South Africa is a country with an approximate area of 1221 thousand sq. km. (UNO, 2001). Its population is 45.214 million, and the sex ratio (men per hundred women) is 95 (UNO, 2004). The proportion of population under the age of 15 years is 33% (UNO, 2004), and the proportion of population above the age of 60 years is 6% (WHO, 2004). The literacy rate is 86.7% for men and 85.3% for women (UNESCO/MoH, 2004).
The country is a lower middle income group country (based on World Bank 2004 criteria). The proportion of health budget to GDP is 8.6%. The per capita total expenditure on health is 652 international $, and the per capita government expenditure on health is 270 international $ (WHO, 2004). The main language(s) used in the country is (are) eleven, with English being important for commerce. The largest ethnic group(s) is (are) African, and the other ethnic group(s) are (is) European and Asian. The largest religious group(s) is (are) Christian, and the other religious group(s) are (is) Hindu and Muslim. The life expectancy at birth is 48.8 years for males and 52.6 years for females (WHO, 2004). The healthy life expectancy at birth is 43 years for males and 45 years for females (WHO, 2004).
Rumble et al (1996) conducted a two-stage survey in a rural community (n=481) using the Self-Reporting Questionnaire (SRQ) and the Present State Examination (PSE). The weighted prevalence of psychiatric morbidity was 27.1%. Depression and anxiety disorder were common. Bhagwanjee et al (1998) assessed 354 rural adults with SRQ-20 and standardized instruments following a two-stage procedure. The weighted prevalence for DSM-IV generalized anxiety and depressive disorders was 23.9% (generalized anxiety: 3.7%, major depression: 4.8%, dysthymia: 7.3% and major depression and dysthymia: 8.2%). Michalowsky et al (1989) evaluated 1239 respondents from 3 mining areas. According to GHQ, the number of cases varied from 14.1% to 23.8%, and between 23.2% and 31.2% of respondents drank alcohol at least once a day. Women had more psychosocial illnesses in comparison to men. Ben Arie et al (1983) examined 139 non-institutionalized coloured elderly (above 65 years) persons using the PSE and the Mini Mental State Examination (MMSE). Dementia (8.6%, severe: 3.6%), other psychiatric disorders (24%, depression: 16.5%) and alcohol dependence (15% of men) were common. Parry et al (2002) reported the findings of the South African Community Epidemiology Network on Drug Use (SACENDU) project. Between 1997-99, alcohol was the most commonly used drug (51.1% – 77% in various regions) and use of alcohol was associated with trauma and comorbid psychiatric disorders. School surveys showed a harmful drinking pattern in 36% to 53.3% of male students. Use of cannabis and methaqualone was also common. There was a significant increase in cocaine and heroin use during the period. Flisher et al (2002) assessed 2930 students of grades 8 and 11. Lifetime prevalence rates of substance use were: 42.1% for tobacco, 43.8% for alcohol, 12.3% for cannabis and 3.6% for methaqualone, ecstasy or crack. London (2000) reported problem drinking and dangerous drinking according to CAGE and a shortened version of the Michigan Alcoholism Screening Test (MAST) in about two-thirds and 9.3%, respectively, of a sample of farm workers. In a rural general practice (n=858), 15.6% of the subjects had major depression (Strauss et al, 1995). Cooper et al (1999) found depression (as per DSM-IV) in 34.7% of 147 women who had delivered two months previously. Maternal depression was associated with poor support from partners and insensitive engagement with the infants. Allwood et al (2001) reported an incidence rate of 2-3 per 1000 births for puerperal psychosis (n=381) and that it was associated with primiparity and family or past history of psychiatric or medical illnesses. Flisher and Parry (1994) analysed the suicide mortality data from the national registry (1984-1986). Suicides accounted for 1.3% of deaths, with higher rates among the Whites, but suicide were very common among young Asian women. The most common method of committing suicide in Whites was firearms and in others hanging. Sukhai et al (2002) reviewed the National Injury Mortality Surveillance System register and police and hospital records (1996-2000) and found that suicides accounted for 5.6% of deaths. The majority of suicides were reported for black women in their thirties. In a sample of 7340 school children, Flisher et al (1993) found that during the previous 12 months, 19% of students had suicidal thoughts and 7.8% had attempted suicide.
Mhlongo and Peltzer (1999) found parasuicidal behaviour in 10% of young patients (15-24 years) attending a regional hospital. Robertson and Juritz (1998) found that 17.6% to 21% of 10-13 year-old children according to parents’ reports, and 9.5% to 10.5% of children according to teachers’ reports met the criteria for behaviour disorders. Behaviour disorders were associated with gender (boys), age (older), IQ (below 100) and learning disability. Robertson et al (1999) administered the Xhosa Diagnostic Interview Schedule for Children Version 2.3 to children and adolescents aged 6-16 years (n=500) in an informal settlement area. Psychiatric disorder with impairment was found in 15.2% of the children and adolescents. Peltzer (1999) assessed 148 secondary school children using the Children’s Posttraumatic Stress Disorder Inventory and the Reporting Questionnaire for Children and found that two-thirds of the children had experienced a traumatic situation and 8.4% met a diagnosis of PTSD. In a sample of 7516 Black primary school children, Cartwright et al (1981) found that 22.4% had a learning problem and 8.7% had a physical or mental handicap. Couper (2002) found a prevalence rate of 6% for various disabilities in a two-stage survey (n=2036) of children (<10 years). Perceptual or learning disabilities were common. Christianson et al (2002) assessed 6692 rural children (2-9 years old) following a two stage procedure and found a rate of 3.6% for intellectual disability (severe – 0.6% and mild – 2.9%). The male:female ratio was 3:2.
MENTAL HEALTH RESOURCES
Mental Health Policy A mental health policy is present. The policy was initially formulated in 1997. The components of the policy are advocacy, promotion, prevention, treatment and rehabilitation. The White Paper for the Transformation of the Health System in South Africa (1997) sets out the policy direction for the development and transformation of mental heath services.
Substance Abuse Policy A substance abuse policy is absent. The substance abuse policy is in the process of being finalized.
National Mental Health Programme A national mental health programme is present. The programme was formulated in 1997. The mental health programme is different for each province. The present move is towards establishing community-based services, with the integration of mental health services into primary health care. Concerted efforts are also being made to assist with preventive and promotive aspects of mental health.
National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. It was formulated in 1998.
Mental Health Legislation The existing legislation, the Mental Health Act, is old. The Mental Health Care Act, was passed by Parliament in 2002. It will be promulgated in 2004. The main aims of the Act are to promote human rights of people with disabilities; improve mental health services through a primary health care approach and an emphasis on community care; protect the health and safety of the public in circumstances where a person with mental disabilities may be a danger to him/herself or others; set out the framework and statutory roles with respect to voluntary users, assisted users, involuntary users, state patients and mentally ill prisoners. Current legislation will allow the possibility of non-medical practitioners having the right to prescribe (CRTP) medication in South Africa. The latest legislation was enacted in 2002.
Mental Health Financing There are budget allocations for mental health. Details about expenditure on mental health are not available. The primary sources of mental health financing in descending order are tax based, private insurances, out of pocket expenditure by the patient or family and social insurance. Quite recently, a study was commissioned to calculate the expenditure on mental health. The study provided highly disputed figures as it failed to calculate the cost of the integrated mental health care. A patient advocacy NGO, the Depression and Anxiety Support Group, found evidence of discrimination against mental illnesses in South African medical aids and state-funded health systems. Specifically, some aids refused to cover hospitalization for suicide attempts and substance use disorders. The country has disability benefits for persons with mental disorders.
Mental Health Facilities Mental health is a part of primary health care system. Actual treatment of severe mental disorders is available at the primary level. Care is provided in some cases by a psychiatric nurse and in others by a primary health care worker.
The current psychiatric practice is varied and a new patient can be initially seen by either a psychiatrist or a community nurse or a primary nurse depending on the place. The patient is then either treated at that place or is immediately referred to a secondary facility. The aim is to make the system more efficient so that there is a comprehensive mental care facility at the community level. However the integration of mental health into primary health care services is sub-optimal.
Regular training of primary care professionals is carried out in the field of mental health. In the last two years, about 450 personnel were provided training. Primary health care practitioners, e.g. nurses undergo integrated training that provides for knowledge and skills needed to handle psychosocial issues. This is supplemented by further training in additional or contemporary mental health issues like crisis intervention/trauma counselling, phacotherapy, management of substance abuse etc. Evaluation of components of these programmes have shown that the interventions have been successful.
There are community care facilities for patients with mental disorders. Other than giving medical care, community care is very limited.
Psychiatric Beds and Professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
The staff-patient ratios cited above may be an over-estimation due to the high rate of emigration of health personnel and the employment of mental health professionals in other sectors. There are 109 occupational therapists, 89 medical officers and 28 community health workers besides a number of trainee mental health professionals working in the mental health services. About a quarter of the beds are acute beds and three quarters medium-long stay beds. There are large differences between bed strengths in each province, with Mpumalanga, North-West Province and Northen Cape having few beds and Gauteng and Northern Province having many beds for mental health care. In some province downsizing has occurred, but it was not accompanied by the development of residential and ambulatory care in the community. The only province to report residential care facilities in the community was Gauteng, which reported a total of 305 places. Most mental health professionals are concentrated in the Cape Town and Guateng (Johannesburg-Pretoria) region. The North-West Province has no psychiatrist, and Northern Cape and Mpumalanga have only one each. These regions have a low concentration of other mental health professionals also. About 56% of psychiatrists in South Africa work in private set-ups. They provide services to about 20% of the population, the majority of whom are funded by medical insurance.
Only 4.7% of psychiatrists are practicing in the rural setting. Most psychiatrists are biologically oriented and the few who practice psychotherapy use cognitive-behavioural models in most situations. However, Jungian School of analytical psychotherapy is practised by some in Cape Town. Limited private practice is permitted to psychiatrists in the Government set-up. A substantial proportion of psychiatrists recruited to English-speaking countries are from South Africa. Not many black doctors have been attracted to psychiatry; as a result only 10.8% of South African psychiatrists are able to communicate fluently in one or more African languages.
Non-Governmental Organizations NGOs are involved with mental health in the country. They are mainly involved in advocacy, promotion, prevention, treatment and rehabilitation. At least 14 support groups are functioning in South Africa. However, 10 areas have no support groups. They rendered assistance in advocacy, providing for basic needs of their members, life skills teaching, crisis intervention and counselling. Rural support groups provide advocacy, treatment and rehabilitation.
Information Gathering System There is no mental health reporting system in the country. The national indicators do not include information on the prevalence of mental disorders. At the district level, data on clinical consultations is collected.
The country has data collection system or epidemiological study on mental health. Data are collected from hospital and community services. A national epidemiological study is under way. The South African Demographic Health Survey conducted in 1998 and the First South African Youth Risk Behaviour Survey (2002) contributed important findings on mental health of populations.
Programmes for Special Population The country has specific programmes for mental health for children. Some of the programmes are run by NGOs and the Government has also started working in some areas. There are some programmes for victims of violence.
Child and adolescent, geriatric and neuropsychiatric services are available, but dedicated staff and facilities are available at only a few centres. Some community psychiatric nurses have been given special training in child and adolescent mental health issues. As a part of the National Crime Prevention strategy, the mental health directorate has taken responsibility for training general health workers in ‘victim empowerment’, setting up ‘violence referral centres’ in disadvantaged areas, setting up violence prevention programmes in schools and developing mother-infant bonding programmes for violence prevention in poor communities. As a part of the national initiative to prevent the spread of HIV among school children, teachers in every school are being trained to teach HIV/AIDS-related and substance abuse-related life skills at primary and secondary school levels. The need for pre-test and post-test counselling on HIV/AIDS will lead to the deployment of counsellors in every clinic in a five-year period. A Mental Health Information Centre has been started to provide psychoeducation.
Therapeutic Drugs The following therapeutic drugs are generally available at the primary health care level of the country: carbamazepine, ethosuximide, phenobarbital, sodium valproate, amitriptyline, chlorpromazine, diazepam, fluphenazine, haloperidol, lithium, biperiden, carbidopa, levodopa. The acquisition costs of new psychotropics is considerably greater than those of their predecessors.
In 1978, the APA compiled a report criticizing the racial bias in psychiatric practice. Similar reports were filed by the Royal College of Psychiatrists in 1983. Isolation from international forums followed from 1987. Though currently racial bias is not present in treatment issues, a recent study (Lee et al, 1999) found that the better centres tended to be utilized more by the white community. This was due to the availability of better services in the white population dominated areas, and the conclusion was to extend some of these services to the poorer sections of the community without compromising the existing structure present in the more affluent white community. In response to the gross violation of human rights in the past, the post-apartheid Government established a Truth and Reconciliation (TRC) in a move to promote national unity and reconciliation. Mental health professionals provided advice regarding the manner in which testimony should be taken, and provided psychological support when necessary to those who testified. TRC members were trained in issues relevant to psychological support, and some of the TRC commissioners were mental health professionals.