The vicious cycle of poverty and mental illness
The sad state of care in SA
Disturbing new research shows the link between poverty and mental health is a strong one and access to care is severely limited when finances are.
The Mental Health and Poverty Project (MHaPP) at the Department of Psychiatry and Mental Health at the University of Cape Town, is a ground-breaking project funded by DFID which aims to develop and evaluate evidence-based policies that break the negative cycle of poverty and mental ill-health and to ensure that the poorest communities have access to mental health care. Their research from service data for the 2005 calendar year has yielded shocking statistics and facts about mental health care in South Africa.
MHaPP researchers, in a review of existing studies, found that psychiatric conditions are ranked 3rd in their contribution to the burden of disease, after HIV and AIDS and other infectious diseases. 16.5% of South Africans suffered from common mental disorders like depression and anxiety in the last year and 17% of children and adolescents suffer from mental disorders. In the low-income and informal settlements surrounding Cape Town, maternal mental health problems have reached epidemic proportions: one in three women in these areas suffer from postnatal depression. Research from rural KwaZulu-Natal showed that 41% of pregnant women are depressed - more than three times higher than the prevalence in developed countries.
"Mental health is not given the priority it deserves in South Africa and there is very little research into mental health and service conditions", says Zane Wilson, Director of the South African Depression and Anxiety Group (SADAG). The study aims to show that the vicious cycle of poverty and mental ill-health can be broken through a range of interventions, including providing cost-effective mental health care in community settings and through a multi-pronged approach to the problem. The fieldwork for the study was conducted between 1 August 2006 and 31 March 2007. Analysis and writing was conducted from 1 April to 30 September 2007.
Mental ill-health is strongly associated with poverty and social deprivation and living in poverty, exposure to stressful life events like crime and violence; inadequate housing, unemployment and social conflict, are all linked to mental ill-health. Poverty is also associated with exclusion, isolation, feelings of disempowerment, helplessness and hopelessness, which can lead to chronic insecurity and social mistrust, affecting people's mental well-being. "We knew that mental health services were under-resourced in South Africa, and that mental health has always been low on the priority list. But what surprised us was the level of inequality between provinces", says Dr Crick Lund, Chief Research Officer of the Mental Health and Poverty Project. "In the public sector there is a 45-fold difference in the number of psychiatrists between the North West (1 psychiatrist per 5,000,000) and the Western Cape (1 psychiatrist per 110,000). When we look at beds in community residential facilities, this varies from 0 in the North West and Northern Cape to 6.5 beds per 100,000 population in Gauteng." But this does not mean the Western Cape and Gauteng are over-resourced warns Dr Lund: "Clinicians and facilities in Gauteng and the Western Cape are stretched to the limit with the current demand. What this shows us is that certain provinces are not taking mental health seriously as a public health and development issue."
Mental health services and human resources are limited across South Africa with 63 community residential facilities (47% of which are run by the SA Federation for Mental Health) providing 3.6 beds per 100,000 people. There are 23 public mental hospitals, providing 18 beds per 100,000 people - only 1% of these beds are reserved for children and adolescents – and the number of mental hospital beds has decreased by 7.7% in the last five years. 0.28 psychiatrists, 0.45 other medical doctors, 10.08 nurses, 0.32 psychologists, 0.4 social workers, and 0.13 occupational therapists per 100,000 people in the country. There are 41 psychiatric inpatient units in general hospitals in the country with a total of 2.8 beds per 100,000 people. Only 3.8% of these beds are reserved for children and adolescents. For South Africa's over 40 million population, there are 3,460 outpatient mental health facilities, 80 day treatment facilities available (half of which are run by the SA Federation for Mental Health),
Dr Lund says the research found the distribution of human resources between urban and rural areas to be disproportionate. In rural areas, there is 1 bed for every 342 patients needing mental health care and no child or adolescent dedicated beds. In the North West province, only 10% of psychiatrists work in government services. Statistics for many rural areas show there are no psychiatrists, limited nurses, and critically low numbers of social workers, even though 1.5% of the rural population was treated for a mental illness in 2005. "Diagnosis, treatment and support for people with a mental illness is difficult enough to find in urban areas," says Johannesburg-based psychiatrist Dr Thabo Rangaka. "In rural settings, where people don't have the information or the funds, this can be virtually impossible."
The Department of Health reported that 53% of hospitals have been listed to provide 72-hour assessments of psychiatric emergencies, in keeping with the provisions of the Mental Health Care Act. However, there remain major concerns about the capacity of staff and facilities to provide adequate mental health care in these hospitals. "Far too often critically suicidal patients have to wait for hours to be admitted and often they are turned away due to lack of space", says Wilson. Frequently mentally ill patients will be admitted to general wards if there is no separate psychiatric inpatient unit. This increases stigma and decreases the quality of care for these patients."
The MHaPP study concluded that public attitudes toward mental health and treatment conditions remain generally negative, and despite a progressive and supportive policy framework for mental health, and in spite of all the emerging evidence of interventions that could enable us to address mental health systematically in this country, mental health is not given the priority that it requires in South Africa and remains a low priority on the public sector agenda. Stigma towards people with mental illnesses is still prevalent and contributes to loss of, or inability to obtain employment, inability to access social security, poor access to health care, receipt of poor quality health care, and loss of housing. "We need to challenge the old stereotypes about mental health, stereotypes that say that people with psychosis are bewitched or possessed by demons; that people who are depressed are lazy", says Dr Lund. He points out that it costs our economy more to ignore the burden of mental disorders than to provide appropriate resources. "These conditions can be accurately diagnosed and effectively treated if we are prepared to commit the resources and change the way we think about them."