World Mental Health Day was observed for the first time on 10 October 1992 and has gained high visibility and momentum around the globe in its 30 years of existence.

This initiative, founded by the World Federation for Mental Health in the United Kingdom, has the singular goal of raising awareness of the full spectrum of mental disorders and advocating for the rights of the mentally ill and their access to appropriate, evidence-based treatments. This year’s theme is “Making Mental Health & Well-Being for All a Global Priority”.

It is perhaps timely to reflect on the commitment by all 194 World Health Organization (WHO) member states, of which South Africa is one, to adopt the WHO’s “Comprehensive mental health action plan 2013-2030”. This action plan has as its main goals the promotion of well-being, the prevention of mental health conditions, the provision of care, and enhanced recovery and reduction of illness, death and disability.

The plan is underpinned by the principles of: 

1. universal health coverage;
2. commitment to upholding human rights;
3. empowerment of those with lived experience of mental illness;
4. a life-course approach that acknowledges critical life stages and transitions where a range of mental health interventions could be effective; and
5. evidence-based mental health and multisectoral care strategies.

Though some progress has been made, with only eight years to go before 2030, South Africa and many member states remain far off the mark in achieving the overarching goal of acceptable, affordable, high-quality, culturally appropriate, community-based mental health care for everyone who requires it.

Yet mental disorders continue to be widespread, under-treated and under-resourced, with Covid-19 contributing to a surge in the demand for these services. This is all the more concerning in light of international and local evidence showing that a core set of cost-effective interventions for priority mental disorders across the life course is both feasible and appropriate.

Earlier this year, the WHO released a mental health report titled “World mental health report: Transforming mental health for all”. In the foreword to the report, Dr Tedros Ghebreyesus, the director-general of the WHO, wrote the following: “Mental health is a lot more than the absence of illness: it is an intrinsic part of our individual and collective health and well-being”.

The report calls attention to the slow progress that has been made to this end and warns that an approach of ‘business as usual for mental health care’ is simply not enough and cannot continue.

Many of us who work in the mental health field would go so far as to say that it is frankly unacceptable that “business as usual” in mental health has persisted for so long. It has failed all stakeholders, most importantly patients, their families, and their communities. Mental health is arguably everyone’s business.

The case for investing in mental health draws on three valid arguments: the first is that investment in mental health service provision (treatment, prevention and promotion) undoubtedly strengthens other spheres of public health. This is best achieved through integration (mental health with physical health) of care, instead of delivery in parallel silos, as is the case in South Africa and in many other parts of the world, as well as through ensuring that mental health services are adequately costed and provided for in essential health coverage packages.

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When there is no integration of mental and physical health, service fragmentation and duplication result, with negative ripple-down effects on the end users of mental health care services — the very patients for whom we should be enhancing access to care, and quality of care.

The second reason relates to human rights, where investment in mental health is sorely needed to curb human rights violations and reduce stigma and discrimination. Poverty is a potent social determinant of a range of mental disorders, and of poorer overall mental well-being.

The third reason pertains to the cyclical relationship and downward spiral into poverty, social exclusion and productivity losses on account of mental illness (productivity losses that outstrip the direct costs of mental health care), underscoring the case for investment in mental health to further economic and social development.

All three reasons are a no-brainer for transforming mental health and doing so at scale. In an unpublished report on investment case modelling in South Africa, Donela Besada, Crick Lund and Sumaiyah Docrat showed that 9% of the projected health budget in 2035 is needed to scale up interventions for common mental disorders (such as anxiety disorders and mood disorders), severe mental disorders (such as schizophrenia), epilepsy, dementia, and alcohol and drug use disorders. Currently, only 5% of the budget is being spent on mental health.

We clearly need to do more to promote mental health because when we have good mental health, we work well, study well, relate well, cope better with stresses and strains of daily life, maximise our potential and contribute meaningfully to society, as the above-mentioned mental report by the WHO indicates.

What could help in this regard, is to do away with the erroneous dichotomy between “mental disorder” and “mental wellbeing”. Mental health (or mental wellbeing) is, in fact, a fluid state not defined by the presence or absence of a mental disorder — pertinent when we consider that persons with mental disorders can over a life course attain high levels of mental well-being.

According to the International Classification of Diseases 11th Revision, a mental disorder is a “syndrome characterised by cognition, emotional regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes that underlie mental and behavioural functioning. These disturbances are usually associated with distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning.” 

The subjective distress experienced by the person and/or the interference of symptoms with daily functioning can be crippling.

While it is true that poor mental health inherently compromises well-being, states of mental wellness and illness exist along a complex continuum, with optimal mental health on one end and very severe, debilitating mental disorder on the other.

Shifts along the continuum of mental health — experienced by us all at varying stages in our lives — are driven by a confluence of individual, societal and structural factors that either confer protection or vulnerability at different time points. Healthcare providers in hospital, clinic and community-based services should be mindful of the erroneous dichotomy between mental disorder and mental well-being.

Endeavouring to help patients attain the highest level of mental health and well-being, on the back of resource constraints both in the public and private sector, is a priority. This is precisely why it is crucial to embed prevention and promotion efforts that enhance mental well-being within general health services that link with other sectors (e.g. education, social development, etc).

Rightly so, the WHO report zones in on three key priorities to promote and protect mental health, namely actions to prevent suicide, interventions aimed at children and adolescents, and interventions in the workplace.

If addressed, alongside the scale-up and integration of community mental health within general health care, these priorities serve to reform mental health services in an impactful way. DM