Anthony’€™s voice rises and falls like a charismatic preacher, words swirling as he talks about heaven and earth, sin, the inner and outer worlds.

‘€œDo you know what diabotic is?’€ he asks each person in the small doctor’€™s room, then launches into a complicated explanation that follows its own kind of logic but makes no sense.

Anthony is psychotic. He has become disconnected from reality and suffers from disorganised thoughts including ‘€œneologism’€, which means he makes up words.

Short, slight and missing most bottom teeth, Anthony has been in a psychiatric ward of Chris Hani Baragwanath (CHB) since March. Before that, he was institutionalised as a state patient at Sterkfontein Psychiatric Hospital for 27 years.

After being cared for by Sterkfontein for all those years, Anthony was discharged into the care of his parents, who were so elderly that they were unable to care for themselves let alone their high-need adult son.

Soon he was not taking his medication, and has had several psychotic relapses, the latest of which has landed him in CHB.

‘€œI have been trying different medications but I can’€™t get him well,’€ says Dr Wendy Friedlander, his psychiatrist.

The more relapses a person has, the harder it gets to treat them as the brain gets more damaged.

Anthony is a typical victim of the government’€™s policy of deinstitutionalisation, say his doctors. The policy was aimed at getting long-term patients out of state care and back into communities, both to encourage their rehabilitation and to save costs.

In theory, deinstitutionalisation was aimed at helping patients re-enter society. But in practice, it has fallen flat because most families are ill-equipped to deal with their mentally ill relatives.

Thus, patients discharged into their families’€™ care often suffer relapses, usually after they have stopped taking the medication that keeps their disorders at bay.

‘€œThere need to be halfway houses and workshops where the mentally ill can go during the day for rehabilitation and to help their families to cope,’€ says Professor Yasmien Jeenah, head of the CHB psychiatric department.

Another man in Anthony’€™s ward, Mdu, clamours to tell his story. With bruise-like rings under his eyes from lack of sleep, Mdu offers a long introductory greeting, then he launches into a non-stop, flat monologue.

After some minutes, Friedlander interrupts and Mdu smiles, as if brought back down to earth: ‘€œI have no full stop and no comma, ne.’€

Mdu then explains that he has bipolar mood disorder. ‘€œSometimes I am happy and strong and high. Sometimes I am sad.’€

‘€œWhat you are seeing is medicated mania. If this is left untreated, it can be very disruptive in families and communities,’€ says Friedlander.

Men in striped pyjamas mill about in the corridors of the ward. They watch each other or television, vie for the doctors’€™ attention and smoke endless cigarettes.

Despite the many problems of her patients, however, Friedlander ‘€“ who has worked at CHB for over five years ‘€“ says she rarely feels afraid. ‘€œThe few times that I do, I make sure that the patient is sedated or I don’€™t see him alone.’€

Interestingly, she says the patients tend to ‘€œcontain each other’€ and often act protectively towards her.

Professor Jeenah’€™s pale yellow office is in a rundown single storey building in the midst of the male wards. It now has a security gate after a patient with a knife got in and threatened to kill himself, and another threatened staff with a hammer ‘€“ rare occurrences but enough to get extra security.

Jeenah took over the psychiatric department in 2000, and oversees the five wards with 155 beds as well as a huge outpatients department that treats about 400 adults and 350 children.

There are also bus loads of white-coated medical students who arrive periodically and need to be taught.

Patients who are admitted to the wards suffer mainly from schizophrenia, bi-polar mood disorder, depression, anxiety and post-traumatic stress (see Box for explanation).

HIV has also exacerbated the demand for beds, with some patients becoming depressed after being diagnosed with HIV, while others suffer AIDS-related dementia.

‘€œOur beds are always full. We get patients from all over the country as well as Swaziland and Lesotho. Their families bring them here and we never turn anyone away,’€ says psychiatrist Dr Cathy Christie.

Ideally, patients are supposed to stay in hospital for up to 30 days, during which time they are stabilised. Those who need longer care are then supposed to be transferred to other facilities but this often doesn’€™t happen as there are few places that can take them.

So the pressure for beds builds up. In the previous 24 hours, 24 patients have been admitted and Jeena wonders where she can fit all of them.

‘€œWe serve a massive population but we have no back-up. There is no regional or district hospital in Soweto that can take our patients,’€ says Jeenah.

But Jeenah’€™s biggest headache is the serious staff shortages, with ‘€œthe cream of our psychiatric nurses now sitting in the UK and Saudi Arabia’€.

Sister Nomalanga Shabangu is one of only two professional nurses in a 35-bed male ward, her only back-up being two assistant nurses.

‘€œWe are so busy today because we have to go and fetch the medication and also look after the patients. A lot of our nurses have gone overseas. There is also a high absentee rate because people get tired,’€ says a flustered Shabangu.

Despite the many challenges, Jeenah is very proud that her department has recently launched the first 10-bed child psychiatric facility in southern Gauteng. Previously, children were seen only as outpatients, for problems as diverse as learning disabilities to psychosis.

In addition, the massive 80-bed male ward has been split into three smaller, more manageable wards, one of which is newly built and includes a secluded outdoor area.

However, the female patients remain in two dormitory-like rooms of 30 patients eac

‘€œThis is not conclusive to housing psychiatric patients,’€ says Jeenah. ‘€œOne agitated or psychotic patients can disrupt the whole ward and there is nowhere quiet for depressed patients.’€

However, plans drawn up six years ago to revamp the entire psychiatric department appear to have been abandoned

Despite the problems, Jeenah has nothing but praise for her overworked staff: ‘€œThey do an excellent job with the limited resources. Patients are seen regularly by specialists and get a high level of care.’€

by Kerry Cullinan