Context of mental health in SA Flashcards
Prevalence of mental illness in SA
- historical absence of prevalence data to map mental illness in SA
- Data on prevalence and risk factors needed to inform interventions/ allocation of resources.
- need for national, community, clinic and alternative practitioner studies. (National prevalence studies only give you an average - you need to look at separate specific community studies to ensure that you are allocating resources according to community needs. )
The South African Stress and Healthy Study (SASH)
- conducted 2002-2004
- first prevalence study of mental illness in sub-Saharan Africa
- nationally representative sample of 4351 adults from randomly selected households
- participants assessed using the Composite International Diagnostic Interview (CIDI), based on DSM-IV diagnoses (use of dsm iv in SA is problematic)
- only common mental illnesses (CMIs) were assessed: depression, anxiety, substance disorders
- CIDI translated into 6 languages
SASH study: most common lifetime disorders in SA population
- alcohol abuse- 11.4%
- MDD- 9.8%
- Agoraphobia-9.8% (due to unsafe environment)
one lifetime mental illness- 30%
2 lifetime illnesses- 11%
SASH gender patterns
- substance abuse affects mainly men
- depression and anxiety disorders affect mainly women
- reflect international findings
SASH age patterns
- Substance abuse has earlier age of onset (21 yrs) than many other countries
- No large-scale prevalence data for childhood disorders in South Africa
Treatment gap in SA
- almost 3/4 SA adults with a current mental illness have not received any treatment in the past year
- this is irrespective of severity of mental illness and of socio-demographic factors
- when treatment is sought it is seldom in the mental health sector.
- mostly use general medicine (16.5%)
Why is mental health so poorly funded in SA?
There are high rates of diseases such as HIV and TB, so health resources in SA are dedicated in majority to physical health and there aren’t enough resources to work with mental health.
Lifetime disorder
Lifetime disorder - a disorder that is experienced at some point in a life. Not permanently, nor presently, just at some point.
Agoraphobia
the fear of having a panic attack in an open space, public space etc
Possible reasons for treatment gaps in SA
- Stigma prevents people from getting treatment as they are worried about the effect the diagnosis would have
- Mental disorders are often assumed as being a character deficit in the person, so treatment may be avoided because the person feels as though they are the problem and it’s up to them to fix it.
- A lack of funding, as treatment can be very expensive.
- A lack of information, leading to the person being unaware of the fact that they are dealing with a mental disorders and that there are ways to treat it.
- A lack of options for treatment - the acceptability of what few treatments there are.
- Denial of the disorder
- Practical accessibility of treatments and resources.
Structural barriers of possible treatment barriers
- lack of capacity
- long waiting time at clinics or long waiting lists for services (requires time off work, extensive and expensive travel requirements etc. )
- The queues can be very long and it is common for people to have to wait for hours and arrive in the early hours of the morning to be in the front of the queue - this can be dangerous in terms of vulnerability to crime.
- inadequate training of primary health care staff in detection of mental illness (there isn’t enough training given to nurses, they are not equipped with the knowledge needed to pick up an underlying psychological cause in a patient that goes in to a primary health care service.)
- absence of refferal pathways once mental illness is detected (There’s a lack of referral pathways, due to poor resources, and even if there are pathways, the health care staff may not be aware of it. )
- lack of community-based services after hospital discharge
NON-STRUCTURAL BARRIERS of possible treatment barriers
- poor mental health literacy- A lack of awareness can lead to missing a mental illness as the cause of distress. (There’s an assumption here that the western ideas of mental disorders are the ‘literacy’ that needs to be privileged - it may be that the South African take on mental illnesses is more important, or beneficial, in this context. )
2. stigma of mental illness (Stigma can be caused by a lack of awareness, a lack of understanding. Also, the lack of discussion around mental disorders would contribute to this stigma.) (The idea that mental illness is self-controlled would also create a barrier for seeking help and treatment.)
3. lack of knowlesge about resources/ services
4. Distrust / discomfort with psychologists and psychiatrists linked to race, class, language and culture (The current demographic structure of mental health professionals is such that the majority are white and english speaking - the cultural distance makes communication and safety very difficult, given the intense personal nature of therapy. )
5. Lack of integration between ‘traditional’ and ‘western’ approaches
Legacy of Apartheid: under apartheid
- Emphasis on institutional care and medical treatment of patients with mental illness
- Protection of society more NB than individual human rights
- Racial segregation of services, inequitable distribution of resources (All psychiatric hospitals, during apartheid and now, were/are within white-populated, urban areas. )
- Tools of psychology used to condemn anti-apartheid activists to institutions and to justify continued torture / ill treatment of political prisoners (Psychology was used as a means of social control, to keep whites in power and allow for intense trauma for anti-apartheid activists. People were deemed ‘crazy’ and ‘unfit to return to society’ as a means of ensuring that anti-apartheid activists were kept away from the great society.)
The discipline of psychology was complicit in the design of racial ‘scientific truths’ - ideas of superior intelligence in white people etc.
POST-APARTHEID MENTAL HEALTH POLICY DEVELOPMENTS
- 2002 Mental Health Care Act consistent with international human rights standards (e.g. legal protection of mentally ill from abuse, discrimination; review boards to monitor treatment of patients)
- 1997 new mental health policy guidelines aimed to:
1. move from institutional care to community-based care
2. integrate mental health into general health care (through community health clinics rather than specialised psychiatric hospitals) - Poor implementation of the new policy:
1. Guidelines never published or distributed to provinces
2. Lack of clear plan for how to implement the policy
3. Lack of staff at national level to monitor implementation
4. Low priority to mental health at provincial level
5. There was no practical plan to implement the policy, it was only in theory
% of health budgets spent on mental health care
-4% of the national health budget is allocated to mental health care.
-Despite evidence that mental illness is third largest contributor to national
burden of disease (after HIV/AIDS and other infectious diseases)
-Indirect costs of mental illness are up to six times greater than the direct
treatment costs: SASH survey found that lost earnings amongst adults with severe
mental illness were R28.8 billion over a 12 month period, compared with the
R472 million that was spent on adult mental health treatment
