Ruth Banda at the Friendship Bench in Harare, Zimbabwe, on 13 August 2021. Ruth, who was suffering from depression due to a family dispute that arose after her father died, managed to get help from a counsellor at the Friendship Bench organisation. (Photo: EPA / Aaron Ufumeli) 
Over the next two to three decades, Africa’s population will reach approximately 2.5 billion. A population of this magnitude will have far-reaching consequences for the region’s socioeconomic future, placing mounting pressure on resources and essential services like healthcare.
The disability burden from mental disorders in sub-Saharan Africa is also projected to dramatically increase over the next few decades, compounding the already heavy load of infectious, parasitic and non-communicable diseases.
Yet, despite this looming crisis, mental health in Africa remains underfunded, under-researched and under-prioritised.
As we mark Mental Health Awareness Month in October — with World Mental Health Day on 10 October — I want to reflect on the scale of the challenge in Africa, the failures of governments and societies, and our shared responsibility. I intend to not only review the negative, but also to shine a light on the good news — the stories of resilience, innovation and progress that remind us that meaningful change is possible.
Scale
The scale of the crisis in Africa is extensive and is reflected in governmental failures, human/system shortcomings, and research gaps. Disappointingly, most governments in Africa have turned a blind eye to the problem and generally devote less than 1% or none of their budgets to mental healthcare services, despite a steadily increasing demand.
The crisis is exemplified by the severe shortage of trained mental healthcare providers. South Africa, for example, has between 800 and 1,100 psychiatrists, with about 1.5 psychiatrists per 100,000 people, whereas in many other African countries the situation is worse, with fewer than one per 500,000 people.
Compounding the issue is the lack of psychotropic drugs — medications that change how a person feels, thinks, behaves or experiences the world.
People who use mental healthcare in South Africa, for example, face continuous problems in accessing medication in the public health sector, putting them at risk of relapse. Promises of availability of essential psychotropic drugs at all levels of care, including primary healthcare clinics, remain largely unfulfilled.
Moreover, mental healthcare and medications are concentrated in urban areas and so the neglect of mental healthcare matters in rural regions persists. As a result, most Africans do not receive care at all, or not the care they need.
This striking neglect persists despite decades of global efforts to reduce stigma, as mental illnesses continue to receive insufficient attention and recognition as an integral component of overall health.
Across much of Africa and other low- and middle-income regions, stigma, neglect and cultural silence remain pervasive, exacerbating structural deficits in already under-resourced health systems. Consequently, families and communities still too often abandon, isolate or even conceal those affected, leaving some of the most vulnerable members of society without support or care.
Moreover, despite a marked and welcome increase in the quantity and quality of mental health research from the African continent in recent years, it remains scarce comparatively. Africa contributes only a fraction of global mental health publications in peer-reviewed scientific journals.
This is disconcerting as research failures may result in poorly tailored interventions that are not aligned with African health systems, local cultural frameworks or available resources.
Vulnerable groups
Vulnerable populations face risks that further deepen the mental health divide in Africa. For example, women disproportionately experience the mental health consequences of gender-based violence, maternal challenges, and unequal access to care. Young people under the age of 20, who make up half of Africa’s population, are vulnerable as they have little access to school-based or youth-focused interventions.
Another at-risk group are those living with HIV/Aids; they face a double burden of stigma and psychiatric morbidity (the presence of mental illnesses or disorders in person or population) reinforcing one another.
People with intellectual disabilities are also vulnerable — they remain among the most neglected, with few services tailored to their needs.
These vulnerabilities do not exist in isolation — female gender, young age, HIV+ status and disability may intersect within the same individuals, creating layers of disadvantage that compound one another.
Falling short
When it comes to mental health, humanity sadly continues to fall short, and this failure is particularly evident in Africa. Beyond the shortcomings of systems and governments, there is a troubling societal complicity.
First, as noted above, within families and communities, stigma often leads to concealment, rejection or abandonment of those members who are mentally unwell.
Second, to this day harmful practices persist, including the chaining of people with mental illness in homes or faith-based institutions as well as the continued use of custodial models of care or institutionalisation that strip people of their dignity.
And third, also troubling is the persistent silence of professionals who too rarely raise their voices for mental health parity, which allows these injustices to persist.
Failure to act, at any level, reflects our failure to care and our lack of compassion. Together, these forms of complicity reinforce the divide, leaving the most vulnerable at even higher risk, and without a voice. Mental health is indeed a shared human responsibility.
Messages of hope
Despite the enormity of the mental health divide in Africa, there are several silver-lining stories. Across the continent, there are powerful examples of innovation and resilience that show what is possible when solutions are grounded in local realities.
In Zimbabwe, for example, lay health workers have been trained to deliver evidence-based psychological therapies such as cognitive-behavioural interventions on park benches, known as the well established Friendship Bench model, which demonstrated that high-quality care need not be confined to specialist clinics.
Similar task-shifting approaches in countries such as South Africa and Uganda have also extended the reach of mental health services by bringing care to people who might otherwise never access it.
These examples illustrate how community-based interventions could potentially transform how care is delivered and remind us that while the challenges are vast, they are not insurmountable. Mental health support could be embedded into clinics for people with HIV, into maternal health clinics, and even into schools.
Africans can also bring their cultural strengths to mental health care. The cultural philosophy of Ubuntu — “I am because we are” — resonates strongly with community-based mental health interventions, as both emphasise collective responsibility and shared wellbeing.
In terms of research, the recent Special Issue in Comprehensive Psychiatry which focused on Psychiatry in Africa can be considered one example of a sign of progress: i.e., the continent producing its own research, voices and solutions for Africa.
In Africa, the story of mental health is one of immense need and chronic underinvestment, but perhaps also of vibrant potential and resilience. It is important that we recognise this and move from reflection to action.
Bridging the divide will require global solidarity to share resources and knowledge, national accountability to prioritise mental health within policy and budgets, and individual responsibility to challenge stigma and nurture compassion in our communities.
Awareness alone is not enough; it must be matched by sustained action if meaningful change is to be achieved. DM
Christine Lochner is a professor of psychiatry in the Department of Psychiatry at Stellenbosch University and co-director of the South African Medical Research Council’s Unit on Risk and Resilience in Mental Disorders.