Mental health services in Gauteng, South Africa: A proxy evaluation using pharmaceutical data.

Background: South African legislation advocates for equitable access to mental healthcare services integrated into general healthcare settings. Mental, neurological, and substance use (MNS) disorders are often comorbid. Pharmacoepidemiology provides indirect evidence of service provision for conditions amenable to medicine treatment. Aim: The study aims to evaluate medicine procurement for MNS disorders at different service levels in the health system. Setting: The Public health sector, Gauteng province formed the setting for the study. Method: A secondary analysis of the Gauteng pharmaceutical database was conducted using Anatomic Therapeutic Chemical (ATC) and defined daily dose (DDD) methodology. Anatomic Therapeutic Chemical classes of medicines for MNS disorders were included. Defined daily doses and costs were calculated per 1000 population served by each facility and service level. Statistical comparisons were made using chi-square testing. Results: General healthcare settings accounted for 90% (R118 638 248) and specialised hospitals for 10% (R13 685 032) of expenditure on medicines for MNS disorders, procuring 94% (n = 49 442 474) and 6% (n = 3 311 528) of DDDs, respectively. Although district clinics procured 60% of DDDs, they procured the least per 1000 population served, whereas district hospitals procured the most. For almost all ATC classes, procurement differed significantly between municipalities at every service level and between specialised hospitals. Conclusion: In Gauteng province, most medicines for MNS disorders are procured by general healthcare services, but access to care may not be equitable. While population coverage at district clinics appears low, district hospitals may experience the greatest care burden. Research regarding quality of care at each service level is recommended. Contribution: This study provides insight into service provision for MNS disorders.

Mental health services in Gauteng, South Africa: A proxy evaluation using pharmaceutical data

Background: South African legislation advocates for equitable access to mental healthcare services integrated into general healthcare settings. Mental, neurological, and substance use (MNS) disorders are often comorbid. Pharmacoepidemiology provides indirect evidence of service provision for conditions amenable to medicine treatment. Aim: The study aims to evaluate medicine procurement for MNS disorders at different service levels in the health system. Setting: The Public health sector, Gauteng province formed the setting for the study. Method: A secondary analysis of the Gauteng pharmaceutical database was conducted using Anatomic Therapeutic Chemical (ATC) and defined daily dose (DDD) methodology. Anatomic Therapeutic Chemical classes of medicines for MNS disorders were included. Defined daily doses and costs were calculated per 1000 population served by each facility and service level. Statistical comparisons were made using chi-square testing. Results: General healthcare settings accounted for 90% (R118 638 248) and specialised hospitals for 10% (R13 685 032) of expenditure on medicines for MNS disorders, procuring 94% (n = 49 442 474) and 6% (n = 3 311 528) of DDDs, respectively. Although district clinics procured 60% of DDDs, they procured the least per 1000 population served, whereas district hospitals procured the most. For almost all ATC classes, procurement differed significantly between municipalities at every service level and between specialised hospitals. Conclusion: In Gauteng province, most medicines for MNS disorders are procured by general healthcare services, but access to care may not be equitable. While population coverage at district clinics appears low, district hospitals may experience the greatest care burden. Research regarding quality of care at each service level is recommended. Contribution: This study provides insight into service provision for MNS disorders.

Medicines used in mental, neurological and substance use disorders in Gauteng, South Africa: A secondary analysis of the 2017-2018 provincial pharmaceutical database, Part 1.

BACKGROUND: Access to essential medicines is an integral part of effective health systems. Analysis of medicine procurement may assist with ensuring sustainable access. AIM: To describe the profile and cost of medicines procured for managing mental, neurological and substance use (MNS) disorders during the 2017-2018 financial year. SETTING: The study was conducted in the public health sector in the Gauteng province, South Africa. METHOD: A secondary analysis of the Gauteng Medical Stores Administration System database was performed. Medicine procurement for managing MNS disorders was analysed descriptively by using the World Health Organization's Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) methodology. Procurement of each medicine was evaluated in local currency (Rands) and in DDD/1000 population served. The District Health Information System was used to estimate population served. RESULTS: Of the total provincial medicines expenditure in 2017-2018, 3.73% was for MNS disorders, which is similar to the spending on cardiovascular (4%) and respiratory (3%) disorders. Antivirals for systemic use comprised 44% of the total expenditure, followed by vaccines at 13%. Of the medicines for MNS disorders, 32.5% of DDDs procured were for anti-epileptics (ATC N03A) at 47.5% of expenditure; 26.2% of DDDs were for antipsychotics (ATC N05A) at 30.9% of expenditure; and antidepressants accounted for 30.8% of DDDs at 6% of expenditure. CONCLUSION: Less than 4% of provincial medicines expenditure was on medicines for MNS disorders, of which almost 78.4% of expenditure was on anti-epileptics and antipsychotics. With limited financial resources, evaluation of procurement patterns raises awareness of relative costs.

Prevalence and clinical correlates of substance use amongst acute psychiatric inpatients in Gauteng, South Africa.

BACKGROUND: Mental disorders and substance use disorders (SUD) commonly occur together, impacting healthcare outcomes. The diagnosis of substance use is often inadequate when comorbidity is present. It is vital to understand the prevalence of substance use amongst psychiatric patients to inform both clinical practice and service development in South Africa. AIM: To ascertain the prevalence and clinical correlates of SUD amongst acute psychiatric inpatients. SETTING: The setting for this study was Helen Joseph Hospital acute psychiatric ward. METHODS: A cross-sectional study was conducted whereby consecutively admitted patients were invited to participate in a structured clinical interview utilising the alcohol use disorders identification test (AUDIT) and drug use disorders identification test (DUDIT) questionnaires. Statistical comparisons were made between those with and without SUD. RESULTS: Of 150 participants, 100 (67%) were identified with a SUD. Those with SUD were younger (p = 0.0010), more often male (p = 0.012), less likely to have a disability grant (p = 0.015) and more likely to be brought to hospital by police, ambulance or self than by a family member (p = 0.025). Almost half of people with bipolar disorder (47.3%) and schizophrenia (41.4%) had comorbid SUD. Twenty-three (15%) participants identified with SUD on questionnaire had been missed clinically. Only two participants were referred for inpatient substance rehabilitation on discharge. CONCLUSION: Substance use disorders are highly prevalent amongst psychiatric inpatients. The AUDIT and DUDIT are potentially useful screening tools in routine clinical practice. Greater collaboration between psychiatric and substance rehabilitation services is recommended.

Predictors of quality of life among community psychiatric patients in a peri-urban district of Gauteng Province, South Africa.

BACKGROUND: Few studies on quality of life (QoL) among people with mental illness have been conducted in South Africa, and none in community dwelling individuals. However, a greater understanding of subjective QoL may inform community-based medical, psychotherapeutic, or social interventions. This study examined the QoL, clinical and sociodemographic characteristics of psychiatric patients attending community mental health clinics in the Gauteng Province of South Africa. METHODS: A cross sectional interview-based study was conducted with 121 adult patients attending community psychiatric clinics. To reduce the impact of acute psychiatric symptoms on subjective QoL, only clinically stable patients were included. Sociodemographic details and clinical characteristics were recorded. Subjective QoL was assessed using the World Health Organization QOL-Bref scale (WHOQOL-Bref), and severity of psychiatric illness measured with the Brief Psychiatric Rating Scale, expanded version 4.0 (BPRS-E). RESULTS: Just over half of the sample rated their overall QoL as good or very good. Residual psychiatric symptomatology was the strongest predictor of a poor QoL in all four domains of the WHOQOL-Bref. The most severe BPRS scores were for the symptoms of depression, anxiety and somatic concern. Perceived social support significantly predicted a better QoL in the psychological, social relationships and environmental domains. CONCLUSION: This study highlights the negative impact of residual psychiatric symptoms on subjective QoL and the importance of social support in enhancing QoL.

The impact of urbanization on mental health service provision: a Brazil, Russia, India, China, South Africa and Africa focus.

PURPOSE OF REVIEW: Asia and Africa are experiencing rapid urbanization and rural growth. This review focuses on the impact of urbanization on preventive and treatment mental health service provision with attention to the Brazil, Russia, India, China, and South Africa economic bloc and sub-Saharan Africa. RECENT FINDINGS: A search of the PubMed, Academic Search Ultimate, and Global Health databases, and use of Google Scholar yielded relevant health, environmental, and urban planning research articles from sub-Saharan Africa and Brazil, India, China, and South Africa. Preventive services are ineffective in addressing violence exposure, substance use, poor quality housing, and spatial segregation, with differing trajectories in the various countries. Similarly, the impact of urbanization on social capital and green infrastructure is variable. Although Brazil appears to have a well-developed mental health system, it is unable to meet the care demand. Integrated country-wide and district-based analyses in China indicate planning is underway. SUMMARY: In general, existing mental and general health services in low and middle-income countries are grossly inadequate in terms of prevention, coverage, and quality to withstand population transitions lying ahead. People with mental disability, as a vulnerable and stigmatized subpopulation, are at high risk of neglect as urbanization progresses, particularly in India and sub-Saharan Africa.

Community mental health services in Southern Gauteng: An audit using Gauteng District Health Information Systems data.

BACKGROUND: Community mental health services (CMHS) are a central objective of the National Mental Health Policy Framework and Strategic Plan. Three core components are described: residential facilities, day care and outpatient services. Primary mental health care with specialist support is required according to an intervention pyramid. Staffing norms provide for a minimum mental health service coverage of 2.7% of the population for adults and 1.5% for children and adolescents. AIM: The aim of this study was to describe the existing CMHS in Southern Gauteng in terms of the National Mental Health Policy. METHODS: The CMHS of the City of Johannesburg, Ekurhuleni, Sedibeng and West Rand districts were studied. Information regarding service organisation and staffing was obtained via the Gauteng Directorate of Mental Health. Routinely collected District Health Information Systems data for the 2014/2015 year were analysed. RESULTS: The organisation of services was not consistent with that recommended by the Mental Health Policy, and specialist CMHS were inappropriately situated within primary care. Only 2.23% of clinic visits were for mental health, and 80% of these were at specialist CMHS. Overall mental health coverage was approximately 0.3% of the population for adults and 0.02% for children and adolescents. Staffing, residential facilities and day care were far below the cited norms for minimal cover. CONCLUSION: Our audit revealed that the CMHS in Southern Gauteng did not meet any of the norms cited by the Mental Health Policy. Barriers to implementation of this aspect of the Mental Health Policy need to be explored.

A retrospective record review and assessment of cost of quetiapine use in a community psychiatric setting in the Sedibeng district of Gauteng.

BACKGROUND: With the revision of the National Essential Medicines List in South Africa, quetiapine is only available at the discretion of individual institutions in the public health sector. However, quetiapine is effective in managing all aspects of bipolar disorder, including preventative treatment of depressive episodes, and may be a cost-effective option in severe illness. AIM: To present the first retrospective review of quetiapine use in a peri-urban health district of South Africa, describing the patient profile, clinical response and prescribing patterns. METHODS: The clinical files of all patients in Sedibeng District who received quetiapine over a defined 3-year period (2011-2013) were reviewed. A positive clinical response was defined as both symptomatic and functional improvement. Demographic and clinical characteristics of responders were compared with that of non-responders. Pre- and post-quetiapine scripts of the responders were audited and costed. RESULTS: Patients who received quetiapine (n = 40) had chronic disabling illness, often with multiple medication trials and hospitalisations prior to quetiapine use. Bipolar II disorder (followed by bipolar I disorder) was the most common primary psychiatric diagnosis documented. Other than improvement in functioning (p < 0.0001), responders differed significantly from non-responders in terms of a higher level of polypharmacy and a significant reduction in median number of medications from pre- to post-quetiapine (p = 0.0057). CONCLUSION: Quetiapine use was associated with a highly significant improvement in functioning; however, it came at a 52% increase in medicine cost. Pre-quetiapine treatments, though, did not achieve an optimal level of functioning, and overall costs may be reduced by more rational prescribing habits.