Outcomes of care among patients admitted to the rehabilitation unit of a specialistthe rehabilitation unit of a specialist neuropsychiatric hospital in Nigeria

bby1Adebowale T.O., 1Onofa L.U., 1Sowunmi O., 

1Majekodunmi O.E., 2Latona O.O.Affiliation:Affiliation:1. Neuropsychiatric Hospital Aro, P. M. B. 2002, Aro, Ab k   O  S  Ni iAbeokuta,  Ogun State, Nigeria.

2. Department of  Epidemiology and Medical p p gyStatistics , University of Ibadan, Ibadan, Nigeria

Presenting Author:D  O f  L k  U kDr. Onofa Lucky UmukoroM.B; B.S, FWACP,  M.SC (Epidemiology), Unit  Consultant Psychiatrist (Rehabilitation)Department of  Community & Rehabilitation PsychiatryNeuropsychiatric Hospital, Aro, Abeokuta,Ogun State, Nigeria.Ogun State, Nigeria.Email: onolucky@yahoo.comTel: +2348033336875Tel: +2348033336875

Being

AN ORAL PAPER PRESENTATION AN ORAL PAPER PRESENTATION 

FOR DOUGLAS BENNETT PRIZE PRESENTATIONS

AT THE ANNUAL RESIDENTIAL CONFERENCE OF

THE FACULTY OF REHABILITAION & SOCIAL 

PSYCHIATRYPSYCHIATRY

ROYAL COLLEGE OF PSYCHIATRISTS 

21‐22 NOVEMBER, 2013

THISTLE BIRMINGHAM CITY, BIRMINGHAM

OCCUPATIONAL THERAPY DEPARTMENT , ARO PSYCHIATRIC HOSPITAL, NIGERIA

INTRODUCTIONINTRODUCTION

M l di d hi h ll i f % f hMental disorders exert a high toll, accounting for 13% of thetotal global burden of disease. In Africa, neuropsychiatricdisorders accounted for about 18% of years lived withdisorders accounted for about 18% of years lived withDisability (YLD) in 2000 (WHO, 2001).Psychiatric rehabilitation is a whole systems approach toPsychiatric rehabilitation is a whole systems approach torecovery from mental illness that maximizes an individual’squality of life and social inclusion by encouraging theirskills, promoting independence and autonomy in order togive them hope for the future and leads to successfulcommunity living through appropriate support(killapsy etcommunity living through appropriate support(killapsy etal, 2005).

INTRODUCTION CONT’D

The unmet needs of the mentally disabled have pointed theway towards longer‐term and more comprehensive in‐

i h bili i i h l di bl d i di id lpatient rehabilitation services to help disabled individualto develop the emotional, social and intellectual skillsneeded to live learn and work in the community with theneeded to live, learn and work in the community with theleast amount of professional support(Adair et al, 2005).

INTRODUCTION CONT’DINTRODUCTION CONT’D

Discharge from in‐patient rehabilitation is a measure of goodDischarge from in patient rehabilitation is a measure of goodoutcome because it marks an important stage in the individual’srecovery. The person would have gained the skills needed fordaily living self medicating engagement with communitydaily living, self medicating, engagement with communitysupport to gain help and sense of identity (Strauss, 1986).

In psychiatric practice, some mentally ill patients spend their lifein continuous hospitalization due to severe mental illness,substance dependence homelessness and abandonment by thesubstance dependence, homelessness and abandonment by thepatient’ relatives(Roger et al 2004, Rosler 2005).

INTRODUCTION CONT’D

In developing countries like Nigeria, the issue of long‐stayis intertwined with the history of orthodox psychiatric care.In the early 20th century asylums were established inIn the early 20th century, asylums were established inselected cities in the country. These were to serve as placesof confinement for psychiatric infirm. When theseof confinement for psychiatric infirm. When theseasylums were converted to full‐fledged psychiatrichospitals, most of the patients had remained in thesefacilities(Boroffka, 1995, Ekpo et al, 2000).

In view of the peculiar mental health situation in Nigeria,there has been strong recommendations for theestablishment of rehabilitation centres to cater for thisestablishment of rehabilitation centres to cater for thiscategory of long‐stay patients(Taiwo et al, 2008).

INTRODUCTION CONT’DINTRODUCTION CONT’D

Th N hi i h i l A h fThe Neuropsychiatric hospital, Aro the foremostpsychiatric hospital in Nigeria(The Mecca of Psychiatry inWest Africa) formally established Rehabilitation unit inWest Africa) formally established Rehabilitation unit in2002 and a transitional half‐way home (Hope Villa) in2009 for the effective rehabilitation and community re‐yintegration of patients.No study had been undertaken on the outcome of theservice. Knowledge of factors associated with outcome isuseful to guide treatment for patients.Thi d h f d k lThis current study was therefore undertaken to evaluatethe outcomes of care among patients admitted to therehabilitation unit of Neuropsychiatric Hospital Arorehabilitation unit of Neuropsychiatric Hospital, Aro,Abeokuta, Nigeria.

OBJECTIVES

This study sets out to determine the outcomes of careamong patients admitted to the rehabilitation unit of a

i li hi i h i l i Ni i bspecialist neuropsychiatric hospital in Nigeria byexamining socio‐demographic profiles, type of mentalillness and associated physical co‐morbidities of theillness and associated physical co‐morbidities of thepatients .The factors influencing rehabilitation outcomes among theThe factors influencing rehabilitation outcomes among thepatients were also assessed.

METHODSThe Study centre is the Neuropsychiatric Hospital Aro(WHO ll b i C f R h & T i i i(WHO collaborating Centre for Research & Training inmental health) Abeokuta, Ogun State, Nigeria.The Neuropsychiatric Hospital Aro started at the LantoroThe Neuropsychiatric Hospital Aro started at the LantoroAnnex which was a colonial local government prison until13th April, 1944 when it was transformed into an asylum for13 April, 1944 when it was transformed into an asylum forthe care of mentally ill soldiers repatriated from the SecondWorld War. This asylum was converted to NeuropsychiatricHospital (526 bed‐space) Aro in 1954 and was designated aWHO Collaborating Centre for Research and Training inMental Health in 1976 In 2002 the hospital establishedMental Health in 1976. In 2002, the hospital establishedrehabilitation wards (60 bed spaces) and later atransitional half‐way home (hope villa) for effectivey ( p )rehabilitation of disabled patients.

METHODS CONT’D

Patients were admitted to the rehabilitation unit based onfulfillment of placement criteria. The Rehabilitation unitili l idi i li h d i iutilizes a multidisciplinary team approach to administer

psycho‐pharmacological, psychosocial, vocational andother structured intervention to patients in the unitother structured intervention to patients in the unitPatients had supervised vocational engagements bothwithin and outside the hospital settingwithin and outside the hospital setting

MULTI‐DISCIPLINARY TEAM MEETING AT THE REHABILITAION UNIT

METHODS CONT’D

Following ethical approval, we conducted aretrospective review of records of all patients admittedretrospective review of records of all patients admittedto the unit over eleven (11) years period fromSeptember 2002 to August 2013.p g 3There were 62 admissions of which 6 patients’ caserecords could not be traced. Consequently, 56 caseC q y, 5records were available to analysis.Data was collected using a semi‐structured proformaData was collected using a semi structured proformaand analysis was done using SPSS version 17.

METHODS CONT’DFrequency tables and cross tabulations of relevant socio‐d hi li i l h bili i ddemographic, clinical, rehabilitation and outcomevariables were drawn up.For survival analysis the desired outcome is achievingFor survival analysis, the desired outcome is achievingdischarge from the rehabilitation unit and re‐integrationinto the community.into the community.Survival data analysis was done using Kaplan‐Meiermethod for censored data. This involved coding thegoutcome variables into 1 – discharge (the desired outcome)and 0 – other outcomes which are censored.The factors influencing discharge were evaluated usingCox’s Proportional Hazard Regression. The factors in themodel ere socio demographic ariables clinicalmodel were socio‐demographic variables, clinicaldiagnoses and rehabilitation variables.

The Chi‐square tests were used to test associationsqbetween categorical variables and Independent student – t‐test to compare the difference in the means of quantitativevariables.Hazard ratios (HRs) and their 95% confidence intervals(CI ) bt i d th f i ti(CIs) were obtained as the measure of associations.P – values of significance was set at P ≤ 0.05.

RESULTS

Table 1: Socio‐demographic Characteristics of P i   d  h i  R h bili i  SPatients and their Rehabilitation Status

Variable Rehabilitation Status of Patients

TotalN = 56 (%)

Test Statistics(Chi‐Square)

P – Value5 ( ) ( q )

DISCHARGEDN = 15 (%)

NON‐DISCHARGED  N = 41 (%)

GenderMaleFemale

11 ( 73.3)4 (26.7)

25 ( 61.0)16(39.0)

36 ( 64.3)20 (35.7)

0.810 0.368

Age20 – 39 12 (80.0)

( )4 (9.8)8 ( )

16 (28.6)( )

15.079 0.00140 – 59Over 60Mean (SD)

3 (20.0)‐

18 (43.9)19 (46.3)

21 (37.5)19 (33.9)54.6 (14.4)

TribeYoruba 10 (66.7) 31 (75.6) 41 (73.2) 1.760 0.624IboOthers

( 7)4 (26.7)1 (6.7)

3 (75 )8 (19.5)2 (4.9)

4 (73 )12 (21.4)3 (5.4)

7 4

Marital StatusSingleM i d

8 (53.3)( )

30 (73.1)( )

38 (67.9)( )

9.212 0.027MarriedDivorcedWidowed

5 (33.3)2 (13.3)‐

2 (4.9)6 (14.6)2 (4.9)

7 (12.5)8 (14.3)2 (3.6)

EducationNo Formal 3 (20.0) 21 (51.2) 24 (42.9) 21.882 0.001o o aPrimarySecondaryTertiary

3 ( 0.0)1 (6.7)1 (0.7)10 (66.7)

(5 . )11 (26.8)7 (14.6)3 (7.3)

4 (4 .9)12 (21.4)7 (12.5)13 (23.2)

.88 0.00

Table 1 Cont’dVariable Rehabilitation Status of 

PatientsTotalN = 56 (%)

Test Statistics(Chi‐Square)

P – Value

DISCHARGENON‐DISCHARGEDISCHARGE

DN = 15 (%)

DISCHARGED  N = 41 (%)

PreviousEmploymentEmploymentYesNo

9 (60.0)6 (40.0)

6 (14.6)35 (85.4)

15 (26.8)41 (73.2)

36.842 0.001

Patients’StatusVagrantNon‐Vagrant

3 (20.0)12 (80.0)

8(19.5)33 (80.5)

11 (19.7)45 (80.4)

2.060 0.357

Social andFamilyySupportPoorGood

5 (33.3)10 (66.7)

36 (87.8)5 (12.2)

41 (73.2)15 (26.8)

41.837 0.01

Activities ofDaily livingPoorGood

‐15 (100.0)

25 (61.0)16 (39.0)

25 (44.6)31 (55.4)

22.347 0.001

VocationalEngagementYesNo

15 (100.)‐

20 (48.8)21 (51.2)

35 (62.5)21 (37.5)

9. 184 0.002

Table II: Distribution of Clinical Diagnoses and Table II: Distribution of Clinical Diagnoses and Co‐morbid conditions among Patients N = 56

V i bl F P  (%)VariablePsychiatric DiagnosisSchizophrenia

Frequency

48

Percentage (%)

85.7pBipolar affective disordersAlcohol/Substance use d d

453

5 78.95.4

disorderCo‐morbid Medical ConditionsConditionsHypertensionEpilepsy

137

23.212.5

ArthritisInfectionsCataract/Sight Problem

543

8.97.15 4Cataract/Sight Problem

Diabetes mellitus32

5.43.6

Table III: Clinical Variables among Discharged and Non‐discharged 

Variable DISCHARGEDN = 15 (%)

NON‐DISCHARGED Total P –

Patients

5 ( )N = 41 (%) N = 56

(%)Value

Psychiatric Diagnosisy gSchizophreniaBipolar affective disorder

13 (86.7)1   (6.7)

35 (85.4)4 (9.8)

48 (85.7)5 (9.8)

0.4910.226

Co‐morbid medicalCo morbid medicalconditionHypertensionEpilepsy

3 (20.0)2 (13.3)

10 (24.4)5 (12.2)

10 (24.4)5 (12.2)

0.5230.667p p y ( 3 3) 5 ( ) 5 ( ) 7

Medication UseConventionalantipsychotics

12(80.0) 32 (78.0) 32 (78.0) 0.867p y

Depot antipsychoticsAtypical antipsychoticsMood Stabilizer

4 (26.7)1 (6.7)1 (6.7)

11 (26.9)3 (7.3)4 (9.8)

11 (26.9)3 (7.3)4 (9.8)

0.9880.7030.226

AntidepressantsAnticholinergicReport of Non‐ adherence

( 7)1 (6.7)

6(40.0)1  (6.7)

4 (9 )2 (4.9)

18 (43.9)5 (12.2)

4 (9 )2 (4.9)

18 (43.9)5 (12.2)

0.4480.2430.068

Table IV: Distribution of Vocational Activities Table IV: Distribution of Vocational Activities Engagement among Patients N = 56

Variable

Barbing

Frequency

5

Percentage (%)

8.9

Shoe making

Fashion designing

5

5

8.9

8.9g g

Hair dressing

Food and Catering

4

3

7.1

5 4Food and Catering

Retailing/Business

V l i i

3

3

5.4

5.4

6Vulcanizing

Computer program

2

2

3.6

3.6

Paid sheltered work 15 26.8

TAILORING SECTION OF OCCUPATIONAL THERAPY DEPT.

HAIRDRESSING SECTION OF OCCUPATIONAL THERAPY DEPT

Table V:  Outcome Measures among the Patients  N = 56Table V:  Outcome Measures among the Patients  N = 56

Variable

h bili i

Frequency Percentage

Rehabilitation Status

Completed and Discharged

Not completed

15

41

26.8

73 2Not completed

Abandoned in the Unit

Improvement Status

41

24

73.2

42.9

Improved

Worsened

43

10

76.8

17.9

Died

Follow Up Care

Good

7

47

12.5

83 7Good

Poor

Absconded/Lost to follow up

47

4

5

83.7

7.2

8.9

Median Duration of Stay: 41.3 Months

Figure 1: Kaplan – Meier estimate of the survival function  f  di h d  d N di h d  i  i  curves for discharged and Non‐discharged patients in 

relation to their engagements in vocational activities

Table VI: Variables affecting discharge using Cox Proportional  Hazard g p

Regression

V i bl H d R i 95% C fidVariables Hazard Ratio (HR)

95% Confidence Interval (CI)

L d i 0 030 0 002 0 287Low education 0.030 0.002 – 0.287

Unemployment 0.046 0.0231 – 0.736p y

Good Social S

3.352 0.897 – 12.553SupportPoor Activities of d il li i

0.02 0.001 – 0.290daily livingAge < 40 years 2.631 0.675 – 10.261

DISCUSSION

In our study, the socio‐demographic and rehabilitationvariables predicting good rehabilitation outcomesp g gwere high education, previous employment, youngerage, being married, having good social and familysupport, good activities of daily living and engagementin vocational activities.These findings were in variance to finding of somestudies (Strauss, 1986; Wiersma et al 1988; Wiersma et

)al, 2000; Harrison et al, 2001) that found only limitedevidence that socio‐demographic variables predict

toutcome.

DISCUSSION CONT’D

The non‐discharged group had inferior socio‐demographic profiles which could be a reflection of g p pthe severity of illness that interfered with normal role performance

LIMITATIONSAll retrospective studies have certain limitations.All retrospective studies have certain limitations.

Some patients’ case records were missing.

No baseline rating of illness severity with any standardsymptoms rating scale.y p g

For some of the patients, their ages may not be exact.p , g y

Small sample size limits generalization of resultsSmall sample size limits generalization of results

CONCLUSIONCONCLUSIONIn a sample of rehabilitation in‐service patients,we conclude that good socio demographic profileswe conclude that good socio‐demographic profilesand engagement in vocational activities weresignificantly associated with achieving dischargesignificantly associated with achieving dischargeduring the eleven year period we studied.I Ni i d h d l i i h iIn Nigeria and other developing countries, there isneed for the recognition of the role ofh bili i i dd i h drehabilitation in addressing the adverse

consequences of mental disability to thei di id l i d h iindividual, community and the nation.Future research on the dynamics and econometricsof this rehabilitation psychiatry service is highlyindicated.

Declaration of Interest –None

Acknowledgements Acknowledgements Matrons Abolaso, Adewoyin,

Multidisciplinary team members of Rehabilitation UnitMultidisciplinary team members of Rehabilitation UnitMiss Kazeem for secretarial job

Rehabilitation in Aro Psychiatric Hospital, Nigeria

The Ugly

The  Bad

The Good 

No Psychiatry without Rehabilitation….

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