OPINION: Equality in mental health hampered by lack of access, lack of investment

  • Mental disorders are a leading cause of ill-health and disability worldwide
  • Mental illness remains largely unknown and unrecognised as a medical condition
  • There is a severe lack of treatment facilities and mental healthcare professionals in SA

Mental wellbeing is something that all human beings should enjoy, but one in three South African adults will experience some form of mental illness in their lifetime and the quest for equal access for all to better mental health is hampered by a severe lack of treatment facilities and mental health professionals, with only 1 000 psychiatrists to serve South Africa’s almost 60 million people.

On World Mental Health Day (10 October 2020), we as the South African Society of Psychiatrists (SASOP) have joined the global call by the World Health Organization (WHO) and partner organisations for scaling-up investment in access to mental healthcare as one of the most neglected areas of public health worldwide.

Lack of mental healthcare professionals

There is a specific need in South Africa to increase funding and training quotas for mental healthcare workers and professionals and improve geographic distribution of mental healthcare facilities to ensure better and more equitable access to treatment for mental health conditions.

South Africa starts on the back foot, with 1 035 registered psychiatrists on the SASOP and SA College of Psychiatrists databases. That is a ratio of 0.5 psychiatrists per 100 000 people, well below the global average of 1.3 psychiatrists per 100 000 population according to the World Health Organisation (WHO) 2017 Mental Health Atlas.

The ratio does vary widely, from 0.06 in low income countries to 11.87 per 100 000 people in high income nations, but this current scenario places South Africa in the same bracket as lower-middle income countries.

SA unable to deliver services adequately

The lack of professionals is worsened by structural barriers to achieving universal mental health coverage, including treatment costs and limited medical aid cover for mental illness, while a lack of public sector treatment facilities and professionals is felt in both high-density urban areas and South Africa’s more rural provinces.

This indicates that from the get-go, South Africa is not in a position to deliver services adequately to its population.

The 2020 World Mental Health Day theme is ‘Mental health for all – Greater Investment, Greater Access. For Everyone. Everywhere.’

This is a noble principle which we should all strive hard to achieve and sustain but, sadly, there are serious barriers to achieving this in South Africa.

Unknown and unrecognised medical condition

Mental disorders are a leading cause of ill-health and disability worldwide, affecting 30.3% of South African adults at some point in their lifetimes according to the South African Stress and Health Study (SASH), with significant impact on quality of life, relationships and earning ability, and there are costs to the economy too in loss of productivity and treatment costs.

Despite the high prevalence, mental illness remains largely unknown and unrecognised as a medical condition, leaving the afflicted undiagnosed and untreated, to the distress of family and community and leading to negative economic, cultural and social impacts.

The reasons for this are many and as diverse as the economic, cultural and social landscape of South Africa.

Covid-19's contribution to mental health

While the Covid-19 pandemic has seen increased levels of stress, anxiety, fear, emotional distress, feelings of isolation and other mental health impacts due to lockdowns, physical distancing and precautions against infection, the pandemic has also further reduced access to mental health care.

For example, face-to-face meetings have been limited, people’s mobility has been restricted and risks of infection put people off seeking help for non-emergency conditions, while some healthcare facilities have had to close temporarily.

A lack of knowledge of mental health, social stigma and a belief that mental illness is a sign of weakness, as well as the risk of discrimination in the workplace by disclosing a mental disorder, are among the attitudinal barriers to achieving good mental health for all. 

An analysis of the SASH study showed that the large majority of people did not perceive that they needed treatment for mental health conditions, or else they believed they could manage without help, that the problem would “go away on its own” or that treatment wasn’t effective.

This is tied to a lack of knowledge and understanding of the causes of mental health conditions and the appropriate treatment for these conditions – what we call mental health literacy.

Addressing barriers to seeking treatment

Culture and traditional beliefs also play a role in South Africa, and solutions to addressing barriers to seeking treatment for mental health conditions need to take these into account.

It is clear that all these barriers will need to be overcome to improve mental health service provision in South Africa.

Treatment dropout is a further concern, which can be due to negative interactions with mental healthcare providers, lack of personal or medical aid funding for maintenance or follow-up care, and lack of support from employers in allowing employees the time to seek help and complete treatment.

Substance abuse and mental health conditions are closely linked, with either one often leading to the other, and substance abuse often leading to dropout from treatment for mental health conditions.

Government should also be making a serious effort to increase the number and availability of substance abuse treatment facilities because the lack of these has an enormous effect on the outcomes of mental health and other medical conditions, which together have a major cost to the economy.

Appropriate funding of mental health will lead to a multitude of positive outcomes for the health of individuals and communities, as well as positive economic impact through greater productivity and the reduction of healthcare costs in the long term.

Appealing to government

Our appeal to government is to make funding available to increase the number of professionals working in mental health, including nursing, occupational therapists, social workers, psychologists, psychiatrists and others involved in mental healthcare delivery.

Public mental healthcare facilities need to be increased and better distributed to ensure geographic accessibility across urban and rural areas, along with community education campaigns to grow understanding of mental health conditions and knowledge on accessing treatment. 

A system of universal mental healthcare coverage must be worked out to eliminate structural barriers like financial accessibility, while employers should be encouraged and supported to facilitate employees accessing help, which would in turn improve workplace productivity.

Image credit: Noah Silliman, Unsplash, and Supplied
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