Mental health still stigmatised and underfunded
PSYCHIATRIC disorders are a cause of major disability and are on the increase, says South African Society of Psychiatrists president Dr Mvuyiso Talatala. Yet the treatment the state offers, and the cover offered by private medical schemes, leaves much to be desired.
“Major depressive disorder is causing major disability, and early diagnosis and treatment makes financial sense for any country, in addition to the benefits to the individuals treated, their families and the community,” says Talatala.
This problem is made more complex because, despite advances in psychiatry and psychology, there is still stigmatisation of patients and misunderstanding of psychiatric disorders, he says.
“That mental illness is still underfunded despite enough evidence that it makes business sense to treat it, is a clear sign of stigma. Mentally ill people suffer stigma from their families, the community and in their places of employment — where people with mental illness, especially depression, are not believed by their managers that they have a genuine illness that requires treatment.”
A World Health Organisation (WHO) study earlier this year, published in The Lancet Psychiatry, backs up Talatala’s contention.
“Every dollar invested in scaling up treatment for depression and anxiety leads to a return of $4 in better health and ability to work,” reads the study, the first of its kind that estimates the global health and economic benefits of investing in treatment of the most common forms of mental illness.
The study says between 1990 and 2013, the number of people suffering from depression and/or anxiety increased nearly 50%, from 416-million to 615-million.
“Close to 10% of the world’s population is affected, and mental disorders account for 30% of the global nonfatal disease burden.”
Humanitarian crises add further to the need for increased treatment options, with the WHO estimating that during emergencies, as many as one in five people is affected by depression and anxiety.
The study calculated treatment costs and health outcomes in 36 low-, middle- and high-income countries for the 15 years from 2016-2030.
“The estimated costs of scaling up treatment, primarily psychosocial counselling and antidepressant medication, amounted to $147bn,” it says. “Yet the returns far outweigh the costs. A 5% improvement in labour force participation and productivity is valued at $399bn, and improved health adds another $310bn in returns.”
According to the WHO’s Mental Health Atlas 2014 survey, governments spend on average 3% of their health budgets on mental health, ranging from less than 1% in low-income countries to 5% in highincome countries.
Jim Yong Kim, president of the World Bank Group, says this is not just a public health issue, it’s a development issue. “We need to act now because the lost productivity is something the global economy simply cannot afford.”
Many South Africans suffering
That mental illness is still underfunded despite evidence that it makes business sense to treat it, is a clear sign of stigma
with a psychiatric condition rely on the state services that are severely underfunded, says Talatala.
A proposed National Mental Health Policy Framework and Strategic Plan to develop mental health services at community level has not been implemented.
Even people on private medical schemes face debilitating restrictions. While most schemes cover counselling and medications for major depressive disorder and bipolar disorder, many patients with depression have plans that do not cover all their treatment.
People diagnosed with bipolar disorder are on a better footing because the condition is on schemes’ chronic medications lists. But depression gets coverage as a chronic condition only on the more expensive medical aid plans.
Medscheme’s executive director for health management, Dr Lungi Nyathi, says additional chronic medication cover “is decided as part of a multifaceted decision-making process which includes an actuarial specialist. Factors considered in decision-making include scheme demographics and risk profiles, health economic models, as well as scheme contributions that define affordability.”
Discovery Health’s clinical policy unit head, Dr Noluthando Nematswerani, explains: “Bipolar mood disorder is a prescribed minimum-benefit condition and one of the only two mental health conditions (the second is schizophrenia) listed on the chronic disease list. This condition is covered across all plan types offered by the Discovery Health Medical Scheme from the chronic illness benefit.”
Major depressive disorder is not a prescribed minimum-benefit condition. Therefore, “access to chronic medication for major depressive disorder is only available to members on the executive and comprehensive plans under the scheme’s additional disease list benefit”, she says.
Talatala says not funding medications and outpatient care for major depressive disorder results in “inadequate treatment”.
“The consequences include frequent relapses and the need for hospitalisation. Hospitalisation is much costlier than maintenance treatment with medications and outpatient psychotherapy.”
On many schemes, patients with depression can now benefit from 15 psychotherapy sessions in lieu of the 21 days’ hospitalisation for which they qualify.
And although most schemes fund 21 days’ hospitalisation for patients with schizophrenia, they do not cover outpatient care.
“Schizophrenia affects only 1% of the population. These patients are likely to suffer from downward drift, where they lose their jobs and cannot afford membership to schemes,” says Talatala.
“The majority of people with schizophrenia are therefore treated in the public sector.
“It would not cost medical schemes a lot to cover the few people who are their members and offer adequate treatment that will prevent the many complications of inadequately treated schizophrenia.”
As awareness of mental illness grows, services are slowly improving, says Talatala.
However, he believes the proposed National Health Insurance (NHI) is unlikely to make a big difference. “The current white paper makes no specific mention of mental illness. Mental illness deserves special mention because it is our current and future major health problem. It is currently not on par with other major medical disciplines in terms of funding both in the public and private sector. It is said that in the NHI dispensation, the Department of Health will buy services from the provincial health departments and the private sector.”
The 36 mentally ill patients who died in Gauteng within three months of being sent from a private hospital to nongovernment organisations has shone a discomfiting light on the system.
“The prescribed minimumbenefits regulations are very likely to be the basis of future costing of mental health and this will set it behind,” says Talatala.