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Papers by SUVIRA RAMLALL

Research paper thumbnail of Depression, anxiety and stress symptoms in patients presenting with dyspepsia at a regional hospital in KwaZulu-Natal province

South African Journal of Psychiatry, 2019

Background: Depression, anxiety and stress (DAS) have been shown to be co-morbid with dyspepsia. ... more Background: Depression, anxiety and stress (DAS) have been shown to be co-morbid with dyspepsia. Local data on the factors associated with these co-morbidities could inform the role of psychiatric intervention in affected patients.Aim: The aim of this study was to describe the frequency of undiagnosed DAS and their associated protective and risk correlates in a sample of patients undergoing endoscopies for dyspepsia.Setting: The study was conducted at a regional hospital’s gastro-intestinal unit in KwaZulu-Natal province.Method: A cross-sectional survey was conducted on 201 in- and outpatients with symptoms of dyspepsia awaiting endoscopy. Information on DAS symptomatology (using the DASS-21 screening questionnaire, as well as socio-demographic and clinical data) were collected.Analyses: Following a descriptive analysis of the participants’ socio-demographic and clinical details, linear regression models were fitted to identify potential risk and protective correlates linked to DAS ...

Research paper thumbnail of Neuropsychological functioning and cognitive reserve in newly HIV diagnosed antiretroviral-naïve South African adults from peri-urban and informal settlements

PLOS ONE

Despite lower incidences of HIV-associated dementia due to antiretroviral therapy, neuropsycholog... more Despite lower incidences of HIV-associated dementia due to antiretroviral therapy, neuropsychological impairment (NPI) remains a persistent challenge in sub-Saharan Africa. Improving cognitive reserve (CR) can mitigate NPI, but there are few investigations on neuropsychological (NP) performance, and its association with CR in newly diagnosed ART-naïve HIV-positive individuals to inform early treatment strategies. A comprehensive battery of tests were administered to assess various NP domains (International HIV Dementia Scale [for memory, motor speed, psychomotor speed], Digit Span Test [for attention], Action Fluency Test [for language] and Clock Drawing Test [for executive/visuospatial function]), and CR (using Cognitive Reserve Index Questionnaire) among 211 newly diagnosed ART-naïve HIV-positive participants from two clinics that serve peri-urban and informal settlement communities in KwaZulu-Natal, South Africa. Regression models were fitted to assess the association between NP ...

Research paper thumbnail of Knowledge, beliefs and mental treatment seeking practices of Black African and Indian outpatients in Durban, South Africa

Mental illness is a major contributor to the global burden of disease in the world. Patients’ kno... more Mental illness is a major contributor to the global burden of disease in the world. Patients’ knowledge of mental illness and their treatment options play an important role in the effectiveness of service delivery and health outcomes in developing countries. The objectives of this study were to assess the knowledge, attitudes and beliefs of mental health outpatients about mental illness and its treatment, and their knowledge and satisfaction with traditional and Western/allopathic health systems. A self-designed questionnaire was used to assess the knowledge, attitudes and beliefs of mental health patients about mental illness and its treatment. Of the 157 outpatients who identified themselves as having a mental illness, 77.7% were aware of their condition, 33.8% only knew it as a mental illness and 21.5% patients did not know what caused their mental illness. Of the 195 patients interviewed, the majority (76.9%) preferred Western treatment, believing that taking medication would he...

Research paper thumbnail of The Impact of Antiretroviral Therapy on Neurocognitive Outcomes Among People Living with HIV in Low- and Middle-Income Countries (LMICs): A Systematic Review

AIDS and Behavior, 2020

Low and middle-income countries (LMICs) are the epicenter of the HIV epidemic. The scale-up of an... more Low and middle-income countries (LMICs) are the epicenter of the HIV epidemic. The scale-up of antiretroviral therapy (ART) has reduced mortality, but HIV-associated neurocognitive impairment (HANI) remains prevalent, which impacts functional performance, medication adherence, and quality of life. We aimed to evaluate the effect of ART on neurocognitive outcomes among people living with HIV/AIDS in LMICs and to identify determinants of these outcomes. We searched electronic databases and reference lists for studies published between 1996 and 2019. Two reviewers screened the primary studies for inclusion and performed the critical appraisal. Results were synthesized using the 'Synthesis without metaanalysis' approach through simple vote counting. We identified 31 studies conducted across four regions (Africa, Asia, South America, and Eastern Europe). Nine studies were cross-sectional, 15 were prospective, and seven were randomized controlled trials. The majority of the articles showed improved neurocognitive performance with ART use but found no association with treatment duration, regimen, central penetrating effectiveness, and conventional biomarkers. Despite the lack of appropriate norms and not accounting for practice effect in most studies, the evidence suggests ART is useful in the treatment of HIV-associated neurocognitive impairment (HANI) but limited in addressing legacy effects, and peripheral, and central viral reservoirs. Improved early ART treatment programs, viral reservoir eradication strategies, and identification of novel biomarkers will be critical in efforts to minimize HIV-associated neurocognitive impairment. PROSPERO registration: CRD42020152908.

Research paper thumbnail of A profile of social isolation and the influence of demographics in older persons living in residential care, Durban, South Africa

International Journal of Africa Nursing Sciences, 2021

Introduction: Residential care settings have shown high social isolation rates with incumbent ris... more Introduction: Residential care settings have shown high social isolation rates with incumbent risks necessitating measurement to formulate health promotion policies. Objective: To measure social isolation levels in older persons living in a lower socioeconomic residential care setting in South Africa. Method: A cross sectional survey with older persons from four inner city residential care facilities. A researcheradministered questionnaire was developed based on the Working Paper No.66, Oxford Poverty and Human Development Initiative. Data were analysed to describe social isolation and assess the influence of demographics. Results: The response rate was 72.14% (n = 277) and representative of the residential care population for age and gender. Nearly half of the respondents (47.3%) met criteria for social isolation in terms of social network support and density and almost 20% for perceived isolation through decreased levels of friendship. Conclusion: Although residential care does not prevent social isolation, the residents in the setting may provide a buffering in the provision of some social support.

Research paper thumbnail of The association of depressive symptoms in patients with acute myocardial infarction in a regional hospital in Durban, South Africa

SA Heart, 2018

Objective: To examine the association of depressive symptoms and contributing psychosocial factor... more Objective: To examine the association of depressive symptoms and contributing psychosocial factors during hospitalisation and 1-month post discharge in patients with acute myocardial infarction (MI). Methods and results: The study population comprised consecutive patients from a multi-ethnic background, admitted June 2015-November 2015 to the Coronary Care Unit at R. K. Khan Hospital, Durban, South Africa, with a diagnosis of MI. Demographic and clinical data stored in a specialised electronic cardiac database were extracted for all patients. Patients were screened for depressive symptoms using the Cardiac Depression Scale (CDS). Levels of perceived stress were evaluated using the 4-item Perceived Stress Scale (4-PSS). The study cohort consisted of 117 patients with a mean age of 58.16 ± 11.12 years, the majority of whom were males (70%, mean age 56.54 ± 1.23 years) and 30% females (mean age 61.97 ± 1.75 years). Forty-nine percent of the participants were diagnosed with depressive symptoms with a signifi cantly greater number of females experiencing depressive symptoms compared to males (p <0.01). Patients with depressive symptoms were more likely to have a previous history of depression (p=0.02), positive family history of depression (p=0.04), greater non-adherence to their medication (p <0.01) and lower levels of physical activity (p <0.01). Depressed patients also reported higher levels of stress on voluntary (p <0.01) and subjective rating (p <0.01), experienced greater fi nancial stress (p <0.01), major life events (p <0.01) and had higher 4-PSS scores (p <0.01). Thirteen percent of patients experienced major adverse cardiac events (MACE) with a significantly greater number of events found in those with depressive symptoms (p <0.01). Conclusion: Depressive symptoms are a common fi nding in a South African population presenting with MI. They are linked to higher rates of MACE, a previous history and/or family history of depression, greater stress levels and major life events. Females with MI are signifi cantly more likely to present with depressive symptoms. These fi ndings suggest that patients with MI should be screened for depressive symptoms and psychosocial factors as this may serve as an important arena for research and therapeutic intervention.

Research paper thumbnail of Doctorates by thesis and publication in clinical medicine: An analysis of examiners’ reports

Perspectives in Education, 2020

This paper analyzes the effects of credit card holding on the structure and distribution of house... more This paper analyzes the effects of credit card holding on the structure and distribution of household expenditure in Mexico in 2016. To the effect, two-stage quantile regressions are used to estimate models for consumption determinants, using instrumental variables on credit card holding. The study evidences that credit cards have a positive effect on aggregate consumption, driven mainly by increased health expenditure and items such as clothing,

Research paper thumbnail of The effectiveness of e-Interventions on reducing social isolation in older persons: A systematic review of systematic reviews

Journal of Telemedicine and Telecare, 2017

As the older adult population group has been increasing in size, there has been evidence of growi... more As the older adult population group has been increasing in size, there has been evidence of growing social isolation and loneliness in their lives. The increased use of information communication technology and Internet-supported interventions has stimulated an interest in the benefits of e-Interventions for older people and specifically in having a role in increasing social networks and decreasing loneliness. A systematic review of e-Interventions to reduce loneliness in older people was conducted with the aim to synthesize high quality evidence on the effectiveness of e-Interventions to decrease social isolation/loneliness for older people living in community/residential care. A systematic search of 12 databases for reviews published between 2000–2017 was conducted using search term synonyms for older people, social isolation and interventions. Three independent researchers screened articles and two reviewers extracted data. The Revised-Assessment of Multiple Systematic Reviews was...

Research paper thumbnail of Depression in older adults: prevalence and risk factors in a primary health care sample

South African Family Practice, 2017

Background: Depression in the geriatric population has been identified as a significant problem i... more Background: Depression in the geriatric population has been identified as a significant problem in view of the associated negative outcomes regarding poor functioning, increased perception of poor health and increased utilisation of medical services. Significantly associated with increased morbidity and mortality, depression has been found to be an independent cause of disability as well as adding to disability due to primary physical illnesses. Early identification and treatment of depression reduces medical costs and lessens caregiver burden. Epidemiological data and prevalence rates of geriatric depression in Africa are limited, although such data are vital to mobilise and plan government mental health initiatives aimed at screening and early intervention. Objective: To determine the prevalence of depression and associated clinical and socio-demographic factors amongst older adult patients attending a primary health care clinic in the Ethekwini District in Kwa-Zulu Natal, South Africa. Methods: The 15-item Geriatric Depression Scale and a socio-demographic questionnaire were administered in English to 255 geriatric outpatients, randomly selected, at a local community clinic in Durban. Data analysis: Data were analysed using SPSS version 23®. Descriptive statistics were used to summarise the sample demographics and response rate and non-parametric statistics were used to test for associations and differences. Results: A Cronbach's alpha for the GDS was calculated (p = 0.793). Some 40% of participants screened positive for depression. Female gender, widowhood and a negative subjective health status rating were significantly associated with depression and marriage appeared to be protective (p < 0.001). Participants with a poor subjective health rating were 21 times more likely to be depressed and widowhood conferred an almost fourfold increased risk of being depressed, with widows at greater risk than widowers. No association between depression and specific medical conditions was identified. Conclusion: There is a high rate of undetected depression among the elderly attending a local primary health care clinic with widowhood and poor subjective health being strong predictors of mood disorders. The findings warrant replication in bigger samples.

Research paper thumbnail of Research competency and specialist registration: Quo vadis ?

South African Medical Journal, 2016

with Prof. Szabo the immediate past president and Dr Ramlall immediate past and current secretary... more with Prof. Szabo the immediate past president and Dr Ramlall immediate past and current secretary. Both have been involved in revision to the College's regulations and contributing to the blueprinting process, and are actively involved in postgraduate training at their respective institutions. The article reflects their collective and personal understanding of the issue.

Research paper thumbnail of Screening for and diagnosing dementia in an elderly residential home population : a validation study

Background: With the projected increase in the elderly population and expected rise in the preval... more Background: With the projected increase in the elderly population and expected rise in the prevalence of dementia, particularly in low-and-middle-income countries, early caseidentification is necessary for planning and delivering clinical services. The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aims of this research study were to report on the prevalence of cognitive impairment (dementia and Mild Cognitive Impairment-MCI), and to assess the performance of selected screening tools and a neuropsychological battery of tests in a heterogeneous local population. Methodology A cross-sectional study was conducted in a heterogeneous elderly South African population and consisted of three stages of data collection. In the first stage, cognitive screening measures were administered to a group of 302 participants, aged +60 years, living in a residential facility for the aged. The second stage consisted of a sub-sample of 140 participants who were assessed for cognitive impairment based on the Diagnostic and Statistical Manual of Mental Disorders 4 th Edition-Text Revised criteria (DSM-IV-TR). Criteria A and B for Alzheimer's and Vascular dementia were applied to assign a diagnosis of dementia without reference to aetiology. The participants were also assessed for Mild Cognitive Impairment (MCI), based on the criteria of the International Working Group on Mild Cognitive Impairment. Of the 140 participants in stage two, 117 were administered a neuropsychological battery of tests in the third stage. The influence of demographic variables and the sensitivity, specificity and optimum cutoff scores were determined for the iv following seven selected screening measures, individually and in combination: the Mini-Mental State Examination (MMSE), Subjective Memory Complaint (SMC), Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO), Subjective Memory Complaint Clinical (SMCC) and the Clock Drawing Test (CDT). The sensitivity and specificity of the neuropsychological tests in the detection of dementia were also determined. Results Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Performance on the screening measures was influenced by race, age and education. Using ROC analyses, the SMCC, MMSE and CDT were found to be moderately accurate in screening for dementia with AUC >.70. Neuropsychological test performance was influenced by the age, gender, race and education level of participants. With the exception of the Digit Span (forward), Digit Span (total), COWAT-A, Narrative Memory Test (delayed recall), Token Test and the Luria Hand Sequence Test, all the neuropsychological test measures displayed significance in distinguishing between the three classification groups (controls, MCI, dementia). Conclusion SMCC's are valid screening questions as a first level of 'rule-out' screening. The MMSE can be included at a second stage of screening at general hospital level and the CDT in specialist clinical settings. Several measures from the neuropsychological battery of tests evaluated have discriminant validity and diagnostic accuracy for the differential diagnosis of cognitive disturbances in an elderly heterogeneous South African population. i ACKNOWLEDGEMENTS My deep appreciation for the accomplishment of this degree is accorded to the following:  My spiritual guru, Sadguru Swami Sivananda, for His unfailing Grace and constant presence in my life.  Swami Sahajananda, whose exemplary dedication to work served as an inspiration to me to treat all work as worship.  Jennifer Chipps-friend, mentor and statistician for her invaluable support at all times.  My supervisors, Prof Ahmed Iqbal Bhigjee and Prof Basil Joseph Pillay, for their time, support, guidance and wisdom.  Prof LeanaUys for her timely support, mentorship and nurturance which was critical to my success on this journey.  My three children, Shivek, Shivarya and Shivam, for their love and support.  Tonya Esterhuizen, psychiatrists Drs Shirlony Morgan, Alicia Porter and Viashnie Moodley, psychologists Deepika Hasmookh Pemaand Claudia Correia Marques for their roles in the assessments; Thirusha Naidu for advice and support and Carrin Martin for assistance with editing.

Research paper thumbnail of Impact of the South African Mental Health Care Act No. 17 of 2002 on regional and district hospitals designated for mental health care in KwaZulu-Natal

South African Medical Journal, 2010

Research paper thumbnail of Mental health services for HIV/AIDS patients versus ARV services for mentally ill HIV/AIDS patients

South African Medical Journal, 2010

Research paper thumbnail of A Model for Telepsychiatry for South Africa

Http Dx Doi Org 10 4314 Ajpsy V15i4 34, 2012

Research paper thumbnail of Screening for and diagnosing dementia in an elderly residential home population

Protocol Submission Administration, Jun 7, 2010

Research paper thumbnail of Sensitivity and specificity of the neuropsychological impairment scale (NIS)

Journal of Clinical Psychology, 1984

Background. Early diagnosis of dementia is important for those who might benefit from treatment. ... more Background. Early diagnosis of dementia is important for those who might benefit from treatment. We designed a brief comprehensive neuropsychological test battery to help differentiate control subjects from patients with mild cognitive impairment (MCI) and dementia. Method. The battery included tests of memory, attention, executive function, speed, perception and visuospatial skills. It was administered to subjects from the OPTIMA cohort : 51 controls, 29 with MCI, 60 with 'possible ' or 'probable ' Alzheimer's disease (AD) (NINCDS/ADRDA) and 12 with cerebrovascular disease (CVD). Mann-Whitney U tests were used to compare performance of controls with other diagnostic groups. The sensitivity and specificity of the tests were determined using Receiver Operating Characteristic curve analyses. The effects of age, gender and years of education on test performance were determined with Spearman's rank correlations. Results. The AD group performed worse than controls on all tests except an attention task. The Hopkins Verbal Learning Test and The Placing Test for episodic memory showed significant discriminative capacity between controls and other groups. Attention and processing speed tests discriminated CVD from controls. Category fluency, episodic memory tests and the CLOX test for executive function distinguished MCI from AD. Spearman's correlations showed negative associations between age and processing speed. Years of education affected performance on all tests, except The Placing Test. Conclusions. Certain neuropsychological tests have been shown to be sensitive and specific in the differential diagnosis of various types of dementia and may prove to be useful for detection of MCI.

Research paper thumbnail of The Sensitivity and Specificity of Subjective Memory Complaints and the Subjective Memory Rating Scale, Deterioration Cognitive Observee, Mini-Mental State Examination, Six-Item Screener and Clock Drawing Test in Dementia Screening

Dementia and Geriatric Cognitive Disorders, 2013

Background: The effectiveness of dementia screening depends on the availability of suitable scree... more Background: The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aim of this study was to evaluate the discriminant validity of 7 screening measures for dementia. Methods: A sample of 140 participants aged ≥60 years living in a residential facility for the aged were assessed clinically and assigned caseness for dementia using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised diagnostic criteria. Sensitivity and specificity of a selection of the following screening measures were tested using receiver operating characteristic (ROC) analysis for individual and combined tests: the Mini-Mental State Examination (MMSE), Six-Item Screener (SIS), Subjective Memory Complaint, Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO...

Research paper thumbnail of The Mental Health Care Act No 17 – South Africa. Trials and triumphs: 2002-2012

African Journal of Psychiatry, 2012

The Mental Health Care Act 17 of 2002(MHCA) was promulgated in 2004. It has been hailed as one of... more The Mental Health Care Act 17 of 2002(MHCA) was promulgated in 2004. It has been hailed as one of the most progressive pieces of mental health legislation. A true measure of its merit is the degree to which it has transformed mental health services and in particular improved the quality of care. This paper will describe the impact of the Act on mental health care service delivery in the country. Literature pertaining to the MHCA published from 2006-2012, a report compiled by the South African Society of Psychiatrists and the results of a national survey conducted among Heads of Departments of Psychiatry, Mental Health Review Boards and Provincial Directors of Mental Health was reviewed. The MHCA has been successful in shifting the emphasis of care from psychiatric institutions to general hospitals. However, the integration of services has been hampered by infrastructure constraints and shortages of mental health personnel. It has been less successful in integrating mental health care into primary health services where the focus remains largely on the pharmacological maintenance treatment of the chronically mentally ill. Little attention has been given to the health promotion, disease prevention and rehabilitation aspects of care. Mental health review boards contend with limited resources, administrative challenges and limited political support. Isolated pockets of success characterised the implementation of the MHCA across the country. Greater investment of resources is needed to ensure the comprehensive implementation of the Act.

Research paper thumbnail of Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile

African Journal of Psychiatry, 2013

Objective: To describe the demographic, clinical and risk profile of Mild Cognitive Impairment an... more Objective: To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting. Method: One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain. Results: The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis. Conclusion: The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.

Research paper thumbnail of Practice guidelines for videoconference-based telepsychiatry in South Africa

African Journal of Psychiatry, 2012

Mission The following guidelines are designed to aid in the development and practice of coherent,... more Mission The following guidelines are designed to aid in the development and practice of coherent, effective, cost effective, safe and sustainable telepsychiatry practices in South Africa. Establishing guidelines for telepsychiatry improves clinical outcomes, ameliorates the maldistribution of specialty care and promotes informed and reasonable Mental Health Care User (MHCU) expectations. Scope These guidelines are designed to serve as both a consensus operational best practice reference base on clinical empirical experience and an educational tool to aid practitioners in providing appropriate telehealth care for MHCUs. The term telehealth generally indicates an inclusion of all health care and health professionals, ranging from dermatology to mental health, to doctors, allied health workers, educators, and nurses. The use of telehealth also refers to the broader scope of e-health and distance education. Telepsychiatry therefore, is the practice of mental health by the specialties at a distance. The practice of medicine is an integration of both the science and art of preventing, diagnosing, and treating diseases. It should be recognized that adherence to these guidelines will not guarantee accurate diagnoses or successful outcomes. The purpose of these guidelines is to assist practitioners in pursuing a sound course of action to provide effective and safe medical care that is founded on current information, available resources, and MHCU needs. The guidelines are not meant to be unbending requirements of practice and they are not designed to, nor should they be used, to establish a legal standard of care. The primary care or mental health practitioner is responsible for the decision about the appropriateness of a specific procedure or course of action, considering all presenting circumstances as indicated under the Mental Health Act no 17 2002 (the Act), the National Health Act 2003 and the Bill of Rights. An approach that differs from the guidelines does not necessarily imply that the approach varied from the standard of care. If circumstances warrant, a practitioner may responsibly pursue a course of action different from these guidelines when, in the reasonable judgment of the practitioner, such action is indicated by the condition of the MHCU, restrictions or limits on available resources, or advances in information or technology subsequent to publication of the guidelines. Nonetheless, a practitioner who uses an approach that is significantly different from these guidelines is advised to document in the MHCU record information to explain the approach pursued. These guidelines do not include the provision of services over the World Wide Web which will be developed at a later time. How to use these guidelines The guideline contains requirements, recommendations, or actions that are identified by text containing the keywords "shall," "should," or "may." "Shall" indicates that it is required whenever feasible and practical under local conditions. "Should" indicates an optimal recommended action that is particularly suitable, without mentioning or excluding others. "May" indicates additional points that could be considered to further optimize the telepsychiatry care process. Applications for the Practice of Telepsychiatry Clinical Applications Currently, the point of delivery for telepsychiatry services is as varied as the type of services that are being provided. Sites may include hospitals, emergency rooms, community mental health centers, clinics, physician offices, nursing homes, assisted living facilities, prisons, schools, and MHCU homes. With careful planning, telepsychiatry services can significantly impact the quality, timeliness, and availability of services in almost any mental health service. 8-20 • Scope of Services Clinical applications of telemedicine encompass diagnostic, therapeutic, and forensic modalities across the lifespan. Common applications may include pre-hospitalization assessment, in-hospital care, assessment post-hospital follow-up care, scheduled and urgent outpatient visits, medication management, psychotherapy, consultation and psychological testing.

Research paper thumbnail of Depression, anxiety and stress symptoms in patients presenting with dyspepsia at a regional hospital in KwaZulu-Natal province

South African Journal of Psychiatry, 2019

Background: Depression, anxiety and stress (DAS) have been shown to be co-morbid with dyspepsia. ... more Background: Depression, anxiety and stress (DAS) have been shown to be co-morbid with dyspepsia. Local data on the factors associated with these co-morbidities could inform the role of psychiatric intervention in affected patients.Aim: The aim of this study was to describe the frequency of undiagnosed DAS and their associated protective and risk correlates in a sample of patients undergoing endoscopies for dyspepsia.Setting: The study was conducted at a regional hospital’s gastro-intestinal unit in KwaZulu-Natal province.Method: A cross-sectional survey was conducted on 201 in- and outpatients with symptoms of dyspepsia awaiting endoscopy. Information on DAS symptomatology (using the DASS-21 screening questionnaire, as well as socio-demographic and clinical data) were collected.Analyses: Following a descriptive analysis of the participants’ socio-demographic and clinical details, linear regression models were fitted to identify potential risk and protective correlates linked to DAS ...

Research paper thumbnail of Neuropsychological functioning and cognitive reserve in newly HIV diagnosed antiretroviral-naïve South African adults from peri-urban and informal settlements

PLOS ONE

Despite lower incidences of HIV-associated dementia due to antiretroviral therapy, neuropsycholog... more Despite lower incidences of HIV-associated dementia due to antiretroviral therapy, neuropsychological impairment (NPI) remains a persistent challenge in sub-Saharan Africa. Improving cognitive reserve (CR) can mitigate NPI, but there are few investigations on neuropsychological (NP) performance, and its association with CR in newly diagnosed ART-naïve HIV-positive individuals to inform early treatment strategies. A comprehensive battery of tests were administered to assess various NP domains (International HIV Dementia Scale [for memory, motor speed, psychomotor speed], Digit Span Test [for attention], Action Fluency Test [for language] and Clock Drawing Test [for executive/visuospatial function]), and CR (using Cognitive Reserve Index Questionnaire) among 211 newly diagnosed ART-naïve HIV-positive participants from two clinics that serve peri-urban and informal settlement communities in KwaZulu-Natal, South Africa. Regression models were fitted to assess the association between NP ...

Research paper thumbnail of Knowledge, beliefs and mental treatment seeking practices of Black African and Indian outpatients in Durban, South Africa

Mental illness is a major contributor to the global burden of disease in the world. Patients’ kno... more Mental illness is a major contributor to the global burden of disease in the world. Patients’ knowledge of mental illness and their treatment options play an important role in the effectiveness of service delivery and health outcomes in developing countries. The objectives of this study were to assess the knowledge, attitudes and beliefs of mental health outpatients about mental illness and its treatment, and their knowledge and satisfaction with traditional and Western/allopathic health systems. A self-designed questionnaire was used to assess the knowledge, attitudes and beliefs of mental health patients about mental illness and its treatment. Of the 157 outpatients who identified themselves as having a mental illness, 77.7% were aware of their condition, 33.8% only knew it as a mental illness and 21.5% patients did not know what caused their mental illness. Of the 195 patients interviewed, the majority (76.9%) preferred Western treatment, believing that taking medication would he...

Research paper thumbnail of The Impact of Antiretroviral Therapy on Neurocognitive Outcomes Among People Living with HIV in Low- and Middle-Income Countries (LMICs): A Systematic Review

AIDS and Behavior, 2020

Low and middle-income countries (LMICs) are the epicenter of the HIV epidemic. The scale-up of an... more Low and middle-income countries (LMICs) are the epicenter of the HIV epidemic. The scale-up of antiretroviral therapy (ART) has reduced mortality, but HIV-associated neurocognitive impairment (HANI) remains prevalent, which impacts functional performance, medication adherence, and quality of life. We aimed to evaluate the effect of ART on neurocognitive outcomes among people living with HIV/AIDS in LMICs and to identify determinants of these outcomes. We searched electronic databases and reference lists for studies published between 1996 and 2019. Two reviewers screened the primary studies for inclusion and performed the critical appraisal. Results were synthesized using the 'Synthesis without metaanalysis' approach through simple vote counting. We identified 31 studies conducted across four regions (Africa, Asia, South America, and Eastern Europe). Nine studies were cross-sectional, 15 were prospective, and seven were randomized controlled trials. The majority of the articles showed improved neurocognitive performance with ART use but found no association with treatment duration, regimen, central penetrating effectiveness, and conventional biomarkers. Despite the lack of appropriate norms and not accounting for practice effect in most studies, the evidence suggests ART is useful in the treatment of HIV-associated neurocognitive impairment (HANI) but limited in addressing legacy effects, and peripheral, and central viral reservoirs. Improved early ART treatment programs, viral reservoir eradication strategies, and identification of novel biomarkers will be critical in efforts to minimize HIV-associated neurocognitive impairment. PROSPERO registration: CRD42020152908.

Research paper thumbnail of A profile of social isolation and the influence of demographics in older persons living in residential care, Durban, South Africa

International Journal of Africa Nursing Sciences, 2021

Introduction: Residential care settings have shown high social isolation rates with incumbent ris... more Introduction: Residential care settings have shown high social isolation rates with incumbent risks necessitating measurement to formulate health promotion policies. Objective: To measure social isolation levels in older persons living in a lower socioeconomic residential care setting in South Africa. Method: A cross sectional survey with older persons from four inner city residential care facilities. A researcheradministered questionnaire was developed based on the Working Paper No.66, Oxford Poverty and Human Development Initiative. Data were analysed to describe social isolation and assess the influence of demographics. Results: The response rate was 72.14% (n = 277) and representative of the residential care population for age and gender. Nearly half of the respondents (47.3%) met criteria for social isolation in terms of social network support and density and almost 20% for perceived isolation through decreased levels of friendship. Conclusion: Although residential care does not prevent social isolation, the residents in the setting may provide a buffering in the provision of some social support.

Research paper thumbnail of The association of depressive symptoms in patients with acute myocardial infarction in a regional hospital in Durban, South Africa

SA Heart, 2018

Objective: To examine the association of depressive symptoms and contributing psychosocial factor... more Objective: To examine the association of depressive symptoms and contributing psychosocial factors during hospitalisation and 1-month post discharge in patients with acute myocardial infarction (MI). Methods and results: The study population comprised consecutive patients from a multi-ethnic background, admitted June 2015-November 2015 to the Coronary Care Unit at R. K. Khan Hospital, Durban, South Africa, with a diagnosis of MI. Demographic and clinical data stored in a specialised electronic cardiac database were extracted for all patients. Patients were screened for depressive symptoms using the Cardiac Depression Scale (CDS). Levels of perceived stress were evaluated using the 4-item Perceived Stress Scale (4-PSS). The study cohort consisted of 117 patients with a mean age of 58.16 ± 11.12 years, the majority of whom were males (70%, mean age 56.54 ± 1.23 years) and 30% females (mean age 61.97 ± 1.75 years). Forty-nine percent of the participants were diagnosed with depressive symptoms with a signifi cantly greater number of females experiencing depressive symptoms compared to males (p <0.01). Patients with depressive symptoms were more likely to have a previous history of depression (p=0.02), positive family history of depression (p=0.04), greater non-adherence to their medication (p <0.01) and lower levels of physical activity (p <0.01). Depressed patients also reported higher levels of stress on voluntary (p <0.01) and subjective rating (p <0.01), experienced greater fi nancial stress (p <0.01), major life events (p <0.01) and had higher 4-PSS scores (p <0.01). Thirteen percent of patients experienced major adverse cardiac events (MACE) with a significantly greater number of events found in those with depressive symptoms (p <0.01). Conclusion: Depressive symptoms are a common fi nding in a South African population presenting with MI. They are linked to higher rates of MACE, a previous history and/or family history of depression, greater stress levels and major life events. Females with MI are signifi cantly more likely to present with depressive symptoms. These fi ndings suggest that patients with MI should be screened for depressive symptoms and psychosocial factors as this may serve as an important arena for research and therapeutic intervention.

Research paper thumbnail of Doctorates by thesis and publication in clinical medicine: An analysis of examiners’ reports

Perspectives in Education, 2020

This paper analyzes the effects of credit card holding on the structure and distribution of house... more This paper analyzes the effects of credit card holding on the structure and distribution of household expenditure in Mexico in 2016. To the effect, two-stage quantile regressions are used to estimate models for consumption determinants, using instrumental variables on credit card holding. The study evidences that credit cards have a positive effect on aggregate consumption, driven mainly by increased health expenditure and items such as clothing,

Research paper thumbnail of The effectiveness of e-Interventions on reducing social isolation in older persons: A systematic review of systematic reviews

Journal of Telemedicine and Telecare, 2017

As the older adult population group has been increasing in size, there has been evidence of growi... more As the older adult population group has been increasing in size, there has been evidence of growing social isolation and loneliness in their lives. The increased use of information communication technology and Internet-supported interventions has stimulated an interest in the benefits of e-Interventions for older people and specifically in having a role in increasing social networks and decreasing loneliness. A systematic review of e-Interventions to reduce loneliness in older people was conducted with the aim to synthesize high quality evidence on the effectiveness of e-Interventions to decrease social isolation/loneliness for older people living in community/residential care. A systematic search of 12 databases for reviews published between 2000–2017 was conducted using search term synonyms for older people, social isolation and interventions. Three independent researchers screened articles and two reviewers extracted data. The Revised-Assessment of Multiple Systematic Reviews was...

Research paper thumbnail of Depression in older adults: prevalence and risk factors in a primary health care sample

South African Family Practice, 2017

Background: Depression in the geriatric population has been identified as a significant problem i... more Background: Depression in the geriatric population has been identified as a significant problem in view of the associated negative outcomes regarding poor functioning, increased perception of poor health and increased utilisation of medical services. Significantly associated with increased morbidity and mortality, depression has been found to be an independent cause of disability as well as adding to disability due to primary physical illnesses. Early identification and treatment of depression reduces medical costs and lessens caregiver burden. Epidemiological data and prevalence rates of geriatric depression in Africa are limited, although such data are vital to mobilise and plan government mental health initiatives aimed at screening and early intervention. Objective: To determine the prevalence of depression and associated clinical and socio-demographic factors amongst older adult patients attending a primary health care clinic in the Ethekwini District in Kwa-Zulu Natal, South Africa. Methods: The 15-item Geriatric Depression Scale and a socio-demographic questionnaire were administered in English to 255 geriatric outpatients, randomly selected, at a local community clinic in Durban. Data analysis: Data were analysed using SPSS version 23®. Descriptive statistics were used to summarise the sample demographics and response rate and non-parametric statistics were used to test for associations and differences. Results: A Cronbach's alpha for the GDS was calculated (p = 0.793). Some 40% of participants screened positive for depression. Female gender, widowhood and a negative subjective health status rating were significantly associated with depression and marriage appeared to be protective (p < 0.001). Participants with a poor subjective health rating were 21 times more likely to be depressed and widowhood conferred an almost fourfold increased risk of being depressed, with widows at greater risk than widowers. No association between depression and specific medical conditions was identified. Conclusion: There is a high rate of undetected depression among the elderly attending a local primary health care clinic with widowhood and poor subjective health being strong predictors of mood disorders. The findings warrant replication in bigger samples.

Research paper thumbnail of Research competency and specialist registration: Quo vadis ?

South African Medical Journal, 2016

with Prof. Szabo the immediate past president and Dr Ramlall immediate past and current secretary... more with Prof. Szabo the immediate past president and Dr Ramlall immediate past and current secretary. Both have been involved in revision to the College's regulations and contributing to the blueprinting process, and are actively involved in postgraduate training at their respective institutions. The article reflects their collective and personal understanding of the issue.

Research paper thumbnail of Screening for and diagnosing dementia in an elderly residential home population : a validation study

Background: With the projected increase in the elderly population and expected rise in the preval... more Background: With the projected increase in the elderly population and expected rise in the prevalence of dementia, particularly in low-and-middle-income countries, early caseidentification is necessary for planning and delivering clinical services. The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aims of this research study were to report on the prevalence of cognitive impairment (dementia and Mild Cognitive Impairment-MCI), and to assess the performance of selected screening tools and a neuropsychological battery of tests in a heterogeneous local population. Methodology A cross-sectional study was conducted in a heterogeneous elderly South African population and consisted of three stages of data collection. In the first stage, cognitive screening measures were administered to a group of 302 participants, aged +60 years, living in a residential facility for the aged. The second stage consisted of a sub-sample of 140 participants who were assessed for cognitive impairment based on the Diagnostic and Statistical Manual of Mental Disorders 4 th Edition-Text Revised criteria (DSM-IV-TR). Criteria A and B for Alzheimer's and Vascular dementia were applied to assign a diagnosis of dementia without reference to aetiology. The participants were also assessed for Mild Cognitive Impairment (MCI), based on the criteria of the International Working Group on Mild Cognitive Impairment. Of the 140 participants in stage two, 117 were administered a neuropsychological battery of tests in the third stage. The influence of demographic variables and the sensitivity, specificity and optimum cutoff scores were determined for the iv following seven selected screening measures, individually and in combination: the Mini-Mental State Examination (MMSE), Subjective Memory Complaint (SMC), Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO), Subjective Memory Complaint Clinical (SMCC) and the Clock Drawing Test (CDT). The sensitivity and specificity of the neuropsychological tests in the detection of dementia were also determined. Results Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Performance on the screening measures was influenced by race, age and education. Using ROC analyses, the SMCC, MMSE and CDT were found to be moderately accurate in screening for dementia with AUC >.70. Neuropsychological test performance was influenced by the age, gender, race and education level of participants. With the exception of the Digit Span (forward), Digit Span (total), COWAT-A, Narrative Memory Test (delayed recall), Token Test and the Luria Hand Sequence Test, all the neuropsychological test measures displayed significance in distinguishing between the three classification groups (controls, MCI, dementia). Conclusion SMCC's are valid screening questions as a first level of 'rule-out' screening. The MMSE can be included at a second stage of screening at general hospital level and the CDT in specialist clinical settings. Several measures from the neuropsychological battery of tests evaluated have discriminant validity and diagnostic accuracy for the differential diagnosis of cognitive disturbances in an elderly heterogeneous South African population. i ACKNOWLEDGEMENTS My deep appreciation for the accomplishment of this degree is accorded to the following:  My spiritual guru, Sadguru Swami Sivananda, for His unfailing Grace and constant presence in my life.  Swami Sahajananda, whose exemplary dedication to work served as an inspiration to me to treat all work as worship.  Jennifer Chipps-friend, mentor and statistician for her invaluable support at all times.  My supervisors, Prof Ahmed Iqbal Bhigjee and Prof Basil Joseph Pillay, for their time, support, guidance and wisdom.  Prof LeanaUys for her timely support, mentorship and nurturance which was critical to my success on this journey.  My three children, Shivek, Shivarya and Shivam, for their love and support.  Tonya Esterhuizen, psychiatrists Drs Shirlony Morgan, Alicia Porter and Viashnie Moodley, psychologists Deepika Hasmookh Pemaand Claudia Correia Marques for their roles in the assessments; Thirusha Naidu for advice and support and Carrin Martin for assistance with editing.

Research paper thumbnail of Impact of the South African Mental Health Care Act No. 17 of 2002 on regional and district hospitals designated for mental health care in KwaZulu-Natal

South African Medical Journal, 2010

Research paper thumbnail of Mental health services for HIV/AIDS patients versus ARV services for mentally ill HIV/AIDS patients

South African Medical Journal, 2010

Research paper thumbnail of A Model for Telepsychiatry for South Africa

Http Dx Doi Org 10 4314 Ajpsy V15i4 34, 2012

Research paper thumbnail of Screening for and diagnosing dementia in an elderly residential home population

Protocol Submission Administration, Jun 7, 2010

Research paper thumbnail of Sensitivity and specificity of the neuropsychological impairment scale (NIS)

Journal of Clinical Psychology, 1984

Background. Early diagnosis of dementia is important for those who might benefit from treatment. ... more Background. Early diagnosis of dementia is important for those who might benefit from treatment. We designed a brief comprehensive neuropsychological test battery to help differentiate control subjects from patients with mild cognitive impairment (MCI) and dementia. Method. The battery included tests of memory, attention, executive function, speed, perception and visuospatial skills. It was administered to subjects from the OPTIMA cohort : 51 controls, 29 with MCI, 60 with 'possible ' or 'probable ' Alzheimer's disease (AD) (NINCDS/ADRDA) and 12 with cerebrovascular disease (CVD). Mann-Whitney U tests were used to compare performance of controls with other diagnostic groups. The sensitivity and specificity of the tests were determined using Receiver Operating Characteristic curve analyses. The effects of age, gender and years of education on test performance were determined with Spearman's rank correlations. Results. The AD group performed worse than controls on all tests except an attention task. The Hopkins Verbal Learning Test and The Placing Test for episodic memory showed significant discriminative capacity between controls and other groups. Attention and processing speed tests discriminated CVD from controls. Category fluency, episodic memory tests and the CLOX test for executive function distinguished MCI from AD. Spearman's correlations showed negative associations between age and processing speed. Years of education affected performance on all tests, except The Placing Test. Conclusions. Certain neuropsychological tests have been shown to be sensitive and specific in the differential diagnosis of various types of dementia and may prove to be useful for detection of MCI.

Research paper thumbnail of The Sensitivity and Specificity of Subjective Memory Complaints and the Subjective Memory Rating Scale, Deterioration Cognitive Observee, Mini-Mental State Examination, Six-Item Screener and Clock Drawing Test in Dementia Screening

Dementia and Geriatric Cognitive Disorders, 2013

Background: The effectiveness of dementia screening depends on the availability of suitable scree... more Background: The effectiveness of dementia screening depends on the availability of suitable screening tools with good sensitivity and specificity to confidently distinguish normal age-related cognitive decline from dementia. The aim of this study was to evaluate the discriminant validity of 7 screening measures for dementia. Methods: A sample of 140 participants aged ≥60 years living in a residential facility for the aged were assessed clinically and assigned caseness for dementia using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised diagnostic criteria. Sensitivity and specificity of a selection of the following screening measures were tested using receiver operating characteristic (ROC) analysis for individual and combined tests: the Mini-Mental State Examination (MMSE), Six-Item Screener (SIS), Subjective Memory Complaint, Subjective Memory Complaint Clinical (SMCC), Subjective Memory Rating Scale (SMRS), Deterioration Cognitive Observee (DECO...

Research paper thumbnail of The Mental Health Care Act No 17 – South Africa. Trials and triumphs: 2002-2012

African Journal of Psychiatry, 2012

The Mental Health Care Act 17 of 2002(MHCA) was promulgated in 2004. It has been hailed as one of... more The Mental Health Care Act 17 of 2002(MHCA) was promulgated in 2004. It has been hailed as one of the most progressive pieces of mental health legislation. A true measure of its merit is the degree to which it has transformed mental health services and in particular improved the quality of care. This paper will describe the impact of the Act on mental health care service delivery in the country. Literature pertaining to the MHCA published from 2006-2012, a report compiled by the South African Society of Psychiatrists and the results of a national survey conducted among Heads of Departments of Psychiatry, Mental Health Review Boards and Provincial Directors of Mental Health was reviewed. The MHCA has been successful in shifting the emphasis of care from psychiatric institutions to general hospitals. However, the integration of services has been hampered by infrastructure constraints and shortages of mental health personnel. It has been less successful in integrating mental health care into primary health services where the focus remains largely on the pharmacological maintenance treatment of the chronically mentally ill. Little attention has been given to the health promotion, disease prevention and rehabilitation aspects of care. Mental health review boards contend with limited resources, administrative challenges and limited political support. Isolated pockets of success characterised the implementation of the MHCA across the country. Greater investment of resources is needed to ensure the comprehensive implementation of the Act.

Research paper thumbnail of Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile

African Journal of Psychiatry, 2013

Objective: To describe the demographic, clinical and risk profile of Mild Cognitive Impairment an... more Objective: To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting. Method: One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain. Results: The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis. Conclusion: The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.

Research paper thumbnail of Practice guidelines for videoconference-based telepsychiatry in South Africa

African Journal of Psychiatry, 2012

Mission The following guidelines are designed to aid in the development and practice of coherent,... more Mission The following guidelines are designed to aid in the development and practice of coherent, effective, cost effective, safe and sustainable telepsychiatry practices in South Africa. Establishing guidelines for telepsychiatry improves clinical outcomes, ameliorates the maldistribution of specialty care and promotes informed and reasonable Mental Health Care User (MHCU) expectations. Scope These guidelines are designed to serve as both a consensus operational best practice reference base on clinical empirical experience and an educational tool to aid practitioners in providing appropriate telehealth care for MHCUs. The term telehealth generally indicates an inclusion of all health care and health professionals, ranging from dermatology to mental health, to doctors, allied health workers, educators, and nurses. The use of telehealth also refers to the broader scope of e-health and distance education. Telepsychiatry therefore, is the practice of mental health by the specialties at a distance. The practice of medicine is an integration of both the science and art of preventing, diagnosing, and treating diseases. It should be recognized that adherence to these guidelines will not guarantee accurate diagnoses or successful outcomes. The purpose of these guidelines is to assist practitioners in pursuing a sound course of action to provide effective and safe medical care that is founded on current information, available resources, and MHCU needs. The guidelines are not meant to be unbending requirements of practice and they are not designed to, nor should they be used, to establish a legal standard of care. The primary care or mental health practitioner is responsible for the decision about the appropriateness of a specific procedure or course of action, considering all presenting circumstances as indicated under the Mental Health Act no 17 2002 (the Act), the National Health Act 2003 and the Bill of Rights. An approach that differs from the guidelines does not necessarily imply that the approach varied from the standard of care. If circumstances warrant, a practitioner may responsibly pursue a course of action different from these guidelines when, in the reasonable judgment of the practitioner, such action is indicated by the condition of the MHCU, restrictions or limits on available resources, or advances in information or technology subsequent to publication of the guidelines. Nonetheless, a practitioner who uses an approach that is significantly different from these guidelines is advised to document in the MHCU record information to explain the approach pursued. These guidelines do not include the provision of services over the World Wide Web which will be developed at a later time. How to use these guidelines The guideline contains requirements, recommendations, or actions that are identified by text containing the keywords "shall," "should," or "may." "Shall" indicates that it is required whenever feasible and practical under local conditions. "Should" indicates an optimal recommended action that is particularly suitable, without mentioning or excluding others. "May" indicates additional points that could be considered to further optimize the telepsychiatry care process. Applications for the Practice of Telepsychiatry Clinical Applications Currently, the point of delivery for telepsychiatry services is as varied as the type of services that are being provided. Sites may include hospitals, emergency rooms, community mental health centers, clinics, physician offices, nursing homes, assisted living facilities, prisons, schools, and MHCU homes. With careful planning, telepsychiatry services can significantly impact the quality, timeliness, and availability of services in almost any mental health service. 8-20 • Scope of Services Clinical applications of telemedicine encompass diagnostic, therapeutic, and forensic modalities across the lifespan. Common applications may include pre-hospitalization assessment, in-hospital care, assessment post-hospital follow-up care, scheduled and urgent outpatient visits, medication management, psychotherapy, consultation and psychological testing.