South African Psychiatry - November 2018

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FEATURE Screening can generate controversy, however sufficient data exists to support the introduction of screening for perinatal depression and anxiety. Perinatal depression meets most of the criteria for the implementation of a screening program. THE CONDITION IS SERIOUS, PREVALENT, TREATABLE AND ACCEPTABLE TESTS OF KNOWN ACCURACY ARE AVAILABLE. THERE ARE MULTIPLE TOOLS FOR USE INCLUDING GENERIC SELF-REPORT TOOLS FOR DEPRESSION SCREENING AND PERINATAL-SPECIFIC SELF-REPORT TOOLS. Some widely used screening tests that have been validated in perinatal populations including women in South Africa, include the Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire–9 (PHQ-9) and case finding questions such as the Whooley questions. The PHQ-9 is a commonly used generic self-report four-point Likert-type scale questionnaire used in primary health care settings. The EPDS is a perinatal-specific self-report 10-item 4-point Likert scale. It is brief, and the most widely used tool used for both antenatal and postnatal depression. The Whooley questions are two case-finding questions that require only a yes or no response. They can identify anxiety and depression with reasonable accuracy. THEY ARE SHORT AND DO NOT REQUIRE LITERACY, OR SCORING AND INTERPRETATION LIKE PENCIL AND PAPER TESTS, AND SO ARE MORE TIME- EFFECTIVE. THESE TWO QUESTIONS ADDRESS SYMPTOMS OF DEPRESSION THAT ARE NECESSARY BUT NOT SUFFICIENT TO MAKE A DIAGNOSIS OF DEPRESSION: “DURING THE PAST MONTH, HAVE YOU OFTEN BEEN BOTHERED BY FEELING DOWN, DEPRESSED OR HOPELESS?” AND “DURING THE PAST MONTH, HAVE YOU OFTEN BEEN BOTHERED BY LITTLE INTEREST OR PLEASURE IN DOING THINGS?” General clinical recommendation suggest that: • Screening should be conducted in order to increase identification of cases, which subsequently should improve outcomes. • The screening should ideally be completed in the presence of a health care professional. • Ask about and assess psychosocial risk factors such as unemployment, and lack of partner support. • Short, simple screening tools with high sensitivity should be used and followed-up with tools with high specificity ie: The Whooley case finding questions first and then the EPDS. • Screening can occur anytime pre- or postnatally. Recommendations are that postnatal screening be conducted between 4 and 12 weeks postnatally. • Screening should take place in settings that are acceptable to women. Ensure the women’s privacy and a non-judgmental environment and explain why you are doing the screening; and what the results mean. • Once screening is implemented it is vital to have a plan and resource for diagnosis, management and follow-up and referral if needed. Be prepare to address suicidality and have an emergency plan in place to assist suicidal women. • A screening test must never replace clinical judgment CONCLUSION Currently there are few routine mental health programmes; or even guidelines for screening perinatal women in South Africa in the public sector, despite evidence showing that these programmes can be effectively introduced to a primary health care setting. AS A RESULT, PERINATAL MENTAL HEALTH PROBLEMS REMAIN UNDER DIAGNOSED AND ARE LEFT UNTREATED IN THE MAJORITY OF CASES. WHAT IS NEEDED IS THE DEVELOPMENT AND IMPLEMENTATION OF EFFECTIVE PERINATAL MENTAL HEALTH POLICIES, WHICH WILL HELP PROTECT AGAINST ADVERSE AFFECTS OF PERINATAL DEPRESSION AND ANXIETY IN A SIGNIFICANT NUMBER OF SOUTH AFRICAN WOMEN. In the meantime however, it is up to the individual health care provider to be aware of the severity of the problem and to make it a habit to screen all perinatal women for depression and anxiety. References available from the author Carina Marsay is a specialist psychiatrist. She obtained her FC Psych (SA) in 2009 and her MMed (Psych) in 2010. Dr Marsay has a PhD from the University of Witwatersrand related to her work in perinatal psychiatry and is an honorary appointee in the Department of Psychiatry at Wits. She is a recipient of the MRC Clinician Researcher Programme Scholarship. Dr Marsay has an interest in perinatal psychiatry and is a member of the International Marcé Society, an organisation dedicated to perinatal mental health. Correspondence: carinamarsay@gmail.com If you would like to know more, please have a look at what the Perinatal Mental Health Project are doing for women in South Africa: https://pmhp.za.org/ 20 * SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018
BOOK SHOOTING WAR Title: SHOOTING WAR Publisher: Glitterati Editions Author: Anthony Feinstein Forward: Sir Harold Evans Conflict photographers are visual historians, bearing witness to stories that must be told. The images they produce seize our attention and, moved by what we see, troubling questions come to mind. What has become of these victims of war whose plight has been so memorably captured on camera? How did human behaviour turn so dark? SHOOTING WAR builds on this narrative by asking a different set of questions that to date has received little, if any, attention. What of the person taking the photograph? What might they have experienced? Neuropsychiatrist Anthony Feinstein provides the answers in a series of essays, one each for 18 of the world’s preeminent conflict photographers. Complementing each essay is a single, iconic photograph around which the text is built. The essays, derived from face-to-face interviews with the photojournalists, relatives, and close friends, give new and revealing insights into those factors, professional and psychological, that motivate photographers to enter zones of conflict repeatedly and the consequences that come from exposure to grave danger. These may include grievous physical injury, PTSD, moral injury, and prolonged bereavement for colleagues lost. While the text lays bare the traumas endured, the images speak to the resilience and creativity of the photographer in shaping our understanding of war and conflict. In addition to opening a new line of investigation into photographers and conflict, SHOOTING WAR includes a definitive foreword by Sir Harold Evans, himself a worldrenowned commentator on conflict and photography. A comprehensive index of photographer biographies and the wars and conflicts they have photographed is cited. This ground-breaking book will stir interest in the essential work of the men and women who, armed with only a camera, venture into the world’s most dangerous places. From Shooting War by Anthony Feinstein, copyright © 2018, Published by Glitterati Editions ANTHONY FEINSTEIN is a professor of Psychiatry at the University of Toronto, a Guggenheim Fellow, and a Peabody winner for his documentary Under Fire: Journalists in Combat. He has published a series of seminal studies exploring the psychological effects of conflict on journalists covering the Balkans, Iraq, Syria, Kenya, Iran, and the refugee crisis in Europe. He lives in Toronto, Canada. SIR HAROLD EVANS is a British-born journalist and bestselling author of The American Century. He was knighted by Queen Elizabeth in 2004 and is the recipient of an International Center of Photography Lifetime Achievement Award, two honors among many he has garnered over the course of a celebrated career. He lives in New York City and East Hampton, New York CONFLICT PHOTOGRAPHERS INCLUDE: • YANNIS BEHRAKIS • ALEXANDRA BOULAT • LAURENCE GEAI • ASHLEY GILBERTSON • DAVID GUTTENFELDER • CAROL GUZY • ROBIN HAMMOND • RON HAVIV • TIM HETHERINGTON • SANTIAGO LYON • PETER MAGUBANE • DON MCCULLIN • TIM PAGE • CHARLES PORTER • SEBASTIAO SALGADO • CHIM SEYMOUR • JOAO SILVA • CORINNE DUFKA SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018 * 21
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South African Psychiatry - November 2018

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