Community psychiatry: an audit of the services in southern Gauteng.
Aim. To audit the community psychiatric services in southern
Gauteng with a view to determining whether the objectives of the
country's mental health legislation and policies are being
Results. Although southern Gauteng's community psychiatric clinics are situated in a primary health setting, primary health clinicians play no active role in the management of mentally ill patients. Care is supplied mainly by specialist psychiatrists, psychiatric registrars (in training) and psychiatric nurses. For first appointments, a mean of 2 patients are seen per doctor per clinic day for a mean duration of 30 minutes. For follow-up appointments, a mean of 17 patients are seen per doctor per clinic day for a mean duration of 8 minutes. The waiting time for new patient appointments is a mean of 6 months. Follow-up patients are seen once a month by nursing staff and approximately once every 4 months by doctors. An average of 1 in 5 patients is treated with oral atypical antipsychotics; in the majority of clinics, this is the total extent of care. However, where psychologists, social workers and occupational therapists are present, only 0.2% of all users have access to them.
Conclusion. The community psychiatric services, although better than those in some other countries, fall short of what is required by South African legislation and policies. General community health services ought to play an active role in the structure and delivery of psychiatric services by developing and strengthening the current limited services, with an emphasis on cost-effective and preventive approaches. Existing community psychiatric services, if so transformed, could serve as a model for other countries in Africa.
(Care and treatment)
Community psychiatric services (Management)
|Publication:||Name: South African Journal of Psychiatry Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 South African Medical Association ISSN: 1608-9685|
|Issue:||Date: June, 2008 Source Volume: 14 Source Issue: 2|
|Topic:||Event Code: 290 Public affairs; 200 Management dynamics Computer Subject: Company business management|
|Product:||Product Code: 8085000 Community Mental Health Centers NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers SIC Code: 8322 Individual and family services; 8399 Social services, not elsewhere classified|
|Geographic:||Geographic Scope: South Africa Geographic Name: Gauteng, South Africa; Gauteng, South Africa Geographic Code: 6SOUT South Africa|
Mental illnesses result in severe distress, impaired productivity
and diminished quality of life for the innumerable afflicted individuals
and their families. The World Bank Report of 1993 (1) and the Harvard
World Mental Health Report of 1996 (2) indicated that about 28% of all
disabilities comprise mental illnesses and, furthermore, that 5 of the
top 10 causes of disability are mental health problems. The reports
projected that by the year 2020 mental health problems would comprise
about 15% of the gross burden of diseases, and much more heavily to
Although there are no published data on the burden of mental illnesses in South Africa, the epidemiology of mental health disorders in South Africa is similar to that found in developed countries. Rapid urbanisation has exacerbated unemployment, violence, substance abuse, child abuse, HIV/AIDS and the disintegration of traditional social support networks and families. These factors probably contribute to the increasing incidence of mental disorders.
In the second half of last century, mental health care underwent restructuring on an international level. Mentally ill patients had been previously confined to 'institutions'; these were generally inefficient and authoritarian, with impenetrable barriers to the outside world, had various rituals and required huge expenditure. Patients developed institutional neuroses characterised by symptoms such as apathy, lack of initiative, loss of interest and submissiveness. (3) More recently, institutions began to be replaced by 'the community', a concept encouraging the development of alternative services including psychiatric units in general hospitals, community-based clinics, residential homes and day centres.
Mental health services in South Africa followed these international trends and were further supported by policy changes and new legislation. The White Paper for the transformation of health (4) proposed a comprehensive, planned and co-ordinated community-based mental health service at national, provincial, district and community levels. The new Mental Health Care Act (5) required that mental health services improve through a primary health care approach with an emphasis on community care. All these features were incorporated into a strategic objective of the Department of Health. (6)
It is evident that the main thrust of mental health care in South Africa had its foundations in community-based services; this resulted in a rapid process of de-institutionalisation--large numbers of chronically mentally ill patients were discharged from institutions for care within the community. However, concerns arose that, prior to the transformation processes, there was a lack of development of new services or strengthening of existing psychiatric services within the community. The funds that accrued from the de-institutionalisation process were not transferred to, nor were additional funds budgeted to bolster, the community-based services.
The objective of this study was to describe the southern Gauteng community psychiatric services with regard to geographical distribution, staff establishments and utilisation.
The study comprised a retrospective audit of community psychiatric services in southern Gauteng in 2005. The services are co-ordinated by the District Mental Health programme managers and the Division of Psychiatry at the University of the Witwatersrand. These authorities were consulted to obtain data on the geographical distribution of the services, service packages and staff establishments of the various clinics, and the psychotropic medications available for prescribing by doctors. Patient statistics were obtained from Human Information Systems at the offices of the regional directorates, and included the number of patients per month attending psychiatric clinics in the various districts. Information on psychotropic medication usage was obtained from the Medical Supplies Depot.
Attendance figures and staff complements at all clinics in the studied region were combined and expressed as means and averages across all the services. Descriptive statistics were computed as counts, percentages and means. All analyses were done using Statistical Package for Social Sciences 10.0 for Windows (SPSS Inc., Chicago, Ill.).
A limitation of this study is that assumptions and generalisations are statistically weak, and that contact time by clinicians is not necessarily an ideal measure of service delivery. However, we believe they are worth noting.
Community psychiatric services for adults (>18 years old) are provided by the District Health Services. Southern Gauteng region is divided into 4 districts: Johannesburg Metro, Westrand, Ekhuruleni and Sedibeng. The adult population of the 4 districts, according to Census South Africa 2001, (7) was 2 579 767 (Metro), 514 459 (Westrand), 1 941 186 (Ekhuruleni), and 576 125 (Sedibeng), respectively. Most of the psychiatric clinics are located within primary health clinics (Table I). Although there are 21 clinics in the Johannesburg Metro, they are concentrated in the south, with a paucity of services in the northern segment of southern Gauteng (Table I).
The Norms and Standards for Mental Health Care for people with severe psychiatric conditions were commissioned by the Directorate: Mental Health and Substance Abuse, Department of Health, in 1998. This tool is used to calculate acceptable levels of mental health care and human resources required for ambulatory care per 100 000 people. The minimum acceptable staffing norms thus calculated, and the multidisciplinary staff that provided services in 2005 in the districts, are listed in Table II.
Although the clinics are located in a primary health setting, primary health care professionals play no active role in the management of mentally ill patients. Care is supplied mainly by specialist psychiatrists, psychiatric registrars (in training), and psychiatric nurses with minimal--if any--support from psychologists, social workers and occupational therapists.
Utilisation of services
Based on clinic rosters, we established that psychiatry registrars and/or nurses provide care at these clinics ranging from 1 day per week to 1 day per month. The mean monthly attendance figures in the various clinics in the districts are listed in Table III. An average of 2 first-appointment patients are consulted per doctor per clinic day. The mean duration of first appointments is 30 minutes, and the wait time is 6 months. Follow-up appointments by doctors and nurses are, on average, once every 4 months and once a month, respectively. The mean duration of a follow-up appointment is 8 minutes for doctors and 10 minutes for psychiatric nurses. Psychologists, social workers and occupational therapists are not available at all facilities; only 1 in 500 of all users has access to them.
Psychotropic drugs available in the services are in accordance with the Essential Drug List (EDL) for Gauteng. This list was expanded in 2004 to include newer psychotropics with restrictions (Table IV).
The antipsychotics used are: oral typical (haloperidol, triluperazine and chlorpromazine)--59.8%; intramuscular depot typical (flupenthixol, zuclopenthixol)--17.3%; and oral atypical (sulpiride, clozapine, risperidone)--22.9%. The antidepressants used are tricyclics (amitriptyline, clomipramine) and selective serotonin re-uptake inhibitors (fluoxetine, citalopram, paroxetine).
The fundamental principles of community psychiatry include: comprehensive services, with treatment reasonably close to the patient's home; continuity of care; and patient participation. (8) Psychiatrists in a community setting, in addition to direct clinical care, are expected to provide home assessments and reviews, psycho-education and early detection screening of most psychiatric disorders. (9-11) They are meant to work in partnership with medical specialists, family caregivers, special needs groups, and public and private agencies in the community. Furthermore, community psychiatric services are also intended to improve the mental health wellbeing of the community by promoting mental health awareness, teaching skills to develop resilience, and challenging stigmatisation. (12)
It would appear from our audit that community psychiatric services in southern Gauteng do not meet all the principles and objectives described above. There are insufficient numbers of community psychiatric clinics to meet the needs of the ever-increasing population of the area. The few clinics in operation are not geographically accessible to all users, are moreover servicing excessively large numbers of patients, and may not be able to deal effectively and comprehensively with their mental health problems in the short contact time available.
Moreover, staff complements are considerably less than the minimum norms recommended by the Department of Health. Specialised psychiatric personnel provide their services only once a week or once a month, and there is little or no support for patients at other intervals. The predominant focus is on direct clinical care with a limited choice of psychotropic medication. There are minimal (if any) multidisciplinary approaches to care, rehabilitation and integration of users back into society.
For the large population in this region, there is inadequate provision of community mental health services, and modern psychiatry does not seem to exist for them. For those patients entering the system, there is insufficient ongoing care, monitoring and psychosocial support.
Recommended strategies to improve services
National mental health policy must be formulated by professionals from the field of mental health as well as public health administration, economics, education and social sciences. Mental health clinics that are geographically accessible to all users need to be established or developed in all districts. The services should incorporate district and regional hospitals so that a system of networking and referral at all levels exists, and all facilities be supported with human and material resources in accordance with the national staffing norms. Active recruitment and retention, through incentive-based approaches, of specialised personnel to work in the community may be considered. In order to achieve these objectives, services have to be adequately financed; the budgets from shut-down institutions should be made available to community services.
The World Health Organization (WHO) Expert Committee (1975)13 stated: 'In the developing countries, trained health professionals are very scare indeed; clearly, if proper health care is to be brought within reach of the mass of the population, this will have to be done by non-specialized health workers at all levels, from the primary health workers to the nurse or doctor working in collaboration with and supported by more specialized personnel. Primary health care workers would need to be trained and provided with guidelines on the principles of basic mental health care. Inherent in this concept is that specialized/teaching institutions should assume a role of providing technical input in the form of human resource development, capacity building, evaluation and development of locally acceptable models of care to enable the system to become strong and dynamic. The approach will not only relieve the congestion at the teaching hospitals but also provide health care assistance at an early stage with tremendous cost-effectiveness in the long run.'
The World Psychiatric Association (WPA) and the London-based National Institute of Clinical Excellence (NICE) issued evidence-based guidelines in 2002 which recommended that oral 'atypical' antipsychotic drugs be considered as the first-line choice of treatment for newly diagnosed schizophrenia and for patients with unacceptable adverse effects caused by 'typical' agents. It is imperative that a wider choice of the newer atypical antipsychotics and antidepressants be made freely available for clinicians to prescribe according to guidelines.
In collaboration with other sectors such as education, social welfare, medical education, legal agencies and other nongovernmental organisations, the mental health care programme would become more comprehensive and effective in achieving its targets.
Health is held to be a fundamental birthright of every individual. Mental health policies should conform to general socio-political and moral precepts and scientific disciplines. Policymakers must seek informed opinion, active involvement and co-operation from professionals and the public. This approach should also be reflected in the structure and functions of clinics, with evidence of the development and strengthening of resources in these units. Furthermore, greater emphasis should be placed on cost-effective, active and preventive approaches, and due consideration be given to the established norms and customs of the local population. The local community psychiatric services, thus transformed, could serve as a model for other African countries.
(1.) World Bank. World Development Report. Washington: World Bank, 1993.
(2.) Murray CJL, Lopez AD. Harvard World Mental Health Report (1996). Global Burden of Disease Study Conducted by the World Health Organization, World Bank, and Harvard University. Cambridge, Mass: Harvard University Press, 1996: 14, 131.
(3.) Barton R. Institutional Neurosis. 3rd ed. Bristol: John Wright, 1976: 47.
(4.) White Paper for the Transformation of the Health System in South Africa. Pretoria: Department of Health, 1997. http://www.info.gov.za/whitepapers/1997/health. htm (accessed 14 April 2008).
(5.) Mental Health Care Act No. 17 of 2002. Chapter II: Fundamental Provisions. Government Gazette vol. 449. Pretoria: Government Printer, 6 November 2002. http://www.info.gov.za/gazette/acts/2002/a17-02.pdf (accessed 14 May 2008).
(6.) A National Health Plan for South Africa. Prepared by the ANC with the technical support of WHO and UNICEF. May 1994. www.anc.org.za/ancdocs/policy/ health.htm (accessed 14 May 2008).
(7.) South Africa: Population Census 2001. Community profile database. Pretoria: Statistics SA. http://www.statssa.gov.za/census 01/html/default.asp (accessed 14 May 2008).
(8.) Caplan G, Caplan R. Principles of community psychiatry. Community Ment Health J 2000; 36: 7-24.
(9.) Rosen A. The community psychiatrist of the future. Curr Opin Psychiatr 2006; 19: 380-388.
(10.) Faloon IRH, Montero I, Sunger M, et al. Implementation of evidence-based treatment for schizophrenic disorders: two-year outcome of an international field trial of optimal treatment. World J Psychiatr 2004; 3: 104-109.
(11.) Johnson S, Nolan F, Hoult J, et al. Outcomes of crises before and after introduction of a crisis resolution team. Br J Psychiatr 2005; 187: 68-75.
(12.) Rosen A. What developed countries can learn from developing countries in challenging psychiatric stigma. Australasia Psychiatry 2003; 11: 589-595.
(13.) Organisation of Mental Health Services in Developing Countries. Sixteenth Report of the WHO Committee on Mental Health. Geneva: World Health Organization, 1975.
M Y H Moosa, MMed Psych, FCPsych, MCFP
F Y Jeenah, MMed Psych, FCPsych
Department of Psychiatry, University of the Witwatersrand
Table I. Adult clinics in southern Gauteng Metro Brixton Chiawelo Diepkloof Discoverers Dobsonville Eldorado Park Ennerdale Hillbrow Ivory Park Jeppe Lenasia Lenasia South Lilian Ngoyi Meadowlands Mofolo Orange Farm Orlando Pimville Rabie Ridge Riverlea Townsview Westbury Zola Westrand Azaadville Bekkersdal Brakpan Carletonville Hekpoort Kagiso Khutsong Krugersdorp Mogale Mohlakeng Munsieville Muldersdrift Randfontein Swanieville Toekomsrus Westonaria Ekhuruleni Actonville Alberton Boksburg Brakpan Daveyton Devon Duduza Eden Park Etwatwa Germiston Goba Katlehong Kempton Park Kwa-Thema Nigel Northmead Springs Tembisa CHC Thokoza/Dresser Tsakane Vosloorus Zonkesizwe Sedibeng Boipatong Bophelong Empilisweni Johan Heyns Kookrus Kopanong Levai Mbatha Ratanda Sharpeville Tabitha Oord Vereeniging Table II. Minimum staffing norms and staff establishments for 2005 Minimum norm (per population) Category Metro Westrand Ekhuruleni Sedibeng Psychiatric nurses 39 12 39 12 Occupational therapists 29 3 10 3 Social workers 19 6 19 6 Psychologists 19 6 19 6 Psychiatrists 6 1 5 3 Medical officers 11 3 10 3 Actual staff establishment Category Metro Westrand Ekhuruleni Sedibeng Psychiatric nurses 31 8 31 8 Occupational therapists 0 0 1 0 Social workers 2 0 2 0 Psychologists 3 0 3 1 Psychiatrists 2 0 1 2 Medical officers 6 3 5 2 Table III. Mean monthly attendance figures in the districts for 2005 Districts Metro Westrand Total number of patients 9 573 3 015 Number of patients seen by nursing staff 6 989 2 214 Number of patients seen by registrars 2 584 801 Number of new patients seen by registrars 396 121 Districts Ekhuruleni Sedibeng Total number of patients 6 067 2 894 Number of patients seen by nursing staff 4 349 2 159 Number of patients seen by registrars 1 718 735 Number of new patients seen by registrars 179 115 Table IV. Expanded EDL for community psychiatry in Gauteng Secondary level (psychiatrist Level of care Primary level (any doctor) only) Anti-depressants Clomipramine Imipramine tabs 10, tabs 10, 25 mg 25 mg AmitrIptyline Paroxetine tabs 25 mg tabs 20 mg Fluoxetine Citalopram tabs 20 mg tabs 20 mg Mianserin tabs 10, 30 mg Hypnotics/ Diazepam tabs Buspirone anxiolytics 5 mg and tabs 10 mg injection 10 mg/2 ml Clonazepam Clonazepam injection tabs 0.5, 1 mg/ml 2 mg; drops 2.5 mg/ml Lorazepam inj. Lorazepam 4 mg/ml tabs 1, 2.5 mg Oxazepam tabs 10, 15, 30 mg Neuroleptics Zuclopenthixol acetate Risperidone 50 mg/ml tabs 3 mg Chlorpromazine Trifluope- tabs razine tabs 25, 100 mg 1, 5 mg Haloperidol Haloperidol Zuclopenthixol tabs tabs 1.5 mg tabs 2, 10 mg 0.5, 5 mg and and 200 mg/ml inj. 5 mg/ml depot inj. Flupenthixol Thioridazine depot inj. 10 mg tabs, 20 mg/ml, 100 mg tabs 40 mg/ml Fluphenazine Clozapine tabs depot inj. 25, 100 mg 25 mg/ml Sulpiride tabs 200 mg Stimulants Methylpheni- date tabs 10 mg Mood stabilisers Carbamazepine Lithium tabs 200 mg, carbonate tabs syrup 100 250, 400 mg mg/5ml Valproate sod. Valproic acid tabs 200, caps 150, 500 mg, syrup 300 mg 200 mg/5ml, Valproic acid caps 500 mg Anti-parkin- Biperiden inj. Biperiden sonian agents 5 mg/ml tabs 2 mg Orphenadrine tabs 50 mg Psychosexual Cyproterone problems acetate tabs 50 mg and depot inj. Alcohol abuse Disulfiram tabs 400 mg
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