When COVID-19 hit, South African Depression and Anxiety Group (Sadag) helplines were flooded with calls. But the outbreak changed more than call volumes, it changed the way Sadag worked. Could the lessons it learned shape the future of mental healthcare in South Africa?
Kaelo Mahao, not their real name, lives with anxiety and bipolar disorder, a mental health condition that causes extreme mood changes. Mahao also uses the pronoun “they”.
Some people with Mahao’s condition experience prolonged sadness and feel hopeless or fatigued at times. At other moments, people with bipolar may have loads of energy — so much so that they struggle to sleep. Psychiatric medication can help them to stabilise these changes in mood.
But when South Africa instituted its national coronavirus lockdown in late March, Mahao was faced with a life-threatening dilemma: to leave home to collect their medication and risk their fear of contracting the new coronavirus triggering their crippling anxiety, or to go without their pills and put themselves in danger of a possible depressive episode. To get by, Mahao decided to split their tablets in half to stretch their remaining stock.
A few days later, they had an episode.
If Mahao struggled to access treatment under South Africa’s coronavirus lockdown, they weren’t the only one. Nearly one in 10 people surveyed by the Human Sciences Research Council also reported difficulty accessing chronic medication during the initial lockdown.
“[The lockdown] impacted people’s ability to travel and get from home to clinics,” Johannesburg health district clinical head of psychiatry Yusuf Moosa told me recently. “There were a significant number of patients who were unable to come to the clinics and collect their medications and see their psychiatrists for their follow-ups.”
Most people told researchers COVID-19 hadn’t affected them, but a quarter also reported being anxious and ‘thinking too much’
The monumental shifts in society brought on by the COVID-19 pandemic — including heightened financial insecurity, loneliness and even instances of police brutality — have raised concern for the mental well-being of many in our country, even those without a previous history of mental illness.
And for others, illnesses, such as Mahao’s, that were previously well managed may now have worsened.
To try to uncover the mental health impacts of COVID-19, I and a team of University of the Witwatersrand researchers surveyed about 220 adults in Soweto during the first six weeks of lockdown. Our study revealed that those who perceived themselves to be at a higher risk of contracting the new coronavirus were also more likely to report more severe symptoms of depression, according to the findings presented at the International Aids Society’s recent COVID-19 Conference.
The research, which is currently in print, also revealed that although almost three-quarters of people we spoke to believed the COVID-19 outbreak had not affected their mental health, one in four people reported major concerns around anxiety, fear of infection or that they spent a lot of time “thinking too much”.
Thinking too much about the same thoughts is also called rumination and tends to happen around thoughts that are sad and that may make us anxious — and as a habit it can also contribute to poor mental health.
South Africa’s mental healthcare system was already stressed. Then COVID-19 came
The growing mental health burdens of the COVID-19 pandemic and its social policies exist against a stark backdrop of a national mental healthcare system that is overburdened and under-resourced. A 2019 study published in the journal Health Policy and Planning showed that the government spends about 5% of the national health budget on mental health, although this figure varied widely between provinces. Almost half of mental health spending was dedicated to care provided by South Africa’s scarce psychiatric hospitals.
Meanwhile, growing research indicates that SARS-CoV-2 infection may itself lead to psychiatric symptoms in some patients, including delirium and psychosis, according to a recent review of research published in the Wits Journal of Clinical Medicine.
Given the pressure on our already strained public mental healthcare system and the pandemic consequences of the lockdown, is it time to rethink how we deliver mental healthcare services?
When COVID-19 hit, South African Depression and Anxiety Group (Sadag) toll-free helplines were flooded with calls. But the outbreak changed more than call volumes, it changed the way Sadag worked. How the organisation adapted could help guide new thinking about how we take mental healthcare out of specialised hospitals and closer to communities. And there may be no better time than now for a new discussion on an old idea.
Calls to Sadag doubled under the initial lockdown. Here’s how the helpline coped.
Sadag has provided telephonic counselling for the last 26 years through more than two dozen toll-free helplines. During that time, Sadag’s operations manager, Vanishaa Gordhan, says the 24-hour call centre has not closed once — not even for a public holiday. In late 2018, the organisation added a WhatsApp line as well.
What Sadag does in texts and telephone chats is called telemedicine — a branch of medicine that uses information communication technologies to provide services that might otherwise be inaccessible because of, for instance, the physical distances between patients and providers.
In 2016, researchers reviewed almost 60 studies published over a decade on the use of telemedicine for mental healthcare, most of which provided counselling and support over the phone in countries such as the United States and Australia. The review, which was published in the journal of Telemedicine and e-Health — found telemedicine for mental healthcare improved access, helped people stick to their treatment, effectively treated disorders such as anxiety and depression and was increasingly cost-effective.
In South Africa, more than 96% of households had access to a cellphone or landline, according to Statistics South Africa’s 2018 general household survey.
When South Africa first instituted its COVID-19 lockdown, call volumes to Sadag’s helplines doubled. But under new social distancing measures to prevent the spread of COVID-19, the non-profit also could no longer send counsellors into its call centre.
Instead, it arranged for calls to its helplines to be routed through an app and sent counsellors home with a smartphone and a laptop. Each counsellor was able to access the data-light app to answer calls from those in need.
But as COVID-19 increased call volumes, Sadag had to rush to recruit more counsellors — and find new, virtual ways to train them. So the organisation did what most other workplaces did: they moved training onto the video conferencing platform Zoom. And for the first time, Sadag staff recorded their training sessions using the app’s recording function, helping streamline the orientation for future volunteers.
The non-profit also found new ways to support counsellors during their shifts. Where usually staff would have been able to approach a supervisor for help with tough calls, working remotely didn’t allow for that. So instead, Sadag created WhatsApp groups for each shift — letting counsellors turn to peers and managers for help.
The move to using platforms such as Zoom and WhatsApp more internally also created a new opportunity for Sadag to support staff. The organisation now holds a weekly virtual debriefing session for all counsellors.
Ringing in a new era in mental health?
Although shifting from in-person to remote operations changed how Sadag used technology in its counselling work, both within the group and publicly, it helped the non-profit expand and reach more people within a matter of weeks. It also helped to streamline some of Sadag’s own internal processes and exposed important policy gaps.
The national health department introduced its first-ever mHealth policy in 2015 — a document outlining how the country could use mobile technology such as apps to improve healthcare. However, there is no policy for the use of telemedicine within mental healthcare and for some, this may create anxiety about how much liability they carry if something happens to a person they are counselling on the other end of the telephone line or app.
It can take time for the national health department to draft and consult on legislation to fill this gap. Although professional associations such as the Health Professions Council of South Africa and the Psychological Society of South Africa have issued some guidance on telemedicine, more specific guidance is needed on mental health.
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Currently, a lack of sufficient phone lines in many clinics and hospitals complicates how clinicians are able to coordinate care with patients, for instance, communicating about changes in appointments. This too may be an area for consideration both now and in the future, should clinic or hospital-based telemedicine be pursued for mental health.
Healthcare helplines and apps are certainly not new ideas, even when it comes to mental health.
COVID-19 brings with it many challenges: hardships that are already shaping the mental health of South Africans. But the outbreak may also bring with it an opportunity and urgency to rethink old ideas about how we provide mental healthcare — and find new ones.
Andrew Wooyoung Kim is a PhD candidate in biological anthropology at Northwestern University, an honorary associate researcher at the Medical Research Council-Wits Developmental Pathways for Health Research Unit at the University of the Witwatersrand as well as a Fogarty Global Health Fellow at the Harvard T.H. Chan School of Public Health and the National Institutes of Health. Follow him on Twitter @kim_woo_young.