Evaluation of mental health services in the free state Part I. Quality of outpatient care

Objectives. The aim of this study was to review aspects of the quality of o utpatient care in the Free-State community mental health service (MHS). Design and subjects. Sixteen clinics were chosen to represent good and indi fferent clinics in all four districts of the province. A retrospective surv ey was done on 626 psychiatric outpatient cards (310 from good clinics and 316 from indifferent clinics) in July 1993. utcome measures. These mesures consisted of the range and variety of diagno ses, the combinations of drugs used, the appropriateness of drugs for the r ecorded diagnosis, the duraation of illness for which patients, and relapse and referral rates. Results. A greater percentage of white patients attended the good clinics ( P < 0.001). The number of patients under 20 years old was extremely low (2% in the good clinics and 3% in the indifferent clinics). Schizophrenia and mood disorders were the two most common diagnoses, while the frequency of a nxiety disorders was extremely low. Schizophrenia was diagnosed significant ly more frequently in indifferent than good clinics and among black than wh ite patients (P < 0.001). Conversely, mood disorder was diagnosed significa ntly more frequently in good clinics and in white patients (P<0.001). Monot herapy was widely practised (90% at the good clinics, 87% at the indifferen t clinics). Attendence was suboptimal at both grades of clinics. Good clini cs had an apparently lower rate of irregular attendence (34%) than did indi fferent clinics (42%)(P=0.15). The defaulting rate was 15% at good clinics and 18% at indifferent clinics. While 4% of patients had been discharged fr om good clinics in the last 12 months, the indifferent clinics had a 0% dis charge rate. Conclusion. The Free-State MHS has made steps at both policy and prctical l evels. However, in decentralising its service problematic areas remain. Rec ommendations made include the provision of a paediatric and adolescent serv ice, provision of an increased psychological component in the service, regu lar review of patients with regard to discharge and drug therapy more activ e caseholding through defaulter tracing, great er racial integration of the service and further study to investigate the reasons for diagnostic differ ences across race.