rates of disease with respect to person, place, time
Analytic: observational studies used to test a specific hypothesis (ecological, cohort, case-
control, cross-sectional)

Ecological Cross-sectional Case-control Cohort

Type of Study
Definition Units of Uses individual Samples a Subjects are
analysis are data on group of people sampled and as
populations exposures and who already a group
outcomes have a classified on the
generated at the particular basis of
same time outcome (case) presence or
and compares to absence of risk
a similar sample factor
group without
the outcome
(control).
Subjects Populations or Sample selected Two or more Group of people
groups samples of with common
individuals with characteristics
and without the
outcome

Ahmed Badat
 Methods Descriptions of Collecting info, Subjects are
average comparing data, followed for a
exposure or risk test associations specific period
of exposure for of time to
a specific pop. determine
outcome
Advantages Quick, readily Determines Used for rare Shows
data available association diseases association
between between risk
variables and outcome
Can use -Stronger casual
validated evidence
surveys
Disadvantages Poor Does not allow Recall bias Selection bias
generalisability for assessment Selection bias
to an individual of temporal Only one
level evidence or outcome
Ecological offer strong measured
fallacy: an evidence for
incorrect causation
inference from between
group to variables
individual
Examples Study looking at Average BMI of
association women at a
between specific clinic
smoking and
cancer in a
specific city

Experimental Study Designs:

Randomised Control Trials (RCT):

-Subjects are assigned by random allocation to groups, where the control group does not
receive the intervention or receives the placebo or standard therapy
-Individuals selected by specific inclusion and exclusion criteria
-Single blind: subject doesn’t know which group they’re in
-Double blind: both subject and observer don’t know groups
-Triple blind: subject, analyst and observer don’t know groups.
-All other conditions between groups are similar

Summary Study Designs

Meta-analysis:
-a form of statistical analysis that synthesises the results of independent studies addressing a
common research question as identified through systemic review
-Selection of studies from literature which meet quality criteria
Ahmed Badat
-Provides a summary statistic of overall results

Case Definition, Identification, Sampling Methods

-The reliable measuring of prevalence, incidence and associated risk factors requires
appropriate and accurate definition and identification of cases in a population.
-Specificity: the capacity to select true cases (does not overinclude false positives)
-Sensitivity: the capacity to identify all affected people within in a specific population (does
not leave out false negatives)
-A case must always be well defined with measures to distinguish between individuals who
meet the case definition and those who do not within a population under study
-DSMV and ICD10 are able to provide definitions for cases in psychiatry.

Case Identification:
1) Cases in treatment contact: recruiting patients from a treatment facility who meet case
definition, however excludes people from general community (selection bias)
2) Case registers: identifying cases from health record systems, relies on quality of data
collected
3) Case finding in the community: can use population based surveys
4) Screening: using tools to identify individuals who may meet the case definition, but
require further assessment.
Sampling methods:
Sample: a selection of individuals from a population
Random sampling: all members equally likely for selection
Systematic: algorithm is used to select a subset
Stratified: population divided into subgroups and each sampled
Cluster: grouped in space/time to reduce costs
Convenience: non-random inclusion, usually volunteers.

Bias
-A systemic error causing results to differ from correct values/inferences
-Sampling bias: selection of sample does not truly represent population
-Measurement bias: inaccurate measurement of subjects
-Recall bias: bias in individual’s responses when reporting past events

SPIN: use a Specific test to rule IN a hypothesis. If a test is specific it is likely to be a true
positive
SNOUT: use a SENsitive test to rule OUT a hypothesis. If you get a negative test, it is likely
to be a true negative.

Principals of Evidence Based Medicine:

-The aim of EBM is to integrate the experience of the clinician, the values of the patient and
the best available scientific information to guide decision making in clinical practice
Key principles:

Ahmed Badat
-Recognition of uncertainty and an answerable question (is this the best option and is there a
better one?)
-The reliable and efficient identification of the best available evidence (see evidence
pyramid)
-The critical appraisal of the evidence (assesses validity and usefulness)
-Integration into practice taking patient factors, cultural, social etc into account
-Evaluating whether there was an improvement

-Critical appraisal is the process of systematically examining research evidence to assess

validity, results and relevance before using it to inform a decision.

Validity and Precision:

-How closely a measurement reflects the entity it claims to measure
-Reliability: how consistent multiple measurements are when the underlying subject of the
measurement has not changed.

Statistics
Types of data: Either numerical or categorical
Numerical data can be discrete (a specific amount e.g. no of pregnancies) or continuous (BP,
weight)
Categorical data can be nominal (names e.g. sex, blood types) or ordinal (e.g. stages of
cancer)

Reliability and Validity:

(see above)
Internal validity: degree to which findings of sample truly represent the findings in the study
population. Dependent on reliability, accuracy and absence of bias
External validity (generalisability): degree to which the results of the study can be
generalised to other situations or populations.
Ahmed Badat
-Reliability (precision) can be assessed by:
Inter-rater reliability: by different observers at the same time
Test-retest reliability: by the same observer but under different conditions.

Types of Error and Bias

Selection Bias: occurs when the subjects studied are not representative of the target
population about which conclusions are to be drawn
Funding bias: results skewed towards interest of external sponsor
Reporting bias: observations of a certain kind are more likely to be reported
Exclusion bias: systematic exclusion of certain individuals
Attrition bias: bias due to some individuals lost to follow up
Recall bias: differences in accuracy of recalled past events

Types of Error:
-The null hypothesis suggests there is no difference between variables and is generally
accepted to be true.
Type 1 error (alpha error): a true null hypothesis is rejected (e.g. a drug may have no
difference in effect on a community (null hypothesis) but we say it does.
-The probability of this error is measured by a p-value
-This error has a larger clinical significance than a type 2 error

Type 2 error (beta error): one fails to reject a null hypothesis that is actually true (e.g. saying
there is no difference in effect, when there actually is)

Statistical Significance:
-The probability that the statistical association between variables is due to random chance
alone (there is no association)
-The preset probability is set sufficiently low that one would act on the result, usually p<0.05
-When the test result is less than the preset limit, the results are said to be statistically
significant (the association between variables is not by chance)

Confidence Interval:
-Provides a range of values within which the true population result (e.g. mean) lies
-Frequently reported as 95% (95% chance that the true value is within this range
-A wider confidence interval implies more variance

Descriptive Statistics (measures of central tendency and dispersion)

-Used to perform exploratory analysis and obtain informative summaries of data from a
study.
Ahmed Badat
-Describe large amounts of data in manageable way e.g. summary measures, graphs and
tables.
-Three main characteristics of a single variable explored (distribution, central tendency and
dispersion).

Frequency of distribution: the number of times individual values or range of values occurs,
can only be done for categorical data e.g. sex

Distribution Shapes:
-Either normal (Guassian-bell curved), skewed and bimodal
-It determines what other types of statistical measures are used.

Normal Distribution:
-Most applicable to continuous data
-Data most likely to be at the mean
-mean=median=mode
-67% of observations fall within one standard deviation of the mean
-95% fall within two.

Measures of central tendency:

-Median(middle observation when data is in order), mean (average), mode (most frequent
value)
-Measures of variability: range, interquartile range, SD and variance
Range= largest minus smallest value
Variance: a measure of the spread of data
Standard deviation: the average distance od data points from the mean (sq root of variance)
-When a variable is normally distributed then the mean will be approx. 2SD will contain 95%
of the values

Parametric and Non-parametric tests:

Parametric: mean/average is the measure of central tendency
e.g. t-tests, ANOVA, linear regression

Non-parametric tests: for non-normally distributed data, categorical data or ordinal data
e.g. rankings, sign ranks

Ethics
-Used with the concept of morality: the current acceptance of what is wrong or right, often related to
values and legal issues.
-The four foundational clusters of ethics:
1) Non-maleficence: do no harm

Ahmed Badat
2) Beneficence: the constant striving for the welfare of the patient which may involve a risk/benefit
determination, welfare of the greater good
3) Justice: Fair and equitable distribution of risks and benefits
4) Autonomy: respect for the decision making capacities of the independent person

Confidentiality:
-Concerns any redisclosure of information that was previously disclosed in confidence.
-Controlled by the person to whom an individual’s privacy has relinquished.
-There is a professional duty in law to remain confidential and failure to do so may result in action for
invasion of privacy, defamation, breach of contract.
Situations in which confidentiality can be breached:
1) Non-fiduciary relationship e.g. psycholegal assessment
2) If a court orders disclosure
3) If the patient provides consent
4) When clinician needs to protect themselves
5) If required by legislation e.g. Children’s Act

Disclosure and Privacy:

-A request for disclosure of information should not occur in the following: if it contravenes
legislation, compromises a police investigation, safety and privacy of third party is compromised, if
request is frivolous.
-Access to clinical records may be requested by
-A family member acting on behalf of the patient
-A body investigating allegations of abuse
-Health professional taking over management
-Medical aid

Ahmed Badat
-Third party e.g. insurance company in relation to a claim
-The patient for their own info.

Privilege:
-An individual’s right to control which information that was conveyed to them in confidence can be
revealed in a judicial proceeding.

Informed Consent:
-An individual is fully and mentally competent to give consent to enter into a procedure at a specific
time.
-The individual is aware of their rights and options prior to making a choice.
-The process has to be voluntary irrespective of the medicolegal status of the patient.
-Consent is situation and time specific and once given can be withdrawn.
4 Principles
1) Competence (capacity): does the mental disorder prevent the user from understanding the
information provided to them, do they understand the problem.
2) Voluntary
3) Full disclosure of info
4) A dynamic process that allows for withdrawal of consent.
Dual Agency:
-Psycholegal assessments are usually conducted for the benefit of third parties (courts, insurance
companies etc).
-HPCSA and SASOP have recommended that treating clinicians should not conduct psycholegal
evaluations on their own patients.

Human Rights and Stigma:

-Mental health users face discrimination and stigma which imposes on their human rights.

Stigma:
-Stigma is the disapproval of, or discrimination against a person based on perceivable social
characteristics that serve to distinguish them from other members of society.
-Corrigan and Wessel use a cognitive behavioural construct to describe stigma and identify four
cognitive processes: cues, stereotypes, prejudice and discrimination.
-These may manifest as public or self-stigma.
-Cues trigger cognitive associations with negative stereotypes and prejudice occurs when these
negative stereotypes are endorsed.
-Discrimination is the behavioural manifestation of prejudice.

Self-stigmatisation:
-An individual identifies themselves with the stigmatising stereotypes associated with mental illness.

Perceived or Felt Stigma:

-Individuals with a potentially stigmatised health condition fear the negative perceptions and
discriminatory behaviour by society.
-Felt stigma describes perceived stigma that is associated with shame.
-Perceived stigma can be measured using the perceived devaluation and discrimination scale (PDD).

Experienced Stigma:
-Actual discrimination and/or restrictions on the part of the person affected.

Ahmed Badat
-Also includes social exclusion and socioeconomic marginalisation of individuals with mental illness.

Label Avoidance:
-Individuals who experience symptoms of mental illness avoid getting in an attempt to avoid the
negative effects of stigma against people with mental illness.

Courtesy Stigma:
-Family, caregivers and MHCP experience stigma due to their association with sufferers of mental
illness.

Institutionalised Stigma:
-Disparities in allocation of resources to mental health services
-Health care workers who have negative attitudes and provide substandard care to mental health care
users.
-Patients are excluded from decision making processes.
-Less likely to receive adequate treatment for their general medical condition.
-The notion held by the general public that mental health care users are violent and dangerous.

Strategies to Address Stigma:

1) Education
2) Protest
3) Contact-based education
4) Legislative reform
5) Advocacy
6) Self-management

Public Mental Health

Basic Principles of Community Based Mental Health Care:

Public Mental Health Care Services (WHO)

Mental Health Services in Primary Care:

-detect and treat common disorders and acute presentation
-promotion and prevention
-delivered by doctors, nurses, community health care workers

General Hospitals:
-District, regional and tertiary academic hospitals
-Provide in and out patient services as well as specialised services e.g. child
-Medical officers, psychiatrists, psychologists, social workers, OT

Institutional Mental Health Services:

-Dedicated psychiatric hospital and specialised institutional services
-Very specialised services like forensic psychiatry.
Ahmed Badat
Community Services:
-To promote community integration
-Rehabilitation centres and support services.
-Can be care provided by informal community members and are a useful complement to
formal services.

Mental Health Policy and Service Delivery in SA:

-Driven by decentralisation of health care (traditionally mental health services were provided
at centralised facilities only, so were not accessible on a community level).
-Efforts have been made to integrate psychiatric care into general and primary health care.
There were challenges to this:
-Mental health services and users were marginalised and stigmatised
-Inadequate training and lack of skills transfer
-Poor collaboration between health, welfare, education and other government and non-
government sectors.

Key Public Health Policies

The SA Mental Health Framework and Strategic Plan

-Prevention and promotion of mental health care for all SA’s through the provision of
evidence based, affordable and effective care.
8 objectives
1) District based mental health care services
2) Advocacy for mental health promotion and prevention
3) Human resources for mental health
4) Building facilities
5) Research innovation
6) Intersectoral collaboration
7) Mental health technology, equipment and medicines
8) Building institutional capacity.

Socio-cultural Psychiatry
Presentation of Distress and Disorders and Cultural Syndromes
Introduction

Ahmed Badat
-One should recognise the impact of a person’s cultural background on the expression of
symptoms as well as their understanding of the illness.
-DSM 5 has aimed for greater cultural sensitivity by updating criteria that reflect cross-
cultural variations in presentations, including cross-cultural variations in presentatoons and a
clinical interview tool.

Cultural Sensitivity:
-Confidentiality when making use of an interpreter
-An awareness of gender issues in certain cultures
-Religious considerations
-Respect for certain ritual obligations

Cultural Syndromes in SA:

-SA has a large variety of cultures and vast differences in cultural perceptions and ritual
expressions.
-Anxiety and depression are expressed differently in some cultures.

Syndrome of Ancestral Calling (Ukuthwasa):

-The calling to become a traditional healer, related to ancestral beliefs.
-Can be associated with dreams of an ancestor, who was a traditional healer, handing over
beads, or other items used by traditional healer’s to the chosen person.
-May also have dreams of disappearing into the river to be in contact with ancestors and then
remerging.
-Traditional healers will identify this calling.
-Mood symptoms are prominent: manic states, depressive episodes, dissociative and somatic
symptoms.
-The length of the process varies, may require animal sacrifices from those undergoing the
process and in most cases some rituals need to be performed before the training can begin.
-The process of training can take weeks to years and may be continuous or intermittent and
therefore requires a strong commitment for the person undergoing it.
-The initiate (umkwetho) may be required to move away from the family subunit to undergo
training by an experienced traditional healer.
-Should illness or misfortune occur, the cause may be attributed to the incomplete process of
training or to not accepting the calling.
-White beads amongst the Xhosa population are an outward representation of an initiate that
has not completed the process.

Bewitchment:
-Belief in witchcraft is common to many cultures in SA and worldwide
-Remains a common explanation for unexplained misfortunes, illnesses, death etc
-Witchcraft beliefs are a potent inducer of unexplained somatic and neurotic symptoms.
-May be difficult to distinguish from a delusion especially if isolated, coherent, in keeping
with cultural beliefs and occurs in the absence of psychotic symptoms.
Ahmed Badat
Amafufunyane:
-A broad construct used to describe a combination of symptoms including:
-hallucinations and delusions
-outbursts of aggression
-hysterical behaviour
-disorientation
-“violent madness”
-It is conceptualised as a manifestation of spirit possession mediated through witchcraft.
-Attacks are frightening and victims are typically young or adolescent females
-May need to be restrained by family to prevent injury

International Cultural Syndromes (few examples)

Amok
-A dissociative state characterised by outbursts of aggressive behaviour directed at people or
objects.
-Often accompanied by persecutory ideas, automatisms, amnesia, exhaustion and a full return
to baseline.
-Usually preceded by brooding and may result in suicide
-Described in far Eastern countries, but seen elsewhere.

Bouffee’ de’lirante
-Syndrome observed in West Africa
-Refers to sudden outburst of agitated and aggressive behaviour and include hallucinations
and paranoia.
-Has been used in France to indicate brief psychotic disorder
-ICD10: acute transient psychotic disorder

Brain fag:
-A term usually used in West Africa to refer to a condition experienced by high
school/university students in response to the challenges of schooling.
-Resulting syndromes can resemble anxiety, depression, somatoform disorders.

Psychosocial Determinants of Mental Illness

-Psychosocial determinants act at multiple levels: individual, family, neighbourhood, society.

-The conditions in which people are born, grow, live, work and age, including the health
system.
-These circumstances are shaped by the distribution of money, power and resources at global,
national and local levels and result in health inequities.

Childhood Adversity:
-A major risk factor for the development of a mental illness across the lifespan.
-Direct experience of trauma and abuse and loss of parents appear to have the most impact.

Ahmed Badat
-Children of parents with mental illness are at risk themselves: genetic vulnerability and may
have poor-parent child interactions.

Family Environment and Support:

-The quality of the family environment and immediate availability of social support is vitally
important for mental health.
-In adulthood, the availability of strong social support is a key contributor to resilience
against mental disorders,
-Older adults who live alone and are socially isolated are at risk of suicide.

Socioeconomic Status:
SASH study (South African Stress and Health Study): low socioeconomic status was
associated with >2 fold increased risk of psychological distress.
-Women in low and middle income countries appear to be especially vulnerable to the effects
of living in poverty.
-A recent decrease in household income is also a predisposing factor

Education, Employment and Work Environment

Adult Adversity
Macro-environmental Level Risk Factors

Urbanicity:
-High rates of schizophrenia have been observed in urban areas and this was originally
ascribed to social drift where individuals with psychosis tend to drift to cities, but this has
been disapproved.
-Growing up in an urban environment is actually a risk factor for developing psychosis

Migration, Ethnicity and Discrimination:

-Migration is a stressful experiences and may be complicated by the extent to which new
neighbourhoods welcome immigrants.
-The risk of mental illness is higher in 2nd generation immigrants.
-Large body of literature confirms that migration is a risk factor for schizophrenia, with
migrants from developing countries at greater risk.

Ahmed Badat
Ahmed Badat