Since deinstitutionalization many patients, instead of remaining in the community, revolve through the doors of psychiatric facilities resulting in the "Revolving Door Syndrome". Hence a biopsychosocial evaluation of readmissions was undertaken to see what processes came into play once a patient was discharged from a mental hospital and subsequently readmitted. Seventy Indian patients admitted to the Midlands hospital complex, Pietermaritzburg were interviewed and the data was collected. This comprised 40 readmissions and a control group of 30 first admissions. The diagnosis was made according to DSM-III-R. The results obtained were statistically analyzed and a chi square analysis was done to ascertain if there were any significant differences between the 2 groups. The following were the major findings 1. Most of the patients were in age group 20-29 years. 2. There was a preponderance of males in both groups. 3. Most of the patients in the readmitted group were unemployed and were receiving a disability grant. 4. The majority of patients was single or separated. 5. Most of the patients were discharged on a combination of drug and depot preparation. 6. A large percentage had two and more previous admissions. 7. Length of stay was less than 1 month in a large number of patients. 8. Community tenure was less than 1 year in most of the patients. 9. Even though the majority of patients reported regular attendance, a fair percentage reported attendance at the community clinic. 10. The reason for readmission was mainly aggressive behaviour and aggressive behaviour associated with substance abuse. 11. The discharge diagnosis was schizophrenia in a large number of patients. This study has several important implications for the community care of the patient and various recommendations are made to curtail the revolving door, as follows : 1. There is an urgent need for community based resources. eg. sheltered workshops, supervised housing, industrial and occupational therapy, halfway houses and day hospitals, which would help the chronically mentally ill patients lead more meaningful lives following discharge. 2. The family of the chronically mentally ill patient needs to be actively involved in the management of these patients and mental health workers must solicit the family's support, by educating them about schizophrenia, helping them to increase coping mechanisms and to decrease stress. It is recommended that support groups be held in the community for the families of patients. 3. The patient's family needs to be advised that when the patient show signs of decompensation, they should take the patient to the community clinic, rather than to the District Surgeon to avoid unnecessary rehospitalization. 4. The importance of maintenance medication cannot be overemphasised. There is a need to change the attitude of the patient and family with regard to their negative attitude about medication. 5. The high rate of readmission due to aggressive behaviour (which is aggravated by substance abuse) needs intervention. Substance abuse groups must be held in the community and the community needs to be educated about the consequences of substance abuse in the mentally ill. / Thesis (M.Med.)-University of Natal, 1993.

Neuroleptic drugs are essential in the treatment of schizophrenia and many other psychiatric disorders. These drugs do however cause a wide range of side effects which can be very distressing to patients. In particular the acute neurological side effects of parkinsonism, akathisia and dystonia, which are termed extrapyramidal syndromes, can be a limiting factor in the use of these drugs (Weiden et al 1987). Fort Napier Hospital is a large psychiatric referral hospital and the majority of patients admitted require neuroleptic drug treatment. Extrapyramidal side effects are regularly seen amongst these patients. This study was designed to discover the incidence of parkinsonism, akathisia and dystonia amongst patients treated with neuroleptic drugs and what specific factors were responsible for these side effects. Relevant literature on this topic was reviewed and comparable studies done in America, Europe and South Africa are discussed. The study sample consisted of one hundred patients who were examined regularly over a two week period for signs of parkinsonism, akathisia, or dystonia which were rated quantitatively according to specific rating scales. Patient and drug variables were then analysed to assess what factors were responsible for these side effects. The incidence of drug-induced parkinsonism was 29%, akathisia 35% and dystonia 20%. Combinations of these three syndromes were observed resulting in an overall incidence of 47%. High potency drugs such as haloperidol and trifluoperazine were responsible for a large percentage of all the side effects, while of the low potency drugs, thioridazine produced less side effects than chlorpromazine. Oral drugs combined with intramuscular depot drugs resulted in a high incidence of side effects. The phase of treatment was clinically important with dystonia occurring more often within the first three days of treatment, akathisia within ten days and parkinsonism after ten to fourteen days. Other factors that were studied included the patients age, sex and prior history of neuroleptic-induced neurological side effects. Due to the predominantly young patient population in this study, the mean age of those patients who developed parkinsonism was 26,7 years, akathisia 27,5 years and dystonia 25,8 years. These side effects were seen more commonly in males than in females. Of the 27 patients in this study who had a prior history of neurological side effects, 15 (56%) developed similar side effects following re-exposure to neuroleptic drugs. Conclusions derived from this study include the need for clinicians to select the correct type and dose of neuroleptic for individual patients in order to minimize the development of neurological side effects. Accurate, early diagnosis of side effects by regular examination of patients is necessary for effective patient management. Clinicians should be made more aware of the side effects that can develop with the use of neuroleptic drugs and the effect these side effects have on patients. / Thesis (M.Med)-University of Natal, 1993.