Neuropsychiatric disorders rank high on the list of the most disabling medical disorders in both the developed and developing worlds. (1) Significant comorbidity also exists between neuropsychiatric disorders and general medical disorders; (2) this is key in the South African context where HIV/AIDS and substance use disorders are highly prevalent. (3,4) It has therefore become essential to provide mental health services in a range of settings, including those that focus on the delivery of general medical services. Furthermore, the Mental Health Care Act 17 of 2002 underlines the importance of providing integrated, accessible mental health care in the local community.
Despite growing recognition of the burden of disability due to common mental disorders, mental health services remain under-resourced in relation to their burden, both in developed and in developing countries. (5) In South Africa, the historical focus has been on providing mental health care in psychiatric hospitals rather than in general medical or community settings. (6) De-institutionalisation has occurred in recent decades, but development of adequate community-based services has lagged in catering for the immense need of community outpatients.
In the Western Cape, considerable effort and energy has been devoted to preparing a strategic plan for providing more effective community- and district-based mental health services in line with the new Mental Health Care Act. This plan is part of the Provincial Government of the Western Cape Department of Health's Comprehensive Service Plan for the Implementation of Health Care 2010 (HC2010). In this plan, a series of models of mental health care services is outlined to determine the number of posts for mental health clinicians, including community-based psychiatric nurses, in coming years (the 2010 Comprehensive Service Plan (CSP)). Additional work, however, is needed to implement the CSP, adjusting it to the realities 'on the ground'.
As part of the province's HC2010 strategy, a clinician was appointed in each of the major specialties as co-ordinating clinician to assist the Department in guiding the discipline towards HC2010. Co-ordinating clinicians have worked with university departments, management, clinicians and the provincial mental health programme in order to identify problems and find possible solutions. A number of challenges were identified across the following levels of care:
1. The first challenge was to assess the burden of psychiatric disease in the population. Estimates of the burden of disease using mortality have led to mental illness being under-represented elsewhere. Locally, a relative absence of data has made it difficult to estimate the burden of mental illness due to disability. Nevertheless, a growing emphasis by international organisations on the burden of mental disorder worldwide, (5) and a range of additional local considerations (e.g. the comorbidity of mental illness with physical trauma, comorbidity with chronic medical diseases including HIV, and the unforeseen dramatic escalation in methamphetamine use in the province) seemed to indicate that the burden of psychiatric disease had been grossly underestimated in the planning of future services.
2. A second challenge has been the past lack of attention to community-based services for patients with mental illness. In recent years, there has been a decrease in funding for chronic hospital services which inter alia has accelerated the discharge of long-stay patients from large psychiatric institutions. At the same time, the development of community-based services has been very slow. More attention has been given to non-profit organisations (NPOs) rather than to developing new community-based services. The relatively low funding norm for existing NPOs, limitations in the ability and availability of NPOs to provide the envisioned services, and difficulties in finding adequately trained and dedicated staff, have contributed further to the slow development of appropriate mental health services in the community. …