Ulla Botha

Perceptions of a South African schizophrenia population with regards to community attitudes towards their illness

BackgroundWith the worldwide shift towards a more community-based psychiatric service delivery approach, stigma and the issues surrounding it have received much attention. However, very little South African data exist and the aim of our study was therefore to investigate the experience of internalized stigma in a South African schizophrenia population with specific emphasis on abuse as a form of stigmatization.MethodsA total of 100 subjects at various stages of schizophrenic illness were subjected to a the Internalized Stigma of Mental Illness scale (ISMI) that was modified to include six items focusing specifically on investigating the experience of stigmatization within the South African context.ResultsA high overall degree of stigmatization was perceived by most subjects, but not equally so for all ISMI areas. When looking at the modified items, 29% felt media-influence to be negative, this seemed to be specifically true for those with matriculation and higher as well as a home-language other than Afrikaans. Thirty nine percent indicated that they had been victims of physical abuse due to their mental illness, with the data suggesting that especially Xhosa-speaking patients, male subjects and those with more admissions and a longer duration of illness experienced this excessively.DiscussionOur study confirmed a high overall degree of perceived stigmatization as well as suggesting some evidence for cultural influences on stigma. It was the first to provide South African data and as such can be regarded as central to our efforts in restructuring psychiatric services and clinical practices in a way that would minimize the effects of stigma and ultimately benefit our clients.

Pathways to Inpatient Mental Health Care Among People With Schizophrenia Spectrum Disorders in South Africa

OBJECTIVE This study examined service utilization patterns and pathways to specialist mental health services among individuals with schizophrenia spectrum disorders in the Western Cape, South Africa, an area that has undergone deinstitutionalization since the mid-1990s. METHODS Individuals who were consecutively admitted to any of the three psychiatric hospitals in the Western Cape from February 2007 to January 2008 were interviewed. Data on demographic characteristics, psychiatric history, service utilization, and pathways to care were gathered from service users, their relatives or associates, and hospital files. Univariate and multivariate analyses examined differences between high- and low-frequency service users. RESULTS Of the total sample (N=152) most were first seen at the primary care level (62%). However, very few received treatment at this level (26%), and many (22%) were admitted directly to the psychiatric hospital, bypassing other treatment options. These service utilization patterns differ from the requirements listed in the recently adopted Mental Health Care Act (2002), which states that unless a patient has been recently discharged, he or she should be admitted for 72 hours of observation before referral to psychiatric hospitals. Compared with low-frequency service users, high-frequency users were younger, had lower income, tended to rely more on disability benefits, and were more likely to bypass other levels of care and be admitted directly to the psychiatric hospital. Poor medication adherence was the most likely precipitant for the episode of illness among all users. CONCLUSIONS The study highlights the inadequacy of current community mental health services in providing for the needs of people with severe mental illness. In South Africa, as in many other middle-income countries, there is an urgent need to develop community-based care.

The rise of assertive community interventions in South Africa: a randomized control trial assessing the impact of a modified assertive intervention on readmission rates; a three year follow-up

BackgroundMany countries have over the last few years incorporated mental health assertive interventions in an attempt to address the repercussions of deinstitutionalization. Recent publications have failed to duplicate the positive outcomes reported initially which has cast doubt on the future of these interventions. We previously reported on 29 patients from a developing country who completed 12 months in an assertive intervention which was a modified version of the international assertive community treatment model. We demonstrated reduction in readmission rates as well as improvements in social functioning compared to patients from the control group. The obvious question was, however, if these outcomes could be sustained for longer periods of time. This study aims to determine if modified assertive interventions in an under-resourced setting can successfully maintain reductions in hospitalizations.MethodsPatients suffering from schizophrenia who met a modified version of Weidens’ high frequency criteria were randomized into two groups. One group received a modified assertive intervention based on the international assertive community treatment model. The other group received standard care according to the model of service delivery in this region. Data was collected after 36 months, comparing readmissions and days spent in hospital.ResultsThe results demonstrated significant differences between the groups. Patients in the intervention group had significantly less readmissions (p = 0.007) and spent less days in hospital compared to the patients in the control group (p = 0.013).ConclusionModified assertive interventions may be successful in reducing readmissions and days spent in hospital in developing countries where standard care services are less comprehensive. These interventions can be tailored in such a way to meet service needs and still remain affordable and feasible within the context of an under-resourced setting.

An Attempt to Stem the Tide: Exploring the Effect of a 90-Day Transitional Care Intervention on Readmissions to an Acute Male Psychiatric Unit in South Africa

Introduction: Pressure on inpatient beds often results in premature discharges, which may precipitate early readmission. This has prompted an increased interest in transitional care interventions to bridge the gap between in‐ and outpatient care to reduce such readmissions. Our study aimed to assess the effect of a Transitional Care Service (TCS) on readmission rates in a high pressure inpatient service which utilizes a premature discharge policy to address bed pressures. Methods: Sixty male patients identified for crisis discharge were offered a TCS for the first ninety days after discharge. Patients received a structured intervention consisting of four phone calls and one home visit, focusing on maintaining adherence, appointment reminders and psychoeducation. The TCS patients were retrospectively compared to a matched control group in terms of readmission after 90 days. Data was collected on adherence to medication, attendance of appointments and incidence of substance use. Results: There was no significant difference in readmission rates. Prevalence of substance use was very high (90%), especially methamphetamine use (48%). Adherence dropped from 45% (n = 27) at one week post‐discharge to 25% (n = 15) at 90 days. Conclusion: Structured telephone‐based transitional interventions have no effect on readmission rates in this setting. Prematurely discharged patients require more comprehensive support with focus on comorbid substance use.