Psychiatric and mental health nursing
Priorities for research into mental illness in the developing world are not the same as those in the West, writes Katherine Nightingale. There are 450 million people around the world living with a mental disorder.
Emigration, he said, was the main reason for the shortage in the public sector, coupled with the loss of psychiatrists to private practice. Roughly one in seven South Africans has a diagnosable mental illness, Allers added. The national director of the South African Federation for Mental Health, Solly Mokgata, said: Without access to services, a lot of people with psychiatric illnesses end up on the street, where they are open to abuse or they end up committing abuses. The national Health Department's policy is to deliver mental care as part of its primary healthcare services, yet professionals this week said these services were often over-extended or simply unobtainable. In the past, psychiatric nurses played a crucial role in managing mental health patients, said Allers. But now the posts for psychiatric nurses have virtually disappeared. Mental illnesses are usually treatable, with only about 10% of patients needing hospitalisation. Dr Sean Kaliski, head of the Forensic Unit at Valkenberg Hospital in Cape Town, said: We constantly have about 40 to 50 people waiting for observation as we only have 15 beds. South Africa has 19 specialised psychiatric hospitals. Allers said suicide rates were rising in black communities and rural areas. A recent study of 30 suicides in the Transkei linked 87% of them to poverty and 23% to alcoholism.(Source: Claire Keeton: The Sunday Times, 24 August 2003)
Health Systems Trust
Mental health has over many decades acquired the unwelcome reputation of being a pariah or stepchild of the health services. This was partly because it was narrowly understood as psychiatric illness, an area of concern for only psychiatrists, psychiatric nurses, patients and their families. However, the past three to four years have seen mental health care steadily moving out of this quarantine, towards mainstream health care. Also, mental health care has begun to address issues that distress South Africans on a day to day basis such as crime, violence and HIV/AIDS. This is starting to change peoples perceptions of mental health as an abstract, mysterious set of interventions, to an understanding that this is a component of health that addresses issues of general psychological well being and problems of day-to-day living. This transformation of mental health has been made possible by a diversity of developments, pioneered by the Mental Health Directorate in the National Department of Health, working in conjunction with provincial departments of health, non-governmental organisations and other interest groups. Some of these developments deserve special mention: * The Draft Mental Health Bill of 1999 which was published for public comment in the Government Gazette on the 4th February 2000. This draft Bill provides the legislative framework for the provision of mental health care in a humane manner, based on the individual rights espoused by our Constitution, and resonant with the times in which we live. Should this Bill be passed in the year 2000, as it is intended, this will be an important milestone. The new challenge that will obviously arise from this is the formulation of pragmatic implementation strategies. * Violence Surveillance Project, undertaken by the Mental Health Directorate in conjunction with the Institute for Health and Social Sciences, as part of the National Crime Prevention Strategy * Training of Primary Health Care Workers in Victim Empowerment * Development of Secondary level studies for Victims of Violence * Development, together with the Centre for the Study of Violence, of the Violence Prevention Project in Schools * Collaboration between the Mental Health and HIV/AIDS directorates to develop policies for pre-and-post test counselling of individuals * Development, together with Columbia University in New York, of interventions to prevent the spread of HIV/AIDS in institutions for people with intellectual disabilities The above areas of focus do not imply that people with psychiatric illness have been neglected. The Mental Health Directorate has also paid attention to: Development of Norms for Severe Psychiatric Care and Standards for monitoring Quality of Care in institutions providing mental health care. This was done together with the University of Cape Town. De-institutionalisation of people with mental health problems, to provide care in a milieu as close to the family of the patients as possible. This project was done together with the Centre for Health Policy (CHP) (see Research hot off the Press). Identification of barriers to the implementation of findings of mental health research. Areas of focus where more attention is needed include: Integration of mental health care into Primary Health Care (PHC) based on the District Health System. A lot of effort has been dedicated to this, for instance, by the Community-based Mental Health Project (CMHP), attached to the University of Durban-Westville. A scientific evaluation by an external team that could help to identify factors that facilitate and those that inhibit integration would be useful. Identification of barriers to the implementation of mental health research findings, most of which have been hailed as breaking new ground. Strengthening the capacity of provincial departments of health (and welfare) to translate the mental health policies of the national department into workable strategies. Focusing on the issues that affect us a nation on a daily basis such as crime and violence will almost certainly enhance peoples understanding of mental health as an integral aspect of daily living and not as a far-off illness that only affects some people who are hidden away in institutions. Of course, results speak louder than aspirations, and I have begun to see some of the interventions, for instance, the training of health workers in victim empowerment, beginning to enhance confidence and change attitudes. The formulation of the legislation is another important development. The partnership between the Mental Health Directorate and various NGOs, academic institutions and other interest groups, in enhancing the mental health care of the people of South Africa, as already been highlighted, is commendable. So although there is still a long way to go before the mental health system in South Africa approaches the ideal for this country, some important steps forward have been taken and the future looks promising.