Uneven standards of community care mean the state’s new policy of releasing mental patients could be a bad plan, writes Andy Duffy
The deaths of seven people at the hands of former state psychiatric patients in the Western Cape have exposed a raw nerve in state health circles.
The Department of Health this week slammed a Mail & Guardian report on the killings, claiming it had sensationalised the incident, leading to “panic and unnecessary paranoia” about mental and psychiatric patients.
But state psychiatrists and NGOs across the country say the deaths are merely an extreme symptom of the lack of funds and staff that hamper the system.
Valkenberg, the Cape Town hospital that treated and released the six patients who killed, says the report was fair.
The M&G reported last week that six patients released from Valkenberg’s high security forensic unit had killed seven people in the past 18 months, including two children.
Forensic unit head Sean Kaliski blamed weak community care structures. A recent provincial health department report also found that staff shortages had weakened community care.
The Western Cape provincial Cabinet was due to decide this week whether to approve a health department proposal to close Valkenberg, as part of a rationalisation of health services.
Other state institutions approached this week said the standard of community care for discharged state patients is often patchy, and in many poor and rural areas is non-existent.
The health department also concedes that, with its “limited sources” community treatment and monitoring of discharged patients “is not always as regular or comprehensive as we would like”.
Three of four major state institutions have cases on their books of discharged patients committing new crimes, of varying seriousness.
The largest institution, Pretoria’s Weskoppies, released a patient who last year killed a child in Mpumalanga.
The Free State’s Oranje hospital, has taken 13 years to establish a community care network that ensures relapses among discharged patients are caught quickly.
State forensic patients, held because they are judged unfit to stand trial for a crime, represent a small minority of the thousands of harmless state psychiatric and mental health patients.
But effective community care is central to the government’s attempts to release thousands of such patients into the community – a project led by health department director for mental health and substance abuse, Melvyn Freeman.
Freeman refused to respond to further questions this week. Instead, he issued a lengthy condemnation of the M&G report. “(This) article dramatises the situation and spreads false fears to the public regarding people with mental disorders,” Freeman says.
“The result is public panic and unnecessary paranoia of people with mental disorders.”
Freeman says the report also “undermines” the government’s deinstitutionalisation programme – “an approach to care which is more humane and rights-oriented than the current system of largely custodial care”.
But the South African Federation for Mental Health, which represents NGOs across South Africa, says Valkenberg fairly reflects the general problems facing state psychiatric and mental health.
The federation also has concerns about the government’s deinstitutionalisation drive. “The health system just isn’t equipped to look after these people,” says federation director Lage Vitus.
“It is a major problem that we don’t have the funds for community service. The [department] has left it for NGOs to pick up, and we’re not really equipped for it either.”
Weskoppies senior medical superintendent Leandre Gauche says two of its discharged patients have killed in the past six years. In the most recent case which took place in Mpumalanga last year, the patient had originally been held at Weskoppies for killing another child.
The 300-bed unit treats patients from across Gauteng, Mpumalanga and the Northern Province. “When [relapses] have occurred we suspect it’s because of inadequate care,” Gauche says. “We find the relapse rate is higher among people coming from these [rural, poorer] areas.”
Dean Stevenson, forensic unit head at Sterkfontein, says the unit knows of one of the 20 patients it has discharged who committed a crime. “We may not always get to hear of it,” he adds. “Where we do have a concern is the patients that are discharged to other [underresourced] provinces.”
John Dunn, principal psychiatrist at Fort Napier in KwaZulu-Natal, says the hospital does not regard its relapse rate as a major cause for concern. But he adds that half of its 180 patients come from far- flung rural areas, where community services are often thin.
Susan Otto, senior executive officer at Oranje hospital, says discharges can only go ahead with a sound community structure in place.
The Free State pioneered the programme, in 1985, that the national department wants other provinces to follow. “We don’t struggle like other provinces do,” she adds.
Around 500 patients were admitted to state forensic units last year. Freeman says the department would rather discharge those deemed rehabilitated than build new institutional facilities. Discharge conditions are stringent.
“The reality is that despite the fact that patients are assessed to the best of our abilities and that community facilities are provided (with resource limitations), there are, at times, awful consequences,” Freeman says.
“However, the freedom of hundreds of people with psychiatric illness cannot be forgone because of unfortunate, and we agree, tragic exceptions.”