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it is Art if A Under-budgeting for mental health is costing SA billions. By Chris Bateman GROSSLY INADEQUATE GOVERNMENT spending on mental health — a disease affecting one-in-four South Africans — is costing South Africa 2.2% of its annual GDP, with 230 attempted suicides recorded daily and 48% of people living with HIV/Aids suffering from a mental health condition. The latest figures from the country's largest medical aid, Discovery Health, show a 41% increase in mental disorder payouts (between 2008 and 2012), rising from R96.7 million to R494.6m, but figures for the public sector (where over 80% of the population are treated), remain unavailable. These telling snapshots emerged from presentations given by several top mental health researchers at a summit held at the University of Cape Town. Neuropsychiatric disorders are now the third biggest contributor to the local burden of disease, trailing close behind HIV/Aids and Ischaemic heart disease. Globally, South Africa languishes among the bottom four countries in providing mental health treatment, recently cutting mental hospital beds across all provinces by 7.7% — with half of all health facilities failing to meet mini- mum mental health quality standards. According to Professor Crick Lund, of the Department of Psychiatry and Mental Health at the University of Cape Town, depression is costing the country "more to not treat, than to treat". He and several fellow UCT psychiatrists and epidemiologists currently estimate mean lost earnings due to severe mental illness (major depression and anxiety disorders), at R54,121 per adult, each year. A South African Stress and Health Survey projected the total annual cost to the country in lost earnings at R40.6 billion, as far back as 2003, (equal to 2.2% of GDP), dwarfing direct national department of health spending on mental health of R665.52m, (2005 figures). "Depression is highly prevalent and has a major social and economic impact in South Africa. Our preliminary findings indicate that providing treatment for mental disorders like depression can actually improve individual and household economic circumstances. Poverty is associated with increased prevalence of mental health disorders, increased severity and a longer course and worse outcome. We need to urgently invest in and scale up mental health care," Lund stressed to summit delegates. Further illustrating the social and economic impact, he said measuring "days out of role," (the inability to work or carry out day-to-day activities) put the average individual figure at 28 days a year for anxiety disorders and 27 days a year for depression. The 12-monthprevalence (the number of people who report having symptoms meeting the diagnostic criteria for anxiety, mood and substance disorders) in South Africa currently stands at 16.5%, with a lifetime prevalence of common mental disorders among adults pegged at 38%. Crick reported women as having twice the risk of depression as men, but said men had twice the risk of substance abuse than women. Living with HIV doubled the risk of depression. "Just treating with anti-depressants leads to better adherence [to anti-retroviral drugs], an improved CD4 cell count and changes the viral load." Lund said the national health department was "keen" to include anti-depressants in the drug regime of HIV-positive patients, adding that it was vital to ask people undergoing ART about "what else is happening in your life, do you need to see a counsellor?" Only one-infour South Africans living with a mental disorder had any access to appropriate care, he said. The country's (in)capacity in terms of available psychiatrists and psychologists emerged during question time in parliament in November — and the fact hardly inspires confidence that anything will be changing any time soon. Limpopo and Mpumalanga have 24.2% and 33% of their psychiatric posts filled, while the North West province has only 31% of the psychologists it needs. Only the Western Cape has filled all its vacancies for both disciplines. The number of psychiatrists per 10,000 population nationally stands at 0.32 and the number of clinical psychologists per 10,000 population is 0.7. The national health department said it had "embarked on a process" to develop workforce staffing norms to ensure equitable distribution Health at UCT, drew a distinction between trauma and PTSD. He said motor vehicle accidents were among the biggest contributors to PTSD in South Africa. Merely witnessing trauma on its own was unlikely to cause major PTSD — however the burden of trauma in South Africa was "so huge" that the effect was unavoidable. He singled out group vigilantism as a major contributor to PTSD and said mental health generally in South Africa was "underdiagnosed and undertreated". Stein is leading a research team analysing blood samples from animals at the time of major trauma to predict PTSD, based on the genes in white blood cells. He is also a world authority on brain functional imaging and genetic studies. Professor Stefan Hofmann, a world psychiatrist, the late Dr Joseph Wolpe, whose initial PTSD work with World War II soldiers moved global thinking away from a Freudian psychoanalytic approach to a more pragmatic systematic "desensitisation approach". Hoffman decried the supremacy, locally, of what he termed less successful therapies, saying CBT was a "hugely effective treatment" with a sound empirical foundation that was evolving with close links to psychiatry and neuroscience. Its newer approaches included strategies to augment specific processes with pharmacological agents (in more severe cases). CBT also had new ways of conceptualising and classifying mental disorders, as well as tailoring treatment to the specific cultural background of the patient. A 2009 global meta-analysis of human resources for health, using World Health Organisation "Workload Indicators of Staffing Need". According to the South African Depression and Anxiety Group, (Sadag), the largest NGO of its kind in South Africa, there are 23 known suicides daily across the nation. A full 11% of all non-natural deaths in the country were also due to suicide. Sadag deals with 400 calls a day on 15 helplines and gets 600,000 hits a month on its website, offering 98 support groups. Sadag estimates that about six million South Africans could be suffering from Post-Traumatic Stress Disorder (PTSD), and that 82.1% cannot afford private health care. One survey revealed that about half of all South Africans do not see mental health as a priority. A total of 8,000 South Africans chose to end their lives every year. Figures from the Council for Medical Schemes (CMS), based on medical aid claims paid out, show that the incidence of bipolar disorder increased by 228% between 2006 and 2011. (From 0.7% to 2.3% of every 1,000 medical aid members). Professor Dan Stein, Chairperson of the Faculty of Psychiatry and Mental expert on cognitive behavioural therapy (CBT) and leader at Boston University's Clinical CBT Programme, told the summit that it was "shocking" to him that CBT was not the first-line treatment in the very country that had helped pioneer it. Referring to South African showed CBT to "consistently outperform or equal all other treatments". Hofmann said a British study had shown that by training an extra 3,600 CBT therapists, a saving of R12,6 billion was achieved. CBT was now part of a "global sea-change in therapy".