Despite decades of evidence, depression remains overlooked and underfunded according to a Lancet-World Psychiatric Association Commission published last month. “Not enough is done to avoid and alleviate the suffering and disadvantages linked with depression, and few governments acknowledge the brake that depression places on social and economic development,” the Commission reported.
“Most countries are not sufficiently equipped to deal with the burden of depression, not only because of the long-standing under-resourcing of mental healthcare systems and the paucity of skilled providers, but also because of the rigid silos that typically separates mental health expertise and mental health care from primary health care and community support sectors, and health policy from other pertinent areas of public policy such as education, employment, migration and welfare benefits.
A week after the Commission published their report the World Health Organization announced at the beginning of March that the Covid-19 pandemic triggered a massive 25% increase in prevalence of anxiety and depression worldwide. “The information we have now about the impact of Covid-19 on the world’s mental health is just the tip of the iceberg,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.
“This is a wake-up call to all countries to pay more attention to mental health and do a better job of supporting their populations’ mental health.”
THE SITUATION IN SA
Speaking to Medical Chronicle’s Nicky Belseck, South African Depression and Anxiety Group (Sadag) board member and psychiatrist, Dr Frans Korb expressed concerns about an apathy towards not just depression in SA, but about all mental health. “When looking at epidemiological studies, our figures are not that different from those of overseas, it’s more or less the same all over the world,” said Dr Korb. “The survey’s that have been done over the years puts the percentage of major depression anywhere between 8%-10% of the population.”Echoing Dr Korb’s sentiments about apathy and inaction towards depression, psychiatrist, and current secretary on the Board of Directors of South African Society of Psychiatrists (Sasop), Dr Alicia Porter added that despite depression being described in literature for thousands of years, there is still a poor understanding of mental health, mental ill health, and in particular depression.
DEPRESSION AND STIGMA
“There are still high levels of stigma in all areas, socially, in the workplace, culturally, and in religious spheres,” said Dr Porter. “There is a deafening silence around this pertinent issue, with discrimination, which results in the people who are most affected not receiving the help that they need.” Dr Korb explained that the issue of stigma goes back to people not understanding depression. “There’s still this mentality of ‘it’s in your head, just pull yourself together, you’ll just feel bad for a couple days and then it should blow over’, and all those kinds of myths,” he said. “But now we know after so many years of research that depression is a physical disease, the chemistry goes wrong with your brain. But there are still all these misperceptions and people are not educated about what depression is about.”
FUNDING: PUBLIC VS PRIVATE SECTOR
Dr Porter raised the issue of inequality in funding in SA’s public vs private sector. “There is poor access to mental health services in the public sector fraught with long waiting lists, lack of resources, and there are often medication shortages. In the private sector there is a limitation of funding by medical schemes. For example, they fund an admission of up to 21 days as an inpatient or 15 outpatient sessions – a benefit shared by psychology and psychiatry, she explained. “Depression is considered a PMB (prescribed minimum benefit) condition, but most medical schemes will not fund depression medication on a chronic illness benefit, it is dependent on your plan type on some medical aids. The same limitations are not placed on conditions like diabetes and hypertension, and there is discrimination of mental healthcare users in this regard. There is also difficulty in funding multi-disciplinary team interventions, for example, occupational therapy, which is often necessary in the treatment plan for return to occupational functioning,” Dr Porter added.
SA LACKS RESOURCES, TRAINING AND COLLABORATION
The mental healthcare service gap in SA is well documented. Life Esidimeni – need one say more?
With approximately 600 psychiatrists in SA to treat a population of 55 million it’s an understatement to say that healthcare professionals are under-resourced to deal with depression. As Dr Porter pointed out, only a third of the 600 psychiatrists work in the public sector and that the number doesn’t account for the ‘many we lost to Covid and immigration since the Covid-19 pandemic’. Furthermore, Dr Porter stressed the lack of training, in particular the fact that mental health training is not prioritised in undergraduate training, and that there is poor collaboration with other disciplines. She explained that due to a lack of awareness and screening for depression it is possible for depression to be completely overlooked and missed by multiple members of the treating team in a patient who presents with predominately physical symptoms. Lack of integration of mental health services into primary care clinics, and primary care is also a concern.
EDUCATION, PROMOTION AND PREVENTION BY DOCTORS
“Healthcare professionals can play a role in health promotion and prevention,” said Dr Porter. “It will require a paradigm shift as most of our training is geared toward treatment and a medical model of care. We need to focus on preventative measures by recognising that depression occurs at all ages and in different ways across different age and cultural groups.”
Dr Porter suggested:
- Primary care programmes: Which aim at health promotion in the general population and then identify individuals who are at increased risk (bereavement, loneliness, violence etc) and offer programmes
and support - Health promotion: Lifestyle modification (eg, diet, exercise, mindfulness) stress reduction, management of stress
- Early detection: recognising that it accompanies multi-factorial illnesses like diabetes, heart disease, and can complicate and prolong the course of these – there should be routine screening for depression, and not a diagnosis of exclusion: ‘I have looked for all the other possible causes and have found none – therefore it must be in your head – refer to psychiatry’.
They can integrate depression care into their practices.
DOCTORS FACING DEPRESSION
“There were already high levels of burnout in healthcare professionals in SA even prior to the pandemic,” said Dr Porter. “Covid-19 has caused significant increase in anxiety, depression and post-traumatic stress. Stressors secondary to the virus itself include fear of contracting Covid-19, infecting loved ones and colleagues, treating colleagues and loved ones with Covid-19, loss of family, friends and colleagues. As well as financial losses, working out of scope of practice, sick leave, staff shortages, resource shortages and moral injury.”
Unfortunately, both Dr Porter and Dr Korb expressed concerns around healthcare professionals having trouble dealing with personal depression. The ‘hero narrative’, increased stigma, and discrimination, among healthcare professionals and a lack of help seeking behaviour were given as possible reasons. “Those on the frontline were on auto pilot, said Dr Porter, “pre-occupied and overwhelmed by the pandemic, and physical care to patients was prioritised over their mental health.”
Where to get help:
24-hour Healthcare Workers Care Network (HWCN) Helpline
www.healthcareworkerscarenetwork.org.za
Call: 0800 21 21 21
SMS: 43001
IMPORTANCE OF DEPRESSION LITERACY FOR DOCTORS
“Depression remains stigmatised in the medical community,” the authors reported. “It is receiving increasing attention in some countries in campaigns addressing physician burnout and wellbeing; a combination of strategies might be effective in reducing depression and high rates of suicide among physicians and nurses. Teaching physicians to recognise depression in themselves and their colleagues and to find solutions that work for them can also be expected to result in benefits to their patients.” When approaching a colleague showing signs of depression, Dr Korb said: “We need to be open, honest, sincere and empathic. If you see someone taking strain, then tell them; ‘I can see you’re taking strain. I can see you’re not yourself. You don’t laugh and smile anymore. Can we sit down and chat?’ Or give them the HWCN helpline number.
According to the Commission: “Health workers across the world, including those in low-income and middle-income countries, acknowledge stigma toward people with depression. This stigma is associated with low rates of depression recognition or poor quality of care. Physicians with stigmatising attitudes often do not offer appropriate physical healthcare to a person with documented depression, a practice known as diagnostic overshadowing. Furthermore, stigma can contribute to bias, firstly, toward presentation of somatic complaints by patients and, secondly, toward health workers treating the somatic concerns without investigating associated mental health problems such as depression. This bias overlaps with earlier constructs of masked depression.”
The authors cautioned that practitioners should also consider how their own attitudes towards people living with depression align with contemporary values in depression care.
COMMISSION RECOMMENDATIONS
Ultimately, the Commission presented recommendations for action by four primary stakeholders: “The general community and people with the lived experience of depression; practitioners who are in a position to prevent and treat depression; researchers who lead scientific endeavours to reduce the burden of depression; and decision makers who design policies and finance
their implementation.”
RECOMMENDATIONS FOR HEALTHCARE PRACTITIONERS
- Learn about depression and the variations in its origins, presentation, and course, and about the lived experience of depression
- Proactively recognise and assess the risks of depression, the onset of the illness early in its course and at any stage in life, and
its consequences - Personalise the management approach to prevention, treatment and recovery in view of each person’s needs, challenges and strengths, keeping in mind their socio-cultural context, family, developmental history, life circumstances, priorities, and the available resources
- Practice collaborative care and implement quality assurance and rights-based approaches, working with the person with depression to achieve optimal outcomes
- Prioritise the therapeutic alliance, continuity of care, the rights of people to receive care with dignity and choice, the needs of families (if appropriate), and the obligation to reduce stigma associated with depression.
“Depression should receive the same attention as would other common conditions, such as diabetes and hypertension, and practitioners should familiarise themselves with its diverse origins, presentations,
and course.”
SOBERING NUMBERS
- 27% of South Africans who report severe mental illness ever receive treatment – considering the high incidence of under reporting, this statistic can be much higher
- One in six South Africans suffer from anxiety, depression, or substance use problems
- Less than 16% of sufferers receive treatment for mental illness, 85% of these patients are dependent on public health sector services. There are 18 beds for every 100 000 people available in such hospitals, and only 1% of these are reserved for children and adolescents
- One in three South Africans will suffer with depression
- There are 23 known suicides in SA every day.
