Non-attendance of psychiatric outpatients.

The failure of discharged psychiatric inpatients to attend for continuing outpatient treatment is an important factor in readmission. A study of 136 such patients indicates that frank resistance to treatment and inadequate information given to patients and their families are important contributing factors. A recommendation for improving the situation is made.

Psychological distress and depression in urbanising elderly black persons.

The findings of a comparative community survey of the socioeconomic, cultural and psychiatric state of elderly black persons in a newly settled township (Khayelitsha--170 persons) and a long established one (Langa--195 persons) revealed marked differences. Symptoms of psychological distress, depression and limitation of daily activities were generally more marked in the former and strikingly so among women: 66% had symptoms warranting further investigation and 44% would have been treated for a depressive disorder if seen by a psychiatrist. Extreme poverty existed in both townships but the Khayelitsha subjects were less well educated, their accommodation was poorer, and fewer had old-age pensions. Elderly black women in newly settled townships have therefore been identified as having high priority for psychiatric and social services.

The value and cost-effectiveness of a home-visiting programme for psychiatric patients.

The high rate of readmissions to psychiatric hospitals constitutes a considerable problem. An attempt to reduce these by a controlled standard home-visiting procedure was carried out for 51 consecutive patients at Valkenberg Hospital, Cape Town. Readmissions were reduced by 31.5% over 1 year and the number of days in hospital by 55.6% from 3714 to 1850 days. Attendance at outpatient clinics also improved by 39%. The cost-effectiveness of this programme was also demonstrated; there was a saving of approximately R786 per patient over the year.

Improving compliance in Xhosa psychiatric patients.

Compliance with psychotropic medication is particularly poor in Xhosa psychiatric patients. A study demonstrated that explicit and repeated verbal and written instructions did not increase compliance with oral medication, but that a single home visit, limited to giving instructions about medication, almost doubled the compliance rate (to 65%). Similar increases also occurred in relation to intramuscular medication and clinic attendance. The most common reason for noncompliance was found to be resistance to, or plain ignoring of, what was actually known (64%). Several possible reasons for this are proposed, the most significant being the patients' cultural and social attitudes and belief system. Recommendations for increasing compliance are given.

Psychiatric research--a new tomorrow.

Problems and priorities in psychiatric research in South Africa are reviewed. Some of the findings of the MRC/UCT Clinical Psychiatry Research Unit in respect of mental disorders in psychiatric hospitals in black patients, the elderly, and in association with substance abuse are given to indicate that each of these is a major medical problem. In particular, the increase in the amount of psychiatric disorder due to an ageing population, and the lack of rehabilitation facilities for the chronic mentally ill have been emphasised. The need to focus psychiatric research on intervention strategies and to co-ordinate neurobiological and clinical areas of investigation is stressed.

The outcome of psychiatric illness. A 2-year follow-up study.

A 2-year follow-up of 328 patients discharged from a psychiatric hospital was carried out to determine the presence and severity of symptoms, disturbed behaviour and functional disability and to assess social performance. Population groups and diagnostic entities (schizophrenia, affective illness, acute and chronic organic brain syndromes and functional non-psychotic conditions) were compared. In general the proportion of patients with symptoms was considerable at discharge in respect of both the diagnostic entities and the population groups, and decreased on follow-up. Disturbed behaviour abated on discharge, but the prevalence of functional incapacity remained high. The pattern for different diagnostic groups was more or less the same, but the proportions differed in some instances. These are discussed in detail. The problem of sequelae of psychiatric illness in patients discharged from a psychiatric hospital is shown to be considerable.

Non-compliance with psychotropic medication.

A 2-year follow-up study of 406 patients discharged from a psychiatric hospital revealed that non-compliance with psychotropic medication was a problem in at least half the cases overall. Non-compliance with oral phenothiazine was particularly evident among the cohorts of patients classified as black and coloured (approximately two-thirds and half respectively failing to comply, compared with approximately one-quarter in the white cohort). Compliance was somewhat better for intramuscular medication. The proportion of poor compliers remained at about the same level at the 6-month, 18-month and 24-month follow-ups. There were more male than female non-compliers (51% and 41% respectively) and more among younger patients of all population groups. Understanding of the details of treatment by the relatives of black and coloured patients was particularly poor, only 14% and 12% respectively understanding the purpose and nature of medication. The main reasons for non-compliance were active resistance to taking medication, unpleasant side-effects and non-attendance at clinics. Several areas which allow remediation of the problem have been highlighted.

Admissions to a psychiatric hospital. Factors associated with admission and inpatient care.

A detailed cross-cultural analysis was carried out of demographic, social, family and diagnostic variables responsible for, or associated with, the admission of 460 sequentially admitted patients to an area psychiatric hospital (Valkenberg Hospital). All patients were socio-economically disadvantaged compared with the population from which they were drawn and socio-economic factors played a significant part in admission. Larger proportions of coloured and black schizophrenics and substance abusers were admitted, and this is related to socio-economic conditions and the fact that the population generally are younger. There were indications that the period of inpatient stay, particularly for coloured and black patients, was too short in many cases for meaningful preparation for discharge, and that supervision after discharge was inadequate. Treatment of the type offered by this hospital appears largely to achieve the diminution or control of aberrant or difficult behaviour and symptoms while functional impairment is little improved.

Readmissions to a psychiatric hospital. Outcome on follow-up.

Readmissions to South African psychiatric hospitals form 45% of their intake and constitute a considerable burden on staff and facilities. The situation was investigated in a series of 460 patients sequentially admitted to a large, actively admitting hospital (Valkenberg Hospital, Cape Town). There was a difference in the proportion of readmissions within 1 year for different population groups--26,5% for white, 41% for coloured and 42% for black patients. The factors influencing this are explored. There was a marked difference in diagnoses--schizophrenics and affective disorders being more common in the black and coloured cohorts. Possible reasons for this are discussed. A 2-year post-discharge follow-up study showed a marked and sustained fall in the severity of psychiatric symptoms and difficult behaviour for all cohorts, but not of functional impairment, which was present in approximately 90% of all patients. Adequate aftercare and rehabilitation facilities in the community are evidently lacking.

A comparison of CATEGO class 'S' schizophrenia in three ethnic groups: psychiatric manifestations.

We compared the psychiatric manifestations of 56 CATEGO S schizophrenic in-patients from three ethnic groups (white, coloured and black). A marked similarity among the groups on both schizophrenic and non-schizophrenic symptoms was found, as well as a high prevalence of depressive and anxiety symptoms. Differences occurred on the syndromes of olfactory hallucinations and subcultural delusions and hallucination. Black patients had both syndromes more frequently than either white or coloured patients.

The rise in readmissions to psychiatric hospitals.

The progressive increase in readmissions to psychiatric hospitals in South Africa is causing concern. Readmissions now amount to 42% of total admissions, and in some cases their number exceeds that of first admissions. The phenomenon has been identified as occurring overwhelmingly among short-stay patients. Factors associated with readmissions have been examined as the first part of an ongoing investigation. Among these are a decline in available beds, an increasing shortage of psychiatric staff, differing readmission rates for different population groups, and the tendency of certain types of psychiatric disorders to relapse more frequently (schizophrenia and affective illness). The inability of the present psychiatric outpatient and community services to lower the readmission rate has been demonstrated. Factors which may have a bearing on the situation such as socio-economic conditions, substance abuse, compliance with medication and rehabilitative services are discussed.

The coloured elderly in Cape Town--a psychosocial, psychiatric and medical community survey. Part I. Introduction and psychosocial data.

A survey of 150 non-institutionalized Coloured persons over the age of 65 years living in Cape Town was undertaken to examine their psychosocial, psychiatric and medical condition. This article covers procedural and psychosocial aspects; Parts II and III will deal with others. Overall, respondents were poorly educated, with low income and occupational status. Social functioning and life satisfaction were reported to be good in over 80%. Family and social support appeared to be strong. Many respondents were involved in household duties (87%), child care (46%) and activities outside the home (66%). The high degree of satisfaction in the face of economic adversity may be due to family support and role maintenance. Findings are compared with those of previous studies, and the possibility that changes in circumstances are occurring is noted.

Life events in Xhosas in Cape Town.

A life events scale for research into Xhosa speaking people of Cape Town was developed. It was standardised on 131 residents of Cape Town's three major Black suburbs. Measures of perceived impact and rate of occurrence were elicited. The Spearman Rank correlation between prevalence and impact scores was not significant (r = 0.04). Items were ranked according to composite impact scores. Cultural and social factors were considered to play a part in explaining differences between the present findings and those of other studies. Limitations on the applicability of the scale and methodological issues were discussed. The problems in direct comparison between different cultural groups were emphasized, with particular stress on constraints on life events research in an African setting.

Dysphoria in the elderly.

Evidence is presented for distinguishing a clinical entity characterized by dysphoria associated with physical impairment, isolation and financial and social disadvantage in the elderly in residential care. Personality factors are believed to play a considerable part in the aetiology of the condition. A distinction is made between similar groups of elderly persons, in one of which dysphoria is associated with depression and a group of non-depressed, dysphoric individuals.

Elderly persons in old-age homes. A medical, psychiatric and social investigation.

A survey of 100 consecutive admissions to homes for elderly Whites in Cape Town showed that an interplay of social, physical and psychiatric factors was responsible for most of the referrals, although psychiatric factors contributed to more than 50% of them. The largest proportion (37%) suffered from confusional states, 31% were diagnosed as having a senile organic condition and 25% showed moderate to severe depression. These old people were physically very frail; 53% had incapacitating muscular weakness or stiff and painful joints, 35% had a significant degree of deafness, 25% had a visual defect and 23% were incontinent. The findings indicate that old-age homes deal with a considerable amount of physical and mental ill health, and they are therefore an essential part of health services. The residents of old-age homes were much older than elderly people in the community, as well as being more socially isolated and very disadvantaged in terms of income and family and social support.

The admission of the elderly to places of care: a socio-psychiatric community survey.

Elderly persons over the age of 60 who were admitted for psychiatric care were compared with a random sample of persons living in the same community in respect of psychiatric, medical and socio-economic variables. The group admitted to hospital for psychiatric reasons was very similar to the latter in general characteristics. However, those people admitted to old age homes, which are the other major resource of psychiatric illness, constitute a distinctly separate population, being older and having considerably more physical illnesses and socio-economic problems. Factors predicting admission to an old age home were largely irremediable age-related conditions (dementia, physical infirmity, etc.), but there were also adverse social circumstances, including marked isolation and a lack of social and emotional support. A comparative analysis of the many psychiatric, social and medical factors is presented, with particular reference to reasons for referral and prevention of admission.