No health without mental health: Establishing psychiatry as a major discipline in an African Faculty of Health Sciences
Lynn GillisI, II; Brian A RobertsonI; Tuviah ZabowI; Dan J SteinI, III
IThe authors have each been Head or Acting Head of the Department of Psychiatry and Mental Health, University of Cape Town
IIFirst Head of Department
IIICurrent Head of Department
ABSTRACT
Psychiatry has not always been a major clinical discipline in medical schools. Although the Faculty of Health Sciences of the University of Cape Town (UCT) celebrates its Centenary in 2012, a closely aligned major psychiatric hospital is older than the Medical School, while the Department of Psychiatry is only 50 years old. These differing dates reflect the history of and challenge for psychiatry; mental disorders contribute a major portion of the burden of disease, while appropriate recognition and resourcing of services and training has been delayed. There are ongoing challenges in aligning the visions of an old state-run system that focused on those with severe psychotic illness, a newer governmental vision of the importance of treating mental disorders in the community, the realities of current under-resourcing, and the international aspiration that psychiatry is one of the clinical neurosciences. Nevertheless, considerable strides have been made towards moving psychiatry from the periphery of society and medicine to a central discipline within the Faculty of Health Sciences at UCT.
Psychiatry is an important discipline within medicine. The contribution of psychiatric disease to burden of illness continues to increase.1 The doctor-patient relationship is key to clinical practice.2 Psychiatric disorders influence behaviours such as adherence to medication, and affect basic physiological processes, so influencing outcomes in medical disorders.3 Basic and clinical neuroscience will benefit from future research in genetics and proteomics.4
Psychiatry is not always viewed as a major medical specialty. The associated morbidity and mortality is often overlooked.5 Many aspects of psychiatry are viewed as 'non-medical'.6 The doctor-patient relationship is not necessarily seen as key, the impact of psychiatric disorder on outcomes is not always recognised, and underdiagnosis and undertreatment of psychiatric disorders persists.7 Psychiatric treatments are often perceived as ineffective or inappropriate.8
We review these debates through the lens of the history of psychiatry that often begins with the asylum and predates the university Medical School. We outline the progression to university department of psychiatry, and a larger department achieving parity with other medical disciplines. Such disjunctures reflect views of mental illness, and contribute to the marginalisation of psychiatry as a medical specialty, and to the treatment gap for mental disorders.9
]]> Phase 1: The asylum
In South Africa, the Robben Island Lunatic Asylum was established in 1846 by the colonial government as part of a larger general infirmary that housed 'lepers, lunatics, and the chronic sick'.10 Concerns were expressed about conditions on the island so that by the 1870s the asylum had a reputation for being a humane institution, employing non-restraint methods,10 and having a high attendant-to-patient ratio.10 However, racial segregation was practised.
It was a typical early asylum as it was cut off geographically and reserved for disruptive patients,10 those with common mental disorders being largely ignored. Expertise in various psychiatric subdisciplines had little scope, interaction with other medical disciplines was lacking and there was no concept of a multidisciplinary team.
Phase 2: Specialist psychiatric hospital
The turn of the 20th century saw advances in psychiatry internationally. In 1891 in the Cape, Valkenberg Hospital, the first local institution specifically designed for the mentally ill, was opened.11 Attempts to establish scientific and humane care for patients were made.12 Dodds, the colony's first Inspector of Asylums, held strong views about the therapeutic effects of regular outings, contact with the community, and visits from family and friends,11 and emphasised the facility's geographical accessibility.
Nevertheless, Valkenberg was on the outskirts of Cape Town,11 and the Medical School, founded in 1912, paid little attention to psychiatry. The focus at Valkenberg remained severe psychotic disorders, with little teaching and research, and limited scope for developing subspecialty interests.13 Potential existed for interactions with other medical disciplines but remained limited, and the multidisciplinary team was not fully developed.
Phase 3: The university department in a general teaching hospital
The 1950s saw new developments, including the introduction of psychotropics.14 Locally, changes were pioneered at Tara Hospital, by the Transvaal Provincial Administration and the University of the Witwatersrand. In the 1950s a psychiatrist, Henry Walton, was appointed at Groote Schuur Hospital (GSH) and in 1962 an academic Department of Psychiatry was established jointly by the Cape Provincial Administration and the University of Cape Town (UCT) with Lynn Gillis as the first consultant and Head. The first 3 registrars and the first clinical psychologist were appointed in 1963 and 1964.
]]> Establishment of a university department within a general teaching hospital, linked to the Medical School, enabled the discipline to move towards the centre of medical services, teaching and research. Geographical isolation ended. Outpatient psychiatric services offered care to people with a broader range of disorders and patients with comorbid psychiatric and medical disorders received integrated care. Multidisciplinary teams were established, and training and research expanded. By 1981 the Medical Research Council had established a Clinical Psychiatry Research Unit in the department.In 1964 the 10 beds in a mixed ward with neurological cases were increased to 20 beds in a dedicated psychiatry ward, and a Psychiatric Emergency Unit was established. In 1978 the inpatient unit moved to purpose-designed premises, while the emergency unit moved into adjacent specially designed premises in 1988. Psychiatry had designated wards when the new GSH was opened in 1991, and the vacated premises in the old hospital were renovated in 1997.
Since its inception the department has served the community ... a day hospital was established in 1963, and a Community Service and Psychiatric Social Club in 1964, promoting continuity of care for patients in the community, and destigmatisation of mental illness. Unfortunately, these services were later closed for financial reasons but departmental staff continue to provide community services, psychiatric advocacy and outreach.
Over time, beginning with consultations at Red Cross War Memorial Children's Hospital and introducing an outpatient clinic in 1964, an active Division of Child & Adolescent Psychiatry was established in the department, and in 1978 moved into larger premises in the Rondebosch Cottage Hospital. In 1983 the division assumed responsibility for the psychiatric needs of patients at Sonstraal Adolescent Unit for behaviourally disturbed children at Valkenberg and for the psychiatric care of patients under 22 years of age at Alexander Care and Rehabilitation Centre. In 1991 a 6-bed inpatient unit, the Therapeutic Learning Centre, was added.
The first general hospital treatment centre in South Africa for alcoholism, the William Slater Hospital, was established in 1959 in an old house in Rondebosch. A community service for alcoholism, staffed by a psychiatrist and psychiatric nurses, was opened in Heideveld in 1971. In 1974 in- and outpatient treatment facilities for alcoholism were provided at Avalon Hospital in Athlone. The facility, which by then had also incorporated patients from William Slater, was unfortunately closed in 1991 for financial reasons.
By the 1970s services run by the UCT Department of Psychiatry were complemented by those run by the newly established Department of Psychiatry at Stellenbosch University. However, many patients in the community, including those living on the Cape Flats, still had no access to care. In 1972 a team of architects and psychiatrists studied new design trends overseas, and a large purpose-designed facility, Lentegeur Hospital, was built at Mitchells Plain, opening in 1975. Several of the staff are affiliated to the UCT department.
In 1976 specialised geriatric psychiatry beds were established at Valkenberg in close co-operation with the Division of Geriatrics (in the Department of Medicine) of GSH. This first such organised service in South Africa functioned effectively for several years, but the inpatient facility was closed in 1998 for financial reasons.
Following negotiations from 1972 to 1988, medical staff at Valkenberg, formerly state employees, were on joint appointment with the Western Cape Provincial Administration and UCT. This made it possible for services that included the Valkenberg admission and long-stay wards, a large forensic unit, a psychogeriatric unit, and wards for children and adolescents to be co-ordinated comprehensively - then unusual in South Africa.
Phase 4: A university and hospital department that achieves parity
]]> Psychiatry has continued to grow, with increasing awareness of the burden of illness posed by psychiatric disorders, advances in treatment permitting deinstitutionalisation, and recognition of psychiatry as a major medical discipline.15 With the advent of democracy, a primary care vision and human rights of psychiatric patients have been emphasised. Racial integration of facilities occurred from 1991. A new Mental Health Care Act was promulgated in 2002.Psychiatric subspecialties have also grown, promoting a broader spectrum of care and establishing parity with the other medical disciplines. The Division of Child & Adolescent Psychiatry strengthened under the leadership of Brian Robertson, a child and adolescent psychiatrist appointed Head of Department in 1989. A postgraduate MPhil degree was established, with the first graduates qualifying in 1986. An Adolescent Health Research Unit was established in 2001, and a donation allowed the establishment of a new Chair in Child and Adolescent Psychiatry in 2007.
A gift from Vera Grover allowed a Chair in Intellectual Disability to be established by UCT in collaboration with Alexandra Hospital in 1992. Alexandra has been significantly deinstitutionalised, with the establishment of community programmes. The current Chair has established a postgraduate programme.
Under the leadership of Tuviah Zabow, acting Head of Department in 2004 and 2005, forensic psychiatry services and teaching grew. The current Head of the division established postgraduate training in forensic psychiatry and is editor of the first local textbook of forensic psychiatry.
With deinstitutionalisation, the character of inpatient services at Valkenberg and Lentegeur Hospitals has changed. Patients must be discharged in a short space of time, demanding inpatient intensive care. A new admissions unit was established at Valkenberg in 2006, and a new step-down facility was established in 2008 (at the old William Slater Hospital).
Despite the closure of services in addiction psychiatry noted earlier, the epidemic of substance use disorders continues locally. Dedicated postgraduate training programmes in this area include training of the first MPhil subspecialist addiction psychiatrists on the continent and training at postgraduate diploma level.
Psychiatry and neurology have had areas of overlap, and the then Head of Neurology played a key role in motivating for a university Department of Psychiatry. The emergence of the HIV/ AIDS epidemic necessitated specialised services in neuro-HIV/ AIDS. A Division of Neuropsychiatry was established in 2005, and the first MPhil (Neuropsychiatry) in the country graduated in 2010. The division also houses outpatient services in geriatric psychiatry.
The provision of psychiatric services to patients presenting with general medical, surgical, and obstetric and gynaecological conditions has developed into a discipline of its own - liaison psychiatry. Such specialised services have long been provided, e.g. pain clinic, transgender clinic, etc. An MPhil programme in this area was established and graduated the first liaison psychiatrist in the country.
Despite closure of psychiatric services led by community nurses, there has been ongoing activity in public mental health. There are dedicated community psychiatrists, and an assertive community team was established in 2005. In 1997 the Department became a Collaborating Centre of the World Health Organization (WHO) and the World Federation for Mental Health, focused on mental health research and training in Africa. The Division of Public Mental Health offers postgraduate degrees in this area, and at Lentegeur Hospital one of the first 'green psychiatry' efforts locally has been set up.
Psychotherapy and pharmacotherapy are key therapeutic modalities. The department has established a postgraduate diploma in psychotherapy, to facilitate university- and hospital-based training and offers psychopharmacology training.
]]>Towards the future
The 4 phases of psychiatry - the asylum, the specialist psychiatric hospital, the university department in a general teaching hospital, and the university department that achieves parity - characterise the evolution of psychiatry globally and locally. These phases moved psychiatry closer to the centre of medical practice.
Specialist psychiatric hospitals associated with the university have undergone significant deinstitutionalisation, and psychiatric services are provided at general teaching hospitals and in the community. Psychiatry provides services to a broad range of patients, from infants to the elderly, and for a variety of disorders, from psychotic to common mental disorders. Liaison services are provided to patients with general medical disorders and patients with psychiatric disorders can access general medical services, particularly in general teaching hospitals. Multidisciplinary teams provide services to people with psychiatric disorders, particularly in general teaching hospitals and in specialised psychiatric hospitals. In recognition of this, the department changed its name in 2000 to the Department of Psychiatry and Mental Health. During undergraduate and postgraduate teaching, basic and behavioural sciences relevant to psychiatry are emphasised. There is considerable basic, clinical and public health research. In terms of South Africa's apartheid history, psychiatric services and staff have significantly transformed.
Under the leadership of the current Head of Department, Professor Dan Stein, the department has continued to strive for parity, with further growth. The staff currently comprise 7 professors, >50 psychiatrists and psychologists on joint appointment, >25 registrars, >40 staff funded on research grants, and >25 other postgraduate students or fellows (e.g. Masters in Neuroscience candidates, doctoral candidates, postdoctoral or clinical research fellows). There have been considerable achievements in services, teaching, research, and outreach. The first College Fellow in Psychiatry qualified in 1966; since then several hundred specialists have been trained. Many specialists from Africa, including the first Malawian psychiatrist, and several of the first child and adolescent psychiatrists in various countries, have been trained. Teaching and training of postgraduate psychologists are achieved in co-operation with the UCT Department of Psychology. The department has played a key role in many research initiatives including UCT's Brain-Behaviour Initiative, the Cross-University Brain Imaging Centre (CUBIC) which houses the first Tesla magnetic resonance imaging centre dedicated for brain research in Africa, and the Mental Health and Poverty Project.16,17 Major research grants have been obtained, including from the MRC (the department currently cohosts the MRC Unit on Anxiety and Stress Disorders), National Research Foundation, National Institutes of Health (USA), European Union, and Department for International Development (UK). The department has perhaps been the largest contributor to research in psychiatry on the continent, with many papers and books published, and contributions to national and international institutions and processes, including WHO and South African mental health policies and guidelines.
Residues of the old asylums remain, e.g. clinician/patient ratios at the specialist psychiatric hospitals are much lower than in the general teaching hospitals, despite the high levels of clinical care required in both settings. Most joint university-provincial specialist posts are based in the acute units, with little inclusion of community psychiatrists. Psychiatric subspecialties have few funded training posts. Liaison services are limited, resulting in most patients with general medical disorders in the community not receiving appropriate diagnosis and treatment of their psychiatric disorders.18 Multidisciplinary teams are limited to a few specialised settings, with little access to such services in the community, and especially for individuals with serious conditions such as substance use disorders.7 There remains little interaction with basic and behavioural sciences at specialist psychiatric hospitals, and psychiatric disorders research is underdeveloped and underfunded relative to burden of disease.19 In terms of our history, much further transformation is required.
Psychiatric nursing is an example of the challenges remaining. At the inception of the department there were no specially trained or qualified psychiatric nurses. Advanced Certificates in Psychiatric Nursing and in Child Psychiatric Nursing were established, and many skilled specialist psychiatric nurses were trained. However, the Nursing Council later discontinued the courses as it was felt that all generic nurses should be trained in psychiatric nursing. There is now a significant need for community mental health workers.20
Greater advocacy for psychiatry and for those suffering from psychiatric disorders, including protection of human rights, is crucial.5 Mental health literacy of the community, clinicians, and decision-makers must be increased.21 We are optimistic about the future: psychiatry has moved to the centre of health sciences faculties globally and locally. Nevertheless, the future of psychiatry globally has many uncertainties.22 Locally, reasons for caution include the troubled history of psychiatry and clinical psychology during apartheid,23,24 that psychiatric disorders have long been stigmatised, and that facilities for substance use disorders, psychogeriatrics, and community nursing have closed. However, the fact that important strides have been made in the Department of Psychiatry and Mental Health over its 50-year history at UCT indicates that much future progress is possible.
Acknowledgements
]]> Thank you to Professor Sally Swartz for her comments on an early draft. Professor Stein is supported by the Medical Research Council of South Africa.
References
1. Lopez AD, Mathers CD, Ezzati M, Jamiso DT, Murray CJL. Global Burden of Disease and Risk Factors. New York: Oxford University Press and the World Bank, 2006. [ Links ]
2. Stein DJ. How we see others: the psychobiology of schemas and transference. CNS Spectrums 2009;14:10-13. [ Links ]
3. Evans DL, Charney DS, Lewis L, et al Mood disorders in the medically ill: scientific review and recommendations. Biological Psychiatry 2005;58:175-189. [ Links ]
4. Insel TR, Quirion R. Psychiatry as a clinical neuroscience discipline. JAMA 2005;294:2221-2224. [ Links ]
5. Lund C, Stein DJ, Corrigal J, Bradshaw D, Schneider M, Flisher AJ. Mental health is integral to public health: a call to scale up evidence-based services and develop mental health research. S Afr Med J 2011;98:444-446. [ Links ]
6. Stein DJ, Kaminer D, Zungu-Dirwayi N, et al. Pros and cons of medicalization: the example of trauma. The World Journal of Biological Psychiatry: The Official Journal of the World Federation of Societies of Biological Psychiatry 2006;7:2-4. [ Links ]
7. Suliman S, Stein DJ, Myer L, et al. Disability and treatment of psychiatric and physical disorders in South Africa. J Nerv Ment Dis 2010;198:8-15. [ Links ]
8. Nesse RM, Stein DJ. Towards a genuinely medical model for psychiatric nosology. BMC Medicine 2012;10:5. [ Links ]
9. World Health Organization. mhGAP: Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders. Geneva: WHO, 2009. [ Links ]
10. Deacon HJ. Madness, race and moral treatment: Robben Island Lunatic Asylum, Cape Colony, 18461890. History of Psychiatry 1996;7:287-297. [ Links ]
11. Louw J, Swartz S. An English asylum in Africa: space and order in Valkenberg Asylum. History of Psychology 2001;4:3-23. [ Links ]
12. Swartz S. Changing diagnoses in Valkenberg Asylum, Cape Colony, 1891-1920: a longitudinal view. History of Psychiatry 1995;6:431-451. [ Links ]
13. Swartz S, Ismail F. A motley crowd: the emergence of personality disorder as a diagnostic category in early twentieth-century South African psychiatry. History of Psychiatry 2001;12:157-176. [ Links ]
14. Healy, D. The Creation of Psychopharmacology. Cambridge, MA: Harvard University Press, 2002. [ Links ]
15. World Health Organization. The World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva: WHO, 2001. [ Links ]
16. Stein DJ, Daniels W, Emsley R, et al. A brain-behaviour initiative for South Africa: the time is right. Metab Brain Dis 2006; 21:279-284. [ Links ]
17. Lund, C. Mental health in Africa: findings from the mental health and poverty project. International Review of Psychiatry 2010;22:547-549. [ Links ]
18. Carey PD, Stein DJ, Zungu-Dirwayi N. Trauma and posttraumatic stress disorder in an urban Xhosa primary care population: prevalence, co-morbidity and service use patterns. J Nerv Ment Dis 2003;19:230-236. [ Links ]
19. Stein DJ, Szabo C. Psychiatry research in South Africa: reason for cautious celebration? South African Journal of Psychiatry 2011;14:86-87. [ Links ]
20. Petersen I, Lund C, Stein DJ. Optimizing mental health services in low-income and middle-income countries. Current Opinion in Psychiatry 2011;24:318-323. [ Links ]
21. Ganasen KA, Parker S, Hugo CJ, et al. Mental health literacy: focus on developing countries. African Journal of Psychiatry (Johannesburg) 2008;11:23-28. [ Links ]
22. Katschnig H. Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry 2010;9:21-28. [ Links ]
23. Dubow S. Scientific Racism in Modern South Africa. Cambridge: Cambridge University Press, 1995. [ Links ]
24. Stein DJ. Psychiatric aspects of the Truth and Reconciliation Commission in South Africa. British Journal of Psychiatry; the Journal of Mental Science 1998;173:455-457. [ Links ]
Accepted 7 February 2012.
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Corresponding author: D Stein (dan.stein@uct.ac.za)
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