Acute mental health care according to recent mental health legislation. Part III. Structuring space for acute mental health care

Objective: This is the third of three reports on the follow-up review of mental health care at Helen Joseph Hospital (HJH). The study reviewed existing South African standards for mental health care facilities. Architectural principles and implications for the use of space were deducted from recent legislation. Objectives were to evaluate the use of space in the existing physical facilities, to identify appropriate architectural solutions considering identified human rights requirements and to provide provisional cost estimates to align the unit towards its designated functions. Method: Personal interviews were conducted. An on-site assessment and survey was made of existing and potential new spaces. Results: Spatial requirements for implementing the Mental Health Act, No. 17 of 2002 (MHCA) were explored. Principles for spatial design of acute facilities include that: - spaces should communicate clear individual identity; - space should be segregated into zones according to user functionality and privacy; - communal leisure spaces should open into safe contained outdoor spaces; - circulation routes should preferably be circular; - sufficient visual connection should exist between circulation space and group activities; and - open lines of sight should be provided to all access points. The potential options for extension included: - an extensive unused single storey structural shell for a potential office wing on the same floor; - a huge vacant double volume space which could be accessed across the existing flat roof for potential occupational therapy activities; and - the existing roof area could be altered and secured to become an adequate outside leisure and garden area. A proposed concept design in two phases – based on these principles - was submitted to hospital and provincial management. Conclusion: To implement the MHCA without violating the human rights of mental health care users at HJH will require specific adjustment and extension of the current use of space at HJH.Key words: Architecture; Hospitals; Mental health services; Human right

Tracking the legal status of a cohort of inpatients on discharge from a 72-hour assessment unit

Scientific Lette

Acute mental health care and South African mental health legislation Part 1- morbidity, treatment and outcome

Objective: This is the first of three reports on a follow-up review of mental health care at Helen Joseph Hospital (HJH). In this first part, qualitative and quantitative descriptions were made of the services and of demographic and clinical data on acute mental health care users managed at HJH, in a retrospective review of clinical records over a four year period. Objectives for this review were to provide information on mental health care outcome, to do a cost analysis and to establish a quality assurance cycle that may facilitate a cost centre management approach. The operational areas identified were service delivery, teaching, and research. Activities within each area were in-patient care, out-patients and consultation/liaison, under- and postgraduate teaching and self initiated or contract research. Method: The study reviewed the existing mental health care program and activities in context of relevant policy and legislation. Results: Norms from a World Health Organization model for acute mental health care showed that significant staff shortages existed, especially for nursing. A total of 520 users were admitted for in-patient mental health care during the financial year 2007/08. The average length of stay was 15.4 days and ranged from 1 to 85 days. Ninety users (17%) had an extended period of stay of 25 days and more, while 39 users had multiple admissions during the 12 month period. The most common Axis I diagnoses made were schizophrenia n=138 (29%), substance-related conditions n=99 (21%) and bipolar mood disorder n=69 (14%). After discharge, 139 users (27%) were referred back to the HJH out-patient department for follow-up. Conclusion: The information from these reports may be used in the allocation of adequate resources to align this acute unit with its responsibilities according to recent legislation.Key words: Mental health service; Legislation; South Afric

A changed climate for mental health care delivery in South Africa

Objective: Traditional health practice was recently mainstreamed in South Africa by the promulgation of the Traditional Health Practitioners Act, No. 35 of 2004. Due to the extent of integration of mental health in the legal definition of traditional health practice, promulgation of this Act also has significant implications for mental health care delivery. This paper explored the documented interface of traditional health practice with mental health care in South Africa over the past almost 50 years. Method: A preliminaryoverview of health literature was done on formal mental health care and traditional alternatives in South Africa since the 1950’s. Important themes were identified as first step in a qualitative approach to identify concepts. Results: The search yielded 143 references, between 1958 and 2004, from articles, case reports, scientific letter, theses and chapters in books. A cross section of 56 references was selected for inclusion in this review of the material. Conclusion: The documentation on the interface betweenthe two parallel systems contribute to establish a context against which the promulgation of the legislation to formally integrate and regulate African traditional health practice in South Africa can be considered. South African policy makers may now have ensured that a multi-faceted, multi-cultural and multi-cosmological context for health and mental health care delivery has come to pass. To health administrators, though, the inclusion of traditional healers into the formal public health system and mental healthmay still prove to be too costly to implement

Diagnosis and treatment of schizophrenia in a general hospital based acute psychiatric ward

Objectives: To review and describe the clinical profile and acute in-patient treatment of patients diagnosed with schizophrenia over a four-year period; to review and describe the documented evidence for the diagnosis of schizophrenia; and to identify possible associated or predictive factors in the acute in-patient treatment outcome of patients at an acute (designated for 72-hour assessments) ward – within a general hospital, Helen Joseph Hospital (HJH). Method: Routine discharge summaries were used in a retrospective clinical review of patients with schizophrenia. The demographic, clinical and treatment profile of these patients were described and the documented evidence for the diagnosis of schizophrenia was reviewed using descriptive and comparative statistics. Factors were evaluated to assess their association with the length of stay (LOS) as outcome variable, using “Generalized Linear Latent and Mixed Models” (GLLAMM). Results: A total of 436 patients were diagnosed with schizophrenia, constituting on average about 20% of the total numbers of admissions. The overall mean LOS was 19.5 days. Considering DSM IV-TR criteria for schizophrenia, behavior problems were confirmed in 71.8% (n=313), perceptual disturbances in 29% (n=126) and thought disorders in 83.5% (n=364). The duration of symptoms were specified in 68% (n=298) patients. Age (

Acute mental health care according to recent mental health legislation Part II. Activity-based costing

Objective: This is the second of three reports on the follow-up review of mental health care at Helen Joseph Hospital (HJH). Objectives for the review were to provide realistic estimates of cost for unit activities and to establish a quality assurance cycle that may facilitate cost centre management. Method: The study described and used activity-based costing (ABC) as an approach to analyse the recurrent cost of acute in-patient care for the financial year 2007-08. Fixed (e.g. goods and services, staff salaries) and variable recurrent costs (including laboratory’, ‘pharmacy’) were calculated. Cost per day, per user and per diagnostic group was calculated. Results: While the unit accounted for 4.6% of the hospital’s total clinical activity (patient days), the cost of R8.12 million incurred represented only 2.4% of the total hospital expenditure (R341.36 million). Fixed costs constituted 90% of the total cost. For the total number of 520 users that stayed on average 15.4 days, the average cost was R1,023.00 per day and R15748.00 per user. Users with schizophrenia accounted for the most (35%) of the cost, while the care of users with dementia was the most expensive (R23,360.68 per user). Costing of the application of World Health Organization norms for acute care staffing for the unit, projected an average increase of 103% in recurrent costs (R5.1 million), with the bulk (a 267% increase) for nursing. Conclusion: In the absence of other guidelines, aligning clinical activity with the proportion of the hospital’s total budget may be an approach to determine what amount should be afforded to acute mental health in-patient care activities in a general regional hospital such as HJH. Despite the potential benefits of ABC, its continued application will require time, infrastructure and staff investment to establish the capacity to maintain routine annual cost analyses for different cost centres.Key words: Cost analysis; Activity-based costing; Acute mental health care; Recurrent cost; Fixed and variable cost; Cost centre management; Hospital expenditur

Clinical and psycho-social profile of child and adolescent mental health care users and services at an urban child mental health clinic in South Africa

Objective: National and international child and adolescent mental healthcare policy and action advocate that the health and well being of children should be increasingly given greater attention. The purpose of this study was to describe the demographic, socio economic and clinical profile of the users at the child and adolescent mental health clinic of the Rahima Moosa Mother and Child Hospital (RMMCH). Method: A descriptive, retrospective clinical audit from users’ clinical files was performed over a one-year period from January to December 2007. Descriptive statistical analyses of demographic and socio-economic variables were made and these variables were compared with the presenting clinical problems. Odds ratios were calculated for variables that showed a statistically significant association (p-value less than 0.05). Results: A total of 303 users attended this clinic. Statistical comparisons between demographic data and disorders revealed that being male increased the likelihood of presenting with AHDH and disruptive behaviourdisorders; being female increased the likelihood of being sexually abused. Race showed a significant association with parent-child relationship difficulties. Regarding socio-economic variables, the identity of the caregiver of the child influenced the risk of disruptive behaviour disorders, sexual abuse, neglect and academic problems. Where the child was placed was a risk factor for disruptive behaviour disorders, sexual abuse, neglect and academic problems. Whether the mother of a user was alive or deceased, was found to be related to ADHD and disruptive behaviour and whether the father of a user was alive or deceased, was found to be related to sexual abuse and academic problems. The education level of the caregiver showed a significant association with sexual abuse, neglectand academic problems; the marital status of the parent (widowed mother) showed a significant association with bereavement. Household income was associated with sexual abuse, neglect and academic problems.Conclusion: This study demonstrated the impact that socio-economic circumstances have on the prevalence of childhood disorders; hence the urgent need for government and social welfare departments to improve the socio-economic status of communities. There is a need to improve psychiatric services for the population served by this hospital, including more clinics in its catchment area, as well as child psychiatry training posts and extended social work services.Keywords: Socio-economic variables; Clinical profile; Child and adolescent mental health services; South Afric

The role of spirituality in specialist psychiatry: A review of the medical literature

A review of the international medical literature was undertaken on the role of spirituality in the discipline of psychiatry, within the context that a perceived change is taking place in the health care environment in South Africa. Revitalized interest in spirituality was evident from the literature partly because Western societies have, through the migration of people, become more heterogeneous in recent years. The literature concurred that spirituality must be incorporated into the current approach to the practice and training of psychiatry, but within the professional scope of the discipline, while all faith traditions and belief systems should be regarded equally. Beyond South Africa, it is envisaged that the review has implications for the practice of psychiatry in Africa.Keywords: Spirituality; Practice and training; Psychiatry; Medical literature; Qualitative inquir

Experience and views of academic psychiatrists on the role of spirituality in South African specialist psychiatry

CONTEXTO: A importância de ter de considerar o papel da espiritualidade na saúde, saúde mental e psiquiatria na África do Sul tem sido especialmente enfatizada pela recente legislação sobre práticas tradicionais de saúde na África. OBJETIVO: Explorar as opiniões e experiências de psiquiatras locais sobre o papel da espiritualidade na prática e no treinamento de especialistas em psiquiatria na África do Sul. MÉTODO: Este estudo é uma pesquisa qualitativa, exploratória, descritiva, contextual, fenomenológica e geradora de hipótese. A fonte principal de dados foram entrevistas semiestruturadas com psiquiatras filiados a uma universidade local. Para assegurar de que os dados fossem confiáveis, as seguintes medidas foram incluídas: credibilidade, transferibilidade, confiabilidade, e confirmabilidade. RESULTADOS: A consciência da espiritualidade, "mindfulness", e uma abordagem de mente aberta sobre a espiritualidade, segundo os participantes, devem ser facilitadas na prática e no treinamento psiquiátrico. Seis temas foram identificados por meio de códigos abertos. DISCUSSÃO: Todos os participantes, independentemente de suas próprias visões sobre espiritualidade e religião, concordaram que, sob certas condições, a espiritualidade deve ser incorporada na abordagem biopsicossocial atual na prática local e no treinamento de especialistas em psiquiatria.BACKGROUND: The importance of having to consider the role of spirituality in health, mental health and psychiatry in South Africa has in particular been emphasized by recent legislation on African traditional health practice. OBJECTIVE: The purpose of this study was to explore the views and experience of local psychiatrists regarding the role of spirituality in South African specialist psychiatric practice and training. METHOD: This study is an explorative, descriptive, contextual, phenomenological and theory-generating, qualitative investigation. In-depth, semi-structured interviews with individual academic psychiatrists affiliated to a local university were conducted as primary data source. Measures to ensure trustworthiness included credibility, transferability, dependability and confirmability. RESULTS: Awareness of spirituality, "mindfulness" and an open-minded approach about spirituality should, according to participants, be facilitated in psychiatric practice and training. Six themes were identified through open coding. DISCUSSION: All participants, disregarding of their own views on spirituality and religion, agreed, that under certain conditions, spirituality must be incorporated into the current bio-psycho-social approach in the local practice and training of specialist in psychiatry

Long-term care of children and adolescents with intellectual disabilities and severe physical abnormalities

Objective: This study sets out to review the clinical profile and treatment program of children and adolescents with intellectual disability in Waverley Care Center (WCC). Method: A retrospective review was done of users from January to December 2004. Reviewed parameters included age, gender, length of stay, DSM IV diagnoses, current medical treatment, and level of functioning and mobility according to the Therapeutic Classification System for Children (TCS). Results: A total of 179 users were receiving care. Although the mean age of users was 14 to 15 years, their ages ranged from 3 to 34 years. The gender ratio of users was 1 (female) to 1.6 (male). The average length of stay was 6.73 years and the range of stay from 0.5 to 29 years. Attention deficit hyperactivity disorder was diagnosed in eight children and pervasive disorders were suspected in some. Intellectual impairment ranged from severe to profound. Specific interventions with regard to severe physical impairments were made by occupational therapy and physiotherapy. Conclusion: Due to the extent of their physical disabilities requiring full-time nursing care, discharge and placement back in the community remained a rare option for most users in the study group.Journal of Child and Adolescent Mental Health 2007, 19 (2): 115–12