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Broken minds need community care

The high cost of treatment makes mental healthcare inaccessible to those using public health services.


One in three South Africans will be affected by a mental illness in their lifetime, according to the South African Stress and Health Study published in the South African Medical Journal in 2009.

But the high cost of treatment means that appropriate and effective care is frequently inaccessible to ­people who use the country’s public health system.

Let’s consider a typical case. When Buyiswa (not her real name) was 24 she turned to drugs in an attempt to forget her traumatic childhood at the hands of an abusive father and the pain of her failed three-year marriage. This triggered a psychotic ­episode, or mental breakdown, and she spent months in a psychiatric hospital ­trying to recover.

Fourteen years later Buyiswa has a degree, works as a teacher and is in a stable relationship. But then she had a relapse. All Buyiswa needs is a little bit of support in her community to get her through a rough patch. But there are no community mental health services where she lives. All that is available is admission to a psychiatric hospital, possibly for weeks.

Lack of service

But Buyiswa is one of the fortunate ones who have access to mental health care. Only half of African countries have any mental health

services outside hospitals. In Namibia there is only one mental health hospital.

This year, I was mentoring a health professional who is helping to establish Zimbabwe’s first inpatient ­facility for the treatment of children and adolescents with mental health problems; prior to this, there wasn’t a ­single inpatient facility catering for their needs.

In South Africa the situation is slightly better, especially in urban areas. The problem is that, for people like Buyiswa, inpatient treatment is not enough. And it often makes the situation worse.

In their 2013 study on how people with schizophrenia remembered their first admission to a South African hospital, Wits University researchers found many participants experienced psychiatric care as traumatic, frightening and distressing.

In the study, published in the South African Journal of Psychiatry, one former patient talked about the experience as being “terrible. It’s like a hell hole … I don’t know what happened, my spirit left me, my mind left me, I was a zombie. That was one of my worst experiences in my life.”

Community involvement

University of Kwazulu-Natal clinical psychologist Suntosh Pillay talks about needing to “move from the couch to the community”.

I agree with this sentiment because the situation for people like Buyiswa does not necessarily get better once they go home. Because there are inadequate services to meet the needs of all who should be admitted, some government hospitals discharge the mental healthcare users who appear to be the “least ill” to make space for new, urgent admissions.

These crisis discharge policies have led to the “revolving-door phenomenon”, in which mental healthcare users are admitted for a short time to a psychiatric clinic, are discharged and are then readmitted soon thereafter. As a result, they spend many months in and out of hospital.

This comes at a high price. Other than the direct costs associated with being in hospital, research tells us that people like Buyiswa, who have a mental health admission, are more likely to lose their jobs and are also likely to earn less when they are able to return to work.

Their relationships with family and friends may also suffer, and they may lose their homes because they can’t pay the rent. The highest cost is the damage to their reputation in the community – admission into psychiatric care comes with a stigma that is hard to shake off.

No follow-up

The root of this problem is the lack of follow-up care in the community. In their review of South Africa’s mental health service provision in 2010, Crick Lund and his colleagues at the Alan J Flisher Centre for Public Mental Health at the University of Cape Town reported that primary health care services focus on symptom management and the dispensing of psychiatric medication.

But few primary health care nurses have specialist mental health training. The advocacy group Stop Stock-outs has found clinics, especially those in rural areas, often run out of medicines.

But this is only part of the problem. People with mental health problems are also affected by a loss of caring for each other, or ubuntu.

As Pillay pointed out in a recent Mail & Guardian Thoughtleader article: “We live in societies that are increasingly less communal, with the ­collapse of previously available support structures, such as extended families and neighbours.”

So what then is the solution for people such as Buyiswa? South Africa’s Mental Health Care Act promotes community-based care for mental healthcare users. This is in line with the provision of psychiatric care in developed countries, and is also more cost-effective than hospital admission.

Stellenbosch University research shows that out patient occupational therapy services that are based on the principles of psychosocial rehabilitation reduce both the number of days mental health care users spend in hospital and the number of times they are admitted over a two-year period. Unfortunately, South Africa’s healthcare system is not changing quickly enough. It also mistakenly focuses on symptom and medication management.

People like Buyiswa need services that help them put the pieces of their lives back together. Medication alone does not help them repair their relationships, look after themselves better, or get back to work.

Without access to multidisciplinary services including occupational therapy, social work and psychiatric nursing in the community in which they live, their hard work at recovery may go to waste.

Nicola Plastow is an Associate Professor, and Head of the Division of Occupational Therapy.