The Hidden Mental Health Crisis in South Africa

By Glenn Ashton · 31 Jul 2009

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South Africa has some of the highest levels in the world of mental health disability and disease, with around one in five people affected. While popular belief holds that mental illnesses such as schizophrenia, obsessive behaviours, depression, bipolar disorder and various phobias are caused solely by individual susceptibility to these maladies, the reality is rather more nuanced.

It appears that susceptible individuals are more likely to exhibit symptoms when stressed by personal or societal triggers. The impacts and effects of economic inequality are conclusively connected to an increased likelihood of debilitating episodes of mental instability. What is remarkable is that although those in the lower economic classes are more chronically affected, even the rich become more prone to mental health problems in unequal societies.

Perhaps the most visible effect in South Africa is the inordinately high proportion of addictive behaviour – drug and alcohol abuse being the most widespread. We also have extremely high levels of stress, driven by crime, economic uncertainty, poor living conditions, HIV and AIDS together with numerous other issues that induce and exacerbate mental problems.

The World Health Organisation has estimated that mental health problems will become the worlds leading cause of disability over the next 15 years. This is an important observation. Mental health has far reaching social ramifications on productivity, physical health, social stability and cohesion.

Besides addictive behaviours, depression probably affects more people than any other single mental health problem in South Africa. A study by the South African Medical Research Council showed that depression is a serious problem, particularly amongst women. More than 40% of women – and around a quarter of all men – are affected by depression to varying degrees.

Given the continued marginalisation of women, this is not entirely unexpected. The social burdens and inordinately high levels of violence against women, including rape, affect women both directly and indirectly. Despite active pursuit of gender equality, change in women's status is slow. South Africa remains a male dominated society, across class and race. Women bear the burden of raising families, often single-handedly.

Although women play such a crucial role, it is usually unrecognised and inadequately supported. Women are often prevented from playing an active role in financial decisions, yet bear the consequences of financial hardship and sense of powerlessness.

Post-natal depression, so called baby blues, has a very high incidence in South Africa. The loss of independence, sense of hopelessness, loss of personal identity, removal from social networks and diminished individual freedoms that accompany the arrival of children is a burden that is often borne in solitude by women, without sufficient support mechanisms.

All these challenges are exacerbated by economic inequality. In fact economic inequality is  itself a major trigger for increased likelihood of depression, with the inevitable stresses of poverty and the consequent powerlessness.

In unequal societies, especially those where inequality is as tangible as in South Africa, there are many triggers that can worsen latent or existing mental health problems.

The book 'The Spirit Level – Why More Equal Societies Almost Always Do Better,' quotes psychologist Oliver James's interesting analogy with infectious disease. James claims the “affluenza” virus “is a set of values which increases our vulnerability to emotional distress.” It places a high value on external appearances and the acquisition of money and possessions. This 'status anxiety' makes people far more likely to be dissatisfied with their lot, fostering mental instability.

As a counterpoint it is interesting that those prone to mental disease are less likely to be stigmatised - and consequently to have improved likelihood of recovery - when there is more community based social inclusion.

A study by Allen Rosen, comparing acceptance of mental health disease amongst developing and developed countries – broadly represented by our rural and urban areas – shows how developing societies are less prone to stigmatise mentally unwell individuals. They have far higher acceptance of those who would be labelled as eccentric, strange, visionary, irrational or mentally unstable in modern, urban society.

Those suffering from latent mental problems become more prone to instability when removed from familiar social settings. The artificial constructs of modern urban life create  circumstantial relationships that are less likely to accept behaviour that may be seen as abnormal. Accelerated urbanisation, influenced by economic necessity directly increases the visibility of mental health problems, especially amongst those who may have otherwise been shielded through traditional social structures.

The public health system is poorly resourced to deal with the challenges associated with recognition of mental health problems. It is estimated that around a quarter of patients at general practitioners suffer from psychiatric rather than purely medical maladies, yet it can take many visits to recognise the problem. All too often problems remain undiagnosed until they present as chronic mental illness. This is a tragedy as many mental health problems are eminently treatable, either through medicines or therapy, especially if identified and treated early.

The stigma attached to mental health problems makes sufferers reluctant to admit to the reality of their situation, diminishing the likelihood of early diagnosis. Even though mental impairment can be classified as a disability and sufferers must legally be integrated into society, just like any other disabled person, there is an extremely low degree of reintegration. It is critically important, especially given the numbers of affected people, to destigmatise mental illness. Any failure to integrate this significant number of otherwise healthy people into our society and economy will create yet another burden on an already strained society.

There are some excellent local initiatives to tackle this extensive yet largely hidden problem. We have progressive and innovative legal structures to reintegrate sufferers. Groups like the Mental Health Information Centre, the Health Systems Trust and the Durban and Coastal Mental Health Association have eased access to information but far more needs to be done.

A strong argument can be made that without the vitality and originality of those who may be labelled as mentally unstable, our society and world would be a poorer place. How many geniuses, visionaries and eccentrics fail to fit our narrow criteria of 'normal?' Can we even meaningfully define 'normality' in an increasingly dysfunctional world? Surely we should embrace such creativity and differences in a society that is as dynamic as ours?

While a more equal, egalitarian society may hold the key to reducing the extent and impacts of mental illness in South Africa, we must utilise every available means to address this social burden as a matter of priority.

Ashton is a writer and researcher working in civil society. Some of his work can be viewed at Ekogaia - Writing for a Better World. Follow him on Twitter @ekogaia.

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