Literature Collection

BACKGROUND: A key feature of South Africa's state health care strategy since 1994 has been the development and expansion of services towards integrated health care at primary health care level. Within the new system, emphasis has been on the integration of patients with mental health care needs with other patients where multiple health conditions and needs would be addressed simultaneously. As part of a larger study into mental health care in a predominantly rural district, we investigated the experiences of facility managers and mental health service users in rural clinics within the system of care. We were interested both in their views as to the advisability of the integrated model and the ways in which they managed any challenges they may have experienced within the system at local level. METHODS: Data were collected through once-off semi-structured interviews with facility managers and mental health care service users to gather qualitative information. Narratives were transcribed and translated into English. Transcriptions were imported to Atlas.ti 22 and analysed through Thematic Analysis. RESULTS: The integration of mental health care into routine primary health services poses challenges to treatment delivery and to patients who come for treatment. Our study also suggests resegregating mental health care as a possible solution to facilitate service delivery and treatment to service users. CONCLUSION: This research provided first insights into facility managers' and service users' views of integrated mental health care at primary health care level in this district. While mental health care services have been expanded and integrated into primary health care over recent years, the system may not have been as streamlined as in other parts of the country. The integration of mental health into primary health care can pose various challenges to facilities, health care providers, and mental health service users. Managers in these constrained circumstances have observed that resegregating mental health care from physical treatment, as in the past, may be deemed more effective for health care provision and reception. Generalised integration of mental health treatment with physical care should be approached with caution unless there is wider scale provisioning and greater organisational change.

BACKGROUND: Despite the World Health Organization listing methadone as an essential medication, effective dose selection is challenging, especially in racial and ethnic minority populations. Subtherapeutic doses can result in withdrawal symptoms while supratherapeutic doses can result in overdose and death. Although CYP3A4 was conventionally considered the principal methadone metabolizing enzyme, more recent data have identified CYP2B6 as the principal enzyme. CYP2B6 has ethnically-associated polymorphisms that affect the metabolic rate. Our objective was to investigate the effects of genetic and nongenetic factors on methadone metabolism. METHODS: We measured trough plasma methadone levels in 100 participants with opioid use disorder. We assessed methadone metabolism by calculating the metabolite ratio (major metabolite: 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine [EDDP] divided by methadone concentration). We assessed hepatic fibrosis and steatosis by transient elastography and CYP2B6 alleles, principally responsible for methadone metabolism. Mixed effects models modeled the data in 97 participants. RESULTS: Participants were largely male (58%), minority (61% African American) and non-Hispanic (68%). Forty percent were HCV mono-infected, 40% were uninfected, and 20% were HCV/HIV co-infected. Female sex had significant effects on (R)- and (S)-methadone metabolism (p = 0.016 and p = 0.044, respectively). CYP2B6 loss of function (LOF) alleles significantly affected (S)-methadone metabolism (p = 0.012). Body mass index (BMI) significantly affected (R)-methadone metabolism (p = 0.034). Methadone metabolism appeared to be lower in males, in individuals with LOF alleles, and elevated BMI. CONCLUSIONS: Genetic analysis, especially in minority populations, is essential to delivering individualized treatments. Although the principal methadone metabolizing enzyme remains controversial, our results suggest that sex, CYP2B6 genotype, and BMI should be incorporated into multivariate models to create methadone dosing algorithms. Methadone dosing algorithms should facilitate medication delivery, improve patient satisfaction, and diminish overdose potential.

To overcome fragmentation in support for children and their families with multiple and enduring problems across life domains, professionals increasingly try to organize integrated care. However, it is unclear what facilitators and barriers professionals experience when providing this integrated care. Our systematic review, including 55 studies from a broad variety of settings in Youth Care, showed that integrated care on a professional level is a multi-component entity consisting of several facilitators and barriers. Findings were clustered in seven general themes: 'Child's environment', 'Preconditions', 'Care process', 'Expertise', 'Interprofessional collaboration', 'Information exchange', and 'Professional identity'. The identified facilitators and barriers were generally consistent across studies, indicating broad applicability across settings and professional disciplines. This review clearly shows that when Youth Care professionals address a broad spectrum of problems, a variety of facilitators and barriers should be considered.Registration PROSPERO, registration number CRD42018084527.