In recent weeks, health authorities in the Western Cape have raised concern over an increase in acute psychiatric admissions in the province’s hospitals. This has ramped up the pressure on the province’s mental health services and limited hospital bed capacity - capacity set to be further strained by an uptick of Covid-19 cases at the end of November that is expected to continue in December.
According to the Western Cape Department of Health, the current demand for mental health services in the province for both beds and human resources outstrips the available resources.
A further concern, says departmental spokesperson Mark van der Heever, is that vulnerable groups, including children and adolescents, elderly patients, and persons with intellectual disabilities, require tailored management, yet there are major bed shortages across the provincial platform for children. “The increase in acute services has impacted negatively on the available beds for therapeutic care,” he says.
Van der Heever says the number of acute admissions in the province in 2013 was about 6 660. By the 2019/20 financial year, this number had increased to 12 790. These admissions, van der Heever says, are mainly persons with serious mental disorders who require admission as involuntary patients (mostly those who present with psychotic disorders and substance-induced psychosis) as provided for in the Mental Health Care Act (2002).
Acute admissions numbers for 2020/21 was not shared with Spotlight, but it seems likely that 2020/2021 and 2021/22 numbers will continue the upward trend.
According to van der Heever, all district and regional hospital emergency centres are now seeing high numbers of patients. These hospitals see on average 100 patients per month (in smaller facilities) to just under 200 patients per month in larger facilities.
“Alcohol and drug use are contributors, as are delays in accessing treatment (chronic medication) during the pandemic and lockdown, which has contributed to patients with mental illness decompensating and relapsing,” he says.
At a recent media briefing, Dr Keith Cloete, head of the Western Cape Department of Health, said mental health services are under severe pressure. Presenting an overview of the last few months (June to November) of patients presenting with mental health issues at 17 emergency centres in the province, he said unspecified non-organic psychosis was at 1 564 cases, mental and behavioural disorders were at 1 157, delirium not induced by alcohol abuse was at 851, schizophrenia was 309 cases, and other anxiety disorders were at 692.
Van der Heever explains the term “non-organic” was used in the past to indicate that the disorder was not caused by a range of medical conditions, for example, tumours, however, there has been a move away from using the terms “organic” and “non-organic”, as psychotic disorders have clear biological underpinnings.
“Serious mental disorders such as schizophrenia and bipolar disorder are associated with psychotic symptoms such as hallucinations and delusions, he says. “There are well-recognised diagnostic guidelines for these disorders and evidence-based treatments are available. In the Western Cape, the use of substances such as Tik and cannabis together with alcohol has significantly contributed to the high admission rates seen at district hospitals,” he says, adding that as a result there is a huge social element to this and reducing this phenomenon is not the responsibility of only one government department.
Van der Heever also stresses that it is important to note that known risk factors for mental illness such as poverty, social isolation, food insecurity, and domestic violence have been magnified by the pandemic. “Women are also at greater risk for depression and anxiety for various reasons, as are carers, children and adolescents, victims of gender-based violence, and those who are more financially disadvantaged are at higher risk of developing these disorders during the pandemic.
The situation in the Western Cape is not unusual. Figures from a World Health Organization survey published in 2020, show the Covid-19 pandemic has disrupted or halted critical mental health services in 93% of countries worldwide while the demand for mental health services is increasing. Estimates published in the Lancet also suggest Covid-19 led to a stark increase in depression and anxiety disorders worldwide.
Relieving the pressure
Van der Heever explains that the mental health service in the province concentrates on those triaged by the emergency centres and requiring acute admissions. “Almost all these patients require a 72-hour assessment period.” He says often 75 to 80% of patients are expected to be discharged from the district or regional hospitals and the balance (20 to 25%) will require a longer stay or are referred to a psychiatric unit or hospital,” he says.
He says that the provincial department of health is “aggressively looking at ways to increase resources for mental health”. “A motivation was tabled for the strengthening of all levels of care, community-based, primary healthcare, district, regional, and specialised hospitals. The department understands the need to invest in mental health,” he says.
“The department is aware of the pressures on the service and is configuring ways to improve patient flow while trying to reduce the risk to vulnerable groups who are often admitted as involuntary patients.” He adds that the department already has some strategies in place to deal with the pressure, including strengthening primary health services by appointing more staff with funding from the National Health Insurance grant.
According to van der Heever, although district hospitals are the entry point for acute admissions, “few hospitals have custom-built units but infrastructure plans are in place. But it will be a lengthy process before all hospitals will be fully equipped. In the meantime, the commissioning of off-site units are part of reducing the pressure on district hospitals,” he says.
Byron La Hoe, also a spokesperson for the provincial health department, says along with capacitating all district hospitals in the province to provide mental health care, the department has developed and expanded the mental health units at all regional hospitals. They also appointed 18 Registered Counsellors, of which ten were in rural areas and eight were in the metro.
La Hoe says they also appointed an additional psychologist and two psychiatrists for the metro, and a psychologist and a psychiatrist for the Valkenberg forensic service, specifically for observation.
A community-oriented approach
La Hoe notes that the department is trying to integrate mental health services in a community-oriented approach and that they are using community health workers (employed by NPOs) to follow up on patients, especially those at high risk of relapsing after an acute admission.
“This strategy has been interrupted by the Covid-19 pandemic. However, in the areas where it has been employed, there is a sense that it provides positive outcomes for retention in care. The department wants to monitor this and gather data to confirm the impact,” he says.
Need for better screening
Common mental disorders are often undetected in busy primary health care settings, says van der Heever. “Disorders such as depression, anxiety and post-traumatic stress disorder could be managed with good outcomes but are often missed as people tend to present with health concerns such as lower back pain, headaches, and physical symptoms and their psychological and mental health concerns are often not detected,” he says.
“In trying to improve detection of common mental disorders in primary care clinics, a standardised tool was developed called PACK, which prompts the clinician to ask certain questions to determine the possible cause of illness,” he says, explaining that if a common mental disorder is detected, the patient could benefit from being treated pharmacologically, or referred for counselling.
"If the patient presents with more severe disturbance, such as schizophrenia, referral to the appropriate professionals will be facilitated, for example, referral to the mental health nurse at the facility or the psychiatric registrar for assessment and appropriate treatment or referral for admission.”
*This article was produced by Spotlight - health journalism in the public interest.