Context of mental health in SA

Question 1

explain Leavell and Clark’s public health model

Answer 1

-A 3 tier model of intervention for addressing public health issues. -Intervention/prevention divided into primary, secondary and tertiary.
-A more comprehensive and cost-effective approach to addressing mental health issues in SA

Question 2

explain mental health policies under apartheid

Answer 2

Emphasis on institutional care and medical treatment of patients with mental illness rather than therapeutic.
● Informed by apartheid idea that “protection of society” was more important than individual human rights. Mentally ill needed to be separated from the rest of society.
● Racial segregation of services, inequitable distribution of resources. Most concentrated in white urban areas, while services in rural areas were almost non-existent.
● When black patients were admitted to institutions they were often abused, used for labour or as “guinea pigs” for new treatments. Rights were constantly violated.

Question 3

explain MH policies post apartheid (2 big shifts)

Answer 3

1997 saw new mental health policy guidelines aiming to transform SA mental healthcare so that people could access services where they were:
1. Moved away from institutional care to community-based care.
2. Integrating mental health into general health care. Rather than only being able to access mental healthcare in specialised psychiatric hospitals.

Question 4

Broadly explain primary prevention

Answer 4

The prevention or reduction of the occurrence of conditions that create risk for mental illness, and enhancing the conditions that promote psychological wellness.

Question 5

List the 2 main aims of Primary Prevention

Answer 5

1. To reduce the number of new cases of mental illness by preventing exposure to risk factors for mental illness.
2. Going beyond absence of mental illness to actively promote psychological well-being, thriving, empowerment.

Question 6

explain secondary prevenetion

Answer 6

-Early identification of those who are at risk for mental disorder or show early subclinical signs of disorder but have not yet developed a full-blown mental disorder. Putting in place early intervention to slow or halt progression of symptoms so they don’t worsen and develop into a full-blown disorder.
-Involves early screening for symptoms so that people can be identified at an early stage.

Question 7

explain tertiary prevention

Answer 7

• the treatment of mental health difficulties that have already fully developed.
• The current focus of mental health services in SA, in practice if not in policy.
  -Aim: to limit the impact of an illness and reduce risk of relapse.
• Human resources in the state mental health sector is inadequate for treating the number of people living with mental health difficulties. Can’t only rely on mental health professionals.

Question 8

explain the NGOs as sector providers

Answer 8

-An important provider, especially in urban areas.
-But chronically underfunded and at risk of having to shut down.’
-Largely funded by donors and some government subsidies.
- NGOs at provincial level tend to offer a mix of counselling services, mental illness prevention programmes and advocacy work.
-Usually have multiple roles.
-NGOs staffed mainly by volunteers, sometimes supervised by mental health professionals.

Question 9

explain the role of THPs (traditional health practitioners) in the sa context and why there is little collobration between state mental health sector and THPs

Answer 9

-200,000 THPs nationally
-5.8% of people with a common mental illness had consulted a THP or other complementary medicines practitioner; only 3.6% had done so exclusivey
-Currently little collaboration between state mental health sector and THPs, even though a lot of people use THPs. Lack of understanding and communication. Patients tend to use one or the other, or use both without telling the practitioners that they’re doing so. Therefore not receiving coherent, collaborative care. There have been calls for research to systematically evaluate the effectiveness of traditional treatments.

Question 10

how can we decide how to allocate limited resourcea and traget interventions effectively

Answer 10

If we know which mental illnesses are most common and who is most at risk

Question 11

how did the legacy of apartheid heavily influences our current healthcare challenges

Answer 11

-“Prior to 1992, the racialized social policies of Apartheid and the political violence and victimization that grew out of the anti-Apartheid struggle created a context conducive to increased risks of mental disorders
- After apartheid, rates of non-political violence, crime, and violence against women have remained high.

Question 12

how do u allocate scarce resources between levels of interventions

Answer 12

-If more resources were put into primary and secondary levels, we would have a smaller need to provide tertiary interventions. Pressure would be reduced.
-Actual spending is almost an inversion of this recommended allocation: very small amount spent on primary level even smaller amount spent on secondary level. Vast majority on tertiary.

Question 13

how does SA compare to other countries in terms of prevalence rates

Answer 13

-Prevalence of alcohol abuse in SA is one of the highest in the
-One of the highest rates of substance abuse disorders in the world

Question 14

how is mental health resources in state sector structured

Answer 14

1.-23 inpatient psychiatric hospital, there is Quite a pressure
2.About 30 psychiatric inpatient units in general hospitals
3. 63 community residential facilities. half provided by NGOs.
4.About 40 day treatment centres
5. 3,460 general hospital outpatient facilities that offer mental health services.
6. Primary health care clinics or PHCs.

Question 15

name 3 most common lifetime disorders in sa adult population

Answer 15

Major depressive disorder = 9.8%
Alcohol abuse = 11.4%
Agoraphobia (fear of public spaces) = 9.8%

Question 16

name and explain the post apartheid policy of “ legal protection of mentally ill from abuse and discrimination”

Answer 16

● Legal protection of mentally ill from abuse and discrimination.
-1997 guidelines never published or distributed to provinces.
- There was a lack of a clear plan for how to implement the policy.
- 10 years later, still a lack of staff at national level to monitor implementation of 1997 policy guidelines.
- Low priority given to mental health at provincial level.

Question 17

provide a useful stat to back up the notion that there is a treatment gap in sa

Answer 17

In the SASH study, 75% (or 3 out of 4) SA adults with a current mental illness have not received any treatment (medical or alternative / traditional) in the past year

Question 18

provide an example of a prevelance issue in south africa

Answer 18

Example of the Covid pandemic:
- If we know: who is likely to be more severely affected, and where, and when, we can target scarce resources to those most at risk
-Example of prevalence rates and levels of risk of Covid in SA: Men at more risk than women; people in 30-49 age range more likely to be infected etc. Raises the question: where are all the data about mental illness in SA? You’re much more likely to develop a mental illness than you are to contract Covid.

Question 19

what are 3 risk profiles found within high prev rates

Answer 19

GAL
-gender patterns
-age patterns
-income level and race

Question 20

what are CAMH services

Answer 20

CAMH-Child and adolescent mental health services
-Nearly 40% of the SA population is under the age of 18. A CAMH policy and plan is therefore important.
-not much good prev data . no SASH study for children/adolsecnets
-There is, however, a National CAMH policy framework (2003):
^strong emphasis on community based mental health services
^emphasis on intersectional colabration
-This is an excellent policy framework, but once again implementation is poor

Question 21

what are the 3 levels of intervention

Answer 21

1. tertiary
   2.secoundary
   3.primary

Question 22

what are the challenges that the mental health system in SA has been experiencing

Answer 22

-Resources once reserved for 5% of population under apartheid have had to be redistributed to serve the whole population.
- High burden of medical health problems e.g. HIV, TB. -Mental health has to compete with these problems for part of the health budget.
-Desciding which interventions are most relevant and acceptable for the SA population

Question 23

what are the sources of mental health prevalence and risk data

Answer 23

-National prevalence studies: take a representative sample of the whole population and determine the average prevalence of different conditions across the country.

-traditional health practioners and service providers

-NGO sector also provides important mental health services. May have important data regarding prevalence and risk

-workplaces and health insurers

Question 24

what are the two main categories of mental health policies in sa

Answer 24

-under apartheid
-post apartheid mental health policy developments

Question 25

what contributes to the treatment gap

Answer 25

Structural barriers – related to how the mental health system is structured
-Lack of proximity to government health clinics
-Costs associated with accessing treatment
-Long waiting time at clinics or long waiting lists for services
-inadequate training of primary health care staff in detection of mental illness

Non-structural or attitudinal barriers-Perceived ineffectiveness of treatment.
-Poor “mental health literacy”
-Stigma of mental illness - seen as shameful and unacceptable by many, a sign of weakness or character flaws.
-Lack of integration between ‘traditional’ and ‘western’ approaches.
-Distrust / discomfort with psychologists and psychiatrists linked to issues of race, class, language and culture primarily

Question 26

what does CIDI stand for

Answer 26

(Composite International Diagnostic Interview)

Question 27

what does CMIs stand for

Answer 27

common mental illnesses

Question 28

what does prevalence mean

Answer 28

= proportion of population with a specific characteristic/health condition in a given time period. I.e. How common a condition is within a population.
There has been a historical absence of prevalence data to map mental illness in SA.

Question 29

what does SASH stand for

Answer 29

south africa stress and health

Question 30

what does the treatment gap mean

Answer 30

difference between the number of people with mental illness and people who have received treatment for it

Question 31

what is SA’s hospi-centric approach

Answer 31

most mental healthcare is happening inside hospitals
-allocation of budget reflects this.
-if hospital-based treatemnts were effective, it would be ok that so much of the budget is being spent on it
-Readmission rate within 3 months of discharge is 24%- 75% across studies
- Suggests that these long hospital stays are not very effective.
-This hospi-centric approach therefore appears inefficient, ineffective, and likely unsustainable. The vision of the new mental healthcare plan and framework has not been achieved: healthcare has not been shifted to communities. This is seen in the allocation of budget, and provision of services and resources.

Question 32

what is the ratio of professionals per 100 000 uninsured people

Answer 32

Ratio of 0.32 psychologists and 0.28 psychiatrists for every 100 000 people in public service

Question 33

what percentage of the national budget goes to MH

Answer 33

5%

Question 34

where is most MH budget spent on

Answer 34

-treating patients in hospital once their illness is severe
-This is an expensive and rather ineffective model. People aren’t receiving other levels of support.
-This hospi-centric approach probably isn’t the best way to deal with the large treatment gap in SA.
-Need to think about other strategies, and the different levels of intervention that psychologists can become involved in.

Question 35

what is one solution to an over burdened health care system

Answer 35

One answer is to use “task-shifting”: shifting many of the tasks usually undertaken by professionals to non-professionals, who are often in more direct contact with people who are in need. Makes more efficient use of the available human resources for health .Able to provide a number of basic, but essential, tasks. Can refer patients to specialists when needed

Question 36

To whom should the tertiary interventions be targeted ?

Answer 36

• People living with difficulties; groups of people; their families.

Question 37

What treatments should be used within tertiary intervention?

Answer 37

• Appropriate to client and state resources. Short-term, effective treatments that are not too costly. Able to be delivered close to where clients live.
• Evidence-based, known to work
• Cultural/contextually appropriate / acceptable. Meaningful within the client’s belief system and world view.

Question 38

one example of an NGO in south africa that is aiding in mental health intervention

Answer 38

South African Federation for Mental Health (SAFMH) = a national society that provides about half of all community residential and day treatment facilities.

Question 39

list 4 goals of the National Mental Health Policy Framework and Strategic Plan

Answer 39

Goal was to scale up community mental health services by 2020 through:
1. Task-shifting basic care to primary care nurses and community mental health workers who could be trained by the health ministry. Thus wouldn’t always need a highly trained specialist.
2. Creating more community residential care homes and daytime care services
3. Specialist mental health teams providing support and training to primary healthcare (PHC) staff and community mental health workers in how to deliver basic mental healthcare services e.g. screening
4. More inpatient facilities at district and regional (general) hospitals instead of being admitted to distant psychiatric hospitals

Question 40

In public health, reliable data on prevalence and risk factors is needed to…

Answer 40

inform interventions and allocation of resources

Question 41

A critique on the levels of MH data available in SA

Answer 41

Covid 19 saw insane levels of data readily available and updated daily. This is highly contrasted with the data available on MH in SA.

Why might this be? (priorities, difficulty assessing/diagnosing?)

Question 42

7 sources of MH data

Answer 42

1.National Prevalence studies
2. NGOs
3. Schools
4. Provincial prev studies
5. Community prev studies
6. Clinic studies (look at clinic records, but this is therefore limited to help-seeking populations)
7. Other practitioners and studies

Question 43

That SASH study in SA in assessed ….. using the ….. which is based on ….. diagnoses

Answer 43

-Common mental disorders
-CIDI (Composite International
Diagnostic Interview)
- DSM-IV

Question 44

The most key stats discovered by the SASH study (learn some stats for essays etc)

Answer 44

-One lifetime mental illness = 30%
-Anxiety disorders = 15.8%
-Substance abuse disorders = 13.3%
-Major depressive disorders = 9.8%

Question 45

Problems with the SASH study

Answer 45

• still don’t know prevalence rates of serious disorders
• presumed the western common MDs applicable to SA
• stigmatized natures of MDs in SA may have encouraged soc des bias in survey

Question 46

The SASH study found that there was a …. treatment gap in SA. This treatment gap was irrespective of

Answer 46

75%
severity of mental illness or socio-demographic factors

Question 47

The SASH study found a ….% treatment gap in uninsured adults

Answer 47

92

Question 48

List 4 of the 6 structural barriers reported by SASH

Answer 48

1. lack of proximity to health clinics
2. Lack of community-based services after hospital discharge
3. Absence of referral pathways after MI is detected
4. Inadequate training of primary HC staff of MI detection
5. Long waiting lines at clinics
6. Costs of accessing treatment

Question 49

List 4 of the 6 non-structural/Attitudinal barriers

Answer 49

1. Perceived ineffectiveness of treatment
2. lack of integration between traditional and western approached
3. distrust/discomfort with pyschs (linked to race, class, language, culture)
4. Lack of knowledge about resources/services
5. Stigma of mental illness
6. Poor mental health literacy (or diff cultural understandings/interpretations of MIs)

Question 50

Even if one overcomes the attitudinal/social structures to obtaining MH care, the…. are still there

Answer 50

structural

Question 51

MI often seen as a…..

Answer 51

“white thing”