Conference
PROCEEDINGS REPORT
ASSAf MENTAL HEALTH SYMPOSIUM The implications of COVID-19 for mental health and substance use
10 March 2023
CSIR International Convention Centre
DOI http://dx.doi.org/10.17159/assaf.2023/0089
Cite: Academy of Science of South Africa (ASSAf), (2023). The implications of COVID-19 for mental health and substance use
DOI http://dx.doi.org/10.17159/assaf.2023/0089
Published by: Academy of Science of South Africa (ASSAf) PO Box 72135, Lynnwood Ridge, Pretoria, South Africa, 0040
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The Academy of Science of South Africa (ASSAf) was inaugurated in May 1996. It was formed in response to the need for an Academy of Science consonant with the dawn of democracy in South
Africa: activist in its mission of using science and scholarship for the benefit of society, with a mandate encompassing all scholarly disciplines that use an open-minded and evidence-based approach to build knowledge. ASSAf thus, adopted in its name the term ‘science’ in the singular as
reflecting a common way of enquiring rather than an aggregation of different disciplines. Its members are elected based on a combination of two principal criteria, academic excellence and
significant contributions to society. The Parliament of South Africa passed the Academy of Science of South Africa Act (No 67 of 2001), which came into force on 15 May 2002. This made ASSAf the only academy of science in South Africa officially recognised by government and representing the
country in the international community of science academies and elsewhere.
This report reflects the proceedings of the ASSAf MENTAL HEALTH SYMPOSIUM:
The implications of COVID-19 for mental health and substance use
Views expressed are those of the individuals and not necessarily those of the Academy nor a consensus view of the Academy based on an in-depth evidence-based study
SESSION 1: WELCOMING AND KEYNOTE ADDRESSES (Facilitator: Prof Liezille Jacobs, Rhodes
University) ... 1
Welcome Remarks (Dr Melusi Thwala, Academy of Science of South Africa) ...1
Keynote Address: The lingering impact of COVID-19 on mental health (Prof Tholene Sodi, University of Limpopo) ...1
Keynote Address: Psychosocial implications of COVID-19: complexities of substance abuse and mental health. (Prof Puleng Segalo, University of South Africa) ...3
Question and Answer Session ...4
SESSION 2: NEUROSCIENCE AND GENETICS (Facilitator: Prof Liezille Jacobs, Rhodes University) ... 5
Platelets bridging the gap between neuroinflammation and gut dysbiosis in stress-related disorders: A narrative review (Ms Carlien Rust, Stellenbosch University) ...5
Factors linked with mental health symptoms among semi-professional cricket players after the re- opening of sporting activities following an extensive lockout (Mr Lesego Malele, University of Johannesburg) ...6
Question and Answer Session ...7
SESSION 3: PUBLIC MENTAL HEALTH AND EPIDEMIOLOGY (Facilitator: Mr Charl Davids, Stellenbosch University) ... 8
The ultimate betrayal: Intimate partner violence in females with severe mental illness during the COVID-19 pandemic (Dr Lynette Moodley, University of KwaZulu-Natal) ...8
SESSION 4: INTERVENTION RESEARCH (Facilitator: Mr Charl Davids, Stellenbosch University) ... 10
Chris Hani Baragwanath Hospital (CHBAH) occupational therapy psychiatry COVID-19 implications on acute mental health services (Ms Khumo Sibanyoni and Mrs Lebohang Saohatse- Banda, CHBAH) ...10
Using telehealth to coach caregivers of young autistic children in South Africa during COVID-19 (Ms Marisa Viljoen, University of Cape Town) ...11
Question and Answer Session ...12
Wrap-up and Closure ...14
APPENDIX 1: LIST OF ACRONYMS ... 15
SESSION 1: WELCOMING AND KEYNOTE ADDRESSES (Facilitator: Prof Liezille Jacobs, Rhodes University)
Prof Liezille Jacobs has a doctorate in psychology from Stellenbosch University. She has worked in public mental health in Washington DC; Wuhan, China; Antwerp, Belgium; and at various science councils in South Africa on substance use disorder-related research.
Currently Prof Jacobs is the head of the Department of Psychology at Rhodes University.
Welcome remarks (Dr Melusi Thwala, Academy of Science of South Africa)
Dr Melusi Thwala welcomed everyone to the Mental Health Symposium, hosted by the Academy of Science of South Africa (ASSAf). He thanked his colleagues in the secretariat, especially Dr Khutso Phalane, for organising the event. He also thanked the speakers for their willingness to participate in the symposium.
Dr Thwala explained that ASSAf has an important responsibility to deliver a service to society through its support for science in South Africa. Its role is also to foster partnerships and to recognise scientific excellence in all disciplines.
Mental health is a societal issue. Apart from the clinical aspects, it is often highly personal. Most individuals have experienced the effects of mental health issues, not only from a psychological perspective, but also in relation to physical well-being. Irrespective of the angle one takes, everyone would like to experience a healthy and productive society.
Mental health research is transdisciplinary and requires the involvement of experts from many fields. The Health and Related Sciences Programme of ASSAf relies on partnerships with scientists, who are often top scholars in their field. The secretariat drives programmes to ensure that, through evidence-based sciences, South African mental health research is strengthened. This symposium serves as a platform towards that goal. Dr Thwala invited the participants to enjoy the symposium and encouraged them to contribute to the constructive debate.
Keynote address – The lingering impact of COVID-19 on mental health (Prof Tholene Sodi, University of Limpopo)
Prof Tholene Sodi is a registered clinical psychologist, currently employed as professor of psychology at the University of Limpopo. He holds a master’s degree in clinical psychology from the University of the Witwatersrand, and a PhD from the University of Cape Town. Prof Sodi recently completed the second three-year term as a member of the Board of the South African Medical Research Council (SAMRC). He has also previously served as vice-president of the Health Professions Council of South Africa (HPCSA). He has published widely and has presented papers at national and international conferences. His key areas of research interest include youth mental health, culture and mental health, mental health policy, behavioural medicine and implementation science.
As from January 2023, Prof Sodi has taken up a position at the University of Limpopo as research chair in mental health and society.
In this presentation, Prof Sodi affirmed how the COVID-19 pandemic touched everybody. Even though people survived the ravages of the pandemic, they were affected by the virus in different ways. Most people infected by the SARS-CoV-2 virus experienced mild to moderate respiratory illnesses and recovered without special treatment. However, some people became seriously ill, and some lost their lives. According to the World Health Organization (WHO)1, as of 7 March 2023 there had been 759,408,703 confirmed cases of COVID-19, including 6,866,434 deaths.
The graph of the Africa region COVID-19 data (from 6 February 2020 to 5 March 2023) indicated four peaks since COVID-19 started: June to July 2020, November/December 2020 to January
1 WHO COVID-19 weekly epidemiological update, Edition 13, published 8 March 2023
2021, May to August 2021, and November 2021 to July 2022. The graph also showed that the number of new deaths in the African region decreased by 73%, compared to the previous 28- day period, with only 30 new deaths reported. There was clearly a downward trend. The question was whether this was a lull before the storm, or whether another wave of infections would occur.
Answers to such questions were uncertain, given that scientists could not predict the extent of COVID-19 in 2020.
This downward trend could be attributed to a number of factors, including the excellence of science, the rapid production of vaccines and large-scale vaccinations, the adoption of preventative measures (mostly behavioural, such as washing of hands and social distancing) and herd immunity. Herd immunity occurs when a high proportion of the community becomes immune to a disease (through vaccination and/or prior illness), making the spread of the disease from person to person unlikely.
Despite the current lull being experienced in COVID-19 infections, the disease has taken a significant toll on individuals, families, communities and the economy, and has caused large losses and pain in society. However, the greatest impact has been on mental health. This has manifested in an increase in common psychological problems such as fear and anxiety, depression, bereavement, post-traumatic stress disorder and sleep problems. Research has highlighted the impact on the psychological well-being of the most exposed groups, including children, students and health workers. The social distancing and security measures affected relationships among people and their perceptions of empathy toward others, mostly in a negative way.
This health impact has continued to linger, with some people developing long COVID (also referred to as ‘post-acute COVID-19’, or ‘chronic COVID’) and showing enduring symptoms long after they contracted the disease. Symptoms include tiredness, respiratory problems, neurological symptoms, difficulty thinking or concentrating and experiencing headaches. These people are living in fear. Mental health practitioners also observed what is described in the International Classification of Diseases (ICD-112) as complex post-traumatic stress disorder (PTSD)3.
Mental health practitioners have tried to explain the impact of COVID-19 on society using models of societal determinants of mental illness. Prof Crick Lund4 and colleagues developed a conceptual framework for the social determinants of mental disorders aligned with the UN Sustainable Development Goals. This model explains the impact of COVID-19 as a result of the intersectionality of many factors such as demographic factors, economic impacts, neighbourhood influences, environmental health and social/cultural aspects.
The recently released South African COVID-19 Report (1st edition)5 bears testimony to the fact that there is an intersectionality of factors behind the pandemic and those social determinants are at play. The report is the government’s response to lessons learned in these challenging times and underlines the necessity of a multisectoral approach to dealing with the pandemic.
2 International Classification of Diseases, 11th revision.
3 This is also described as complex PTSD (C-PTSD), prolonged duress stress disorder (PDSD), rolling PTSD, chronic post-traumatic stress disorder, severe post-traumatic stress disorder, type 2 PTSD, cumulative stress disorder, complex trauma disorder, and chronic stress disorder.
4 Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, Haushofer J, Herrman H, Jordans M, Kieling C, Medina-Mora ME, Morgan E, Omigbodun O, Tol W, Patel V, Saxena S. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry. 2018 Apr;5(4):357-369. doi: 10.1016/S2215-0366(18)30060-9. PMID: 29580610.
5 Presidency of South Africa, 2021. Development of a Country Report on the Measures Implemented to Combat the Impact of Covid-19 in South Africa. South Africa Covid-19 Country Report [First edition]. DPME (Department of Planning, Monitoring and Evaluation), GTAC (Government Technical Advisory Centre) &
NRF (National Research Foundation), Pretoria: June. Downloaded from
https://www.gov.za/sites/default/files/gcis_document/202206/sa-covid-19-reporta.pdf
To conclude the presentation, Prof Sodi returned to the aim of this symposium, which stemmed from the realisation that the COVID-19 pandemic has had both short- and long-term implications for mental health and substance use, especially for groups at risk of new or exacerbated mental health disorders. For those members of society facing barriers to accessing care, and who needed a collective sense of responsibility towards a proactive public health regime, it remained to be asked how to respond to this situation.
Oliver Mtukudzi (a Zimbabwean musician) was famous for his songs on the HIV/AIDS epidemic in Africa, the most famous of which was entitled ‘Todii’, or ‘What shall we do?’ Singing in both Shona and English, he described how the epidemic had devastated the social fabric of human relations. Through the song, he was trying to encourage people to develop collective responses to address the epidemic. The song could equally be applied to COVID-19 and was as relevant to this pandemic as it was to the HIV/AIDS epidemic.
The impact of COVID-19 might linger for a long time. Mental health practitioners would need to work proactively, in multisectoral and multidisciplinary ways, to deal with this impact.
Keynote address – Psychosocial implications of COVID-19: Complexities of substance abuse and mental health (Prof Puleng Segalo, University of South Africa)
Prof Puleng Segalo is a National Research Foundation rated Fulbright scholar and a professor of psychology at the University of South Africa. She is the incumbent of the Chief Albert Luthuli Research Chair, which is housed in the College of Human Sciences. She was the 2013 recipient of the Unisa Principal’s Prize for Excellence in Research, the 2014 winner of the National Science and Technology Young Women in Science Award, and the 2021/2022 regional winner of The World Academy of Science award for her role in popularising science. She was the recipient of the 2019 SARIMA SToRM fellowship grant.
Her research focuses on historical trauma, public health and gendered experiences of various forms of gender-based violence. Prof Segalo is the 2023 research affiliate of the Institute of African Studies at the University of Ghana, and the African affiliate fellow at the African Studies Centre of the University of Kansas.
In her talk, Prof Segalo reflected on how 2020 would stay in the memories of most people for ever. The life to which people were accustomed had been changed with the arrival of COVID- 19, which called into question some of society's most basic norms and assumptions. Another effect of COVID-19 has been the removal of a sense of connectedness due to the necessity of isolation. Now, as society resumed to a state of normality, it was necessary to re-establish and re- learn social rules. For example, people needed to learn what this meant for the work environment, since employees tend to be defined by their work environment and functions, but when COVID-19 hit, workers were confined to their homes. Many people lost family members and colleagues. Going back to physical work spaces required people to confront what it meant to work face to face again and to adjust to colleagues. Consideration would have to be given to how to address these issues. The psychosocial implications were challenging, including whether and how workplaces had created environments conducive to mourning the losses experienced during the COVID-19 pandemic.
The underprivileged were most affected by the COVID-19 pandemic, due to issues such as poverty, joblessness and lack of access to health care and other services, which were exacerbated in this time. Before COVID, mental health issues were not considered a critical priority. But today it had become important to centre mental health in the societal debate, and fortunately this is increasingly taking place, for instance at platforms such as this symposium.
During COVID-19, many people experienced mental health issues such as anxiety and fear of the unknown. They asked themselves whether they might be affected next. They experienced depression, feelings of loneliness, hopelessness and loss of control. The question is what happens to this trauma now?
In many cultures, traditional rituals could not be performed due to COVID-19. It is well known that rituals contribute to alleviating post-traumatic stress, and not having these rituals leaves open wounds. The mourning process is incomplete, and people cannot get peace if these ceremonies are not held.
Mental health issues were not often central to what was considered priority issues, but the impact was seen daily. Unless mental health issues were visibly manifested, people were not considered unwell. Moreover, mental health was not necessarily included in the general conception of the health sector. However, COVID-19 has amplified the mental health gap, and this is seen in the higher rates of suicide in this period. During level 5 lockdown, simple acts that contribute to well- being, such as going to church or to the gym, were restricted. According to the WHO, South Africa had the fourth highest rate of suicides. Women were less likely to carry out suicides, with a suicide rate of less than 10%, compared to men at 37%. However, attempted suicides, especially amongst women, should be taken seriously.
South Africa's history, its predisposition to trauma and the multi-faceted dimensions of society impacted on how COVID-19 affected the general public. Mental health care workers were unable to reach places of service such as clinics, and online support services were not feasible for communities lacking resources. This highlighted the glaring inequalities, such as access to transport, unemployment and others.
COVID-19 also had an impact on substance abuse. In the USA, for instance, there was a significant increase in substance abuse. The World Drug Report found that over 35 million people had some form of substance abuse disorder. These persons were also considered at increased risk to the SARS-CoV-2 virus and were more vulnerable to diseases such as breathing disorders.
Substance users turn to drugs as a mechanism for coping. An Eyewitness News interviewer, speaking to a matriculant in the Alexandra township in South Africa, was told that the youth smoked to escape the reality of COVID-19. However, using drugs such as CAT6 caused them to increasingly resort to crime, to fund their drug use. Although the impact of COVID-19 on the youth was devastating, it was not always possible to measure. In fact, it was easier to record the effects of HIV/AIDS or teenage pregnancies. Understanding the impact of COVID-19 on mental health and substance abuse requires collective effort and collaboration between all parties in the health sector.
Lastly, the issues of stress, burnout and lack of productivity in the workplace must also be understood in the broad context of mental health challenges. Negative well-being had a direct impact on the climate of productivity. Often, social media platforms were used to vent these frustrations. There was a saying that “hurt people hurt others”. Issues such as bullying were indications of bigger challenges. As a nation, South Africans needed to find ways to ensure that people did not hurt one another and that they would take care of themselves, especially in times of pressure.
Question and answer session
Comment: Prof Jacobs commented that there was a common theme between both keynote presentations, namely the mental health toll on society. She suggested that the issues of bereavement and the role of African rituals needed more attention. Many people in South Africa were still suffering from post-traumatic stress disorders, and preventative behavioural measures need to be implemented. The high suicide toll and its relation to COVID-19 is a serious concern.
South Africans had not yet healed from the colonial and apartheid past, and the COVID-19 impact has aggravated and compounded this trauma. Furthermore, coping strategies in times of hardship need to be revisited. When people are stressed, they gravitate towards their coping mechanisms to alleviate the pain, whether these are substances or medication. In this context,
6 Methcathinone (ephedrone) is a synthetic cathinone with an amphetamine-like chemical structure and pharmacological properties.
Prof Jacobs recommended an article7 by Prof Sodi, which was published in the South African Journal of Psychology in 2021.
Question: Regarding the PTSD complex, is ICD-11 recognised in the new DSM8 (Diagnostic and Statistical Manual of Mental Disorders)?
Response: It does not appear in DSM-5. Until the codes are revised, ICD-10 is still used, especially by medical aid schemes. It will probably be some time before the new code is implemented.
Comment: There is a perception that symptoms of depression often lead to suicide, but in many cases, students showed no history of depression, and suicide was often a very compulsive act.
Furthermore, substance abuse is very often linked to trauma. Substance abuse is generally treated, but not necessarily the trauma that leads to the abuse.
Comment: Mental health researchers and practitioners in South Africa should be encouraged to read the articles in the South African Journal of Psychology, because these papers relate to the South African context.
SESSION 2: NEUROSCIENCE AND GENETICS (Facilitator: Prof Liezille Jacobs, Rhodes University)
Platelets bridging the gap between neuroinflammation and gut dysbiosis in stress-related disorders: A narrative review (Ms Carlien Rust, Stellenbosch University)
Ms Rust is a second-year PhD candidate in the Department of Psychiatry at Stellenbosch University. Her research focuses on finding a correlation between the blood and gut microbiome of neuropsychiatric cohorts, including Parkinson's disease, PTSD and schizophrenia. She has a background in molecular biology and plant biotechnology, but always wanted to pursue human genetics and medical science.
In her presentation, Ms Rust described the correlation between gut and microbiome organisms in psychological disorders, and how platelets contribute to the relation between the gut and the brain. Depression and anxiety disorders are leading contributors to global disability and economic burden. As comorbidities to disease, these disorders are associated with greater social and functional impairment, reduced quality of life and increased risk of suicide, especially during a pandemic such as COVID-19. Environmental stressors and stress response were suggested to be central to the pathogenesis of depression, anxiety and posttraumatic stress disorder (referred to as ‘stress-linked disorders’ in this presentation).
The gut–brain axis is a pathway between the gut and the brain, through a connection of the vagus nerve. Neurotransmitters acting in the brain, affecting mood and memory, are produced in the gut, and malfunctioning of this process impacts the functions of the brain. An imbalance of gut bacteria is called ‘dysbiosis’. A strong association between stress-linked disorders and the gut has been suggested, especially dysbiosis of the gut microbiome, the collection of microorganisms and their genomic information. Currently it is unclear whether the correlation is due to downstream regulation of the brain or upstream regulation of the gut microbiome;
however, the immune system, the hypothalamic-pituitary-adrenal (HPA) axis and neurotransmitters are involved, and platelets are suggested to be the link between the inflammatory response and stress-linked disorders. However, as far as is known, the association between stress-linked disorders, the gut microbiome and the role of platelets had not been reviewed.
Alteration in microbial composition due to stress increases intestinal permeability, which allows the translocation of microbial products known to trigger the release of pro-inflammatory cytokines, causing platelets to become hyperactive and secrete serotonin into the plasma.
7 Sodi T, Modipane M, Oppong Asante K, et al. Mental health policy and system preparedness to respond to COVID-19 and other health emergencies: a case study of four African countries. South African Journal of Psychology. 2021;51(2):279-292. doi:10.1177/00812463211012177
8 https://www.psychiatry.org/psychiatrists/practice/dsm
Consequently, increased circulating levels of serotonin induce the activation of indoleamine 2,3 dioxygenase (IDO 1). IDO 1 participates in the tryptophan/kynurenine pathway, which subsequently reduces 5-hydroxytryptamine (5-HT) levels in the brain. Moreover, higher levels of pro-inflammatory cytokine levels, possibly a result of increased intestinal permeability, increase the blood–brain barrier permeability, allowing inflammatory mediators entry into the brain to cause inflammation.
Inflammation is suggested as a key causative factor for stress-linked disorders. Microbiota- dependent effects significantly impact platelet function and consequently affect several downstream pathways, altering serotonin levels to contribute to inflammation. Platelets could be considered a link between gut dysbiosis, neuroinflammation and stress-linked disorders.
Factors linked with mental health symptoms among semi-professional cricket players after the re-opening of sporting activities following an extensive lockout (Mr Lesego Malele, University of Johannesburg)
Lesego Malele is a biokineticist with a special interest in high performance and metabolic syndrome. At the University of Johannesburg (UJ), he graduated first in his undergraduate programme (BCom Sport Management), as well as in his honours degree programme (Biokinetics). Other honours he has received include the UJ Faculty of Health Science Top Achievers Award, the Golden Key International Honor Society Award, and membership in the UJenius Club, which recognises the top one per cent of academic achievers at UJ.
A number of professional teams, including Cape Town Spurs Football Club and individual athletes from a variety of sports, have sought his assistance in improving their performance. Currently, his portfolio is in the Biokinetics Association of South Africa (BASA). He obtained his master's degree at UJ on the relationship between mental health and performance metrics among semi-professional male cricket players during COVID- 19.
Mr Malele’s presentation brought a sport perspective to the discussions on mental health. For optimum performance, sport requires high cognitive function. Mental health can be linked to performance, and athletes suffering from mental health disorders are unable to train, unable to compete and suffer from financial as well as mental harm. The stigma linked to mental health disorders creates pressure on athletes not to disclose that they are feeling unwell. Due to COVID- 19, it had become imperative for the mental health of athletes' to be monitored.
In South Africa, knowledge of the psychological effects of the COVID-19 lockout on performance among athletes at professional and amateur levels is limited. COVID-19 was identified as a catalyst in the increase in mental health illness among athletes. Three factors contributed to this, namely: the disease itself which increased the prevalence of mental instability, the bio-bubble which isolated teams from the public, and general mental states during lockdown. The extensive lockdown of sporting activities had a profound effect on semi- professional cricket players. The lack of physical activity and social interaction led to an increase in mental health symptoms, such as depression, anxiety and stress.
The effects of extensive lockdown on semi-professional cricket players' mental health has been largely unexplored. This study aimed to investigate the extent of mental health symptoms among semi-professional male cricket players experienced during COVID-19 and the impact it had on their well-being.
This is an epidemiological cross-sectional study, conducted among semi-professional (provincial B and university squad) cricket players residing in the Western Cape. Among the sample, descriptive statistics including means and standard deviations were calculated. Mental health screening among cricketers was assessed with the Depression, Anxiety and Stress Scale 21 (DASS 21), the Satisfaction with Life Scale (SWLS) and the Athlete Burnout questionnaire.
According to the DASS 21 subscales, depression was mild; stress was interpreted as mild stress,
while anxiety was interpreted as moderate anxiety. The SWLS indicated that players were slightly satisfied, but there were some areas for improvement. The Athlete Burnout subscales are physical and emotional exhaustion, devaluation of sport practice, and reduced sense of achievement.
The results showed that cricketers suffer from symptoms of anxiety as it is higher than other subscales of DASS 21. Cricketers sometimes experience reduced sense of achievement, which may contribute to the scoring on SWLS (neither satisfied nor dissatisfied with their lives). The study also showed that a cricket player's age showed no correlation with their predisposition to symptoms of depression, anxiety and stress. However, depression and anxiety had correlations with stress. These findings could not, however, be compared to pre-pandemic mental health profiling because of a lack of baseline data.
The study confirmed that players need mental health evaluations, since their performance is at risk. Athletes' success is deeply influenced by burnout, mental health and life satisfaction.
Incorporating mental health monitoring into the existing systems of Cricket SA would improve the organisation holistically and might indirectly result in improved performance management of players.
Question and Answer Session
Question: Is science any closer to answering the question of whether physical health precedes mental health, or vice versa?
Response: The cricket study had three components, namely mental health, performance and the relationship between the two. It was found that athletes that had performance anxiety actually increased their performance, indicating that some anxiety is actually positive up to a threshold level (as explained in the ‘inverted U’ theory), but the ‘golden thread’ between mental health and physical performance is still being investigated. What is needed is to arrange with the cricketing authorities for counsellors to accompany the cricketers and assess them on a regular basis.
Question: In a study done by the UCT Department on Psychiatry and Mental health, it was reported that respondents of non-binary gender indicated the lowest rating of mental health challenges. What does this mean?
Response: Non-binary refers to individuals that consider themselves neither male nor female. The reporting of the lowest level of mental health issues from this group seems controversial, because the perception is that non-binary individuals are more outspoken and forthcoming. Whereas traditionally females are seen as more responsive, and males as less responsive, the non-binary group should be a combination of the two responses. Yet, the data cannot easily be explained in this way, and more research is needed to clarify the data.
Question: Does the study of the gut bacteria include the impact of nutrition and how it affects the gut–brain axis?
Response: It is not included in this study. A different research group covers this aspect and looks at genetic markers. Another group is investigating which bacteria prefer different food types.
Question: Relating to the bio-bubble, has there been any follow-up research after the lockdown was lifted?
Response: A study conducted in 2022 was recently released by the University of Cape Town. This study looked at professional players and showed that elite players are better equipped to deal with high pressure, whereas players in lower divisions suffer more from anxiety. A possible explanation is that players in lower divisions did not have much exposure to play in front of large crowds during the lockdown.
Question: What innovative ways can the speakers think of to communicate the information gained from their research, and filter it down to the general public? For instance, how can this information be relevant to sport at school level?
Response: One example of communicating research is to attend science festivals such as Scifest Africa9, which is an opportunity to explain science to children by engaging with schools. It is a good experience to learn how to translate science to be understandable. It also offers opportunities for lecturing and giving talks to the public outside the scientific field.
Response: Regarding the outcomes of the study on mental health in sport, it is helpful to consult with team psychologists and to inform them of the results. Another way to communicate the results is to create infographics and posters aimed at the public and scholars. This is currently being done for the project.
Comment: More sport psychologists are needed. There are too few people working on mental health in sport. Athletes that suffer from anxiety and stress end up not getting proper treatment.
Rhodes University offers courses on performance psychology at second year and honours levels.
Question: Is any work done to educate people around the concept of masculinity and the denial of depression and anxiety? Men tend not to acknowledge mental health issues. Education is needed to address this.
Response: There is recognition of the need to focus more on masculinity, especially toxic masculinity. Prof Kopano Rathele from Stellenbosch University is prominent in this field.
Unfortunately, there are too few psychologists, especially in practice, that focus on this issue.
SESSION 3: PUBLIC MENTAL HEALTH AND EPIDEMIOLOGY (Facilitator: Mr Charl Davids, Stellenbosch University)
Mr Charl Davids is the director at the Centre for Student Counselling and Development at Stellenbosch University. He holds an MPsych from the University of the Western Cape (UWC) and is a registered psychologist with the Health Professions Council of South Africa.
He is currently a PhD candidate looking at developing a community-based substance- abuse intervention. Mr Davids is also a former Youth Programme Manager at Selfhelp Manenberg; Training Department Manager at the Trauma Centre for the Survivors of Violence and Torture; and Principal Psychologist in the South African Police Service. He started his private practice in 2003. He joined the Department of Psychology at UWC in 2006 where he lectured at both undergraduate and postgraduate levels. In 2016 he held the position of head of the Department of Psychology, and from 2013 to 2015 he was the deputy head. Since 2018 he has also served as the SADC regional coordinator of the International Consortium of Universities for Drug Demand Reduction (ICUDDR). He is involved in a number of non-government organisations (NGOs), where he serves on various boards with different portfolios. He is the founder of the NGO, Youth Development Specialist Services (YDSS). Mr Davids is also the executive director of Social Development Practitioners (Pty Ltd) and the former chairperson of the board of the Western Cape Small Business Network (NPC).
The ultimate betrayal: Intimate partner violence in females with severe mental illness during the COVID-19 pandemic (Dr Lynette Moodley, University of KwaZulu-Natal)
Dr Lynette Moodley obtained a Bachelor of Medicine and Bachelor of Surgery degrees from the University of Witwatersrand and specialised in psychiatry at the University of KwaZulu-Natal (UKZN). She is currently working at Fort Napier Hospital in Pietermaritzburg, KwaZulu-Natal (KZN). Her areas of interest include forensic psychiatry and women’s mental health. Her research degree focused on intimate partner violence in females with mental illness. She advocates for women’s rights, gender equality and female empowerment.
In this presentation, Dr Moodley reported on a study that investigated the prevalence of adverse childhood events (ACEs) and intimate partner violence (IPV) among women living with severe mental illness (SMI), and the association between age and IPV. For better understanding, definitions were given of the terminology:
9 https://www.scifest.org.za/
• Gender-based violence (GBV) is defined as an act of violence that is based on biological gender and results in, or is likely to result in, physical, sexual or psychological harm or violations of rights.
• Intimate partner violence (IPV) is GBV occurring within the context of an intimate relationship.
It may occur in the context of a current or previous relationship. The perpetrators may be present or former spouses or partners of the victims.
• Adverse childhood events (ACEs) are traumatic or abnormal events in the first 18 years of life and refer to some of the most intensive and frequently occurring sources of stress that children may suffer. These include abuse, neglect and violence between parents.
Interpersonal violence may directly lead to physical injury or death and may negatively influence maternal and perinatal health outcomes, mental health and increased risk of chronic illness.
These experiences may predispose victims to both mental illness and future violent victimisation and perpetration. The literature also suggests a strong association between ACEs and IPV, which may be mediated by several factors, including mental illness and substance abuse.
Providing some context around the extent of this violence, Dr Moodley indicated that in 2018, an estimated one in seven women had experienced physical and/or sexual violence from an intimate partner or husband in the past 12 months10. IPV is the most common form of violence world-wide. South African data show that one in every five women is physically abused by her intimate partner, and that every six hours a woman is killed by her current or former intimate partner11. During 2019, an average of 87 290 domestic violence cases per week were reported to the South African Police Service (SAPS).
The COVID-19 pandemic had a significant influence on domestic violence. During the first week of lockdown in March 2020 due to containment measures, SAPS received 2 320 complaints of GBV. This was 37% higher than the weekly average prior to the emergence of the COVID-19 pandemic and lockdown experience12. In addition, the South African Gender-Based Violence Command Centre alone recorded more than 120 000 victims in the first three weeks of COVID- 19 lockdown in March 2020.
The study was undertaken in the light of the alarming increase in IPV in the general population, the vulnerability of the mentally ill in such violent relationships, and the paucity of research on this issue in South Africa. Adverse childhood experiences and interpersonal violence in mentally ill women are often neglected and need to be reviewed in light of the suggested increase in IPV during the COVID-19 pandemic.
The study was conducted at a general district hospital (Addington Hospital) in KZN among women attending an outpatient psychiatric service during the COVID-19 pandemic. All participants who met the study criteria were approached to participate. The inclusion criteria were women aged 18 and older with SMI who received outpatient mental health services and were able to read and write in English. Potential study participants were provided with a description of the study, and their written informed consent was obtained. Data were collected through participant self-reporting in keeping with COVID-19 transmission contingency plans from January 2020 to April 2020. A total of 154 women completed a written survey comprising a sociodemographic and a clinical questionnaire, the WHO Adverse Childhood Experiences International Questionnaire (ACE IQ) for ACEs, and the women abuse screening tool for IPV.
The results showed that 141 (91.6%) participants scored positive for ACEs and 104 (67.5%) had experienced three or more ACEs. The most prevalent forms of ACEs were emotional neglect (46.8%), absence of one or both parents due to parental separation or divorce (67.5%), contact sexual abuse (43.5%) and witnessing a household member being treated violently (43.5%). Of the
10 UN Women, 2021
11 Capazorio, 2017
12 Naidu-Hoffmeester, 2020
participants, 61 (46.6%) reported IPV with scores higher than 13, indicative of abuse. The most common types of IPV reported in this study were tension, arguments, feeling disempowered and emotional abuse.
The prevalence of IPV in females living with SMI in this study is higher than the global estimated rate in the general population (35%)13 and the estimated prevalence for IPV in sub-Saharan Africa (35.5%). The lockdown for COVID-19 containment measures probably contributed to these high rates, as there may have been high levels of anxiety and tension in households where people were living together in close proximity. The associated unemployment, financial strife, food insecurity, social isolation and uncertainty probably also played a role. Many, if not most, South African families experience these kinds of stress, which were worsened during the COVID- 19 pandemic, with limited ability to access social support services.
Furthermore, the high prevalence of IPV and the association of IPV with cumulative ACEs reflect the hidden epidemic of intimate partner violence and the vulnerability of those with ACEs to become victims of abuse later, which is often missed in the care of women with SMI. Routine screening for IPV at every visit to a psychiatric clinic, similar to how patients are checked for psychotic depression symptoms and suicidality, is recommended, in order to detect IPV early and to provide counselling.
SESSION 4: INTERVENTION RESEARCH (Facilitator: Mr Charl Davids, Stellenbosch University)
Chris Hani Baragwanath Hospital (CHBAH) occupational therapy psychiatry: COVID-19 implications for acute mental health services (Ms Khumo Sibanyoni and Ms Lebohang Saohatse-Banda, CHBAH)
Khumo Sibanyoni is an occupational therapist by profession. She is employed in an acute academic tertiary psychiatric facility that assesses and treats persons with mental disorders. She graduated from the University of Cape Town in 2017 and completed her service year in 2018. She is currently pursuing a master’s degree in occupational therapy (psychiatric disorder).
Lebohang Saohatse-Banda has 15 years of experience as an occupational therapist and is currently working at Chris Hani Baragwanath Academic Hospital (CHBAH) as chief occupational therapist in psychiatry. As a professional in mental health, Ms Saohatse- Banda is passionate about empowering individuals to lead fulfilling lives and is committed to making a positive impact in the field of occupational therapy. Her primary areas of interest are substance abuse, vocational rehabilitation of individuals with mental illnesses, and mental health. She is dedicated to developing personalised treatment plans tailored to the unique needs and circumstances of individuals, to help them achieve their maximum potential. Throughout her career, Ms Saohatse-Banda has been actively involved in community outreach programmes and supporting the mental health needs of disadvantaged communities. She has also participated in research projects aimed at improving mental health care in South Africa.
Occupational therapy provides valuable and unique services in addressing challenges in the daily functioning in the areas of self-care, work, education, sleep and leisure14. Individuals with mental illnesses experienced harsh changes and limitations during the COVID-19 pandemic, which caused significant disruption in their self-efficacy, daily routine, roles and interests15. This made them vulnerable to relapse reoccurrence and decreased vocational opportunities.
Models such as the Model of Human Occupation are utilised to assess and treat changes in daily occupations to ensure that the person can function independently.
13 UN Women, 2016
14 American Occupational Therapy Association, 2020
15 Lin & Fisher, 2020
To equip persons with mental illnesses with strategies for home modifications, activity adaptation and advocacy are the foundations of group therapy. Humans are known as social beings; thus, the use of group therapy ensures interaction with others. The following groups are run in the occupational therapy department at CHBAH: Prevocational skills, Substance abuse, Gardening and Social skills. These sessions focus on prevention of relapse, readmissions and promote a harmonious lifestyle and the maintenance of support systems.
CHBAH is the third-largest hospital in the world, situated in Soweto, southwest of Johannesburg.
It is a central hospital with over 3 200 beds that serves a catchment area of over one million people, of which 18% of households do not have an income. The occupational therapy team is responsible for both inpatient and outpatient care, and treats over 30 inpatients daily, and over 70 outpatients for individual therapy monthly.
The lack of knowledge of the role of occupational therapists in mental health settings has resulted in misguided perceptions and impacted on the availability of qualified occupational therapists. These perceptions include a misunderstanding of the purpose of activities being used in treatment (as these may be perceived as child-like), a lack of knowledge of the return-to-work services offered in mental health, and a notion that occupational therapists are only ‘keeping patients busy’.
During the COVID-19 pandemic, the lockdown measures increased the public’s vulnerability to mental health challenges. The statistics indicate that there was a rise in the diagnosis of depression, anxiety and mood disorders. Mental health patients were challenged, because they were isolated and could not access support services and treatment. In order to decrease the risk of infection, time spent with outpatients at CHBAH was reduced, this affected the quality of services. Occupational therapy was deemed as non-essential and thus patient consultation was affected. This necessitated a change in the services delivered, and a change of the role of occupational therapy in psychiatry. There was a greater focus on primary health care, adaptation to the home environment and adapting to other roles and routines.
During COVID-19, there was a 16% increase in admissions for substance-related disorders, which prompted a change in focus on substance use. The occupational therapy staff partnered with speech therapists and audiologists and designed communication boards, which were specifically focused on interventions and skills to combat substance abuse. More focus was also directed towards caregivers, to assist families that had to care for patients at home. Other activities entailed financial management training, to empower patients to apply for disability grants or manage their money better. Lastly, indigenous South African games and activities such as storytelling were promoted and resources distributed to patients, in order to assist in stimulation and relaxation. New services were also introduced, such as discharge sessions of patients, to assist with the transition of the patient to the home. Health talks with a focus on psychoeducation were also held.
This new approach demonstrated how occupational therapy plays an essential non- pharmaceutical treatment role that encompasses all aspects of human functioning. By ensuring quality in delivery of occupational therapy psychiatry, regardless of the challenges, an inclusive standard of care was maintained that would help realise the constitutional right of ‘health for all’.
Using telehealth to coach caregivers of young autistic children in South Africa during COVID-19 (Ms Marisa Viljoen, University of Cape Town)
Ms Viljoen is a PhD candidate in neuroscience at the University of Cape Town. Her research explores the use of telehealth for autism interventions in low-resource communities. She is also the project coordinator for an early autism intervention study at UCT, that aims to provide access to evidence-based autism services for families in underserved areas. With a background in occupational therapy and over a decade of
experience working with children, she is dedicated to creating and implementing sustainable evidence-based solutions for children and families with neurodevelopmental disorders, particularly in low-resource settings.
This presentation demonstrated that telehealth-delivered intervention has the potential to meet some of the service needs of families in underserved, low-resource areas of South Africa. In March 2020 the COVID-19 pandemic interrupted an autism clinical trial at the University of Cape Town, where informed caregiver coaching based on naturalistic developmental behavioural interventions (NDBIs) was being delivered by non-specialists. Consequently, researchers were encouraged to adapt the interventions for telehealth delivery.
Autism is characterised by deficits in social communication and social interaction, and restrictive, repetitive patterns of behaviours, interests or activities. Early intervention increases positive social, communication and language outcomes in autistic children. However, the challenges that caregivers face in low- and middle-income countries include late diagnosis of the disorder, poor availability of and access to diagnostic and intervention services, lack of trained health care workers and the stigma and lack of public awareness around autism. Telehealth has the potential to address these challenges, and there is evidence that it can be used effectively.
When the COVID-19 lockdown was imposed, the interventions that had been used in the project had to be adapted in order to continue the trial. This included specific adaptations made to the non-specialist coaching sessions to facilitate telehealth delivery with smartphones. The appropriateness, acceptability and feasibility of the adapted telehealth-delivered coaching sessions were evaluated, and signals of change in children with autism and their caregivers were assessed following participation in the telehealth-delivered coaching intervention. The research explored what kinds of adaptations were made to the in-person intervention, what informed these adaptations and how participants perceived the sessions.
Ten adaptations were made to the intervention content, delivery context, training and evaluation, and implementation strategies respectively. Adaptations were informed by outer contextual factors (government mandated COVID policies, national internet infrastructure, participant characteristics, and inter organisational network factors), inner contextual factors (supportive organisational characteristics, leadership, and internal organisational support) and innovation factors (intervention adaptability). Telehealth coaching was described as acceptable, appropriate and feasible by participants. Challenges to the telehealth adaptation included internet connectivity issues, data costs and restrictions to uploading of videos.
Suggested improvements included tailoring WhatsApp pictures, self-reflection checklists and video-recording protocols.
Caregiver implementation reliability increased for seven of the nine caregivers. Signals of change were observed in the child-supported joint engagement, child responsiveness to the caregiver’s communication, fluency and connectedness. Findings were supported by qualitative data, with caregivers reporting changes in the children’s social attention, social skills and participation in daily activities.
The results indicate a good fit between contextually adapted telehealth caregiver coaching and the South African context and provide early evidence for the feasibility of this type of coaching implemented by non-specialists. It can be concluded that contextually adapted telehealth-delivered caregiver coaching may improve access to services for autistic children in low- and middle-income countries.
Question and Answer Session
Question: A number of high-profile athletes have recently come out and declared themselves to be suffering from mental health issues. These are often highly paid professional athletes. What needs to be done to address mental health problems among athletes?
Response: Sport coaching needs to have life skills programmes attached to empower athletes on mental health issues. Mental health interventions are needed at all levels within sport. In the UK, for example, sport psychologists are included in the panels for team selection, and a psychological assessment is done for upcoming team members. Most importantly, athletes should be given time away from training, if necessary, to address any mental health issues that arise.
Question: Would there be any benefit to continuing the telehealth intervention of the autism programme, or is it better rather to go back to face-to-face interventions?
Response: From experience, it might be better to resume in-person interventions, but the feedback from caregivers regarding telehealth sessions has been very positive. The telehealth sessions allow for more flexibility and give caregivers more choices. It would, however, be interesting to see how the signals of change would be affected by resuming in-person sessions.
More research would be required in this regard.
Comment: Telehealth-delivered coaching is important and needs to be retained to reach a wider public, especially in rural areas with less support services.
Question: What happened to autistic children with special needs that could not receive care at their homes during COVID-19?
Response: Children that needed placement in special schools went back to these schools after the strict lockdown requirements were lifted. However, some younger children did not get placement in these schools and ended up in mainstream schools, which was problematic for these children.
Question: How simple were the questions in the clinical questionnaire in the IPV study?
Response: The questions had straightforward yes/no answers. There were a few medical questions that were simple closed-ended questions and required short answers.
Question: Were there concerns around access to participants and the ethical aspects of the IPV study, especially since the research involved vulnerable individuals? How did the researchers get access to the participants?
Response: The project obtained ethical permission and was considered to be of medium risk.
Access to the participants was through a process of sampling in a number of clinics, which identified suitable participants and referred them to the project. After their participation in the project, they were referred to clinical professionals for counselling and support services.
Comment: It would be good to implement the IPV project in other geographical regions of South Africa, for example the Saartjie Baartman Centre for Women and Children in Cape Town.
Question: In terms of geography, what areas were the participants from?
Response: Only one hospital based in South Beach, Durban, participated in the study. The participants were mostly black females from the surrounding urban areas, but they were diverse in terms of employment and education status. No rural participants were part of the project.
Question: Are the communication boards developed by the occupational therapy team at CHBAH available to other users?
Response: The boards are not available and cannot be made public, because they are not yet approved by the Department of Health.
Comment: The compilers of the occupational therapy communication boards are encouraged to speak to practitioners at this symposium and in other institutions, because they might be able to gain valuable input and advice on how to increase the effectiveness and impact of these boards.
Question: Is there a specific age until which children with learning disabilities are still considered for treatment? At what age would they be ineligible for the programmes?
Response: The CHBAH occupational therapy programme do not work with children under the
age of 13, because of limited resources. The programme mostly focuses on compensatory interventions, in that the children are referred to a skills school to develop as artisans or receive practical training. The occupational therapy team collaborates with, and relies heavily on, the Department of Basic Education (DBE), to place those children in suitable schools.
Comment: Regarding children with intellectual impairment, interventions are only mandatory for children under 16. After the age of 16, these children are not obliged to go to school. There are challenges in the system. One case involved two siblings that needed special schools. The one child received placement in a state-funded vocational school, but the second child was not able to get access to the same school and needed to go to another school, which was not registered with the DBE. In many cases the parents do not know whether these schools are registered and are operating legally.
Question: What is the occupational therapy community doing to lobby the DBE to assist children with impairments? Could a future policy be expected that mandates the occupational therapy community to lobby the DBE?
Response: Occupational therapists experience challenges with the DBE at all levels. Mostly they have problems to place the children in special schools. Occupational therapists are advocates for children at risk and they strive to find placements for them, mostly case by case. In some instances, the parents do not know whether the schools their children are placed in are registered and legal. Furthermore, a number of those institutions closed due to the COVID-19 pandemic, leading to more challenges to accommodate the children.
Another important aspect is the pre-vocational training that the CHBAH occupational therapy team is doing with older children that are difficult to place in schools. The purpose is to empower and encourage those children to start their own small enterprises, by teaching them basic financial and life skills necessary to earn a living.
Wrap-up and Closure
Dr Phalane wrapped up the session by thanking the facilitators and the speakers for their contributions. Delegates were encouraged to visit the ASSAf website to familiarise themselves with the work of the academy and opportunities for young scientists.
APPENDIX 1: LIST OF ACRONYMS
ACE Adverse childhood event
AIDS Acquired immunodeficiency syndrome ASSAf Academy of Science South Africa CHBAH Chris Hani Baragwanath Hospital COVID-19 Coronavirus disease 2019
DASS Depression, Anxiety and Stress Scale DBE Department of Basic Education
DSM Diagnostic and Statistical Manual of Mental Disorders GBV Gender-based violence
HIV Human immunodeficiency virus
HPCSA Health Professions Council of South Africa ICD International Classification of Diseases IDO 1 Indoleamine 2,3 dioxygenase
IPV Intimate Partner Violence KZN KwaZulu-Natal
NDBI Naturalistic Developmental Behavioural Intervention NGO Non-government organisation
NRF National Research Foundation PTSD Post-traumatic Stress Disorder
SADC Southern African Development Community SMI Severe mental illness
SWLS Satisfaction with Life Scale UCT University of Cape Town UJ University of Johannesburg UKZN University of KwaZulu-Natal UWC University of the Western Cape WHO World Health Organization
A. Academy of Science of South Africa (ASSAf) Publications B. ASSAf Workshop Proceedings and Other Reports
2023
The implications of COVID-19 for mental health and substance use
Academy of Science of South Africa (ASSAf)
Academy of Science of South Africa (ASSAf)
Academy of Science of South Africa (ASSAf), (2023). The implications of COVID-19 for
mental health and substance use [Available online] DOI http://dx.doi.org/10.17159/assaf.2023/0089 http://hdl.handle.net/20.500.11911/345
Downloaded from ASSAf Research Repository, Academy of Science of South Africa (ASSAf)
