Community psychiatry : An audit of the services in southern Gauteng

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 and the Harvard World Mental Health Report of 1996 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 total disabilities.

Patients developed institutional neuroses characterised by symptoms such as apathy, lack of initiative, loss of interest and submissiveness. 3More 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 communitybased 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 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 foregoing facts motivated the opportunity and need to audit psychiatric services in a community-based setting.The basis for this evaluation was the community psychiatric services for adults in southern Gauteng because these were the most developed services in the country.Although the findings are not generalisable, they may provide some pertinent information and serve as a basis for further regional studies.

Aim
The objective of this study was to describe the southern Gauteng community psychiatric services with regard to geographical distribution, staff establishments and utilisation.

Method
The study comprised a retrospective audit of community 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.

Geographical distribution
Community  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).

Staff establishments
The

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

Discussion
The fundamental principles of community psychiatry include: comprehensive services, with treatment reasonably close to the patient's home; continuity of care; and patient participation. 80][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 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.

Conclusion
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 articles articles 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.).

Table I . Adult clinics in southern Gauteng
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 (TableIV).The antipsychotics used are: oral typical (haloperidol, triluperazine and chlorpromazine) -59.8%; intramuscular depot typical Volume 14 No. 2 June 2008 -SAJP Volume 14 No. 2 June 2008 -SAJP articles

Table IV . Expanded EDL for community psychiatry in Gauteng
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.'TheWorld Psychiatric Association (WPA) and the Londonbased 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.