Pulane, (not her real name) a 36-year-old mother living with HIV from Thabong in Welkom in the Free State, is among the many millions of people in South Africa who rely on public healthcare services. Also, like many others, the Covid-19 pandemic and its associated disruptions have left her in a constant struggle with anxiety. 

Pulane tells Spotlight she was stressed and felt depressed but found it difficult to access mental health services at her local clinic. She says she suspects that she may be suffering from depression and anxiety but does not have the resources to have it confirmed by a professional.

“I don’t know what to do or where to start so that I can get help. I told the nurses at the clinic last year where I collect my antiretroviral medication that I am depressed. I asked them to help me but they did not know what to do so they only gave me tablets for pain,” she says.

“A year later, I still struggle to sleep at night and I cannot cope with my life. There is just too much that is happening in my life and I wish that my problems could disappear for good,” she says. “All the stress that I have is eating me up. I am at a point where I just want to break down. Sometimes I just want to take my life, but every time when I think of taking my life, I think of my child.” 

Primary (mental) healthcare

Stressing how critical mental healthcare is at the primary care level, Professor Lesley Robertson, Adjunct Professor at the Department of Psychiatry at the University of Witwatersrand recently told Spotlight that there is a need for everybody in the primary healthcare setting to be trained accordingly. 

“We need somebody there to recognise the condition and what to do next. What we need are empathy and gentleness. And then we need to draw and keep a person in that system because it takes time to work out what is happening. I would say at that level we need somebody like a social worker and we need community health workers to be highly trained in dealing with home visits because they have no training in mental health. We need everybody at primary healthcare to be trained according to the scope of practice of the staff,” she said.

Spokesperson for the Free State Department of Health, Mondli Mvambi, says no one should be denied mental health services and that the department is investigating Pulane’s case. He says professional nurses at all health facilities in the province are “skilled to screen, counsel, and refer to either a social worker, psychologist, psychiatrists, or to the next level of care”.

“Community healthcare workers are also trained to conduct basic mental health screening during household visits and they also trace the mental health defaulters back to primary healthcare clinics,” Mvambi says. “Professional nurses at the clinic level are skilled to provide all PHC services including mental health and where there is a need for further assessment, mental healthcare users can be referred to the next level of care.” 

Mvambi says the province has 12 professional nurses with a mental health specialist qualification, 21 clinical psychologists, and nine psychiatrists (seven are permanent and two are contract appointments).

He says the department is in the process of appointing two more psychiatrists, one at Mofumahadi Manapo Mopeli Regional Hospital in Thabo Mofutsanyane and another at Boitumelo Regional Hospital in Fezile Dabi District.

Not affordable?

Statistics from the South African College of Applied Psychology indicate that about one in six South Africans suffers from anxiety, depression, or substance abuse. According to a blog post published by the South African Depression and Anxiety Group (Sadag) on its website, many South Africans cannot afford the high costs of medical aid in the private sector. In the private sector, “psychologists’ fees vary from province to province and different regions, but they generally range from R600 to R1,200 per session,” it reads. 

Mental health specialist and manager at Aurora Alcohol and Drug Youth Centre in Bloemfontein, Rethabile Lenkoe says many people are in need of help but they cannot afford it. 

“So it is very difficult for poor people to access mental health facilities because they cannot afford to access private institutions and as a result have to rely on public facilities which also do not have enough resources or do not have enough psychologists and psychiatrists.” 

Angie Vorster, a clinical psychologist at the School of Clinical Medicine at the University of the Free State says with the increasing number of people suffering mental illness, especially now due to the trauma, loss, and stress caused by Covid-19, there is not enough awareness about mental health, not only in Free State but across the country and globally.

“Even though mental health practitioners campaign for greater awareness, we come up against the brick wall of stigma on a daily basis. Society still has a very long way to go in understanding and regarding mental illness the same as physical illness and the best way for us to change this is to encourage open and non-judgemental discussions about mental health in all areas of society,” says Vorster.

Lenkoe adds that it is important to make as much noise about mental health as possible, but also “to normalise seeking help”. “We also find that a lot more people are vocal about their mental health struggles now more than they were before.” 

Risks of not getting treatment

Vorster says if mental health conditions are left untreated, or even where it is sub-optimally treated, it can lead to significant functional impairment of the individual.

“Unfortunately, as is the case with most illnesses, mental illness can become progressively worse over time and have a negative impact on all aspects of one’s life including your work performance, academic performance, social functioning, physical health, and your close relationships,” she says.

“Severe mental illness, if left untreated (and treatment almost always includes a combination of medication as well as psychotherapy), can impair people to such an extent that they become at risk of developing psychosis or suicidality. It is vital for us to raise awareness of the potentially life-threatening consequences of untreated mental ill-health.”

Vorster also adds that the immense strain that the Covid-19 pandemic has had on governments around the world has also impacted the already limited resources available for mental healthcare. She says in these times of crisis, the need for psychological care and support has intensified due to the trauma, loss, and stress caused by Covid-19.

“Until government and communities regard mental health as just as important as physical health, this unequal distribution of resources will continue. This is why mental health needs to be prioritised by us as the voters and residents of Free State before we can expect our elected officials to recognise the importance of our psychological wellbeing,” says Vorster.

Lenkoe adds, “This pandemic shook us all. At this point, each and every person’s mental health is in one way or another affected, as nothing ever prepared us for this. People are anxious about losing their jobs, their income, losing loved ones, not being able to grieve the way we are used to, and so many other factors, and now, more than ever, there is a lot of pressure on the public health system where there are not enough resources to cater for the increased number of people seeking help.”

Available mental health services in the Free State

Mvambi says the entry point to access mental health and all health services for people who depend on government and cannot afford a psychiatrist or a psychologist, is at the nearest primary healthcare facility, such as a clinic.

“The Free State Department of Health has listed 29 hospitals for a 72-hour assessment. Five [of these] facilities are in the Mangaung Metro and cater for 795,414 people, six in Lejweleputswa District that cater for 596,065 people, four in Xhariep that cater 137,275 people, four in Fezile Dabi for 520,210 people, and ten in Thabo Mofutsanyane that cater for 714,060 people,” says Mvambi.

He also listed the three designated mental health facilities in the province as Boitumelo Regional Hospital in Kroonstad, Mofumahadi Manapo Mopeli Regional hospital in Qwaqwa, and one specialised mental health facility — the Free State Psychiatric Complex (FSPC) in Bloemfontein with a total of 877 beds. The FSPC provides services to the Free State province and parts of the Northern Cape. According to Mvambi, the facility has monthly outreach services in Free State communities providing mental healthcare services and sees 495 adult outpatients and 430 child and adolescent outpatients per month.

Budgeting for mental health in the Free State 

Mvambi says the total provincial health budget is R12.135-billion for the 2021/22 financial year and from this, R2.7-million (0.02%) is set aside for mental health governance, programmes, and coordination. He says a further R365-million (0.3%) is set aside for specialised mental health service delivery at the Free State Psychiatric Complex and R2-million (0.01%) is allocated for licenced community-based mental health non-governmental organisations.

 “A further R5.3-million (0.04%) is allocated for contract appointments of additional mental health specialists for forensic mental health and district services in the province,” he says.

According to Mvambi, the Lejweleputswa District, where Pulane is from, is in the process of finalising the appointment of a clinical psychologist who will have to service all public sector patients in the district. 

Mvambi adds that the mental health budget at the primary healthcare level and district hospitals are integrated into the budget allocations to facilities. He did not provide figures for these levels, but the budgeted amounts he provided show about 0.37% of the total health budget is allocated to mental health. This number may increase if the facilities’ budgets are added. 

For FREE mental healthcare assistance call:

LifeLine

• Crisis line: 0861 322 322 is a 24-hour helpline
  

SADAG:

• To find a Support Group in your area, phone SADAG on 011 234 4837
• Suicide Crisis Line: 0800 567 567, or SMS 31393

SAFMH:

• Tel: 0861 322 322

DM/MC

**This article is part of Spotlight’s series on mental health.

*This article was produced by Spotlight – health journalism in the public interest.