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Catherine (not her real name), a Mpumalangan woman with a family history of depression, has learned the hard way about the failure of our health services in looking after the mentally ill.

If struggling with debilitating depression wasn't bad enough, a disastrous marriage drove her over the edge. After a particularly bad fight over her husband's latest affair, Catherine, watched coolly by her spouse who did nothing to help her, swallowed more than 50 tablets. Some time later, before lapsing into unconsciousness, Catherine somehow remembered the help she had received from the South African Depression & Anxiety Group (SADASG) and phoned the region’s support group co-ordinator, who rushed her to hospital.

That Catherine lived to tell her tale is more a miracle, than due to the treatment she received in the local government hospital. A skeleton staff was busy with accident victims, so Catherine lay, untreated, for over an hour before a bed was finally found and only the most peremptory treatment was administered. She was discharged the next morning with no further monitoring, no counselling and, unbelievably, with a month's supply of the very same drugs with which she had tried to kill herself!

"This is unfortunately just one of several similar cases," says Dr Anne Marie Potgieter, a psychiatrist and chairman of the advisory board of SADASG. She is one of many concerned psychiatrists worried about mental health care funding and treatment.

Dr Potgieter commented on the closure of several local and rural clinics. "These were set up according to the government's policy on primary health care, but the plan has not worked. People now had have to travel very long distances to get help and sometimes it is just not there," she says. Many hospitals have deteriorated and offer sub-standard conditions, which applies particularly in less developed areas like Mpumalanga, Limpopo and KwaZulu-Natal.

Catherine, as a long-standing medical aid member should, by right, have been entitled to better care. Medical aid schemes, however, allocate minimal funding for psychiatric treatment and do not cover suicide-related treatment. A spokesman for Discovery Health, reflecting most medical aid societies, explained that "a person who deliberately causes himself harm affects the level of risk that the scheme is exposed to." Even though suicide is more often than not an act of mental incapacity such as depression, it is categorised as self-inflicted injury for which medical and life insurance companies will not accept liability.

She should also have access to psychiatric expertise, but would never be able to afford it. Current rates for private psychiatric consultation range between R380 and R750, no mean sum for the affluent, but definitely out of reach of the country's middle to lower income earners. Government psychiatric facilities are not a solution. They barely cope with the sheer numbers of patients requiring attention. There is also concern that government clinics may only provide one or two of the older generation generic drugs, rather than the newer and more effective drugs available. Many patients stop their medication as soon as they feel better, or because they haven’t been warned about temporary side effects. It comes as little surprise, therefore, that many of these illnesses go untreated for years, often with devastating results.

Mental illness certainly seems to be getting the short end of the stick when it comes to medical care and funding. Psychiatric wards have closed down in many state hospitals. And staffs are not adequately trained to cope with mentally ill or severely depressed patients. There is also a critical shortfall in the number of psychiatry-related specialists. Founder and chairman of SADAG, Zane Wilson, revealed that only 320 psychiatrists service South Africa's 42 million inhabitants. Typically, these services are concentrated in larger cities. The disparity is further evident in the largest concentration of psychiatrists and psychologists being found in the wealthier northern suburbs of Johannesburg, with pitifully few operating in the less affluent south of the city.

This is discouraging news because poverty is a major cause of depression and suicide, especially among the increasing numbers of unemployed youth in South Africa. The people who need help the most are therefore people most deprived of it.

"Suicide," Dr Potgieter says, is "the most dangerous complication of depression." Yet depression is all too often misunderstood. It is serious enough, however, to have the dubious distinction of being one of the leading causes of shorter life expectancy in industrialised nations in the 21st century, affecting close on 200 million people around the globe.

The World Health Organisation estimated that in the year 2000, one million people world-wide committed suicide and those numbers are rising. In South Africa, the suicidal death rate increased from 23.7 to 38.6 per 100 000 of the population between 1993 and 2000. Clearly there is a need for government to re-examine and re-structure primary health care in order to stem the alarming consequences of neglected mental health. Its effects on the economy – in lost working days due to physical manifestations of depression alone - warrant drastic action.

Whatever its cause, mental illness has a devastating impact on the sufferer, on his or her family, and in many cases, on society as a whole. It is also one of the least understood illnesses, but the most under-treated. SADAG is campaigning for recognition of depression and anxiety disorders as a 'normal' illness that can be treated successfully with modern medicine and therapy. Perhaps Catherine's future, and that of many like her, will depend on meaningful change in the medical aid companies' acceptance and treatment of her illness.


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