Context of Mental Health in South Africa

Question 1

What is prevalence?

Answer 1

The proportion of a population with a specific characteristic/health condition in a given period of time.

Question 2

Where can mental health prevalence and risk data come from?

Answer 2

• National prevalence studies
• Provincial prevalence studies
• Community prevalence studies
• Clinic studies
• Other practitioners/service providers
• NGOs
• Schools

Question 3

What was the national prevalence study in South Africa called and when was it conducted? What was unique about it?

Answer 3

• The South Africa Stress and Health (SASH) study.
• It was conducted from 2002-2004
• It was the first and only national prevalence of mental illness study in Sub-Saharan Africa.

Question 3

Why is it ideal to combine different sources of data when assessing prevalence?

Answer 3

Because each source of data has its benefits and limitations. E.g. clinic studies might only look at people who already have health-seeking behaviour.

Question 4

How many participants were in the SASH study, and how were they sampled?

Answer 4

• There were 4351 adults
• A nationally representative sample was used. (random sampling employed within this).

Question 5

How were participants assessed in the SASH study, and what illnesses were assessed?

Answer 5

Participants were assessed using the Composite International Diagnostic Interview (CIDI), which is based on DSM-IV diagnoses.
- Only common mental illnesses (CMIs) were assessed: depression, anxiety, and substance disorders.

Question 6

How many languages was the CIDI translated into?

Answer 6

Six languages

Question 7

What was the prevalence of lifetime disorders in SA adult population according to the SASH study?

Answer 7

• Alcohol use disorder: 11.4%
• All substance use disorders: 13.3%
• Major depressive disorder: 9.8%
• Anxiety disorder: 15.8%
• One lifetime mental illness: 30%
• Two lifetime mental illness: 11%

Question 8

What is the treatment gap?

Answer 8

The discrepancy in the proportion of the population in need of services and the proportion that actually receives them.

Question 9

What was the treatment gap in SA according to the SASH study?

Answer 9

75% of SA adults with a current mental illness have not received any treatment in the past year (medical or alternative/traditional)

Question 10

What percentage of uninsured adults in SA with a mental illness have not accessed treatment as of 2016/2017?

Answer 10

92%

Question 11

What are structural barriers to treatment and what is their prevalence according to the SASH study?

Answer 11

• Structural barriers refer to objectifiable factors associated with health services.
• These were reported by 34% of the SASH sample.

Question 12

What are the 6 different treatment barriers?

Answer 12

1. Lack of proximity to government health clinics
2. Lack of community-based services after hospital discharge
3. Absence of referral pathways once mental illness is detected
4. Inadequate training of primary healthcare staff in detection of mental illness
5. Long waiting time at clinics or long waiting lists for services
6. Costs associated with accessing treatment.
   (remember to be specific)

Question 13

What are non-structural/attitudinal barriers to, and what is their prevalence in SA?

Answer 13

• These are attitudinal barriers. They were reported by 100% of the SASH sample.

Question 14

What are 6 attitudinal barriers to treatment?

Answer 14

1. Perceived ineffectiveness of treatment
2. Lack of integration between “traditional” and “western” approaches
3. Distrust/discomfort with psychologists and psychiatrists linked to race, class, language, and culture.
4. Lack of knowledge about resources/services
5. Stigma of mental illness
6. Poor “mental health literacy”

Question 15

What was the state of mental health in South Africa during apartheid? (3 points)

Answer 15

1. The emphasis was on institutional care and medical treatment of patients with mental illness
2. Protection of society was more important than individual human rights
3. Racial segregation of services, inequitable distribution of resources

Question 16

What were the aims of the 1997 new mental health policy guidelines? (2 points)

Answer 16

• To move from institutional care to community-based care.
• To integrate mental health into general health care (through community health clinics rather than specialised psychiatric hospitals)

Question 17

What was the 2002 Mental Health Care Act?

Answer 17

This was a new act that was consistent with human rights standards which included:
- Legal protection of mentally ill from abuse and discrimination
-Review boards which were meant to monitor the treatment of patients

Question 18

What factors influenced the poor implementation of the new policy?

Answer 18

• Guidelines never published or distributed to provinces
• Lack of clear plan for how to implement the policy
• Lack of staff at national level to monitor implementation
• Low priority to mental health at provincial level.

Question 19

What were the aims of the National Mental Health Policy Framework and Strategic Plan 2013-2020 (MHPF)?

Answer 19

• Scale up community mental health services through task-shifting to primary care nurses and community health workers
• More emphasis on mental health promotion and prevention of mental illness
• Mental health financing will be increased to reflect the role of mental health in the national burden of disease

Question 20

What percentage of the national health budget was spent on mental health care?

Answer 20

Nationally: 4% (2005) and 5% (R9.8 billion) (2016)
WC: N/A (2005) and 7.7% (R307.40 per uninsured person) (2016)

Question 21

What is the role of mental health in the national burden of disease?

Answer 21

• Mental illness is the third largest contributor to national burden of disease
• Indirect costs of mental illness are up to six times greater than the direct treatment costs

Question 22

What are the statistics of human resources in state mental health per 100,00 people in the uninsured population?

Answer 22

Nationally:
2005: 0.3 Psychiatrist, 0.3 psychologists, 0.4 social workers
2016: 0.3 psychiatrists, 0.9 psychologists, 1.8 social workers
Western Cape:
2005: 0.7 Psychologists
2016: 1.2 Psychologists

Question 23

What is the hospi-centric approach?

Answer 23

• In both 2005 and 2016/17, 86% of the national mental health budget was allocated to psychiatric hospitals. in 2016/17 only 8% was spent on primary level care.

Question 24

How efficient is hospital-based treatment of mental illness in SA?

Answer 24

• The average hospital stay for mental illness is 157 days (2-5 times more than for any other type health admissions)
• Readmission rate within 3 months of discharge is 24-75% across studies.
• 18% of total mental health budget is spent on re-admissions.

Question 25

What is the vision of the National Mental Health Policy Framework and Strategic Plan 2023-2030?

Answer 25

• Comprehensive, high quality, integrated mental health promotion, prevention, care, treatment and rehabilitation for all in South Africa by 2030.

Question 26

What are the strategies of 2023-2030 MHPSP?

Answer 26

• Scale up mental services
• In the NHI, mental health services will be given financial parity with other health services. The NHI will specifically include packages of care for mental health in line with the evidence for the most cost-effective interventions
• Mental health promotion and prevention initiatives will be integrated into the policies and plans of a range of sectors including, but not restricted to health, social development, and education.
• Addressing the social determinants of mental illness by improving daily living conditions and reducing inequalities.
• All health staff working in health settings will receive basic mental health training, inclusive of anti-stigma training, and ongoing routine supervision and mentoring.
• Task-sharing to expand mental health workforce

Question 27

What is the role of non-governmental sector?

Answer 27

• It is funded by donors and they receive some government subsidies
• NGOs at provincial level tend to offer a mix of counselling services, mental illness prevention programmes and advocacy.
• NGO staffed mainly by volunteers and are supervised by mental health professionals.

Question 28

What is the South African Federation for Mental Health (SAFMH)?

Answer 28

National society that provides about half of all community residential and day treatment facilities

Question 29

How many traditional health practitioners are there nationally?

Answer 29

200,000. This is far more than the number of mental health professionals in the state system.

Question 30

What number of people have visited traditional health practitioners to address psychological distress?

Answer 30

Community and clinic studies report that 40-60% of people with mental health difficulties.

Question 31

Is there collaboration between THPs and the mental health sector?

Answer 31

yes but very little

Question 32

What were the problems with the SASH study?

Answer 32

• The study is no longer relevant as it was conducted almost 20 years ago.
• The CIDI was developed using the DSM-IV and we now have an updated version
• It was funded by the WHO so it was directed by western psychiatric ontologies.
• They interviewed people in their homes. This might have caused them to miss some people; particularly those who are struggling and might not want to let people into their homes for fear of judgement. Or it might miss socially anxious people