HUMAN RIGHTS AND MENTAL HEALTH

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HUMAN RIGHTS AND MENTAL HEALTH

• Dan J. Stein, MB ChB, FRCPC, PhD
• Prof and Head, Dept of Psychiatry / MH, UCT
• Chief Psychiatrist, PGWC
• Director, MRC Unit on Anxiety Disorders, US

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OVERVIEW

• International mental health context
• Data on mental health in South Africa
• Explore reasons for stigmatization
• Attempts to combat stigmatization
• A call for parity for mental health

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International Context

• What are psychiatric disorders?

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International Context

• Psychiatric disorders are medical disorders!
• - they can be diagnosed reliably
• - they have an underlying brain basis
• - they respond well to effective treatment
• - deserve dignity / care not blame / shame

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Advances in Imaging / Genetics
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Advances in Imaging / Genetics
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Modern Treatment
Baseline
After SSRI
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International Context

• Psychiatric disorders are crucially important!
• - associated burden of illness v. large (gt20)
• - associated burden of illness will grow in SA
• - but treatments are cost-effective / saving
• - treatment pathways from primary to tertiary

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WHO Most disabling conditions

• Unipolar major depression
• Iron deficiency
• Falls
• Alcohol abuse
• Chronic obstructive airways disease

• Bipolar disorder
• Congenital abnormalities
• Osteo-arthritis
• Schizophrenia
• Obsessive-compulsive disorder

Murray, C. J. L. Lopez , A. D. (1996). Global
Burden of Disease. Harvard, WHO.
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RSA Most disabling conditions

• 1. HIV/AIDS
• 2. Neuropsychiatric disorders

Bradshaw, D. (2003). Initial Burden of Disease.
Estimates for South Africa. Cape Town, MRC.
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WC Most deathly conditions

• 1. HIV/AIDS
• 2. Suicide / homicide
• During adolescence - suicide!

Bradshaw D, et al (2005). Provincial mortality in
South Africa, 2000--priority-setting for now and
a benchmark for the future. S Afr Med J 95,
496-503.
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Cost-Effectiveness of Treatment

• It saves the Government money to spend on
  appropriate mental health care services

Wang PS, Simon G, Kessler RC. Int J Methods
Psychiatr Res. 200312(1)22-33. The economic
burden of depression and the cost-effectiveness
of treatment.
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Cost-Effectiveness of Treatment

• Even in a developing world setting, it is cheaper
  to treat than not to treat!

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Advances in Psychiatry

• Development of Psychiatric Subspecialities
• Neuropsychiatry (eg neuroHIV)
• Liaison Psychiatry (eg womens MH)
• Intellectual Disability
• Addiction Psychiatry
• Geriatric Psychiatry
• Child and Adolescent Psychiatry
• Forensic Psychiatry

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Advances in PsychiatryNeuropsychiatry / HIV

• An 18 year old man presented with sudden onset of
  emotional lability, repeated hand-washing, and
  choreoform movements
• Special Investigation - Streptococcal infection
• Diagnosis PANDAS
• Treatment Antibiotics, SSRI, Cognitive-Behaviour
  al Rx

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Advances in PsychiatryLiaison Psychiatry /
Womens MH

• 34 year old woman presents with hallucinations
  shortly after giving birth by Caesarian section
• Special Investigation - MRI with focal areas of
  atrophy
• Diagnosis Post-partum psychosis
• Treatment SSRI, Cognitive-Behavioural Rx, Help
  with infant care

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What about South Africa?

• SA Stress and Health Survey (SASH)
• 4351 adult South Africans sampled
• Rigorous probability sample design
• Representing all races and groups
• Comprehensive diagnostic interview

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12-Month Prevalence of Psychiatric Disorders in SA
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Lifetime Prevalence of Psychiatric Disorders in
SA
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Treatment of Psychiatric Disorders in SA
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Under-Resourcing of Mental Health
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Under-Resourcing of Mental Health

• Very few mental health professionals (eg rural
  areas with only a handful of psychiatrists / MH
  nurses)
• Very few beds for psychiatric patients in general
  hospitals (eg in
  the Western Province there are 12 such beds)

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Under-Resourcing of Mental Health

• Hospital deinstitutionalization without building
  of community treatment services (eg intellectual
  disability services, addiction services)
• Vast systems with little attention to MH (eg
  military, EPAs, correctional services,
  emergency/trauma services)

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Under-Resourcing of Mental Health

• Almost no expertise in sub-specialties (eg no
  intellectual disability psychiatrists, very few C
  A or addiction psychiatrists)
• Addiction psychiatry is a particular problem, as
  DoH is not the primary driver (eg despite WC
  epidemics, hospital closure)

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Under-Resourcing of Mental Health

• Very little prevention at the primary level
  (eg lack of school mental
  health nurses)
• Underfunding of MH by DST / MRC / NRF and
  unacceptable delays in approving MH research by
  the MCC

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Under-Resourcing of Mental HealthMRC Funding in
R millions
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Under-Resourcing of Mental Health

• No parity in budgets / posts for MH (both in
  public and in private sectors eg discrimination
  by medical aids)

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Yes, but

• Policy-making is resource constrained
• - This ignores the data on cost-efficacy of
  treatment for psychiatric disorder (precedent
  from nevirapine)
• Other medical areas also need more
• - This ignores the data on lack of parity for
  those who suffer from mental illness (any
  precedent?)

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Why The Lack of Parity?

• Poor mental health literacy amongst the public -
  Most South Africans would rather die than admit
  to suffering from a mental illness, few know
  about things like an addiction psychiatrist

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Why The Lack of Parity?

• Poor mental health literacy amongst clinicians -
  Few doctors, nurses, and other health care givers
  with capacity to provide current treatments of
  psychiatric disorders

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Why The Lack of Parity?

• Poor mental health literacy amongst policy-makers
  - Past discrimination against mentally ill during
  apartheid, continued neglect of facts on
  cost-effectiveness of MH treatments

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Why The Lack of Parity?

• Physical disorders always seem so much more
  important eg HIV/AIDS
• - but behavioural factors contribute to the
  epidemic
• - the majority of HIV/AIDS patients will develop
  a neuropsychiatric disorder

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Why The Lack of Parity?

• Culturally, it is hard to accept the view that
  mental illness is a medical disorder
• - this is particularly the case with alcoholism
  and drug dependence
• - where few policy-makers would easily agree
  that this is a medical disorder

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National Health Policy

• 1997 Dept of Health, White Paper
• Emphasised lack of parity for mental health
  services
• 2004 Mental Health Care Act
• Emphasized human rights of those using mental
  health services

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National Health Policy

• We do have many reasonable facilities and highly
  dedicated staff
• With some progress eg new hospitals, mental
  health review boards, etc
• And with growing advocacy from mental health
  consumer groups

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National Health Policy

• National DoH has a very small Mental Health
  Directorate (eg guidelines?)
• Each of the Provinces have different posts and
  policies
• Within provinces, significant splits between
  hospital and community care

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National Health PolicyHalf-full vs half-empty?
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National Health PolicyParity as an Objective
Measure

• No evidence that policy emphasizing parity has
  been implemented in provinces - this seems
  medicolegally indefensible
• Mental Health Care Act review boards have focused
  on gross abuses, rather than service access and
  parity

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Conclusion Parity for MH Remains the Goal

• Parity for mental health services would be
  effective and cost-effective
• Parity for mental health services would help
  reverse stigma and is a human rights issue

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ConclusionParity for MH Remains the Goal

• SAHRC In view of clear and ongoing
  discrimination against mental health users in
  South Africa, with less of a voice and relatively
  lower access to mental health services, parity
  (including budgetary parity) and leadership
  (including parity of posts) for such services
  needs to be formally legislated and urgently
  implemented