asmal translational neuropsychiatry research

Bridging Bedside and Bench Translational Neuropsychiatry Research in Africa

Dr Laila AsmalUniversity of Stellenbosch, Cape Town, South Africa

Schizophrenia Research Overview

• 120 FEP participants (matched controls)– Treated with Flupenthixol decanoate, 2 year follow-up

– Predictors of outcome, course of illness, ethnic differences, structural brain changes

• Confluence subsample– RCT, risperidone or flupenthixol imi

– Structural and functional MRI changes

• Stanley discontinuation study– Omega 3 and ALA

• Other – cochrane, genetics, family therapy study, metabolic disease, early childhood trauma, criminality

Translational Neuropsychiatry Research in Africa

Bedside to bench and back

1. Woolf SH, 2009

Translational Neuropsychiatry Research in Africa

Africa is not a country!

But what do we have in common?

• Wide-based age pyramid • Rural populations with recent but rapid urban

migration• Social and political instability• Widespread poverty and unevenly distributed

health resources• Absence of sound strategies for data collection• Quadruple burden of disease

Preux PM, 2005

Quadruple burden of disease

• Pre-transitional diseases and poverty related conditions– childhood undernutrition and infections, maternal

mortality• Emerging chronic diseases – obesity, heart disease, diabetes

• Injuries– including interpersonal violence

• HIV/AIDS, TB, malaria

MRC Burden of Disease Unit, 2004

World Land Area

www.worldmapper.com

Urban slums

www.worldmapper.com

Undernourishment

www.worldmapper.com

HIV Prevalence

www.worldmapper.com

Syphilis deaths

www.worldmapper.com

Epilepsy deaths

www.worldmapper.com

Stroke deaths

www.worldmapper.com

Translational Neuropsychiatry Research in Africa

What is Neuropsychiatry?

• Mental disorders caused by:– Structural brain dysfunction– Electrical malfunction– Extrinsic toxic-metabolic derangements

• Emphasises neurological basis of mental illness

• Utilises modern neurodiagnostic investigations in evaluation and treatment

Hurwitz M, 2009

Challenges facing Neuropsychiatry Research in Africa

• Studies in SSH are not easily accessible• Methodological constraints make epidemiological

studies difficult to compare. • Clear endpoints difficult to measure• Questionnaires not suitable for diverse populations• Medical records are commonly incomplete• Lack of specialised personnel, diagnostic equipment • Use of different terminologies to classify disorders.

Preux, 2005

Dementia: a Developed World problem?

• 71% of dementia in developing countries by 20406

• Prevalence is increasing in developing countries5

• Confounders5: – shorter survival, lack of awareness, inadequate

diagnostic assessments, variability of costs of care – under-reporting

• Research focus on elderly population• Some work on HIV

5. Kalaria R, 20086. Prince M, 2009

Dementia Developing Countries

6. Kalaria J, 2008

Case vignettes

Alternate pathophysiology?

Poverty

• Economic deprivation

• Low education• Unemployment• Inadequate

housing• Lack of basic

eminities• Overcrowding

• Infectious diseases• High stressors• Inadequately

treated depression• Reduced access to

social capital• Malnutrition• Obstetric risks• Epilepsy• Violence and trauma

Dementia

• Higher prevalence

• Earlier onset

• Poor/lack of care

• More severe course

Layering of risk factors

Perinatal insults

Infectious diseases

Nutritional deficiencies

Head injuries

Vascular risk factors

Epilepsy

Poor education

Genetic risk

Dementia

What do we need?

• Multi-centric prevalence survey across Africa– Sufficient participants encompassing diversity – Common protocol– Focus on co-morbidity– Carer, need for care, disability, health care use

• Biological samples (DNA, haematology, fasting glucose and lipids and frozen serum)

• Longitudinal studies to better estimate incidence, morbidity, and mortality.

• Dissemination of knowledge

References

1. Woolf SH. JAMA, Jan 2008; 299(2) The Meaning of Translational Research and why it matters: 211-213

2. Preux PM, Druet-Cabanac M. Epidemiology and aetiology of epilepsy in sub-Saharan Africa. Lancet Neurol 2005; 4: 21–31

3. MRC Burden of Disease Unit, 20044. www.worldmapper.com5. Hurwitz, Fundamentals of Neuropsychiatry, UBC, 20096. Kalaria et al. Alzheimer's disease and vascular dementia in

developing countries: prevalence, management, and risk factors. Lancet Neurol. 2008 Sep; 7(9): 812–826.

7. Prince MJ, The 10/66 dementia research group - 10 years on. Indian J Psychiatry. 2009 January; 51(Suppl1): S8–S15.