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Depression

10 October 2020

OPINION | World Mental Health Day: Under-investment in mental health has never been more acutely felt

Over the ensuing months and years, the mental health sequelae of Covid-19 will place additional strain on staffing and budgets in both the public and private healthcare sectors.

  • Universal health coverage is defined as ensuring that all people have access to needed health services  
  • In terms of mental health, Sustainable Development Goals have sadly not been prioritised in South Africa
  • In this country, the treatment gap for mental disorders is over 90%


The central theme for this year’s World Mental Health Day (October 10), is “Mental Health for All Greater Investment – Greater Access”. Globally, and particularly in low- and middle-income countries, the historic under-investment in mental health has never been more acutely felt than at this juncture. 

It is reasonable to assume that over the ensuing months and years, the additional medium- and long-term mental health sequelae of Covid-19 – which may manifest as direct and/or indirect effects of the virus – will place additional strain on staffing and budgets in both the public and private healthcare sectors. 

It was only five years ago that mental health and substance abuse were explicitly named as health priorities in the Sustainable Development Goals (SDGs), acknowledging for the first time that mental illness, and serious mental illness (e.g. schizophrenia and bipolar disorder) in particular, is a major bottleneck in the attainment of sustainable development. 

Ensuring universal access to needed health services

Though mental health is closely tied to, and cross-cuts, almost all of the 17 SDGs, Goal 3 specifically relates to mental health and substance abuse. Goal 3 seeks by 2030 to reduce, by one third, premature mortality from non-communicable diseases through the prevention, treatment and promotion of mental health and well-being, to strengthen prevention and treatment of substance abuse, including the harmful use of alcohol and narcotic drugs, and to achieve universal health coverage that includes mental health.

Universal health coverage is defined by the World Health Organisation as “ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective”.  

Sadly, these SDG targets have not been prioritised in health action plans and fiscal allocations in many countries, including South Africa, and resultantly not translated into universal scale-up of mental health treatment, prevention, and psychosocial support services. Yet, from a public health, economic and human rights perspective, mental health access for all should be a priority. Improving mental health and well-being and reducing substance abuse correspondingly improves physical health, reduces violence, strengthens social capital, increases productivity and furthers economic growth. 

Mental illness is associated with distress and functional impairment that can have pernicious consequences not only for those with the illness, but also for their families and their work and social spheres. In their 2016 article, Sebastian Trautmann, Jürgen Rehm and Hans-Ulrich Wittchen argued that mental illness deeply affects the fabric of society incurring both visible costs (e.g. costs associated with diagnosis, health care costs, medication, psychotherapy sessions, hospitalisation etc.) as well as hidden costs (e.g. costs associated with lost income, disability, medical boarding, work absenteeism, medical boarding and mortality). 

Physical abuse and sexual victimisation

In South Africa, the treatment gap for mental disorders – that is, the gap between South Africans with mental illness who need treatment and those who actually receive it – is close to 92%. This gap is even wider for children and adolescents (i.e. persons under 18 years) who make up a third of the population. This is hugely concerning considering that half of all mental illness starts by mid-adolescence. 

About a quarter of South Africa’s adolescents experience physical abuse by an adult, and roughly the same number experience sexual victimisation, as Lillian Artz and her co-authors pointed out. Exposure to violence is intricately linked to mental health, and the devastating early and long-term impacts of violence on the mental health of children, adolescents and adults are widely recognised.

The consequences extend to depression, post-traumatic stress disorder, anxiety disorders, alcohol and drug use disorders, eating disorders, sleep disorders and suicide, among others. The Covid-19 pandemic has magnified this situation, with an exacerbation of violence perpetrated against youth associated with confinement at home, increased contact with violent caregivers, parental stress and tension, lack of access to school-based resources, and limited to no access to mental health services. 

Expenditure on mental health in the South African public health sector is only 5% of the country’s total health budget. For the majority of provinces this allocation is in fact less than 5%, with a disproportionate spend (>80%) on inpatient care, even though outpatients comprise the vast majority receiving mental health treatment and psychosocial care in both public and private health sectors. 

The stark reality

Among South Africans who have no medical aid, less than 1% receive some form of inpatient mental health care and less than 10% mental health outpatient care. This is compounded by a national shortage of psychiatrists (0.31 psychiatrists  per 100 000) to service South Africans without any medical aid and a woeful lack of the child and adolescent psychiatrists in the public sector, with several provinces without a public sector child and adolescent psychiatrist. 

This is the stark reality that confronts us on World Mental Health Day. Mental illness is stymying economic growth and will continue to do so unless efforts to address the inequities in access to mental health care, and the intersecting social determinants that pose a risk for mental illness (e.g. poverty, violent crime, stigma, tighter restrictions on alcohol access), are urgently intensified.

In Covid and post-Covid eras, the ongoing mental health needs of South Africans with pre-existing mental illness and the needs of those with new-onset mental illness must be adequately catered for. This includes the provision of mental healthcare for health-care workers and other essential workers who have been front and centre of this pandemic. 

The Covid-19 pandemic represents an important turning point. The government has stepped up efforts to expand its gender-based violence response systems. Flattening the gender-based violence curve is one way to flatten the mental health curve. Capacitating mental health services and facilitating timely access to mental health services for those with lived experience of mental illness is another. 

It should be mandatory to increase investment in mental health in national and provincial health budgets, through multi-sectoral approaches that combine universal and targeted interventions for preventing mental disorders and promoting well-being, with the many evidence-based treatments that have demonstrated effectiveness, cost-effectiveness, and scalability potential.

The costs of not doing so are too high to ignore. The Life Esidemeni tragedy highlighted the systemic deficits regarding the treatment of people with mental illness and the pervasive neglect of mental health services. On the mental health landscape, this is one tragedy too many.   

*Prof Soraya Seedat is the Executive Head of the Department of Psychiatry in the Faculty of Medicine and Health Sciences at Stellenbosch University. 

Image credit: Supplied