Between 75% and 95% of people with mental disorders in low- and middle-income countries cannot obtain mental health services. The level of suffering and distress and their social consequences can be considerable, writes Ashraf Kagee and Katherine Sorsdahl.
Some people continue to think of mental health services as a luxury only for wealthy persons and that people living under conditions of poverty and precarity have no mental health needs. This misperception needs to be corrected.
Common mental disorders such as major depression, generalised anxiety, posttraumatic stress, and behavioural and emotional disorders are highly prevalent in many low-and-middle income countries, including South Africa.
Also, discrimination and social oppression on the basis of race and ethnicity, sexual orientation and gender identity, disability status, health status, or having a migrant or refugee background can have profound effects on people psychologically and emotionally. Social inequality, characteristic of our society, has an undoubted impact on the mental health of people.
Two explanations can account for this phenomenon.
The social causation theory states that the stresses of living under economic hardship and precarity conditions increase the risk of developing a mental health condition. The social drift theory suggests that having a mental health condition can contribute to someone experiencing reduced socioeconomic circumstances. Some evidence supports both these explanations.
Currently, psychologists and psychiatrists charge several hundred of rands per therapy session, which is prohibitive for most people. Consequently, many people living with a mental health condition do not receive the treatment they require, such as psychotherapy, medication, or both.
According to the World Federation of Mental Health, between 75% and 95% of people with mental disorders in low- and middle-income countries cannot obtain mental health services. The level of suffering and distress and their social consequences can be considerable.
Scaling up services
On World Mental Health Day (10 October), we want to emphasise that scaling up mental health services is a matter of considerable urgency. However, upscaling requires investment in mental health, which is currently insufficient. Government, health professionals, civil society, communities, and families all share a responsibility in scaling up services. Currently, most available services for mental health are provided at highly specialised psychiatric hospitals, with little service provision in the community at district hospitals or primary healthcare centres.
The World Health Organisation’s Mental Health Gap Action Programme seeks to build partnerships for collective action to narrow the mental health gap. It encourages governments, international organisations, and activist groups to work together to provide services to people in need in places where resources are limited.
Part of the problem in scaling up services is training mental health professionals. It requires several years to train psychiatrists, psychologists, social workers, and professional counsellors before they are able to offer their services.
Opportunities for specialised training are limited due to the high costs involved, for example, in ensuring that trainees are properly supervised in their work with service users who have complex problems. As a result, the concept of task-sharing has received considerable attention in helping to reduce the mental health gap.
Task-sharing means that tasks previously considered only for specialists such as psychiatrists or psychologists can often be performed by healthcare workers who do not have specialist training. So, for example, persons with a less complex mental health condition such as emotional distress or anxiety can receive counselling and other services by non-mental health specialists, including general practitioners, nurses and community health workers. This approach frees up highly trained professionals to work with those who require specialist expertise and management.
Task-sharing can be cost-effective in delivering mental health services to more people and can help to narrow the mental health treatment gap, particularly for common mental disorders.
There have been some significant research findings that show that task-sharing can effectively improve mental health outcomes. For example, the PRIME study led by University of Cape Town Professor Crick Lund and colleagues, showed that when tasks were shifted to primary care nurses, detection of depression and alcohol use disorders were significantly improved and more than half of people with depression showed a clinically significant improvement, compared to under a quarter of the control group.
Task-sharing can help reduce the costs of mental health treatment and make it more accessible to low-income individuals.
Another reason that many people do not seek mental health services is stigma.
Persons with a mental health condition, along with their families and carers, continue to experience stigma and discrimination. Stigma is detrimental can affect educational opportunities, job prospects, earning potential, and social connections. We all have a role to play to reduce the stigma associated with having a mental health condition.
Many people have internalised the idea that having a mental health condition is a matter to be ashamed of or to be embarrassed about. It is time we rid ourselves of such prejudices and accept that a mental health condition such as depression and or schizophrenia is similar to other health conditions such as diabetes or hypertension.
With the correct treatment, symptoms for such conditions can be controlled and people can live fulfilling and meaningful lives.
There is also a misconception that persons with mental health conditions are violent and should be feared. Actually, someone with a serious mental disorder, such as schizophrenia or bipolar disorder, is far more likely to be on the receiving end of violence than to harm someone else.
If you know someone with a mental health condition or if you have such a condition yourself, resist the tendency to stigmatise or ridicule the person. Understand that people are suffering and are usually in distress. Suggest that they seek help for their condition.
Covid and mental health
A discussion on mental health will be incomplete without mentioning the impact of the Covid-19 pandemic. Fear of infection and becoming ill has created considerable stress for many people.
Deaths from Covid-19 result in grief and bereavement for surviving family members. Job losses and business closures bring economic anxiety. Physical distancing can lead to social isolation and loneliness. Lockdown requirements can increase rates of family violence and thus cause trauma.
Over-exposure to news and social media related to the pandemic can result in anxiety and stress symptoms. School stoppages disrupt routines and can be a cause of stress to teachers, learners and parents. The disruptions created by the pandemic have in some cases exacerbated symptoms of mental health conditions among people already living with these.
Where to get help
On World Mental Health Day and beyond, it’s essential that people realise that if they or someone they know are experiencing symptoms of a mental health condition, such as depression, anxiety, suicidal thoughts, or hallucinations, the following sources of help are available:
· Suicide Crisis Helpline: 0800 567 567
· Lifeline SA Helpline: 0861 322 322
· South African Depression and Anxiety Group: 0800 567 567
· Adcock Ingram Depression and Anxiety Helpline: 0800 70 80 90
· Destiny Helpline for Youth & Students: 0800 41 42 43
– Professors Ashraf Kagee and Katherine Sorsdahl are the co-Directors of the Alan Flisher Centre for Public Mental Health, a World Health Collaboration Centre located at both Stellenbosch University and the University of Cape Town.
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