Tag: psychiatric disorders

Categories : Hospitals Mental HealthTags :

Health Ombud’s Findings on Complications and Deaths of Psychiatric Patients in the Northern Cape

On By ModernMedia
Photo by Wesley Tingey on Unsplash

Pretoria – The Health Ombud, Professor Taole Mokoena, has released the findings of an investigation into the treatment, complications, and deaths of psychiatric patients at the Northern Cape Mental Health Hospital (NCMHH) and the Robert Mangaliso Sobukwe Hospital (RMSH). The investigation revealed that two patients died, and another underwent craniectomy and remains bedridden.

The investigation was initiated following a complaint filed by the Honourable Minister of Health, Dr. Aaron Motsoaledi (MP), regarding the Northern Cape Mental Health Hospitals in October 2024. The reported incidents took place in July and August 2024, during which it was alleged that two patients died at NCMHH, and two others were admitted to RMSH in critical condition.

In response to the Minister’s request, the Health Ombud deployed a team of two investigators in accordance with Section 81(3)(c) of the National Health Amendment Act (NHAA). This investigation report is issued based on Section 81A (11) of the NHAA, 2013 (Act No. 12 of 2013), pertaining to the functions of the Office of Health Standards Compliance and the handling of complaints by the Health Ombud. The report is intended to inform both the complainant and the health establishments as well as the general public of the findings and recommendations derived from the investigation.

ISSUES INVESTIGATED

The investigation was carried out through a detailed analysis and triangulation of information and documentary evidence obtained from the NCMHH and RMSH, as well as through on-site visits. The following issues were identified for investigation based on the analysis of the complaints, allegations, and engagement with both health establishments:

  • The circumstances surrounding Mr. Cyprian Mohoto’s care at NCMHH and his subsequent death at RMSH;
  • The circumstances surrounding Mr. Petrus De Bruins’s care at NCMHH and his admission to RMSH;
  • The circumstances surrounding Mr. Tshepo Mndimbaza’s care and death at NCMHH; and
  • The circumstances surrounding Mr. John Louw’s care at NCMHH and his admission to RMSH.

The investigation revealed that, at the time of the incidents, NCMHH and several neighbouring health facilities were facing challenges with their electricity supply due to cable theft and vandalism at their power substation. This power loss impacted the communication infrastructure, leaving the hospital without telephone lines.

Electricity supply was restored within days at two of the neighbouring hospitals; however, it took an entire year for the electricity to be restored at NCMHH. The investigation found that the delay in repairing the electricity supply to NCMHH was due to dysfunctional Supply Chain Management processes within the Provincial Department of Health. This delay rendered the hospital’s Heating, Ventilation, and Air Conditioning (HVAC) system nonfunctional, exposing patients and staff to extreme weather conditions during the summer and winter. Additionally, because of the lack of electricity, the available resuscitation equipment was not operational, as it could not be charged, and other necessary equipment was unavailable for use. NCMHH procured poor quality pyjamas and blankets which were inadequate to provide warmth to patients during the severe winter’s cold, especially at night.

It was established that the Clinical Manager at NCMHH had written a complaint letter to the Acting Head of the Provincial Department of Health, detailing the adverse conditions which patients at NCMHH were being subjected to. These circumstances negatively impacted their health and violated their human rights.

FINDINGS

The investigation uncovered several findings regarding the medical care of four patients:

  1. Circumstances surrounding Mr. Cyprian Mohoto’s care and admission to RMSH: The investigation revealed gross mismanagement surrounding Mr. Mohoto’s care, which ultimately led to his death. He was admitted to RMSH on 13 July 2024, with a suspected abdominal or bowel obstruction following complications at NCMHH on 12 July 2024. Admission abdominal X-rays ruled out bowel obstruction while the chest X-ray revealed multi-lobar pneumonia. The pneumonia was never treated during the 3 days that the patient stayed in the Surgical Recovery Unit until his death. His deteriorating clinical status was never attended to by either the nursing personnel nor the doctors. Mr. Mohoto died on 16 July 2024, in the Emergency Centre at the Surgical Recovery Unit at RMSH.
  2. Mr. De Bruin was transferred from NCMHH to the Emergency Centre at RMSH on 30 July 2024, after collapsing and being unresponsive in Ward M2 at NCMHH. He was stabilised and later admitted to the RMSH Medical Recovery Unit for hypoglycaemia, the medical care and investigations conducted in the Emergency Centre were appropriate. However, the monitoring by nursing personnel was found to be inadequate.
  3. The Circumstances Surrounding Mr. Tshepo Mdimbaza’s Death: Mr. Mdimbaza was discovered unresponsive in his bed on 3 August 2024, at NCMHH. The resuscitation process was delayed due to the unavailability, malfunction, or unpreparedness of resuscitation equipment. There was also a lack of monitoring of the patient’s vital signs before and during resuscitation by medical or nursing personnel. Mr. Mdimbaza did not survive the resuscitation attempt. The post-mortem report indicated that he died due to “exposure to the elements” at NCMHH.
  4. The investigation into the circumstances surrounding the care and admission of Mr. John Louw to RMSH revealed that he had an acute subdural haemorrhage. An emergency craniotomy and craniectomy were successfully performed on 07 July 2024 and 23 July 2024, respectively, and he was discharged back to NCMHH on 28 October 2024. Mr. Louw remains bedridden.
  5. The investigation also established additional findings, including leadership instability in the Northern Cape Provincial Department of Health, which negatively affected service delivery, safety, and the quality of patient care at NCMHH and RMSH.
  6. Northern Cape Mental Health Hospital was found to have poor governance and systemic lack of leadership and poor management at all levels, unpreparedness for emergency cases, crumbling infrastructure, poor pharmacy and medicine control management, shortage of staff, poor quality assurance management, non-compliance with patient record keeping, and poor laundry services.
  7. Robert Mangaliso Sobukwe Hospital was found to be experiencing critical staff shortage across the board; lack of oversight with nursing supervision; communication breakdown of reporting systems, non-compliance with guidelines on principles of good record keeping and overcrowding at the hospital emergency centre, aggravated by the absence of a district or regional hospital.
  8. The investigation concluded that the general care provided at the Northern Cape Mental Health Hospital and the Robert Mangaliso Sobukwe Hospital to the patients was substandard, and patients were not attended to in a manner consistent with the nature and severity of their health condition, as required by Regulation 5 (1) of the Norms and Standards Regulations Applicable to Different Categories of Health Establishments, 2018 (Norms and Standards Regulations).

RECOMMENDATIONS

The Health Ombud made clear, actionable recommendations to address the systemic failures observed at both health establishments to improve the overall safety and quality of patient care. Key recommendations include; the Provincial Head of Department of Health must immediately appoint a Task Team to monitor the implementation of the recommendations as outlined in the report, hold accountable officials found to be in breach through formal disciplinary processes, the National Department of Health should initiate a forensic investigation into the procurement processes for the NCMHH, priority should be given to the development, reinstatement, and implementation of an effective and efficient reporting system for continuity of care and effective communication, and the development of comprehensive Standard Operating Procedures (SOPs)/Protocols/Guidelines to guide healthcare personnel in providing healthcare services. The complete set of recommendations is included in the report.

A detailed report is available on the Health Ombud’s website at www.healthombud.org.za.

Categories : Mental Health Substance UseTags :

Psychiatric Hospitalisations for Methamphetamine Use on the Increase

On By ModernMedia
Photo by Alex Green on Pexels

A new study on psychiatric hospitalisations, out now in Drug and Alcohol Dependence, found that while most hospitalisations did not involve any substances, methamphetamine-related hospitalisations have increased even as the overall number of psychiatric hospitalisations remained stable.

Additionally, researchers detail that psychiatric hospitalisations caused by methamphetamine use was highest in a region which has higher reported methamphetamine use, but were also shifting geographically.

“Rates of methamphetamine-involved psychiatric hospitalisations were by far the highest in the Mountain West,” said Susan Calcaterra, MD, MPH, professor at the University of Colorado Anschutz Medical Campus and study lead author. “As expected, this mirrors rates of self-reported methamphetamine use and methamphetamine-related overdose deaths in the Mountain West,” Calcaterra said. “Psychiatric hospitalisations involving methamphetamine use is really taking off in the Midwest and Northeast, in particular.”

Study underscores need for clinic-based harm-reduction tactics

While rates of methamphetamine-related psychiatric hospitalisations increased 68% over the study period, opioid-related hospitalizations decreased by 22%. Methamphetamine rate increases may be attributed to methamphetamine’s ubiquity and affordability, as well as the lack of resources available to manage methamphetamine use. Why opioid-involved psychiatric hospitalizations declined is less clear but may be related to the lethality of fentanyl.

“An important takeaway from this study is the need for resources to address the mental and physical treatment of methamphetamine use,” Calcaterra said.

“While the vast majority of psychiatric hospitalisations in this timeframe did not involve substance use, the significant increase in methamphetamine use means we have to better consider harm reduction in clinical settings,” she said.

“Evidence-based interventions such as contingency management, which involves offering incentives for abstinence, harm reduction education, provision of naloxone for overdose reversal and access to expanded mental health treatments are proven to help mitigate dangerous effects from methamphetamine use, especially when contaminated with fentanyl much like the campaigns aimed at public awareness around opioid use.”

Source: University of Colorado Anschutz Medical Campus

Categories : Mental Health PaediatricsTags :

Focus on Children, Urges President of SA Society of Psychiatrists

On By ModernMedia
Dr Anusha Lachman is the first child psychiatrist to hold the position as president of the SA Society of Psychiatrists. Photo supplied to Spotlight

By Sue Segar for Spotlight

There are serious gaps in psychiatry regarding treatment, prevention and care for children and adolescents in South Africa. Offering solutions, Dr Anusha Lachman tells Spotlight psychiatric services should be offered in ways that are Afro-centric and culturally sensitive.

“There’s a mental health crisis in South Africa and yet, today, there are fewer than 40 registered child psychiatrists in the country,” Dr Anusha Lachman tells Spotlight.

She is the first child psychiatrist to hold the position as president of the SA Society of Psychiatrists (SASOP) and she hopes to prioritise the “grossly under-represented and under-resourced” field of child and adolescent health in the country. While the field is certainly neglected, Lachman is not alone in trying to draw more attention to it – the 2020/2021 edition of the Children’s Institute’s excellent Child Gauge also concentrated on the mental health of children in South Africa.

Lack of data

One of the biggest issues in child and adolescent psychiatry, Lachman laments, is the lack of reliable data. She explains that most of the current research, literature and thinking about infant mental health is focused on Western, high-income settings but her focus is on the African context and in limited-resource settings. “We don’t have many figures on how many young people are suffering from the various mental health disorders,” she says.

While it is a struggle to get concrete, reliable statistics, Lachman adds there are some data to work with but South Africa lacks a collective data base that ties it all together.

Insight into the country’s mental health crisis, she says, is partly gauged from the number of referrals to primary health care centres for mental health support and evidenced by the long waiting lists for children to be assessed at specialist mental health clinics and at hospitals. “All we have, across our public hospitals, is the waiting list data which only tell us the duration that children with severe mental illness wait to get into secondary and tertiary level hospitals to access hospital-based care,” she says. The problem is that this type of data tells us little about the vast majority of adolescents with mental health issues who do not require hospitalisation.

Lachman is also head of the Clinical Unit Child Psychiatry at Tygerberg Hospital. The unit is the Western Cape’s only tertiary hospital based assessment unit for adolescents aged from 13 to 18 years with complex psychiatric presentations and severe mental illness. The young people they help often face not only mental health issues, but the full range of psychosocial challenges – from poverty to exposure to violence, substance abuse, and HIV.

“We know, for example,” she says, “what substance-use disorder looks like in children under twelve, and in young people under 21 because we get that from substance-use centres and rehabilitation centres. We know what proportion of children have HIV and TB and some infectious diseases, which by extension have psychosocial consequences and comorbidities, and we know about neurodevelopmental delays because we track things like school attendance and requests for access to support in special needs.

“We do have statistics on issues which affect children in South Africa disproportionately,” she says, “on food insecurity, intimate partner violence, instability in terms of accommodation etc. There are huge occurrences of abuse but there are inadequate services for children to be removed from those abusive homes, because we don’t have sufficient children’s homes or safety placements for example. So these are children who are disproportionally disadvantaged and that in itself is hard to quantify – and the psychosocial support structures are just not there.”

Lachman says the Western Cape department of Health and Wellness is making inroads into the lack of data by tracking and digitising child mental health statistics, through its Child and Adolescent Mental Health Strengthening Project. “This will give us some important data across emergency rooms throughout the Western Cape. Hopefully that can roll out to the rest of the country so that we can understand what children are presenting with.”

Hard to categorise

Asked which mental illnesses South African children and adolescents mainly suffer from, Lachman says child mental health is a function of multiple psycho-social stressors, structural problems, and fundamental relational challenges  –  and that’s hard to categorise.

“It’s a complex relationship between environmental stressors and vulnerabilities to mental illnesses.” She explains that environments that are high risk – with violence, poverty, untreated mental illness in caregivers, food insecurity and economic burdens – predispose children to mental illness expressed commonly in mood disorders, anxiety and trauma responses. “These take the form of poor functioning at school, learning challenges, suicide and self-harming attempts, drug-seeking behaviours and, in some instances, expressions of severe mental illnesses. ADHD is also commonly seen in this context.”

Lack of relevant research

Lachman bemoans what she calls the “distaste” for research that originates from the global South. “The biggest problem we face is the inability to publish and compete in international journals, not because our research is inadequate but because there’s a distrust of information originating from the lower-middle income countries or the global South.”

In terms of publication bias, she says the huge issue is that editorial boards and funders of journals consist largely of privileged white men.

“They don’t represent people of colour and ethnic majorities outside of the industrialised northern hemisphere countries. When we aren’t able to publish, we aren’t able to get the data out there, and when you don’t get the data out, there’s a vacuum of information and evidence-based treatment – and interventions are often  coloured by information that doesn’t represent the lower-income communities and population groups.”

Lachman says research published a few years ago, by Stellenbosch University academic Mark Tomlinson, showed that less than three percent of all articles published in peer reviewed literature include data from low- and middle-income countries, where 90 percent of children live.

Low number of child psychiatrists

Turning to the shockingly low number of registered child psychiatrists in the country, Lachman notes that in the last three years, South Africa has lost five child psychiatrists to New Zealand. “This is about the brain drain, where there is targeted recruitment of qualified people [by] first-world or industrialised regions who can offer incentivised work opportunities which we, in South Africa, cannot compete with.”

She adds: “One child psychiatrist is trained only every two years. And only from a university that can train them. There are only four universities that can  do that here – Stellenbosch, Wits, UCT and Pretoria. It depends after two years if the student passes the exam or not so that is why there are so few.” (Prior to training in child psychiatry candidates first have to complete the normal training to become a medical doctor.)

“So far there were two that qualified 2022 and one that qualified in 2023. And at the beginning of 2023, we had lost five child psychiatrists to New Zealand and Australia. It’s dire,” she emphasises. People remain registered with the Health Professions Council of South Africa (HPCSA) but that doesn’t mean they are physically in the country, Lachman adds. “Recent stats show that we have under 40 [child] psychiatrists in working environments, including those who have retired.

“We still sit with provinces that have zero representation for child psychiatry. We recently deployed one to the Eastern Cape, but, currently North West, Limpopo, Mpumalanga, don’t have any qualified [child] psychiatrists.”

‘Everybody’s business’

Yet, Lachman does not believe the only answer is to train more child psychiatrists. “The answer is more nuanced. It’s about upskilling and task shifting, and an openness to the idea that child and adolescent psychiatry is everybody’s business.”

“If you’re an adult psychiatrist, a physician a paediatrician, or a nurse, or even somebody treating adults, it’s your job to be aware of mental health problems in children,” Lachman adds. “I feel strongly about changing the narrative and moving away from the idea that it’s a specialist realm, because mental health is everybody’s business and child mental health should be pervasive in terms of focus, across various sectors.”

She also feels strongly that psychiatric services should be offered in ways that are Afro-centric and culturally sensitive. Such an “Afro-centric approach”, she says, “must include a diverse spectrum of input – so not just the mental health care providers who punt a specific model of medication and therapy – but partnerships with the educators, community workers, caregivers and allied health professionals to be able to effectively attempt to support and re-think models that can work in our setting.”

She suggests exploring opportunities for children to be screened early, recognised, and offered treatment. For instance, Lachman says, nurses at Well Baby clinics – where babies get immunised – can be trained in child mental health. “Whilst checking the child’s growth and immunisations, they could also look at whether the child is making eye contact, or engaging in reciprocal contact. If this is not happening, they need to know what further questions to ask and what to do next.”

Similarly, mental health awareness and screening should be in schools. Why do we offer sexual education, but not address mental health issues, she asks. “Just as we have so easily incorporated into school curriculums how people can get condoms, we need to ask them how they’re feeling, whether they feel isolated, want to harm themselves or want to die.”

Republished from Spotlight under a Creative Commons licence.

Source: Spotlight

Categories : COVID Mental HealthTags :

A Case of Three Teens with COVID and Psychiatric Symptoms

On By ModernMedia
Photo by Alex Green on Pexels

A case study details three teenagers with mild or asymptomatic COVID presented with suicidal thoughts, “paranoia-like fears,” delusions and “foggy brain”, which could be explained by anti-neural antibodies – ‘turncoat’ antibodies that may attack brain tissue.

Mounting evidence points to neurological and psychiatric effects of COVID, with a UK study finding a 13% risk of a first-time diagnosis after COVID. The study, published in JAMA Neurology, is the first to look at anti-neural antibodies in paediatric patients previously infected with SARS-CoV-2.

Over five months in 2020, 18 children and teens were hospitalised with confirmed COVID at UCSF Benioff Children’s Hospital San Francisco, three of whom were the patients in the study who underwent neurological evaluations.

The researchers examined the patients’ cerebrospinal fluid (CSF) and found that two of the patients, both of whom had histories of unspecified depression and/or anxiety, had antibodies indicating that SARS-CoV-2 may have invaded the central nervous system. They also had anti-neural antibodies in their CSF, suggesting a rampant immune system accidentally targeting the brain.

The research follows a previous UCSF study that also found a high level of autoantibodies in the cerebrospinal fluid of adult patients with acute COVID, who experienced neurological symptoms, including intractable headaches, seizures and loss of smell.

“It is way too soon to know whether COVID is a common trigger for neuropsychiatric illnesses, but it does seem to be a potent trigger for the development of autoantibodies,” said co-corresponding author Samuel Pleasure, MD, PhD. “It is currently totally unknown whether patients predisposed to neuropsychiatric illnesses are more likely to develop worsened symptoms after COVID, or whether COVID infection can act as an independent trigger.”

Unlike most psychiatric presentations, the three patients in the UCSF study had symptoms with sudden onset and rapid progression, representing a marked change from their baselines, said co-first author Claire Johns, MD. “The patients had significant neuropsychiatric manifestations despite mild respiratory symptoms, suggesting potential short and long-term effects of COVID.”

After hospitalisations lasting weeks and ongoing psychiatric medications, the two UCSF patients, whose cerebrospinal fluid tested positive for SARS-CoV-2 antibodies and anti-neural antibodies, were treated with intravenous immunoglobulin, an immunomodulatory therapy that curbs inflammation in autoimmune disorders. After five days, the first patient had “more organised thoughts, decreased paranoia and improved insight.”

Autoantibodies targeting the protein TCF4 were also found, which has genetic links in some schizophrenia cases. However, “we don’t know that the antibodies are actually interfering with the protein’s function,” said co-corresponding author, Michael R. Wilson, MD, noting that the diagnosis of schizophrenia is based on a constellation of symptoms, not a biomarker.
The second patient partially responded to immunotherapy with improved cognition and working memory, but continued to have “impaired mood and cognitive symptoms” six months later. The third patient, with no psychiatric history and without SARS-CoV-2 antibodies or anti-neural antibodies in their cerebrospinal fluid, recovered with psychiatric medications. Their symptoms were attributed to recreational drug use.

In another case study, a 30-year-old patient with mildly symptomatic COVID who presented at a hospital emergency department with delusions, violent outbursts, hyper-anxiety and paranoia was unresponsive to antipsychotic medication but after being diagnosed with possible “autoimmune-mediated psychosis”, responded to intravenous immunoglobulin.

Nonetheless, the researchers agree it’s unlikely that there were pre-existing autoantibodies, and they point to other disorders with psychiatric symptoms, like anti-NMDAR encephalitis syndrome, that are caused by anti-neural antibodies and respond to treatment directed at these rogue antibodies.

The researchers agree that more study is warranted, although Dr Pleasure noted that the rarity of cerebrospinal fluid samples from paediatric patients is a challenge, as they rarely have severe enough COVID to warrant a lumbar puncture.

Source: University of California San Francisco