The objective of the study was to assess level of knowledge and attitudes of SUDEP among people living with epilepsy (PLWE) and healthcare workers providing epilepsy care in Uganda.This cross-sectional study of 48 PLWE and 19 epilepsy care providers used a tailored questionnaire to evaluate epilepsy and SUDEP knowledge, frequency of SUDEP discussion, reasons for not discussing SUDEP, timing of SUDEP discussions, and perceived patient reactions to being provided information on SUDEP.Median PLWE sample age was 25 (IQR; 19-34) years, 10 (20.8%) were male, median age of onset of epilepsy 12 (IQR; 6-18) years. Half of the PLWE reported that they had never heard of SUDEP. Most PLWE desired detailed information regarding SUDEP and preferred this information during the subsequent visits. Healthcare provider sample mean age was 35.7 (22.8) years, 12 (63.2%) were male and composed of 4 physicians (21.1%). Only 15% (3/20) of providers discussed SUDEP with their patients while 85% (17/20) have never discussed it. The main reasons for not discussing SUDEP were not knowing enough about SUDEP (89.5%) and no adequate support network available (30%). Providers that discussed SUDEP (100%) reported that negative reactions were the most common patient response.In this Ugandan sample, most PLWE are not aware of SUDEP and epilepsy care providers rarely discuss SUDEP with their patients or patient caregivers. Negative reactions to SUDEP discussions are common but not universal. There is an urgent need for epilepsy educational programs in clinics and targeted communities addressing SUDEP.
Abstract Background Opioid use disorder among adolescents with sickle cell disease (SCD) patients increases their risk of complications from sickle cell disease such as infections, stroke, acute chest syndrome, sudden death, and organ failure. This not only has a negative impact on families and communities but also to the national health system and economy. Aim This study aimed to determine the prevalence and factors associated with opioid use disorder among adolescents with SCD at Mulago Hospital Uganda. Setting This study was carried out at the Sickle Cell Clinic of Mulago Hospital, the national referral hospital in Uganda Methods Study participants were adolescents aged 10-19years. Following informed consent/ assent, a sociodemographic questionnaire, the WHO Alcohol, Smoking and Substance Involvement Screening Test- Young (ASSIST-Y), the Beck Depression Inventory II (BDI II), and Generalized Anxiety Disorder-7 (GAD-7) questionnaires were used to collect data. Data was entered in EpiInfo and analyzed in STATA 15. Results We enrolled 384 participants and after cleaning of data, our final sample size included 381 participants. The prevalence of opioid use disorder was 5.3%. The significant risk factor was increasing depressive score OR: 1.11(95% CI: 1.01-1.22, p=0.035), while living with a family was protective against opioid use disorders OR: 0.01; (95% CI: 0.0004, 0.27, p=0.007). Conclusion: There was a significant problem of Opioid Use Disorder among adolescents with Sickle Cell Disease. There is therefore need to integrate screening of OUD and mental illness like depression among adolescents with SCD and to emphasize the importance of family support in their care.
Introduction: Chronic pain classification in HIV positive patients is essential for diagnosis and treatment. However, this is rarely done despite association with poor outcomes.Methods: A cross-sectional survey of 345 consented patients at a specialized HIV care center in Uganda was conducted. Chronic pain was defined as pain of more than two weeks duration. Data was collected using a socio-demographic questionnaire, the IASP classification of chronic pain; the StEP; Mini Mental Status Examination, Patient Health Questionnaire, Mini International Neuropsychiatric Interview and the World Health Organization quality of life instrument brief version. Chi-square, Fisher’s exact, t-test and logistic regression analyses were carried out to determine factors associated with chronic pain.Results: Description of pain aetiology was difficult. Chronic pain was reported in 21.5% of the participants. Non-neuropathic (92.0%) was more common than neuropathic pain (8.0%). Chronic pain was found to be associated with feeling ill [OR=6.57 (3.48 – 12.39)], and worse scores in the quality of life domain for physical health [OR=0.71 (0.60 – 0.83)].Conclusion: People living with HIV/AIDS commonly have chronic pain that is associated with poor quality of life. More sensitive tools are needed to accurately describe chronic pain in resource limited settings.Keywords: Chronic pain, classification, HIV/AIDS.
Neuropsychiatric disorders are a major contributor to functional impairment and mortality in low-income and middle-income (LMIC) settings, such as sub-Saharan Africa.1Patel V Chisholm D Parikh R et al.Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities.Lancet. 2016; 387 (3rd edition): 1672-1685Summary Full Text Full Text PDF PubMed Scopus (408) Google Scholar Given the increasing population size and life expectancy in this region, years lived with disabilities associated with psychiatric diseases are estimated to double in the next 30 years.2Charlson FJ Diminic S Lund C Degenhardt L Whiteford HA Mental and substance use disorders in sub-Saharan Africa: predictions of epidemiological changes and mental health workforce requirements for the next 40 years.PLoS One. 2014; 9: e110208Crossref PubMed Scopus (72) Google Scholar To compound the severity of these statistics, available treatment options are largely ineffective, only yielding desirable results in about 50% of cases.3Insel TR Translating scientific opportunity into public health impact: a strategic plan for research on mental illness.Arch Gen Psychiatry. 2009; 66: 128-133Crossref PubMed Scopus (387) Google Scholar Despite the clinical burden and high heritability of neuropsychiatric disorders, their genetic backgrounds are poorly understood. Furthermore, populations of African ancestry are substantially under-represented in global research of neuropsychiatric genetics.4Duncan LE Ratanatharathorn A Aiello AE et al.Largest GWAS of PTSD (n=20 070) yields genetic overlap with schizophrenia and sex differences in heritability.Mol Psychiatry. 2017; (published online April 25.)DOI:10.1038/mp.2017.77Crossref PubMed Scopus (241) Google Scholar, 5Dalvie S Koen N Duncan L et al.Large scale genetic research on neuropsychiatric disorders in African populations is needed.EBioMedicine. 2015; 2: 1259-1261Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 6Schizophrenia Working Group of the Psychiatric Genomics ConsortiumBiological insights from 108 schizophrenia-associated genetic loci.Nature. 2014; 511: 421Crossref PubMed Scopus (5107) Google Scholar From a scientific perspective, the study of modern African genomes might provide key insights into gene discovery and mapping of disease-associated variants.7Hansen ME Hunt SC Stone RC et al.Shorter telomere length in Europeans than in Africans due to polygenetic adaptation.Hum Mol Genet. 2016; 25: 2324-2330Crossref PubMed Scopus (70) Google Scholar, 8Hassanein MT Lyon HN Nguyen TT et al.Fine mapping of the association with obesity at the FTO locus in African-derived populations.Hum Mol Genet. 2010; 19: 2907-2916Crossref PubMed Scopus (68) Google Scholar The genetics of African populations, which feature increased allelic variability and reduced linkage disequilibrium compared with European populations, might reveal the missing layer of human variation that arose between 100 000 and 5 million years ago.9McClellan JM Lehner T King MC Gene discovery for complex traits: lessons from Africa.Cell. 2017; 171: 261-264Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar From a clinical perspective, discovering the genetic make-up of these populations is integral to addressing global inequities in neuropsychiatric service delivery and health-care infrastructure and to translating empirical data into public health interventions in sub-Saharan Africa. To date, advancements in neuropsychiatric genetics research in sub-Saharan Africa have been limited by low capacity—funding availability, appropriate infrastructure, and qualified researchers are under-represented in African institutions compared with counterparts in high-income countries (HICs). To improve representation of African institutions in neuropsychiatric genetics research, researchers and funding bodies should prioritise projects involving collaborations between institutions in HICs and LMICs that contain a capacity-building component. Initiatives such as Human Hereditary and Health in Africa (H3Africa), the International Brain Research Organization (IBRO), and the Wellcome Trust Developing Excellence in Leadership, Training, and Science Initiative (DELTAS) programme have been invaluable in building these collaborations and in providing genomics-related research training opportunities for researchers from African institutions.10Rotimi C Abayomi A Abimiku A et al.Research capacity. Enabling the genomic revolution in Africa.Science. 2014; 344: 1346-1348Crossref PubMed Scopus (253) Google Scholar Training events, online courses, and workshops have provided unprecedented learning strategies for medical, bioinformatics, and public health education in LMICs. However, most of the existing training components are often developed without input from prospective trainees, not specifically focused on neuropsychiatric genomics, and convened over a restricted time period. Therefore, a tailored approach, wherein researchers from the targeted populations continuously participate in defining neuropsychiatric training needs, might add value to the established methods through ensuring ownership and effectiveness of research training programmes. The Global Initiative for Neuropsychiatric Genetics Education in Research (GINGER) programme seeks to address these limitations. GINGER is a collaboration between the Stanley Center for Psychiatric Research at the Broad Institute of Massachusetts Institute of Technology and the Harvard T H Chan School of Public Health, and several academic institutions in sub-Saharan Africa (University of Addis Ababa, Ethiopia; University of Cape Town and Stellenbosch University, South Africa; Moi University and the Kenya Medical Research Institute, Kenya; and Makerere University, Uganda). Comprising 17 investigators from these countries, GINGER aims to enhance the capacity of neuropsychiatric genetics research in Africa by training early-career researchers in genetics analysis, psychiatric phenotyping, epidemiology, bioinformatics, biostatistics, ethics, and manuscript and grant writing. A unique feature of the 2 year GINGER programme is the active participation of the fellows and African mentors in selection of programme topics on the basis of the individual and collective needs of the fellows and their host institutions. Intra-African networking and collaborations are strongly encouraged to expand the training and capacity-building of the first GINGER cohort and to contribute to innovative research driven by African investigators. Furthermore, the initiative seeks to increase the awareness of key stakeholders and policy makers about the burden of neuropsychiatric disorders in sub-Saharan Africa. The first cohort of GINGER fellows aims to establish an interdisciplinary group of African researchers, with the potential for sustainability beyond GINGER. Through continued conversations, skills building, and collaborative efforts between African institutions, this group will be equipped to produce first-class research equal to that produced in HICs. This Comment, therefore, serves as a call to action to develop and reaffirm the relationships needed to study neuropsychiatric genetics research in Africa. Improved characterisation of the prevalence and molecular causes of neuropsychiatric disorders in Africa might lead to development of population-specific and individual-specific treatment methods. These discoveries might ultimately improve global health-care strategies. We thank Lori Chibnik, Bizu Gelaye, Kristianna Post, and Wairimu Mwaura at GINGER, and Karestan Koenen at NeuroGAP. We declare no competing interests.
Abstract Introduction Most patients with psychotic disorders in Africa initially use alternative and complementary therapies leading to delays accessing evidence-based treatments. This delay, known as the duration of untreated psychosis (DUP), is associated with suboptimal response and reduced efficacy in short-term and long-term outcomes. In this study, we explore facilitators for transitioning from alternative and complementary therapies to evidence-based treatments for psychotic disorders, comparing these facilitators between patients and their caregivers. Methods The study was conducted at Butabika hospital in Kampala, Uganda. Participants included patients with first-episode psychosis who had used alternative and complementary therapies and their caregivers. An exploratory qualitative design using in-depth interviews was performed with thematic analysis used to analyze the data. Results We interviewed eight patients and eight caregivers. The key themes that led to a switch were the high cost of alternative therapies, a desire to know the cause of the illness, seeking better care and the influence of friends and community members. Themes were similar among the participants and their caregivers except for stigma, which was only found among the caregivers. Conclusions The reasons for transitioning from alternative and complementary therapies to evidence-based treatments are similar between patients and caregivers, except for stigma that is a more important factor for transition among caregivers. Since this was an exploratory study, additional research with a larger sample and more diverse population would enable a deeper understanding of these factors and guide the development of interventions to reduce DUP and improve outcomes for psychotic disorders.
Neurocognitive impairment (NCI) is commonly exhibited among patients experiencing their first episode of psychosis. However, there are few resources in many low-income countries, such as Uganda, that allow for the administration of extensive neurocognitive test batteries for the detection of NCI. NeuroScreen is a brief tablet-based neurocognitive assessment battery that can be administered by all levels of healthcare staff. We examined the validity of NeuroScreen to assess neurocognition and detect NCI in first-episode psychosis (FEP) patients in Uganda.We enrolled 112 participants FEP patients and matched controls at Butabika Mental Referral Hospital. Each participant completed NeuroScreen and a traditionally administered neurocognitive battery: the MATRIC Consensus Cognitive Battery (MCCB). We examined correlations between participant performance on NeuroScreen and the MCCB. A ROC curve determined sensitivity and specificity of NeuroScreen to detect NCI as determined by MCCB criterion.There was a large, statistically significant correlation between overall performance on NeuroScreen and the MCCB [r(112) = 0.64, p < .001]. Small to large correlations were found between tests in the MCCB and NeuroScreen batteries. The ROC curve of NeuroScreen performance to detect MCCB-defined NCI had an area under curve of 0.80 and optimal sensitivity and specificity of 83 % and 60 %, respectively.There was a moderate positive correlation between overall performance on both batteries. NeuroScreen shows promise as a valid assessment battery to assess neurocognition and detect NCI in FEP patients in Uganda. Further studies of NeuroScreen in healthy individuals and in a range of mental disorders are recommended.
Individual and group level interventions have the largest effect on outcomes in patients with the first episode of psychosis. The quality of these individual and group level interventions provided to first-episode psychosis patients in Uganda is unclear.To determine the quality of the individual and group level interventions provided to first episode psychosis patients in Uganda.The study was performed at the only tertiary psychiatric hospital in Uganda.A retrospective chart review of recently discharged adult in-patients with the first episode of psychosis was performed. The proportion of participants who received different essential components for individual and group level interventions were calculated. From the different proportions, the quality of the services across the individual and group interventions was determined using the first-episode psychosis services fidelity scale (FEPS-FS). The FEPS-FS assigns a grade of 1-5 on a Likert scale depending on the proportion of patients who received the different components of the intervention. Twelve essential components across the individual and group interventions were assessed and their quality quantified.The final sample included 156 first-episode psychosis patients. The median age was 27 years (inter-quartile range [IQR] [24-36]) and 55% of the participants were female. All 12 essential components had poor quality with the range of scores on the FEPS-FS between one and three. Only one essential component assessed (use of single antipsychotics) had moderate quality.Amongst current services at the Butabika National Referral Mental Hospital in Uganda, the essential components for individual and group level interventions for psychotic disorders are of poor quality. Further studies are required on how the quality of these interventions can be improved.
Depression with pain comorbidity (DPC) has not been clearly defined among HIV positive patients in sub-Saharan Africa. It still remains a challenge despite many studies in Africa documenting a high prevalence of pain and depression among people living with HIV/AIDS. Both are associated with a grave impact on the health related outcomes in this pandemic. This study aimed at determining the prevalence, factors associated and effect on quality of life of DPC among HIV positive patients. In a cross-sectional survey, 345 HIV positive patients were enrolled into the study. Using a pre-tested standardised questionnaire the presence of DPC was assessed after a written informed consent. The associations between DPC, quality of life, depression history, severity, and cognition were determined. A p-value of <0.05 was considered to be significant. Among people living with HIV/AIDS (PLWHA), the prevalence of DPC was about 5 %. PLWHA with DPC were more likely to perceive their overall quality of life as poor and scored poorly in all the domains on the WHOQOL-BREF. They were also more likely to have more severe forms of depression and recurrent episodes of depression. DPC is common, under diagnosed and undertreated in PLWHA in Uganda. Depression and pain screening as well as appropriate access to care for DPC have potential to improve quality of life and health outcomes. This calls for the integration and training of mental health services into HIV/AIDS care and future efforts by policy makers and HIV caregivers to address this treatment gap to advance the care of people living with HIV in Uganda.
ABSTRACT Introduction Hospital based studies for psychotic disorders are scarce in low and middle income countries. This may impact on development of intervention programs. Objective We aimed to determine the burden of psychotic disorders among first treatment contact patients at the national psychiatric referral hospital in Uganda. Methods A retrospective patient chart-file review was carried out in March 2019 for all patients presenting to the hospital for the first time in the previous year. Patients were categorised into those with and without psychotic disorders. We collected sociodemographic data on age, gender, occupation, level of education, ethnicity, religion and home district. We determined the one year prevalence of psychotic disorders among first treatment contact patients. Using logistic regression models, we also determined the association between psychotic disorders and various exposure variables among first treatment contact patients. Results In 2018, 63% (95% CI: 60.2 – 65.1) of all first time contact patients had a psychosis related diagnosis. Among the patients with psychotic disorders, the median age was 29 years (IQR 24 – 36). Most of the patients were male (62.8%) and unemployed (63.1%). After adjusting for patients’ residence, psychotic disorders were found to be more prevalent among the female gender [OR 1.58 (CI1.46-1.72)] and those of Pentecostal faith [OR 1.25 (CI 1.10-1.42)]. Conclusion Among first treatment contact patients in Uganda, there is a large burden of psychotic disorders. The burden was more prevalent among females as well as people of Pentecostal faith who seemed to use their church for faith-based healing. Incidence studies are warranted to determine if this phenomenon is replicated at illness onset.
As seen elsewhere, the COVID-19 pandemic in Africa has created an urgent need for an isolated space in which to manage patients with COVID-19. In high-income countries such as China, the UK, and the USA, standalone units were built to cater for the extra isolation space required to manage a surge in COVID-19 confirmed cases. In much of Africa, building such units was not possible because of financial, infrastructural, and human resource constraints.1Ssebunnya J Kangere S Mugisha J et al.Potential strategies for sustainably financing mental health care in Uganda.Int J Ment Health Syst. 2018; 12: 74Crossref PubMed Scopus (9) Google Scholar Mental health units that conventionally stand alone, far from other health services, were deemed appropriate for the isolation of patients with COVID-19. In Uganda, the only national referral inpatient mental health unit (Butabika Hospital, Kampala, Uganda) has only 638 inpatient psychiatric beds for a population of almost 50 million people. Between Jan 1 and Dec 31, 2018, the bed occupancy rate of Butabika Hospital was 149%.2Mwesiga EK Nakasujja N Nakku J et al.One year prevalence of psychotic disorders among first treatment contact patients at the National Psychiatric Referral and Teaching Hospital in Uganda.PLoS One. 2020; 15e0218843Crossref PubMed Scopus (17) Google Scholar Even with such a high demand for beds in Butabika Hospital, lower level regional psychiatric units were converted into isolation units for COVID-19.3The IndependentSoroti hospital creates more space for COVID-19 patients.https://www.independent.co.ug/soroti-hospital-creates-more-space-for-covid-19-patients/Date: June 13, 2020Date accessed: February 6, 2021Google Scholar The transformation of psychiatric units into isolation centres in low-income countries such as Uganda requires mental health providers to adopt new care models that do not involve these standalone units. Models for community mental health care, such as integrating psychiatric care into everyday clinical practices, are crucial during this pandemic. Integrated mental health care is an attempt to combine behavioural health services wholly or partly with general and specialty medical services.4Wakida EK Okello ES Rukundo GZ et al.Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers.Int J Ment Health Syst. 2019; 13: 16Crossref PubMed Scopus (18) Google Scholar Care models that ensure staff and patient safety while managing psychiatric and non-psychiatric patients together should also be promoted. For example, the Safewards model aims to reduce conflict between patients and health-care workers so that coercive or restrictive measures are not put in place.5Gerdtz M Daniel C Jarden R Kapp S Use of the Safewards Model in healthcare services: a mixed-method scoping review protocol.BMJ Open. 2020; 10e039109Crossref PubMed Scopus (4) Google Scholar Musisi and colleagues have even argued for the introduction of outreach mobile mental health clinics.6Okpaku SO Essentials of global mental health. Cambridge University Press, Cambridge2014Crossref Google Scholar Community mental health care needs to become the primary form of care for patients with psychiatric illness in African countries both during and after the COVID-19 pandemic. With a surge of the pandemic in African countries, the need for isolated spaces and the alternative use of inpatient psychiatric beds for patients with COVID-19 are only expected to rise. An expected increase in the incidence of mental health-related complications will also pose a challenge because of the inadequate space; yet existing patients need ongoing care. Now rather than later, a discussion of community models of care for patients with mental illness need to be expedited. Because of the insufficient financing available before the onset of the COVID-19 pandemic, alternative care models were never fully developed in low-resource settings such as Uganda.1Ssebunnya J Kangere S Mugisha J et al.Potential strategies for sustainably financing mental health care in Uganda.Int J Ment Health Syst. 2018; 12: 74Crossref PubMed Scopus (9) Google Scholar More substantial funding is required to scale up community mental health services, integrated care, and the Safewards model. This scale-up will ensure that after the COVID-19 pandemic, health systems can help reduce the possibility of a second pandemic, this time of mental illness. We declare no competing interests.
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