Mental Health: The Challenges

Published on 16th April 2012

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Mental disorders are associated with significant distress and impairments of human functioning, including in working, learning and in family relations. It was with this in mind that the World Health Organisation (WHO) defined health as “a state of complete physical, mental and social well-being and not merely the absence or infirmity.”

The message is that no health can be achieved without mental well-being. WHO has gone further than this too now by asserting that mental health is key to development. Poor mental health is not just an individual or personal issue but one that is critical to social and economic development.

While there have been important reforms in mental health policies and legislation since 1994 perhaps most notably the Mental health Care Act of 2002 which is regarded as one of the most progressive legislations in the world, there are still several challenges in the mental health care system and in ensuring that all those that need mental health care actually receive it.

Recent studies show that there is a need to review our mental health policies and strategies. There is also a need to scale up investment in mental health.

It is of major concern to us that the prevalence of mental disorders in our country is high and that vulnerability and associated risk factors are increasing. About 14% of the global burden of disease has been attributed to neuropsychiatric disorders and while this figure is slightly lower in developing countries because of the high burden from other diseases, the numbers of people suffering from mental disorder is very high. Local studies on the disease burden rank neuropsychiatric disorders third in their contribution to the overall burden in this country, after HIV and AIDS and other infectious diseases.

The first nationally representative psychiatric epidemiological study, the South African Stress and Health Survey (SASH) conducted in 2004 found 16.5% of adults have experienced a mood, anxiety or substance use disorder in the previous 12 months.

While I understand that the occurrence of mental disorders are a result of complex interaction of biological, psychological and social determinants, the inequitable and adverse socio-economic environment which remains a legacy of apartheid provides a fertile ground for predisposition, causation, and exacerbation of mental illnesses.

The adverse living conditions, racial discrimination, childhood trauma, and alienation brought about by the political, social and economic conditions has resulted in significant mental health challenges and continues to put many of our citizens at risk to develop mental illnesses.
An individual’s potential to lead a fulfilling work, family, academic, or social life can be sharply interrupted by an episode of mental illness and this has implications well beyond them as individuals. Where there are no or inadequate services to deal with this, the situation deteriorates from bad to even worse.

The high levels of violence and trauma in our society impact negatively on the mental health of all South Africans. We also have a major challenge regarding substance abuse. With respect to substance abuse, you will recall that the president appointed an Inter-Ministerial Committee to work on substance abuse in 2011.

A Summit was held and the resolutions that were adopted have been translated to a plan that was adopted by the Cabinet last year. The health sector has adopted a substance abuse health sector plan to give effect to the areas that were allocated to the health sector.

The key elements of this plan involve:

  • institutionalizing screening and management of substance abuse at selected health programmes (trauma units, antenatal care, HIV and Aids/TB/STI clinics etc.);
  • improving capacity and competencies of health workers to detect and manage substance abuse;
  • improving the implementation of regulations relating to the manufacture and control of precursor chemicals used to manufacture of illicit drugs;
  • scaling up public information and awareness of substances;
  • introducing alcohol advertising restrictions.

This plan must be implemented with the necessary vigour it deserves.

Another major concern is that both global and local studies show that mental ill-health features prominently in its high level of co-morbidity with infectious diseases, such as HIV and AIDS and tuberculosis. When I recently heard that 43% of people living with HIV also had a mental disorder this did not surprise me. There are obvious links for mental health being both a precursor and a consequence of HIV.

This is an area that we need to take more seriously to assist those that need mental health care but also because by doing so we will be able to improve treatment adherence and thereby improve life expectancy. Mental health is also associated with the growing burden on non-communicable diseases such as heart disease and cancer and also with high levels of violence and injury. Mental health is thus important to all the major contributors to our disease burden as well as being important to redress in and of itself.

The link between mental health and the Millennium Development Goals is confirmed by the Lancet review on Global Mental Health published in 2007. This publication reported that mental health affects progress towards the realisation of several of the Millennium Development Goals such as “promotion of gender equality, and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV and AIDS.” It is therefore imperative that mental health services are integrated into all health programmes, as well as health and social policy, health systems planning, and at all levels of the health care system.

Studies show that there is substantial burden of untreated mental disorders in our country. The SASH survey reported that only one in four of people with a mental disorder had obtained some form of treatment. This is in line with WHO surveys that show that between 76% and 85% of people with severe mental disorders in low and middle income countries receive no treatment.

We know that mental health services have and continue to be inequitably distributed, fragmented and inadequately resourced and characterised by significant provincial variability. For example, the results of the 2008 survey by the College of Medicine show that during the year of the survey in the public sector in Mpumalanga province there was one psychiatrist and 111 in Gauteng - out of a total of 302 public sector psychiatrists.

We know that there continues to be over-reliance on psychiatric hospitals as the mode to care, treatment and rehabilitation. We followed colonial practices and adopted a hospi-centric approach and neglected the critical aspects of primary health care.

But while many countries, and particularly more developed countries, have shifted away from large psychiatric facilities, we still put the majority of our mental health resources into such facilities. While clearly a lot has already been done since 1994 to scale down on large psychiatric warehouses and to reduce length of hospital stays, changing this and integrating mental health into general health care is still one of the key challenges we now face.

Other problems we face include the lack of community-based mental health services, slow progress with the implementation of aspects of the Mental Health Care Act, lack of accurate information, not enough mental health promotion and prevention programmes, inadequate public awareness of mental health, stigma and discrimination, and poor inter sectoral collaboration.

Despite all the resources dedicated to revitalising infrastructure, our infrastructure audit shows that the psychiatric hospitals are dilapidated and inappropriate for the modern requirements.

It is difficult to understand how it came about that health infrastructure degenerated to the state that it is in. Some blame must be placed at the door of history, where Mental Health care was something to be hidden away and not spoken about – and where any old, used and abused building was identified for use as a mental health care facility.

In some provinces modern facilities have been built and conditions for the people in psychiatric care has improved very substantially but we still find ourselves with a legacy of many unsuitable facilities, situated in inappropriate places far away from family and community, in which scarce mental health care workers are expected to render a caring, rehabilitative service to users.

An infrastructure master-plan must be developed and costed. This plan must provide details of what the requirements are for this country including all types of mental health facilities and specialist programmes. For example, we know that we have limited facilities for children that have been declared state patients. This is a vulnerable group and the state must respond to their needs.

While the Mental Health Care Act provides for children who have severe or profound intellectual disabilities, we have tended to rely on non-governmental organisations to provide residential services for this group of children. The state must play an active role and develop such services.

The mental health system mirrors many of the characteristics and the problems that characterise the health sector. We must accept and with humility, take responsibility where we have failed the country and now do what is necessary to rectify previous neglect or mistakes that we may have made.

Mental health care users must enjoy the full benefits of our constitution and Bill of Rights. We cannot claim to be free when some members of our society do not benefit from the liberties and freedom we enjoy. It is an offence against the constitution and against human rights to neglect the worst off in a society and people with mental disorders are often amongst the worst off. Because of their condition they are often “voiceless” and it is critical they we both give this group the space to voice their needs and then to respond appropriately through including mental health in all health plans and programmes.

Our human resources plans, infrastructure plans, social mobilisation plans, employment targets, etc., must include mental health issues.

We must increase the production and employment of other mental health professional categories too. At the same time we must ensure that mental health does not become the sole domain of dedicated mental health practitioners but that mental health becomes integral to the training of all health professionals, especially those that work in primary health care services.

History has led us to this crossroad. Bold steps are required of us and I believe we are ready for the challenge. I urge the summit to be brave and propose far reaching interventions, that not only provide cosmetic changes, but a well thought out and sustainable plan into the future.

There is growing evidence on the effectiveness and cost effectiveness of interventions to promote mental health and to prevent mental disorders, particularly in children and adolescents. The school health programme that we are rolling out from this financial year, may be an avenue for such interventions, especially in the areas of screening and managing mental health problems among learners, and the prevention of some of the social problems such as substance abuse and violence.

The interventions targeting children and adolescent must go hand in hand with developing child and adolescent mental health services that are lacking in this country.

We need to scale up the investment on community based mental health services and reverse the trend of institutionalised care. We must examine how mental health will be integrated into general health care and particularly into primary health care.

We must identify the factors that impede the implementation of the Mental Health Care Act as the intentions of the legislation are to comply with the human rights environment that was created by our Constitution.

Stigma and discrimination continues to flourish and is exacerbated by lack of information and ignorance. In this regard the National Strategic Plan for HIV and TB, 2012-2016 also prioritises the issue of de-stigmatisation of HIV and TB. We should find ways of linking with this initiative.

I firmly believe that like other health areas, mental health will benefit tremendously through the National Health Insurance (NHI) system that I am very proud to say has now started implementation. Eleven pilot sites have been identified and we are already starting to strengthen public sector services in these areas so that the integration with private health care will take place from a position of quality and well managed services. We want to slowly bring people currently working in private health care to also start working in public health care as part of this integration process.

The need for NHI is well illustrated by looking at current human resource distribution. For example currently there are something like one psychiatrist for every 30 000 people in the private sector and one per 120 000 in the public sector. This just cannot be right and just in a democratic society. For psychologists and other professions these ratios are even worse.

We must also strengthen user participation in planning services. Strengthening user groups will ensure that the health system responds to mental health user’s needs and priorities.

It is also important to strongly assert that mental health is not just a health responsibility. Many other government as well as non-governmental partners are critical to improving mental health. This summit must deliberate and pronounce on the key areas that must form part of the inter-sectoral arrangements and relationships.

By Dr Aaron P Motsoaledi.
Minister of Health, South Africa.

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