THE NATURE AND TYPE OF MENTAL DISORDERS
PRESENTING AT DR GEORGE MUKHARI
HOSPITAL,PSYCHIATRY OUT-PATIENT DEPARTMENT, IN
A TWELVE MONTH PERIOD , JANUARY 2006 TO
DECEMBER 2006.
Paslius Sizwe Mazibuko
THE NATURE AND TYPE OF MENTAL DISORDERS
PRESENTING AT DR GEORGE MUKHARI
HOSPITAL,PSYCHIATRY OUT-PATIENT DEPARTMENT, IN
A TWELVE MONTH PERIOD , JANUARY 2006 TO
DECEMBER 2006.
By
Paslius Sizwe Mazibuko
Submitted in partial fulfilment of requirements for the Degree of Masters of
Medicine in the Department of Psychiatry at the University of Limpopo,
Medunsa Campus.
06 April 2009
Supervisor: Prof S. T Rataemane. MBCHB (Natal), FFPsych (SA), Dipl. Child
Psychiatry (UK).
Co-Supervisor: Dr HF Bale. MBCHB (Medunsa), Mmed Psych (Medunsa).
II
DECLARATION
I declare that this dissertation hereby submitted to the University of Limpopo
for the Degree of M asters of Medicine – Psychiatry , has not been previously
submitted by me for a degree at this or any other university , that it is my work
in design and in execution and that all material contained here has been truly
acknowledged.
Signed at the University of Limpopo on the 27th of March 2009
Paslius Sizwe Mazibuko
………………………………
III
ACKNOWLEDGEMENTS
I would like to acknowledge the support and encouragement received from the
supervisors – Prof. S. T. Rataemane and Dr. H.F Bale for your valuable
contributions and assistance.
To my wife Thembi, our darlings Lethokuhle and Ntuthuko and the whole
family, thanks for all sacrifices made throughout my studies.
The contribution made by fellow colleagues is much appreciated.
To the Almighty, thanks for all the blessings.
IV
DEDICATION
I dedicate this research to my mom, my late father and all family members for
the support given towards reaching my goal of becoming a Psychiatrist.
V
Table of contents
Dedication…………………………………………………………………………...v
Abstract……………………………………………………………………………...2
CHAPTER 1………………………………………………………………………….3
INTRODUCTION AND BACKGROUND……………………………………..3
CHAPTER 2………………………………………………………………………..5
LITERATURE REVIEW………………………………………………………...5
CHAPTER 3……………………………………………………………………….8
3 RESEARCH DESIGN AND METHODOLOGY………………………………..8
STUDY OBJECTIVES………………………………………………………............8
SETTING……………………………………………………………………………..8
STUDY DESIGN……………………………………………………………………..8
DATA COLLECTION……………………………………………………………….8
DATA CODING……………………………………………………………………...9
VALIDATION………………………………………………………………….........9
RELIABILITY………………………………………………………………….........9
BIAS ……………………………………………………………………………........9
CHAPTER 4………………………………………………………………………..11
4.1 REVIEW…………………………………………………………………………..11
CHAPTER 5…………………………………………………………………………..19
5.1 DISCUSSION…………………………………………………………………….19
CHAPTER 6………………………………………………………………………….22
6.1 CONCLUSION…………………………………………………………………...22
6.2 LIMITATION OF STUDY…………………………………………………….....22
6.3 RECOMMENDATION…………………………………………………………...23
6.4 REFERENCES……………………………………………………………….........24
VI
TOPIC
NATURE AND TYPE OF MENTAL DISORDERS PRESENTIN
AT DR. GEORGE MUKHARI HOSPITAL,PSYCHIATRY
OUT-PATIENT DEPARTMENT IN A TWELVE MONTH
PERIOD, JANUARY 2006 TO DECEMBER 2006
1
ABSTRACT
Profiling of mental disorders in tertiary institutions is relatively an understudied
subject .The aim of the study was to delineate the types, age and gender distribution
of psychiatric disorders in Dr. George Mukhari hospital .This is a tertiary psychiatric
unit which caters for mental health care users in Garankuwa , Soshanguve , Mabopane
region. The study is retrospective and caters for a period January 2006 to December
2006.
Dr George Mukhari being a tertiary institution ,the types of mental disorders seen are
the emergency ones i.e. aggressive ,life threatening or complex in nature .
Schizophrenia was the most common disorder , affecting more males than females in
adults , whereas mental retardation was more common in children affecting more males
than females. . This underlay the devastating nature of neuoro-developmental problems in
psychiatry.
Most of the mental health care users seen were single and un-employed(most on
disability grants)
2
CHAPTER ONE
Introduction
The World Health Organization (WHO) put into perspective the burden of mental
disorders, with an
estimate of about 450 million people affected and the number
increasing. Mental disorders are mostly stigmatized in our communities and this affect
the overall care of mental health care users . According to WHO Global burden of
disease 2003, 33% of the years lived with disability are due to neuro-psychiatric
disorders.
Depression,
alcohol
use
disorders, schizophrenia
and Bipolar
disorders
constitute four (among six) of the leading causes of years lived with disability1.
It is the researchers opinion to note that Medical aid schemes provide limited
resources(e.g. 21 days hospitalization in a year) to mental health care users than to
other physical conditions with unlimited resources, and this show the utter disdain in
which mental illness is looked upon. The Mental Health Care Act (2002) is meant to
protect the wellbeing mental health users, and to safeguard their rights as enshrined
in the constitution of the republic2. There are huge cost implications in dealing with a
mental health care user, ranging from the intrinsic cost of treatment of the individual
condition and its associated rehabilitation, to the loss of healthy life years as a result
of disability.
In the researcher’s opinion, profiling of mental disorders helps in capacity development of
health care providers and to restructure the budget in terms of effective treatment modalities
for specific disorders, all this done to maximize the limited resources available in the public
health system and also improve the quality of care of the mental health care users. In South
Africa there are about 350 qualified psychiatrists, mostly in the private sector, leaving
therefore limited expertise in the public health system
The researcher notes that Dr George Mukhari hospital caters mostly for mental health care
users from disadvantaged communities, therefore priority need be given to common
debilitating mental conditions in order to improve functioning of the majority.
3
Limited research is done on profiling of mental disorders, and therefore little information is
available on profile distribution of this disorders and the impact they have in their
communities.
The study determined the profile of this disorders seen at Dr George Mukhari Psychiatry
OPD, and will look at variables contributing to specific disease profiles. These disorders
would have certified the DSM IV TR3 diagnostic criteria. The study will help the department
(Dr. George Mukhari Psychiatry OPD) in terms of specific human resource structuring and
capacity development, and budgetary planning with regards to treatment modalities for
specific disorders.
The study was done to determine the nature and frequency of different mental health
disorders of patients seen at Dr.George Mukhari Hospital Psychiatry Out-Patient Department
(Tertiary referral unit)
The study objectives were:


To delineate the types of psychiatric disorders as defined by DSM IV TR ,presenting
at Dr. George Mukhari hospital, Psychiatry Out-Patient Department
To study the age and gender distribution of each mental health disorder presenting at
this period
The research will show that Mental retardation in children and Schizophrenia in adults were
the predominant conditions.
4
CHAPTER TWO
LITERATURE REVIEW
The WHO estimate of people with mental disorders to be about 450 million (out of a total of
6 billion), with about 150 million suffering from depression,25 million from schizophrenia,
more than 90 million from alcohol or drug use disorders. The impacts of this disorder are
severe, with approximately 1million people committing suicide annually. There is also an
increase in co morbidity of this different conditions1.
Kleintjies et al. give an insight of the distribution of selected mental disorders in the Western
Cape4. Their major findings in adults were as follows:
1. Nicotine use-48% annual prevalence (unadjusted)
2. Major depressive disorder/dysthymia-15%
3. Alcohol dependence-15%
4. Alcohol abuse -7%
Anxiety disorders constituted second largest as a group>26%
Schizophrenia and Bipolar disorders had 1% prevalence each, which is consistent with much
of the literatures.
In children and adolescents the common disorders were: Anxiety disorder> 27%, Major
depressive disorders/dysthymia 8%, Oppositional defiant disorders 6%, ADHD
5%.Schizophrenia and Bipolar disorders were about 1% each.
The above study is consistent with the findings of Gureje o et al. done in Nigeria5. Their
findings noted that Anxiety disorders had a higher prevalence, followed by MDD, then
substance use disorders. They noted that differential age of onset and the age structure of the
population contribute to different rates in populations.
5
Mngoma MC et al did an analysis of common mental disorders in those attending primary
health clinics and traditional healers. Mixed anxiety-depressive disorders had a higher
prevalence rate 15%, phobic disorders >7%, MODERATE DEPRESSION >2%, WITH
MILD DEPRESSION AT >1%. In this study cultural believes impacted on symptoms
presentations and disease profiles. Prevalence of mental disorders was twice more in those
attending traditional healers than those attending primary health care6.
Cho JM et al looked at DSM IV Disorders among Korean adults in a twelve months
prevalence study7. In terms of gender profiling of mental disorders they came to this
conclusion:
1.Substance use disorders-Male (21%); Females (4%)
2. Affective disorders-M (1%); F (4%)
3. Anxiety disorders [-M (3%); F (10%)
4. Psychotic disorders-M (0.2%); f (0.8)
Though Psychotic disorders had a lower prevalence it is important to note that mental
institutions were not included in this studies.
The gender of mental health care users seems to influence the distribution of mental disorders
as supported also by Vega et al8. They also noted higher incidence in males for substance use
disorders and anxiety disorders. Contrary to Mngoma et al6, Vega et al8 found a higher
incidence and association between affective disorders and female gender. They also noted an
increased morbidity associated with social assimilation. Dhadphale M et al9 also confirmed
the distribution of mental disorders according to gender and socioeconomic status.
Mental disorders are associated with gender, disability, economic deprivation, and indigenous
labels of distress states (Patel et al10). The pattern of profiling of mental disorders seems
consistent in most studies irrespective of economic status of countries. Thom et al11 however
show us the impact of low socioeconomic status in psychotic spectrum. The impact of
HIV/Aids in our country will skew some of the disease profiles, with interesting diagnostic
difficulties.
6
Stein DJ et al, conducted a 12-month and lifetime prevalence estimate of psychiatric
disorders in developing world setting 12, and South Africa had

2nd highest prevalence for substance use disorders

6th highest prevalence for anxiety disorders

7th highest prevalence for mood disorders
The provincial 12-month prevalence estimate, in Gauteng revealed:

Anxiety disorders-9.2%

Mood disorders-4.6%

Substance use-5.8%

Impulse-3.2%
7
CHAPTER THREE
Methodology
The study objectives were:

To delineate the types of psychiatric disorders as defined by DSM IV TR ,presenting
at Dr. George Mukhari hospital, Psychiatry Out-Patient Department

To study the age and gender distribution of each mental health disorder presenting at
this period
Setting
The study was undertaken at the Dr. George Mukhari Hospital Psychiatry OPD. Dr. George
Mukhari Hospital is a tertiary teaching hospital located near Pretoria in Ga-Rankuwa.
Methods
Study design
This is a descriptive, retrospective (ex post facto) cross sectional study which was conducted
at the Dr. George Mukhari Hospital Psychiatry OPD. Through the study, the nature of mental
health problems emanating from Dr. George Mukhari Psychiatric OPD is described. The
study is cross-sectional in that the required data for the purposes of the study as stated above
was collected retrospectively within one particular point in time and in this instance a
calendar year 2006 from month January through to month December was chosen.
Data Collection
The method used in the collection of data for the purposes of this study hinged on
retrospective methods whereby documents from January to December 2006 were reviewed to
facilitate the determination of the profile of mental health disorders emanating from
Psychiatric OPD. Patient records were used as the source of data for the study.
8
A data collection tool used in the collection of data is an electronic checklist which
comprised of the following variables in no order of significance, these included and limited
to: 1) age, 2) gender, 3) psychiatry diagnosis (according to DSM IV TR)
The age and gender of patients in this case was necessary in the determination of the
distribution of cases from which correlates and other dependant parameters was drawn.
Psychiatry diagnosis facilitated the determination of cases proportions within the population
in the period under review.
Data Analysis
Data coding
The services of a bio-statistician were used. Data coding preceded analysis of data. This was
important in that variables with the exception of age were converted in a format that was
computer readable to facilitate its analysis. Simple integers were used for this purpose.
A statistical package, EpiInfo 2003 version was used in the analysis of data. Frequency
distribution of mental health problems was determined. The results are presented using
frequency tables and graphs.
Validation
In order to minimize bias and ensure high integrity and external validity of the study, the
study envisaged 1) the inclusion in the collection and analysis, of all major DSM IV mental
disorders as presented in the Department of Psychiatry in the prescribed period and 2) the
concurrent use for purposes of case validation, patient records and inpatient admission
registers to minimize any duplication which may arise.
9
Reliability
The study is reliable because the study can be replicated. The probability of obtaining similar
results in future similar study is high provided the study is conducted using same records,
same department and time period as the one prescribed for this study.
Bias
The effect of age as a potential confounder was minimized through stratification of cases in
the analysis phase. Where necessary non-parametric statistics were employed to determine
any significant difference .There was sample bias because the population under study is from
a tertiary, referral unit. Diagnosis bias could occur, as some diagnosis made in OPD could not
have been made.
10
CHAPTER FOUR
RESULT
The total number of files assessed for mental health care users
attending out-patient department during the study period January
2006 to December 2006 were ….Males constituted 54%.,whilst females
constituted 46%.The age of distribution was from 0-75+.
TABLE 1 : Gender distribution of mental disorders
Ranking Order Mental Health Disorders
1 Schizophrenia
MALE FEMALE Frequency Percent
290
204
494 50.90%
2 Mental Retardation
70
47
117 12.00%
3 Major Depressive Disorder
19
78
97 10.00%
4 Bipolar
26
50
76
7.80%
5 Cannabis Induced Psychosis
47
3
50
5.10%
6 Psychosis(Epilepsy)
21
17
38
3.90%
7 ADHD
21
6
27
2.80%
8 Psychosis (RVD)
7
14
21
2.20%
9 Dementia
7
9
16
1.60%
10 Enuresis
6
2
8
0.80%
11 Epilepsy
3
4
7
0.70%
12 PTSD
1
3
4
0.40%
13 GAD
2
1
3
0.30%
14 Alcohol Psychosis
3
0
3
0.30%
15 Brief Psychotic Disorder
0
2
2
0.20%
16 Autism
1
1
2
0.20%
17 Psychosis (NOS)
1
1
2
0.20%
18 Adustment Disorder
1
0
1
0.10%
19 Conduct Disorder
0
1
1
0.10%
20 Oppositional Defiant Disorder
1
0
1
0.10%
21 Learning Disorder
1
0
1
0.10%
528
443
11
971 100.00%
Profile distribution
The profile distribution of mental disorders indicated that Schizophrenia
accounted for 50.9%, Mental retardation 12%, Bipolar 1-mania 7.8%, Major
depressive disorder 10.0%.
GRAPH 1
Distribution by mental disorder
Proportion of Mental Health Disorders Among Patients at Dr. George Mukhari Hospital
1.60%
2.20%
2.80%
3.90%
5.10%
Schizophrenia
7.80%
Mental Retardation
Major Depressive Disorder
Bipolar
Cannabis Induced Psychosis
Psychosis(Epilepsy)
ADHD
Psychosis (RVD)
Dementia
10.00%
50.90%
12.00%
12
Proportion of Schizophrenia
Schizophrenia constituted 50.9% of total mental health care users seen and 290
were males(59%), with 204 females (41%)
GRAPH 2
Proportion of Schizophrenia by Gender and Age group
25
20
20
14.8
% Percentage
15
15.2
14.5
12.1
Row 32
Row 35
10
9.3
Female
Male
5
3.8
3.8
3.4
1.7
1
0.3
0
5-9
10-14
15-19
20-24 25-29
30-34 35-39
40-44 45-49
50-54 55-59
60-64
65-69 70-74
75+
Age Groups (yrs)
More males were seen on the age range 30-34, whilst more females were on the
age range 35-35. Only 6.5% had co-morbidity of cannabis abuse
13
If gender was removed, more patients were seen on the 30-34 age range. Note
that age of onset was not included in the data.
GRAPH 3
Proportion of Schizophrenia by Age Groups
20
18
16
14
% Percentage
12
10
8
6
4
2
0
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
Age groups
14
45-49
50-54
55-59
60-64
65-69
70-74
75+
MENTAL RETARDATION
Mental retardation accounted for 21.1% of patients seen, with 60% being
male and 40% female. The degree of mental retardation could not be
ascertained
GRAPH 4
Proportion of Mental Retardation by Gender and Age group
50
45
40
35
% Percentage
30
25
Row 45
Row 48
20
Female
15
Male
10
5
0
5-9
10-14
15-19
20-24 25-29
30-34 35-39
40-44 45-49
Age Groups (yrs)
15
50-54 55-59
60-64
65-69 70-74
75+
BIPOLAR DISORDER
Bipolar 1- mania accounted for 7.8%.The specifiers and severity could not be
identified in the files. Females were fifty in total (66%) whilst males were
twenty six (34%)
TABLE 3
PROPORTION OF
BIPOLAR BY
GENDER AND AGE
GROUP
GENDER
5-9
1014
15- 20- 2519 24 29
30- 35- 40- 45- 50- 55- 60- 65- 7075+
34 39 44 49 54 59 64 69 74
0
0
0
6
7
1
5
2
0
1
2
0
1
0
0
0
0
0
24
28
4
20
8
0
4
8
0
4
0
0
0
0
1
6
1
8
7
9
5
3
5
3
2
0
0
Row %
0
0
2
12
2
16
14
18
10
6
10
6
4
0
0
TOTAL
Row %
0
0
1
12
8
9
12
11
5
4
7
3
3
0
0
0
0
1.3
16 10.7
12
16 14.7 6.7 5.3 9.3
4
4
0
0
MALES
Row %
FEMALES
16
GRAPH 5
Proportion of Bipolar Disorder by Gender and Age Group
30
25
% Percentage
20
15
Row 72
Row 75
10
Female
5
Male
0
5-9
10-14
15-19
20-24 25-29
30-34 35-39
40-44 45-49
50-54 55-59
60-64
65-69 70-74
75+
Age Groups (yrs)
The age group 35-39 represented the highest combined gender proportion
17
MAJOR DEPRESSIVE DISORDER
Major depressive disorder accounted for 10.0% of total patients’ seen.78
were females(81%), with only 19 males(19%). The severity was not noted.
GRAPH 6
Proportion of Major Depressive Disorder by Gender and Age Group
25
20
% Percentage
15
Row 58
Row 61
10
Female
5
Male
0
5-9
10-14
15-19
20-24 25-29
30-34 35-39
40-44 45-49
Age Groups (yrs)
18
50-54 55-59
60-64
65-69 70-74
75+
CHAPTER FIVE
DISCUSSION
DELIENATION OF DISEASE,
SCHIZOPHRENIA
Data collected showed that Schizophrenia accounted to 50% of the total mental health care
users seen .Males represented 59% whilst female accounted for 41%.This is a chronic,
debilitating illness with poor outcome .Studies have shown that over the 5-10 year period
after the first psychiatric hospitalisation for schizophrenia, only about 10 to 20% of patients
can be described as having a good outcome13. The reason for higher male incidence could be
explained by increased cannabis use in males than females .Studies show that early cannabis
use(pre-morbidly) lead to schizophrenia in later life.
Substance use is more common in patients diagnosed with schizophrenia than in the general
population and is associated with poorer clinical and social outcomes compared to patients
with schizophrenia who do not use substances. Co-occurring substance use disorders (SUD)
have emerged as one of the greatest obstacles to the effective treatment of patients with
schizophrenia. Considerable progress has been made over the past 2 decades in understanding
the need to integrate substance use treatment and mental health treatment to provide more
effective care for this population with dual diagnosis14.
19
MENTAL RETARDATION
The 2nd highest common disorder seen was mental retardation (12%), which was also more in
males than females. This is a neuro-developmental disorder characterised by sub-average
intelligence (IQ less than 70) and impairment in present adaptive functioning. Literature used
to have linkage between schizophrenia occurring in mild to moderate mental retardation .The
condition is called pfropfschizophrenia15. DSM IV TR does not recognise such a name, but
the essence of this diagnosis was to show that schizophrenia was a neuro-developmental
condition rather than neuro-degenerative. We now know that there is a strong emphasis on
both. In a large longitudinal study of 50087 male subjects, lower pre-morbid IQ score was
associated with increased risk for schizophrenia, severe depression, and other non-affective
psychoses, but not bipolar disorder15.
MOOD DISORDERS AND RVD
Mood disorders(Bipolar and depression) represented 18% of all files studied ,with greater
preponderance of females .South Africa has the highest incidence of HIV/AIDS in the world,
with that in mind one would have expected greater numbers of psychiatric manifestation of
this disorder, but 2.2% was recorded in our unit in the studied period.
The above results are in contrast to prevalence studies, which find Anxiety disorders being
high, followed by depression and alcohol abuse/dependence16.
AGE PROFILE OF THE DISORDERS
Schizoprenia was seen more in mental health care users between the ages of twenty (20) to
fifty(50). This represents a population which is supposed to be the providers in society, and
therefore being afflicted by this disorder are mostly unproductive. This representation also
occurs in mood disorders.
20
Mental retardation was seen more in those less than twenty years(more than 85%),and this
could be explained by that we see less referrals of behavioural problems associated with this
condition in adults. In children, ADHD is second common to mental retardation. This finding
is consistent to those of S Kleintjies et al4.
21
CHAPTER SIX
CONCLUSION
The findings of this study have shown that more male schizophrenics visited the Dr George
Mukhari Outpatient facility than female schizophrenics and that more females with mood
disorders visited the Dr George Mukhari Outpatient facility than males with mood disorders.
Dr George Mukhari hospital being a tertiary institution, schizophrenia accounted to more
than half of total mental health care users, with the majority of them in the productive age
range of 30-34 and 35-39 years.
The study will help in terms of resource (human and financial) allocation, in order to improve
service delivery. our standard of care must be on par with Batho Pele18 principles and also
with WHO guidelines for improvement of mental health services19.
LIMITATION OF STUDY
The limitation of this study is that some of the diagnosis were not done by consultants .This is
shown by the glaring absence of nicotine –related disorder, this in view of studies showing
link between psychiatric populations and increased cigarette use20,21,22.Studies have also
shown that mental health care users with schizophrenia have the highest nicotine use21,24,25.
Schizophrenia is the most devastating condition; therefore most of files seen had the
diagnosis, which limits exposure to more common conditions seen in private practice like
adjustment disorder. In the time period of the study, ‘nyaope’-which is the combination of
cannabis and low-grade heroine/cocaine, was not yet prevalent?
22
RECOMMENDATION
Studies of this nature needs to be regularly conducted. They may not seem groundbreaking
in nature, but help in terms of proper planning with resultant improvement in service
delivery. Consultants must be at the forefront of making proper diagnosis, so that conditions
like nicotine abuse, sexual disorders and sleep problems (which influence treatment
compliance) can get maximum attention.
23
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2007
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2004
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26