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ORIGINAL
Acute mental health care and
South African mental health
legislation
Part 1- morbidity, treatment and outcome
ABR Janse van Rensburg
Division of Psychiatry, University of the Witwatersrand, Johannesburg, South Africa Abstract
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 Africa
Received: 13-02-2009
Accepted: 28-09-2009
Introduction
changes in the extent and scope of services were expected from Reliable data is necessary to facilitate the effective planning, the unit since its designation as a 72-hour assessment unit management and restructuring of mental health care facilities.
according to the Mental Health Act, No. 17 of 2002 (MHCA).
Access to accurate information on clinical conditions, treatment However since the promulgation of the MHCA in December outcomes and expenditure is essential to ensure accountability, 2004, no additional resources have been made available to this quality and cost-effective mental health care. This article is the facility on hospital or provincial level for this purpose. There is first of three that reports on a review of a local acute mental also still no delineation of the catchment area or clarity on the health care unit in a general specialist hospital in Johannesburg, size and profile of the population that HJH as a regional hospital The in-patient mental health care unit at Helen Joseph A pilot clinical audit study of mental health care at HJH was Hospital (HJH) is a mixed (male and female), 30-bed, acute, adult undertaken during 2003/04, prior to the implementation of the assessment unit in a general regional referral hospital setting MHCA to: - obtain a provisional state of affairs analysis of care with an average length of stay (LOS) of about 3 weeks. Major activities; - provide a baseline for future cost centremanagement; and - provide a framework for more focusedresearch on the morbidity, treatment and outcome of care. As anintroductory study, it focused on mental health care at HJH as a Correspondence
Dr. B van Rensburg
care component in a specific geographical area, which is part of PO Box 1247, Pinegowrie, 2123, South Africa a network of referral facilities on different levels, including community psychiatric services. It meant to contribute to the African Journal of Psychiatry • November 2010
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process of clinical audit of mental health services in the southern Gauteng area, or at least to serve as some benchmark for other (g) calculate projected cost applying appropriate, reasonable acute units with similar mandates. Although a description and norms and standards to (re-) construct and refurbish physical assessment of the program and of expenditure was included in facilities according to activities expected from a designated 72- reports to local hospital and academic management at the hour assessment unit of this nature.
time1,2, only the data on the clinical profile of the acute in-patientsat HJH was published previously.3,4 Following implementation of Methods for this first report (Part I), included Steps 1 and 2.
the MHCA, this follow-up review was undertaken of a four-year Methods for Part II (Activity-Based Costing) included Step 3, while period (2004-2007) of mental health care activity and outcome at methods for Part III (Structuring Space for Mental Health Care) HJH, reviewing service delivery, teaching and research. Where the pilot study for example offered only a provisional and Data used for the quantitative review of the demographic and proportional calculation of expenditure, the purpose of this clinical profile of users was the routine clinical discharge summaries follow-up study was to provide a more detailed review of mental of users completed by doctors on discharge. It was assumed that it health care activity and outcome at this facility, employing would be unlikely for the general clinical profile of the cohorts of activity-based costing as a method to do a cost centre analysis of acute in-patient users to change significantly over a 4-year study recurrent cost. An architectural assessment was also made of the period. Therefore, instead of a clinical review of each successive current physical facilities and structure of the unit and of the year, it was decided to only do a review of the more recent twelve months (financial year of 2007/08) and compare it with the earlier The objectives of this study in parallel with the original pilot twelve months of the pilot study (2003/04). The study period was study were to: - provide continuous quantitative and qualitative coordinated with the financial year 2007/08 to accommodate the information on mental health care activities; - establish a financial analysis to follow. A comprehensive review of all the in- continuous quality assurance cycle in order to facilitate cost patient users that were diagnosed with schizophrenia was however center management; - provide realistic estimates of cost to align done for each year of the 4-year period Jan 2004 to Dec 2007 and the current facilities and program with requirements and acceptable standards according to the unit’s designatedfunction; and - provide regular, reliable information on the Ethics clearance was obtained from the WITS Health ResearchEthics Committee in December 2007 for the protocol: “Mental health care at Helen Joseph Hospital according to recent mental As no catchment area for the hospital had been determined, no health legislation.” (reference number M071010). This protocol also calculation was possible of the incidence and prevalence of covers the other two articles that were part of the original mental illness in the regional population HJH is supposed to submission to AJOP (Part II - Activity-based costing and III - serve. Therefore, only an analysis of trends for specific cohorts of Structuring space for acute in-patient care.) in-patient users was possible. Both studies - the current reviewas well as the previous pilot, were retrospective descriptive clinical record reviews of mental health service delivery, training and research functions performed at HJH. Assessments in this A review of current legislation regulating mental health care follow-up study were undertaken in several steps (which rendering in South Africa was done previously and discussed in an encompass the range of content to be presented in the current earlier report.6 Apart from the new Mental Health Care Act, No.17 of 2002, a substantial body of other health related legislation exists thatconstitutes the basis for current policy, in particular the Constitution of the RSA, No. 108 of 1996, the National Health Act, No. 61 of 2003 (a) review and interpret current hospital, provincial and national and the Traditional Health Practitioners Act, No. 35 of 2004.7 policy, as well as appropriate applicable norms and Muller, Flisher, Lund and others have reported extensively on the process of developing norms and setting standards for mental (b) define and describe the operational areas of service, health care in South Africa.8-11 They adopted the World Health teaching and research as cost center domains and the Organization’s (WHO) model for calculating quantitative norms for acute mental health care beds and for associated staff ratios.9 Basedon the one-year prevalence of certain severe psychiatric conditions (SPC), this model calculates the average expected number of users (c) describe the demographic and general clinical profile of in a population of 100 000 people older than 15 years of age users, the management and outcome of treatment; suffering from a SPC to be 3004. Based on this number of users’ (d) describe the demographic and clinical profile of HIV positive need for acute hospitalization per year, at an average length of stay of 17 days, it is calculated that 28 acute mental health care beds areneeded per 100 000 population. For these 28 beds, the following associated staff allocation is proposed: 1 psychiatrist; 1 (e) calculate current cost of each activity to establish resources registrar/medical officer; 14 professional nurses and related necessary to continue the status quo program; categories at a nurse/bed ratio of 1:0.5; occupational therapist (OT) (f) estimate projected cost if appropriate norms and standards - not indicated; psychologist (0.5); and social worker (0.5). Although were to be implemented to align the quality and scope of it corresponds well with the average length of stay observed for HJH during the pilot study, this model however refers to a service African Journal of Psychiatry • November 2010
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delivery unit and does not take the “70:30/service:academic”- health care users – i.e. users with a compromised capacity to make principle as applicable to HJH into account, where joint appointed informed decisions about their own mental health care - in the same staff also have academic responsibilities. As a regional hospital, HJH physical area, some on-site security cover has been provided by has 480 approved but 530 operational beds.10 Applying the WHO model’s norm will mean that the hospital is supposed to serve apopulation of 530,000 people. In reality though, users from different In-patients - The inpatient care program consisted of medical, regions across the city base rely on the hospital’s services. The total psychological, psychiatric, functional and social examination population figure for Gauteng province currently used by the and assessment of service users; initial containment and provincial department of health is 10.1 million people (HJH, treatment; obtaining collateral information; family intervention; Statistics and Information Section), of which 3.7 million are allocated health education; referral or placement after assessment; and to Johannesburg Metro region, 2.9 million to Ekurhuleni region and reporting on treatment and recommendations. 0.8 million to the West Rand region. Historically, the vast majority of Out-patients - Psychiatric out-patient care consisted of a follow- users admitted to HJH’s acute mental health care unit are routinely up clinic on Wednesdays to review prescriptions and users’ from the Johannesburg Metro area, although some from the other progress, as well as a clinic for new users on Thursdays.
Psychology and OT rendered separate routine out-patientservices. Consultation-liaison - One doctor and one psychology intern The operational areas of the mental health care program at HJH were typically allocated to do routine and emergency consisted of service delivery, teaching, and research. Activities consultations on a rotational basis. Psychiatric consultations within each area included: in-patient care, out-patient care and included emergency assessments and management in the consultation/liaison; under- and postgraduate teaching; and self casualty department or routine consultations referred from initiated and contract research (Table I). From this a “footprint” of medical and surgical departments. Routine consultations duties can be derived according to adopted care norms and included assessments after attempted suicide, co-morbid standards, from which staff ratios, job descriptions and performance psychiatric and medical conditions; personality and intellectual objectives for different categories of workers can be established. capacity, as well as behavior modification, pain intervention andpsychological assessments prior to dialysis. Table I: Operational elements of the mental health care
program at HJH, 2004-2007
The supervision and clinical training of medical staff and students was shared between the two consultants. Although the nursing staffand the OT were not joint appointees and while the latter was often a community service worker, they were all involved with and were made responsible for the regular clinical teaching and supervision of undergraduate nursing and OT students from the affiliatedcollege and universities.
Undergraduate (medical) – Under- and postgraduate medicalteaching involved registrars and consultants and required Self initiated (degree and non degree purposes) specific time inputs. Since 2004, the old MBChB-curriculum was restructured and subsequently “Graduate Entry Medical * For joint staff – 70% of core working hours (28 hours). Program” (GEMP) III and IV undergraduate students were ** For joint staff – (combined) 30% of core working hours (12hours) accommodated in the unit for their respective clinical blocks. Postgraduate (psychiatry) - Typically 3-4 doctors at a time wereallocated on six-month rotations during the study period, who were medical officers (not in training posts) or registrars (with For the 30-bed acute adult assessment unit, the clinical team during specific academic obligations). Structured teaching in the unit the study periods consisted of 1-2 (mainly female) professional for registrars included case presentations, journal reviews, nurses (PN) and 3-4 enrolled nurses (ENA) or nursing assistants clinical case supervision and psychotherapy supervision. (NA) on duty during an average routine shift for inpatient care, 2consultant psychiatrists, 4 doctors (medical officers or registrars), 1- 2 clinical psychologists, 3-4 psychology interns, 1-2 community The unit started to operate as an identified “syndicate” of the service psychologists, 1 OT and a part time social worker. All University of the Witwatersrand Health Consortium (WHC) during doctors, psychologists and the OT were responsible for out-patient 2007. Protocols were submitted to the WITS Human Research care and doctors and psychologists for consultation/liaison services.
Ethics Committee (HREC) for approval and monitoring. The nursing allocation for outpatient care (one ENA for 2 two clinicdays) was shared with three other departments on a rotation basis.
Self initiated (degree and non-degree purposes) – Since 2007 A full time administrative officer was allocated to the unit only by the all MMed candidates (registrars) have been required to end of 2006 and is responsible for all administrative duties as complete a research project in order to fulfil requirements for regulated by the MHCA and for archiving and communication registration as specialists. Four postgraduate protocols for involved with the implementation of the Act. As the unit has to degree purposes and two for non-degree purposes have been accommodate voluntary, as well as assisted and involuntary mental registered with the HREC since 2007.
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Clinical contract research - Some capacity for clinical contract Table II. Staff establishment for acute mental health care at
research at the mental health care unit at HJH was established HJH: existing (2007/08) and proposed according to WHO
during 2007. The two consultants were investigators for the site model ¹¹
and a part–time study co-ordinator was designated by WHC.
The unit has been involved in two clinical trials since 2007.
Applying the WHO model to the HJH scenario The reality about the nursing ratios during most of the study period was that only 1-2 PN’s and 3-4 ENA’s/NA’s were typically available for duty per day shift. Compared with the WHO norm, this translated into a situation where the average nursing staff member on duty was carrying the load of 2 to 3 workers at a given time. In other words, being 200 to 300% “over employed”.
The result in practice was indeed that most of the time only the most essential nursing tasks were performed and that the potential risk element for individual workers often escalated to unacceptable levels. Inadequate time was routinely available for individual case management, group therapy, health education or attending ward rounds by nurses. Some professional nurses resigned during this period, while others were transferred to other wards, exacerbating a vicious circle. An unreasonably risky demand remained on the available nursing staff to uphold service standards. The practice of using outside agency-nursing to alleviate the problem, was costly and limited in its effect, as inexperience and discontinuity often added to the challenge of dealing with difficult users after-hours. A 1:10 doctor to user/bed ratio was mostly maintained during the study period. It was calculated that given the high turn-over of (*1 post blocked by medical disability application) users, they were regularly affording a 1-hour initial assessmentinterview and 2 subsequent 30-minute follow-up interviews to eachuser per week, in parallel with their regular outpatient duties, occupational therapy and 100% for social work. Comparing the meetings with families and telephone calls, were actually already WHO model’s nurse to bed ratios of 1:0.5, the 5-6 nurses per 30 spending 80% of their time on service delivery (excluding acute beds at HJH during the study period implies that the current consultation/liaison). With no formal provision for lunch, tea or nursing staff should be more than doubled to be on par with this research time, only 16% of the 40-hour week remained available for norm. While the medical staff ratio per acute bed was much better formal academic activities (e.g. lectures and journal club). If one in comparison, constraints still exist if 30% academic time is fully hour for lunch per day was added, doctors were utilized at “110%” applied. A full-time occupational therapist and social worker, as during an average 40-hour week. The common result was that well as two full-time psychologists are minimum requirements for doctors had to spend less time with in-patient users on the ward. The existing staff establishment for the financial year 2007/08, as well as a proposed staff establishment calculated in terms of Demographic and clinical profile of in-patient users the WHO model’s norms and standards, is presented in Table II.
An increase in the numbers of users managed by the 72-hour The proposed staff establishment according to this calculation assessment unit at HJH was observed during the study period, in represents an overall increase of 103% for all staff categories. For particular from 2004 to 2006 where a 35% relative increase in the medical staff 37%, 48% for psychology, 267% for nursing, 69% for total number of admission was found (Table III). A total of 438 Table III. Total number of acute in-patient mental health care users, HJH (2004-2007)
* Data covering the 12 months Apr2007-Mar2008 was compared with the earlier 12-months Sep03-Aug04 covered by the pilot study; ** An outpatient register was only compiled in Jan 2005; *** A full record of consultation/liaison service was only available since Jan 2007.
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service users were admitted during the earlier study period of users stayed significantly longer than the average 15 days (2003/04) with a monthly average of 37, while a total of 520 service (>25 days), resulting in an increase of the average cost per user. users was admitted during 2007/08 (43 monthly average). Themajority of referrals were from the casualty unit: in 2003/04 n=317 (72.4%) and 2007/08 n=443 (85%) and the Department of During the 2007/08 study, 39 users (8%) were re-admitted to the Medicine: in 2003/04 n=43 (9.8%) and 2007/08 n=56 (10.8%). Non- ward, of which three users were admitted three times in twelfth compliance with previously prescribed treatment was confirmed in months. Of these users, 9 were diagnosed with schizophrenia, 6 206 (47%) service users admitted in 2003/04, while in 2007/08 203 each with bipolar mood disorder and mood disorder due to a users (39%) were non-compliant. About 40% of users in 2003/04 general medical condition (GMC) and 5 with mainly substance (n=176) and in 2007/08 (n=204) actively abused substances.
abuse and personality related problems. The other diagnoses Substance abuse by diagnostic group is summarized in Table IV. included dementia (n=2), psychosis due to GMC or substanceabuse (n=6) and schizo-affective disorder (n=2). Co-morbid substance abuse was documented for twelve of these users. The The average LOS in 2003/04 was 18.5 days, while in 2007/08 it average LOS of 32 days for these readmitted users were was 15.4 days and ranged from 1 to 85 days. About 17% (n=90) markedly longer than the general average of 15.4 days per userand would therefore contribute much more to the proportion ofresources used during this period. Table IV. Co-morbid substance abuse of acute in-patient
Average bed-occupancy 2007/08 – See Table V(a) mental health care users per diagnosis, HJH 2007/08
Table V(c): HIV-status of acute in-patient mental health care
users, HJH
* Bipolar mood disorder; ** Schizo-affective disorder; Table V(a): Average bed-occupancy rate for acute in-patient mental health care users, HJH (2007/08)
Table V(b): Demographics of acute in-patient mental health care users at HJH
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Axis II diagnoses were specified in 142 users (27%): See Table V(d). The 2003/04 pilot study reported that almost a personality traits/disorder (n=119, 27.3%) and intellectual quarter (23.9%, n=105) of the total (n=438) in-patient users were diagnosed with schizophrenia. During the subsequentfour years (2004-2007) 436 of a total of 2143 users were diagnosed with schizophrenia. The observation was consistent A total of 467 in-patient users were documented to have that on average 20% users were being diagnosed with received routine medication during 2007/08. Trends in the use schizophrenia as in-patients - Table V(e). Most users with of medication were very similar to the use in 2003/04. Agents schizophrenia (n=348, 80%) were admitted once over this 4- for acute sedation (n=280,39%) included zuclopenthixol year period. Twenty percent (n=88) had multiple acetate, clonazepam and lorazepam. Antidepressants re-admissions: twice (n= 66), three times (n=18), four times (n=80,15.4%) mostly used included citalopram (n=20,25%) (n=3) and one user 5 times in four years. Axis II - Most and fluoxetine (n=38,47.5%). Antipsychotics (n=357, 68.7%) common diagnoses made in 2003/04 were: mental retardation routinely used were haloperidol (n=185, 51.8%); risperidone (n=19, 4.3%), cluster-B personality traits or disorder (n=50, (n=115,32.2%) and fluopenthixol deconoate (n=30,8%). Mood 24%) and cluster-C traits or disorder (n=12, 2.8%). In 2007/08, stabilizers (n=156, 30%) mostly used, were lithium(n=22,17.7%) and sodium valproate (n=124,79.5%). Othermedications included anti-cholinergics (n=71,11.9%) for extra- Table V(d): AXIS I diagnoses of acute in-patient mental
pyramidal side-effects and medical treatment for concomitant health care users at HJH
Referral after discharge from HJHSee Table V(f).
Demographic and clinical profile of HIV tested users Of the total of 443 service users that were admitted to Ward 2 during 2003/04, only 77 (17.4% of total) were tested for HIV status. Of these, 34 service users (7.7% of total) tested positive and 43 negative. The majority of users tested were between 20 to 40 years of age (n=28). About double the amount of females (n=22) were tested compared to males (n=12). The users during 2003/04 who were tested for HIV, stayed on average markedly longer (29.3 days as opposed to 19) compared to other users (Janse van Rensburg and Bracken, 2007).
Presenting symptoms then included elevated mood,psychosis, disorganized behaviour, confusion, aggression andmutism. A very similar picture was observed for 2007/08: 97 Table V(e): Acute in-patient mental health care users at HJH
(18.7%) users’ HIV status were known, with 35 positive, 52 diagnosed with schizophrenia, 2004 TO 2007
negative and 10 tested but no results documented. Theseusers stayed on average 20 days compared to the general average of 15 days. It was not determined whether this difference represented a statistically significant longer LOS.
For the users with schizophrenia (n=436) over the four year period 2004 to 2007, 53 users’ HIV status was known, with 7 Discussion
A particular limitation of this review was that the quantitative investigation was only able to focus on the in-patient aspect ofservice delivery activities. Future reviews and cost estimates *Data covering the 12 months Apr2007-Mar2008 was compared with the should in more detail also include out-patients and earlier 12- months Sep03-Aug04 covered by the pilot study consultation liaison, as well as the academic activities in the Table V(f): Referral of acute in-patient mental health care users after discharge from HJH
*SFH – Sterkfontein Hospital; **TARA –Tara, the H Moross Center; ***PCSG – Psychiatric Community Services in Southern Gauteng; ****OPD – Helen Joseph Hospital Out-patients; *****LHE – Life Health Esidimeni African Journal of Psychiatry • November 2010
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unit. The study was subject to the inherent limitations of a mental health care has been compromised. Involuntary retrospective review of this nature regarding the availability users often have to be treated against their will when and completeness of data from routine clinical records. The refusing treatment. In addition, over the four years 2004- fact that no statistical comparisons were made - as it 2007, a steady increase in numbers of acute in-patient moved somewhat beyond the primary scope of the study - mental health care users was observed, especially from should also be cited as a limitation of the review. Future 2004 to 2006. This could be due to an increased demand studies should include the comparison of different for services or it might be due to the fact that following the variables for their effect on – for example - the length of promulgation of the MHCA, all 72-hour observations of users are being done in state facilities, as no private facilityin the Johannesburg area has yet been licensed for this purpose. The users readmitted during the study period The WHO model for the calculation of norms for services generally stayed longer than others, therefore represented and staff as quoted by Muller, Flisher, Lund and others, was a relatively larger proportion of resources used and thus a useful point of departure. But as they also suggested, played a role in adding to the burden and cost of acute additional factors and refinements applicable to a admissions. Readmissions also implied that inadequate particular unit or region should be taken into account. In follow-up of these users in community psychiatric services the case of HJH, the nursing ratio’s represented a critically should be addressed. Another factor that was also often understaffed situation of almost 270%, posing a daily contended with in this acute unit was the co-morbidity of unacceptably high level of safety risks to staff and users concomitant acute medical conditions. The nursing of alike, significantly compromising an acceptable quality and medically ill users in an acute mental health care unit, standard of care in this acute 72-hour assessment unit. For stretched the demand on available nursing staff even joint appointees in the unit with a responsibility for training and research, the principle of 30% of time to be allocatedfor academic responsibilities should be included in the Demographic and clinical profile of users calculation of the requirements for the unit. The 3-4 The profile of users over the four-year period stayed fairly registrars/medical officers and 2 consultant psychiatrists consistent - Table V(g). A possible explanation for the fact therefore represented an understaffed scenario, especially that (mostly uninsured) white and coloured users continued if the number of beds may be increased. An additional to be relatively predominate could be that while HJH is (third) specialist and another (fifth) registrar/medical located closer to the historically ‘’coloured’’ suburbs of officer should be motivated for HJH. It is also suggested, Westbury and Riverlea and the ‘’white’’ suburbs of that a clear differentiation of joint appointees’ academic Westdene, Auckland Park and Discoverers, the hospital still responsibilities and the routine service delivery of other operates as the main referral facility for these areas.
non-academic staff should be established, with a different Further investigation into the reasons for this observation career path and appropriate remuneration for each. A may be needed. The information on the clinical profile of particular problem that continued to exist in the application users whose HIV status was known, could not be of the WHO model was that no formal catchment area has generalized due to the ad hoc nature of the testing. During been identified for HJH and that population figures have the follow-up study period (2007/08), HIV-status was still also not been readily available in a format that allowed for not routinely tested in this unit, although the outcome of the calculation of incidence and prevalence rates for the testing did significantly influence the clinical management population served by the hospital.11 In addition to and outcome of these users. The view also held by other quantitative norms for beds and staff, qualitative standards investigators that a new policy approach is needed to allow for mental health services at HJH should also be routine HIV testing given the availability of effective anti- established and should include the guarantee of human retroviral treatment, can be supported by the clinical rights and the redress of historical inequalities. It should experience and outcome in this unit.13,14 also cover special issues facing the care of people withSPC, legal aspects, as well as abuse and complaints.12 Table V(g): Demographic and clinical profile of acute in-
patient mental health care users at HJH, 2003/4 and
Additional burden on the unit was caused by recent legislation, by an increasing number of users, by the re- • White and colored users were relatively proportional y predominant.
admission of the same users and by the frequent • The average length of stay of 15.4 days in 2007/08 was shorter than co-morbidity of medical conditions. Since the promulgation of the MHCA, the program at HJH had to be adjusted to • Schizophrenia diagnosed in about a quarter of users was consistently accommodate the differentiated but integrated care of three different legal categories of users - voluntary, • A 40% rate of both documented co-morbid substance abuse and assisted and in-voluntary, for male and female users in one confined area. While rights of voluntary users for example • Anti-psychotics (about 70%) were the pharmacological agents most to unrestricted movement need to be protected, at the same time, users in the latter two categories often have to • On discharge about a third of users were referred to community be managed in a more secure environment, as their psychiatric services, a third to HJH out-patients and the remainder to capacity to make informed decisions about their own intermediate and long-term in-patient stay.
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Conclusion
This study described the areas and activities that were used to Janse van Rensburg ABR. Clinical profile of acutely ill psychiatric make detailed estimates of the current and projected patients admitted to a general hospital psychiatric unit. African recurrent and capital cost of in-patient mental health care at Journal of Psychiatry 2007;10(3): 159-163. HJH as a cost centre. The documented clinical profile of in- Janse van Rensburg ABR, Olorunju SAS. Diagnosis and treatment of patient users at HJH can also be used for comparison in schizophrenia in an acute 72-hour assessment unit. African Journal of subsequent reviews and by other acute units in similar settings with similar duties. The analysis of the morbidity, treatment and Janse van Rensburg ABR. “A framework for current public mental outcome of cohorts of acute in-patient mental health care health care practice In South Africa”. African Journal of Psychiatry users managed at HJH, must however eventually be assessed in the context of services provided by the rest of the referral Department of Health, South African. Retrieved October 17, 2006; system and in view of the actual incidence and prevalence of from hhtp://www.doh.gov.za/docs/top.html. SPC in the population that the hospital has to be made Department of Health. Norms Manual for Severe Psychiatric responsible for. Information from this review may motivate and may be used to allocate more adequate resources to the unit World Health Organization (WHO). Public mental health guidelines in view of its responsibilities according to the recent mental for the elaboration and management of national mental health 10. Helen Joseph Hospital, Statistics and Health Information Section. Personal communication, 19 Jan 2009. References
11. Statistics South Africa, 2003. Census 2001 in brief. Report no 03-02- Janse van Rensburg ABR. Clinical Audit Of Mental Health Care At 03 (2001). Retrieved January 26, 2009; from Helen Joseph Hospital. Sep2003 to Aug 2004; Internal report http://www.statssa.gov.za/census01/html. 12. Muller L, Flisher AJ. Standards for mental health services in South Clinical Audit of Mental Health Care at Helen Joseph Hospital. Africa. South African Psychiatry Review. 2006; 9(1a). Minutes of Executive Committee Meeting: Division of Psychiatry, 13. Joska JA, Kaliski SZ, Benatar SR. Patients with severe mental illness: A Faculty of Health Sciences of the University of the Witwatersrand; new approach to testing for HIV. S Afr Med J 2008; 98(3) 213-17. 14. Singh D, Berkman A, Bresnahan M. Seroprevalence and HIV- Janse van Rensburg ABR, Bracken CA. Acute psychiatric in-patients associated factors among adults with severe mental illness. S Afr tested for HIV status: a clinical profile. South African Psychiatry African Journal of Psychiatry • November 2010

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