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Poverty and mental illness

Disparities in care in rural and urban South Africa

New research shows access to mental health care more limited in rural areas.

In a review of studies, MHaPP researchers at the Department of psychiatry and Mental Health UCT found that significant psychiatric conditions prevalent among South Africans - 16.5% suffered from common mental disorders like depression and anxiety in the last year. Even more concerning perhaps is that 17% of children and adolescents suffer from mental disorders. Research found that mental illness rank 3rd in their contribution to the burden of disease, after HIV and AIDS and other infectious diseases. Poverty plays an important part - 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.

Dr Crick Lund, Chief Research Officer of the Mental Health and Poverty Project, says that their 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.”

Another issue, which exacerbates the urban-rural split, is the Mental Health Care Act which legislates for least restrictive care, offered as close to the user’s community as possible. The Act states that inpatient mental health care should preferably be offered in a general hospital setting, with specialised hospital care available for more intensive mental health care, if required. In reality, however, rural areas lack even basic health care services and with increased deinstitutionalisation, large institutions have been closed or downsized without the development of community residential, hospital and outpatient mental health care services. “Mental health patients in rural areas have very little help or resources available to them”, says Zane Wilson, Director of the South African

Depression and Anxiety Group (SADAG). “In reality, may patients have to travel kilometers to get any health care and psychiatric facilities are very poor..” This places an increased burden of care on families and negatively impacts the patients’ well-being. The lack of community-based mental health services also puts additional pressure on already stretched primary health services and hospital beds. “The gap between the wonderful legislation… and what we find when it comes to implementation, the resourcing, the providing, the infrastructure for people to access services… is it’s either seriously lacking, or is in fact, absent...”says Zane Wilson

Mental illness not only leads to increased health expenditure, reduced productivity, and social exclusion, it also increases poverty which in turn heightens the risk of violence, malnutrition, obstetric risks, and increases the prevalence of mental illness while worsening their treatment outcomes.

“South Africa has a wonderful National Mental Health Care Act but it is often a hindrance to getting people the appropriate help”, says Dr Rangaka., Psychiatrist “Service providers often don’t know how the act works or what is expected of them, and services simply do not exist. This seriously affects the quality of patient care and response to crisis.” Dr Lund agrees. “We need a clear national mental health policy that is endorsed by a range of stakeholders in a truly consultative process. We need provincial Department of Health buy-in from all provinces, as well as multi-sectoral involvement, including Departments of Education, Social Development, Housing, SAPS, Correctional Services, Labour and Justice.”

The MhaPP study concluded that while poverty erodes mental well-being, mental health concerns are poorly integrated into the policies of other sectors, and the link between poverty and mental is poorly understood which results in a lack of inclusion of people with mental disability in poverty alleviation initiatives. 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. Stigma also contributes to the low priority of mental health on the government agenda.

Dr Lund and the MHaPP study team believe that it is not only the government's responsibility to address mental health - there needs to be greater awareness in the wider society about mental health issues. “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. It is vitally important that rural communities be educated about mental illness and community caregivers and nurses be trained in psychiatric care so that all South Africans with a mental illness can have access to diagnosis, treatment, and support.


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