Objective: This study used data from the South African Stress and Health Study (SASH) to examine both structural and attitudinal barriers to treatment initiation among South Africans with mental disorders and to investigate predictors of treatment dropout. Methods: Face-to-face interviews were conducted with 4,315 adult South Africans living in households or hostel quarters. The interview included a core diagnostic assessment of past-12-month mental disorders and assessments of disorder severity, service use, and barriers to treatment. Multivariate logistic regression models were used to determine predictors of not seeking treatment in relation to disorder severity and sociodemographic characteristics, as well as factors that were predictive of premature treatment discontinuation by participants who had received mental health treatment in the previous 12 months. Predictors of dropout were identified by cross-tabulation and discrete-time survival analysis. Results: Of the 4,315 adults, 729 (16.9% weighted) met criteria for a mental disorder in the past 12 months. Across all levels of severity, the most frequently cited reason for not seeking professional treatment was a low perceived need for treatment. Among those who recognized the need but did not access treatment during the past 12 months (7.2%), attitudinal barriers to treatment seeking were reported more commonly than structural barriers (100% and 34%, respectively). Of the 182 respondents who received treatment (25% weighted), 20% discontinued prematurely. Various factors, such as substance use disorders and absence of health insurance, increased the odds of treatment dropout. Conclusions: Low rates of treatment seeking and high treatment dropout rates for common mental disorders among South Africans are a major concern. Public health efforts to improve treatment of mental disorders should consider the multiple influences on treatment initiation and discontinuation. (Psychiatric Services 62:774–781, 2011)

peer reviewed

Anxiety disorders are considered to be the most prevalent of the psychiatric disorders, with generalized anxiety disorder (GAD) being one of the most common in primary care practice. GAD is a chronic and disabling disorder, which is frequently underdiagnosed and undertreated. It is characterized by both psychic symptoms (particularly worry) and somatic symptoms, and often complicated by comorbid conditions such as depression. Agomelatine, the first melatonergic antidepressant, has been shown to be effective and well tolerated, not only in treating major depressive disorder, but also in treating the anxiety symptoms of depression. These findings give impetus to investigation of its potential anxiolytic properties in GAD. Two randomized, double-blind, placebo-controlled studies assessed the efficacy of agomelatine in GAD. The first, a 12-week study, used the HAM-A total score as the primary outcome measure. In the second, a relapse prevention study, the responders to a 16-week open treatment period with agomelatine were randomized to maintenance treatment with either agomelatine or placebo for a 26-week period. In the short-term treatment of GAD, 1 agomelatine was superior to placebo with a HAM-A total score difference of 3.28 (P = 0.04). In the maintenance treatment of GAD, the incidence of relapse was significantly lower with agomelatine than with placebo. Agomelatine was well tolerated in both trials. In summary, these studies showed that the novel antidepressant agomelatine is also efficacious in the treatment of GAD.

There is an urgent need for valid, reliable, and simple-to-use screening tools for HIV-associated dementia (HAD) in South Africa, as little is known about its impact on South Africa's 5.5 million people living with HIV (PLWH). Screening for HAD in South Africa involves several challenges, including few culturally appropriate and validated screening tools, and a shortage of trained personnel to conduct screening. This study examined rates of positive HAD screens as determined by the cutoff score on the International HIV Dementia Scale (IHDS) administered by nonspecialist community health workers (CHWs) in South Africa and examined associations between positive HAD screens and common risk factors for HAD. Sixty-five Xhosa-speaking HIV-positive individuals on antiretroviral therapy (ART) with low CD4 counts and documented ART adherence problems were administered a battery of demographic, psychiatric and neurocognitive screening measures. Positive HAD screens were present in 80% of the sample. Presence of a current alcohol dependence disorder and CD4 counts of 200 or lower were significantly associated with positive HAD screens. HIV-positive South Africans on ART with low CD4 counts and ART adherence problems may be at a very high risk for HAD, highlighting the need for more routine screening and monitoring of neurocognitive functions among South Africa's millions of PLWH on ART. Future research is needed to: (1) validate IHDS performance against a gold standard neurocognitive battery for the detection of HAD among larger samples of Xhosa-speaking South Africans with ART adherence difficulties and (2) compare performance of CHW to expert health care personnel in administering the IHDS.

Partner violence against women is a significant public health problem in South Africa, associated with health-risk behaviours and increased use of medical services. Public health programmes should incorporate interventions to mitigate the impact of violence on victims and reduce the risk of negative behavioural outcomes. Further investigation of the pathways between violence exposure and health behaviours is needed to inform the design of such programming.

Background Although many studies have indicated that psychosocial factors contribute to hypertension, and that early childhood adversity is associated with long-term adverse mental and physical health sequelae, the association between early adversity and later hypertension is not well studied. Method Data from 10 countries participating in the World Health Organization (WHO) World Mental Health (WHM) Surveys (N = 18,630) were analyzed to assess the relationship between childhood adversity and adult-onset hypertension, as ascertained by self-report. The potentially mediating effect of early-onset depression-anxiety disorders, as assessed by the WHM Survey version of the International Diagnostic Interview (WMH-CIDI), on the relationship between early adversity and hypertension was also examined. Results Two or more early childhood adversities, as well as early-onset depression-anxiety, were significantly associated with hypertension. A range of specific childhood adversities, as well as early-onset social phobia and panic/agoraphobia, were significantly associated with hypertension. In multivariate analyses, the presence of 3 or more childhood adversities was associated with hypertension, even when early-onset depression-anxiety or current depression-anxiety was included in the model. Conclusions Although caution is required in the interpretation of selfreport data on adult-onset hypertension, the results of this study further strengthen the evidence base regarding the role of psychosocial factors in the pathogenesis of hypertension.