Crazy system traps mental patients

A third of the patients in government psychiatric hospitals could be released and have somewhere to live if community support services were improved, a Department of Health study has found.

Bureaucratic or legal obstacles would prevent the discharge of the majority of patients, who are either “certified” or “state” patients admitted to the institutions without their consent because they are thought to pose a risk to themselves or others, or are serving prison sentences.

The study, which has been published in the latest issue of the department’s publication, Epidemiological Comments, was conducted in five Eastern Cape and three KwaZulu-Natal psychiatric institutions and involved 737 of the 2 655 patients in these hospitals. It concluded, however, that the majority of patients currently in these mental hospitals could not be discharged easily, for a variety of reasons, including “lack of care recovery environment, admissions status, level of functioning and issues of risk”.

The study said the survey highlighted the complex nature of assessing the discharge of patients and the need for the provision of a mix of services and facilities in communities to sustain patients successfully in those areas.
“There is a clear recognition of the need to ensure that development of community-care services occurs in conjunction with or ahead of patient discharge. In more wealthy nations, individually tailored solutions are provided to patients before discharge.

“In the context of South Africa, these challenges are even more daunting. With limited national resources, restrictive national economic policies and massive community development challenges, the extent to which resources will be channeled into community-based support services for the mentally ill, in the short term, is at the most limited.”

The more likely was that provincial health departments, battling with budget deficits and current low bed occupancy in psychiatric hospitals, would find it difficult even to maintain current levels of spending on mental health. It said the typical KwaZulu-Natal and Eastern Cape psychiatric patient is black, male and unmarried, with no children.

“He is an adult between 30 and 49 and has a low level of education. This is not his first hospital admission. He has spent between six months and five years in hospital over his lifetime. Before entering hospital, he lived with family or friends and contributed to the family income via a disability grant. If employed, he most likely worked as a contract/unskilled labourer.

“Admission was most often stimulated through some form of violence or disruption in the community. He is a certified patient with a diagnosis of schizophrenia. “His behaviour is most likely to be appropriate for community living, although the potential for him to be either a danger to himself or the community needs to be assessed before he is discharged.

“He is able to feed and bathe himself. He experiences difficulties with using public transport and handling money. He does not have any physical disabilities or diseases. Although he is cooperative with taking medications he is likely to forget to take them unless supervised. He may have a drug or alcohol problem.”

But it is preferable that community services be improved before such a patient can be successfully discharged to the community. “For successful community living, nurses propose that he requires assistance in the areas of family intervention and education, day activities and respite services for the family, employment services, medications monitoring and financial support.”

Realistically, the study concludes that these community-based support services are unlikely to be provided in the near future, which means that the third of psychiatric patients who could be released from hospital, if they could overcome the legal and bureaucratic barriers in their way, are likely to remain inside psychiatric institutions.

The study also found that there is another smaller group of patients who possess basic community living skills and who could be released but lack non-hospital accommodation and there is “no recovery environment. “The lack of residential community options in both provinces compromises the discharge potential of these patients.”

In short, many patients in psychiatric hospitals in South Africa could be released but they won’t be discharged because of the lack of support services outside of those institutions and because of legal obstacles.