/ 15 October 2021

In an unequal world, mental health must be redefined

How To Square The Inequality Circle
Reducing socioeconomic inequalities and improving mental health are twin goals that cannot be separated

“When it comes to mental health, all countries are actually developing countries … none of them have got it right.”

This was the sage opinion of Professor Shekhar Saxena, a psychiatrist who spent many years as the director of the department of mental health and substance abuse at the World Health Organisation (WHO). He was speaking to me during an interview for the annual Durban Mental Health Symposium, a virtual event launched online on World Mental Health Day on October 10. This year’s global theme is “Mental Health in an Unequal World”. In South Africa, this painfully hits home, as we navigate living among obscene levels of inequality.

Saxena was clear on one thing: the era of hefty psychiatric hospitals housing a handful of patients is over; mental health care must be integrated across the health system. He is right but this is easier said than done. 

Research by Sumaiyah Docrat, of the Medical Research Council, and her colleagues show that South Africa’s department of health spends less than 5% of our total public health budget on mental health, with major differences across provinces. At the bottom was Mpumalanga, which spent a measly 2.1% on mental health in 2016-17, and at the top was the Western Cape at 7.7%. The most startling statistic was that 86% of national expenditure goes towards inpatients, but after being discharged one in four people get readmitted within three months. Something is amiss.

Saxena remains sympathetic to these problems, having led the WHO’s work to implement the Comprehensive Mental Health Action Plan, which was adopted by all 194 member states in 2013. This was a historic moment because it was the first such commitment in the WHO’s history. But the timeline was recently extended by a full decade to 2030.  These shifting goalposts are unsurprising, because political promises on the global stage rarely translate to practical outputs at the local level, such as funding for community-based psychosocial programmes.

When I asked Saxena what he considered to be the most remarkable innovations in mental health, I was surprised — but encouraged — by his responses. First, he praised the idea of task-shifting, whereby less specialised teams offer some provision of care, lower down the service rung, to decrease the burden of care on specialised professionals, such as psychologists or psychiatrists. Second, he cited the active involvement of people who are living with mental illnesses in decision-making, because “mental health is too important a topic to be left to professionals and policymakers”. I couldn’t agree more.

Task-shifting (or task-sharing) has been the subject of extensive research, with promising results, and is a cornerstone of our own — now expired — National Mental Health Policy Framework and Strategic Plan (2013-2020). But the focus tends to be on upskilling nurses at primary healthcare clinics to screen and initiate treatment for common mental disorders, such as depression, anxiety, and alcohol abuse. There is minimal focus on peer-led innovations, which involves capacitating citizens with the ability to help people in emotional need. This needs more attention.

A lovely example is the Mums Support Network in Durban. This initiative started four years ago with three women meeting regularly to help each other cope with perinatal distress. Alexandra Wallis, one of the founders, realized that many mothers do not have a safe space in which to share their true feelings. Eventually, as word spread, the trio expanded into a regular peer-led support group, both in-person and on WhatsApp, with dozens of other mothers. Today, they are now a fully-fledged nonprofit organisation doing incredible work.

This version of task-shifting intersects with Saxena’s second point about involving people with lived experiences of mental illnesses into the fold, giving practical voice to the maxim “nothing about us without us”. An international example is the Global Mental Health Peer Network, which is based in South Africa but has over 100 representatives from 38 countries. Their aim is to help cultivate a new generation of leaders to drive change and transformation in the global mental health sector. 

These exciting projects reinforce the idea of “giving psychology away”, a concept made popular in 1969 by George Miller, then president of the American Psychological Association (APA). Arthur Evans, the chief executive of the APA, reflected that “giving psychology away does not mean simply making it free. Giving psychology away means sharing the broad benefits that psychological science and expertise have to offer in order to enhance society and improve the lives of others … By sharing our science more intentionally and elevating the public’s understanding of psychology.” In an unequal world we must rely on solutions that are rooted in good evidence, while remaining sensitive to where that evidence comes from. “Science” in mental health is never neutral and ideological underpinnings often go unexamined. “Standard” models of mental healthcare are usually rooted in Euro-American ideas of individualised personal change and biomedical management, without much consideration for how families, communities, broader society and cooperative governance affects mental health.

Take, for example, our astronomical unemployment rate. Any attempts to help people navigate their mental distress at being jobless cannot only happen in a consulting room. As a psychologist, my time would be better spent advocating for the introduction of a basic income grant as a mental health intervention. This is a crucial upstream economic policy that has proven to lift people above the poverty line. Tackling these structural determinants of health means placing poverty at the top of our priority list. Intersectoral collaborations, such as provision of decent housing, water and sanitation, tarred roads, consistent electricity, access to libraries, and creating jobs, to name a few, promotes human dignity and reduces vulnerabilities to emotional distress that are entirely preventable. This is the type of critical, community psychology that we must co-create.

One could argue — and I would — that the upcoming local government election is a crucial factor in the determination of population mental health for the next five years. The types of neighbourhoods that we live in affect our wellbeing on a daily basis — from greater access to green spaces and public parks to litter-free pavements, our ward councillors are key players in creating the conditions for positive mental wellbeing.

Psychology is therefore not only about “the mind” — it is about society. Ours is a society contoured by historical disparities that continue to oppress people in intersecting ways. Improved mental health cannot be solely outsourced to government, healthcare workers or anti-depressants. Public health is our collective responsibility. Provincial MECs for health have a major role to play in improving the pittance that they allocate to mental healthcare expenditure. But, more importantly, as citizens, we must ensure consistent grassroots advocacy, multi-sectoral partnerships, creative use of task-shifting, and the routine inclusion of experts with lived experience in anything to do with mental health. Together we can do more, while also demanding better.