Mental health service delivery in South Africa from 2000 to 2010: One step forward, one step back
TL;DR: There has been some progress in the decentralisation of mental health service provision, but substantial gaps in service delivery remain and intervention research is needed to provide evidence of the organisational and human resource mix requirements and cost-effectiveness of a culturally appropriate, task shifting and stepped care approach for severe and common mental disorders at primary healthcare level.
Abstract: In 2000, Rita Thom published a systematic review of mental health services research in southern Africa, conducted from 1967 to 1999. 1 The review suggested a need to shift from centralised institutional care, which characterised apartheid South Africa, towards decentralised, integrated and community-based services provided within a human rights framework. The use of trained non-specialists to provide mental healthcare was also suggested as a strategy to increase access in the context of a shortage of mental health specialists. Research gaps identified included the need for accurate epidemiological studies; intervention studies demonstrating the efficacy of sustainable models of service delivery in line with policy imperatives for deinstitutionalised and integrated primary mental healthcare; and economic evaluation studies of service delivery models. 2 The latter included cost-effectiveness, cost-benefit and cost-utility analyses. Policies and legislation in post-apartheid South Africa have been consistent with the suggestions emanating from this review in a bid to increase access and quality of care within a human rights framework. 3,4
Citations
More filters
TL;DR: Transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its citizens.
542 citations
TL;DR: In this paper, the authors assessed the effect of job loss and job furlough on the mental health of individuals in South Africa during the COVID-19 pandemic and found that adults who retained paid employment during the lockdown had significantly lower depression scores than adults who lost employment.
Abstract: OBJECTIVES: Existing literature on how employment loss affects depression has struggled to address potential endogeneity bias caused by reverse causality The COVID-19 pandemic offers a unique natural experiment because the source of unemployment is very likely to be exogenous to the individual This study assessed the effect of job loss and job furlough on the mental health of individuals in South Africa during the COVID-19 pandemic DATA AND METHODS: The data for the study came from the first and second waves of the national survey, the National Income Dynamics-Coronavirus Rapid Mobile Survey (NIDS-CRAM), conducted during May-June and July-August 2020, respectively The sample for NIDS-CRAM was drawn from an earlier national survey, conducted in 2017, which had collected data on mental health Questions on depressive symptoms during the lockdown were asked in Wave 2 of NIDS-CRAM, using a 2-question version of the Patient Health Questionnaire (PHQ-2) The PHQ-2 responses (0-6 on the discrete scale) were regrouped into four categories making the ordered logit regression model the most suited for assessing the impact of employment status on depressive symptoms RESULTS: The study revealed that adults who retained paid employment during the COVID-19 lockdown had significantly lower depression scores than adults who lost employment The benefits of employment also accumulated over time, underscoring the effect of unemployment duration on mental health The analysis revealed no mental health benefits to being furloughed (on unpaid leave), but paid leave had a strong and significant positive effect on the mental health of adults CONCLUSIONS: The economic fallout of the COVID-19 pandemic resulted in unprecedented job losses, which impaired mental wellbeing significantly Health policy responses to the crisis therefore need to focus on both physical and mental health interventions
148 citations
TL;DR: The implementation of community mental health models has been extremely difficult, given that attaining the additional funds required to establish outpatient services has frequently not been available in low- and middle-income countries.
Abstract: Mental health disorders (especially psychotic disorders such as schizophrenia) constitute the leading cause of disability-adjusted life years (DALYs) from all non-communicable diseases (1). These disorders relate to severe social, educational and occupational impairment, physical illness, and premature mortality (2). Approximately, three-quarters of the burden of mental illness comes from low- and middle-income countries (LMICs) (3).
Governments from LMICs spend the lowest percentages on mental health worldwide (4). Most of these countries model their mental health systems based on care that is primarily delivered through psychiatric institutions. Hence, the implementation of community mental health models has been extremely difficult, given that attaining the additional funds required to establish outpatient services has frequently not been available in these countries. Additionally, human resources are limited and inequitably distributed. This explains why in LMICs more than 75% of people that require mental health care do not receive any kind of intervention (5). This statistic refers to the “treatment gap”: the proportion of people who need but do not receive care. The World Health Organization (WHO) has reported that the treatment gap for serious mental disorders is 35–50% in developed countries and 76–90% in LMICs (6).
Stigma comprises a major problem related to help seeking in people with mental health difficulties in developing countries. Stigmatized individuals may anticipate devaluation and discrimination from others, leading them to adopt harmful coping mechanisms such as secrecy or withdrawal (7). Studies conducted in LMIC such as Ethiopia and India have reported this tendency, whereby consumers prefer to not disclose their problems or symptoms with health professionals or even with their own relatives (8). Such harmful coping strategies further obstruct effective treatment use. Several authors have recommended the implementation of national public education campaigns and local interventions to increase mental health literacy to reduce discrimination in these countries (9).
121 citations
TL;DR: Key governance strategies identified to address challenges included strengthening capacity of managers at sub-national levels to develop and implement integrated plans; strengthening key aspects of the essential health system building blocks to promote responsiveness, efficiency and effectiveness.
Abstract: Poor governance has been identified as a barrier to effective integration of mental health care in low- and middle-income countries. Governance includes providing the necessary policy and legislative framework to promote and protect the mental health of a population, as well as health system design and quality assurance to ensure optimal policy implementation. The aim of this study was to identify key governance challenges, needs and potential strategies that could facilitate adequate integration of mental health into primary health care settings in low- and middle-income countries. Key informant qualitative interviews were held with 141 participants across six countries participating in the Emerging mental health systems in low- and middle-income countries (Emerald) research program: Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. Data were transcribed (and where necessary, translated into English) and analysed thematically using framework analysis, first at the country level, then synthesized at a cross-country level. While all the countries fared well with respect to strategic vision in the form of the development of national mental health policies, key governance strategies identified to address challenges included: strengthening capacity of managers at sub-national levels to develop and implement integrated plans; strengthening key aspects of the essential health system building blocks to promote responsiveness, efficiency and effectiveness; developing workable mechanisms for inter-sectoral collaboration, as well as community and service user engagement; and developing innovative approaches to improving mental health literacy and stigma reduction. Inadequate financing emerged as the biggest challenge for good governance. In addition to the need for overall good governance of a health care system, this study identifies a number of specific strategies to improve governance for integrated mental health care in low- and middle-income countries.
113 citations
Cites background from "Mental health service delivery in S..."
...However, once again, implementation remains a challenge, with infrastructure and specialist staff being found to be inadequate for the 72-h emergency management and observation service, despite findings that 75.6% of psychiatric admissions were involuntary or assisted (Petersen and Lund 2011)....
[...]
...6% of psychiatric admissions were involuntary or assisted (Petersen and Lund 2011)....
[...]
TL;DR: The plan leverages resources and systems availed by the emerging chronic care service delivery platform for the integration of mental health, and strengthens the potential for future scale up.
Abstract: South Africa has a 12-month prevalence estimate of 16.5% for common mental disorders (anxiety, mood and substance use disorders),1 with almost a third (30.3%) of the population having experienced a common mental disorder in their lifetime.2 These estimates are relatively high when compared with international prevalence estimates of the WHO (World Health Organization) World Mental Health surveys.3 As is the case internationally,4,5 the treatment gap in South Africa is also high, with only one in four people with a common mental disorder receiving treatment of any kind. For those with psychotic disorders, although identification and access to treatment is better, there are insufficient resources at community level for promotion of recovery.6,7 The aim of the formative phase of the PRogramme for Improving Mental health carE (PRIME) in South Africa was to (a) develop a mental healthcare plan (MHCP), customised to local conditions at district level that provides acceptable and feasible collaborative care packages for depression, alcohol use disorders and schizophrenia and can be integrated into existing service delivery platforms; (b) identify the human resource mix to deliver the MHCP and develop implementation tools to support and facilitate scale up of the packages; and (c) identify potential barriers to implementation at scale. The reason for the focus on these conditions is their relatively high burden of disease and disability and evidence of cost-effective interventions for their treatment.8
92 citations
References
More filters
TL;DR: Mental health affects progress towards the achievement of several 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/AIDS.
2,943 citations
01 Jan 2003
TL;DR: Group interpersonal psychotherapy was highly efficacious in reducing depression and dysfunction and a clinical trial proved feasible in the local setting.
Abstract: CONTEXT
Despite the importance of mental illness in Africa, few controlled intervention trials related to this problem have been published.
OBJECTIVES
To test the efficacy of group interpersonal psychotherapy in alleviating depression and dysfunction and to evaluate the feasibility of conducting controlled trials in Africa.
DESIGN, SETTING, AND PARTICIPANTS
For this cluster randomized, controlled clinical trial (February-June 2002), 30 villages in the Masaka and Rakai districts of rural Uganda were selected using a random procedure; 15 were then randomly assigned for studying men and 15 for women. In each village, adult men or women believed by themselves and other villagers to have depressionlike illness were interviewed using a locally adapted Hopkins Symptom Checklist and an instrument assessing function. Based on these interviews, lists were created for each village totaling 341 men and women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression or subsyndromal depression. Interviewers revisited them in order of decreasing symptom severity until they had 8 to 12 persons per village, totaling 284. Of these, 248 agreed to be in the trial and 9 refused; the remainder died or relocated. A total of 108 men and 116 women completed the study and were reinterviewed.
INTERVENTION
Eight of the 15 male villages and 7 of the 15 female villages were randomly assigned to the intervention arm and the remainder to the control arm. The intervention villages received group interpersonal psychotherapy for depression as weekly 90-minute sessions for 16 weeks.
MAIN OUTCOME MEASURES
Depression and dysfunction severity scores on scales adapted and validated for local use; proportion of persons meeting DSM-IV major depression diagnostic criteria.
RESULTS
Mean reduction in depression severity was 17.47 points for intervention groups and 3.55 points for controls (P<.001). Mean reduction in dysfunction was 8.08 and 3.76 points, respectively (P<.001). After intervention, 6.5% and 54.7% of the intervention and control groups, respectively, met the criteria for major depression (P<.001) compared with 86% and 94%, respectively, prior to intervention (P =.04). The odds of postintervention depression among controls was 17.31 (95% confidence interval, 7.63-39.27) compared with the odds among intervention groups. Results from intention-to-treat analyses remained statistically significant.
CONCLUSIONS
Group interpersonal psychotherapy was highly efficacious in reducing depression and dysfunction. A clinical trial proved feasible in the local setting. Both findings should encourage similar trials in similar settings in Africa and beyond.
531 citations
TL;DR: In this paper, the authors evaluated the efficacy of group interpersonal psychotherapy in alleviating depression and dysfunction and to evaluate the feasibility of conducting controlled trials in Africa, and found that it was highly efficacious in reducing depressive disorders and dysfunction.
Abstract: ContextDespite the importance of mental illness in Africa, few controlled intervention
trials related to this problem have been published.ObjectivesTo test the efficacy of group interpersonal psychotherapy in alleviating
depression and dysfunction and to evaluate the feasibility of conducting controlled
trials in Africa.Design, Setting, and ParticipantsFor this cluster randomized, controlled clinical trial (February-June
2002), 30 villages in the Masaka and Rakai districts of rural Uganda were
selected using a random procedure; 15 were then randomly assigned for studying
men and 15 for women. In each village, adult men or women believed by themselves
and other villagers to have depressionlike illness were interviewed using
a locally adapted Hopkins Symptom Checklist and an instrument assessing function.
Based on these interviews, lists were created for each village totaling 341
men and women who met Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV)
criteria for major depression or subsyndromal depression. Interviewers revisited
them in order of decreasing symptom severity until they had 8 to 12 persons
per village, totaling 284. Of these, 248 agreed to be in the trial and 9 refused;
the remainder died or relocated. A total of 108 men and 116 women completed
the study and were reinterviewed.InterventionEight of the 15 male villages and 7 of the 15 female villages were randomly
assigned to the intervention arm and the remainder to the control arm. The
intervention villages received group interpersonal psychotherapy for depression
as weekly 90-minute sessions for 16 weeks.Main Outcome MeasuresDepression and dysfunction severity scores on scales adapted and validated
for local use; proportion of persons meeting DSM-IV major
depression diagnostic criteria.ResultsMean reduction in depression severity was 17.47 points for intervention
groups and 3.55 points for controls (P<.001).
Mean reduction in dysfunction was 8.08 and 3.76 points, respectively (P<.001). After intervention, 6.5% and 54.7% of the intervention
and control groups, respectively, met the criteria for major depression (P<.001) compared with 86% and 94%, respectively, prior
to intervention (P = .04). The odds of postintervention
depression among controls was 17.31 (95% confidence interval, 7.63-39.27)
compared with the odds among intervention groups. Results from intention-to-treat
analyses remained statistically significant.ConclusionsGroup interpersonal psychotherapy was highly efficacious in reducing
depression and dysfunction. A clinical trial proved feasible in the local
setting. Both findings should encourage similar trials in similar settings
in Africa and beyond.
501 citations
TL;DR: Despite few resources and marked deprivation, women with major depression responded well to a structured, stepped-care treatment programme, which is being introduced across Chile.
422 citations
TL;DR: High levels of depression, PTSD and alcohol dependence/abuse among HIV-infected individuals in this setting are demonstrated and HIV care and treatment services represent an important venue to identify and manage individuals with common mental disorders in resource-limited settings.
Abstract: Despite the high prevalence of both mental disorders and HIV infection in much of sub-Saharan Africa, little is known about the occurrence of mental health disorders among HIV-infected individuals. We conducted a cross-sectional study among individuals enrolled into HIV care and treatment services near Cape Town, South Africa. Psychiatric diagnoses were measured using the Mini-International Neuropsychiatric Interview (MINI) administered by trained research nurses. In addition, all participants were administered brief rating scales for depression (the Center for Epidemiological Studies Depression Scale [CES-D]), posttraumatic stress disorder (PTSD), the Harvard Trauma Questionnaire (HTQ), and alcohol dependence/abuse (the Alcohol Use Disorders Identification Test [AUDIT]). The median age among the 465 participants was 33 years and 75% were female; 48% were receiving antiretroviral therapy. Overall, the prevalence of depression, PTSD and alcohol dependence/abuse was 14% (n = 62), 5% (n = 24), and 7...
414 citations