Thinking about mental disorders and psychosocial disability – key issues in low- and middle income contexts Dr Marguerite Schneider Alan J Flisher Centre for Public Mental Health Dept of Psychiatry and Mental Health University of Cape Town

Alan J Flisher Centre for Public Mental Health Joint initiative: Psychology at Stellenbosch University and Psychiatry and Mental Health at University of Cape Town Vision: collaborative inter-institutional multi-disciplinary centre on public mental health Build capacity Undertake high quality research – MH Policy services, legislation and human rights Advocate for inclusion of MH in development agendas in Africa Provide advisory services to governments in African countries

Some key issues Common and severe mental disorders Cultural conceptualisation of mental disorders Mental health policies and implementation plans Poverty cycle related to mental disorders Mental disorders within a disability framework

Common and severe mental disorders Common mental disorders (CMD) reflect the more common and generally less severe end of the continuum of mental health to mental illness Anxiety, Depression, Post traumatic stress disorder Wide variation in prevalence depending on measures used and context (e.g. level of poverty) Often included in general population based surveys Severe mental disorders (SMD) reflect more severe end of the continuum Psychosis, mood disorders, major depression Prevalence relatively stable across all contexts Rarely directly measured in general population based surveys

Cultural conceptualisations Same symptoms but different terminology and categorisations Conceptualisations and symptoms of perinatal depression in a low income context in South Africa matched ICD 10 and DSM 5 categorisations E.g. thinking too much – ruminations Different conceptualisations of causative factors Different descriptive or diagnostic categorisations

Mental health policies and implementation plans Few policies and even fewer implementation plans with clear budgetary allocations, indicator selection for monitoring, enforcement mechanisms and information management systems Generally shift to community care but still primarily funding institutional care Limited understanding of community care requirements e.g. Isidimeni crisis in South Africa - cost saving measures led to thousands of in-patients being discharged to unregistered NGOs with the result that the death rate increased significantly over the next few months.

Cycle of poverty and mental illness Social causation: Social exclusion High stressors Reduced access to social capital/safety net Malnutrition Obstetric risks Violence and trauma Poverty Economic deprivation Indebtedness Low education Unemployment Lack of basic amenities Inadequate housing Overcrowding Mental Ill Health Higher prevalence Poor/lack of care More severe course Poverty and mental health are closely associated Poverty leads to a number of social factors that in turn affect mental health – social causation pathway for mental illness – results in higher prevalence, poor or lack of care (treatment gap) and a more severe illness trajectory Mental illness in itself can cause a drift into poverty – social drift causal pathway through increased health expenditure, loss of employment, reduced productivity and stigma – resulting in poverty Social drift: Increased health expenditure Loss of employment Reduced Productivity Stigma

But what about the social determinants of mental health? Where all the SDGs are relevant if we look at the social causation and social drift causal pathways between mental health and poverty

Breaking the cycle of poverty and mental illness: the evidence so far… Mental ill-health Conditional Cash transfers Unconditional Cash transfers Loans Asset promotion Group or individual psycho- therapy Family psycho- education Psychiatric medication Community rehabilitation programme Residential drug rehab. Epilepsy surgery Review 1 Social causation Social drift Slide 7: the main message from the poverty/mental health cycle review is that mental health interventions carry economic benefits (for individuals and households), i.e. Improved functioning and recovery leads logically to improved social engagement and income generation – hence the importance of mental health in broader development discourse. Review 2 Lund, C. et al (2011). Poverty and mental disorders: Breaking the cycle in low and middle-income countries. Lancet, 378, 1502-1514.

Health disparities of people with SMD Much lower life expectancy Globally there is a “2·2-times greater risk of mortality and an average of 10 years of potential life loss for people with serious mental illness compared with the general population.” Bartels & DiMilia, Lancet commentary, 16 March, 2017 Primarily due to chronic health conditions Bartels and DiMilia suggest considering people with SMD as a health disparity group Access to health care and stigma Psychiatric health care providers do not address physical health sufficiently General health care providers ‘fear’ people SMD Side effects of psychotropic medication

Mental disorders within disability framework Functional limitations Domestic/household activities: Self-care: Social functioning and relationships and community activities Communication Memory and thinking Controlling behaviour Mobility Formal work Informal work (farming) and domestic activities Barriers Attitudes: community beliefs and attitudes, stigma, family/caregivers attitudes, lowered expectations of the person with SMD, fear Support: Lack of support (no autonomy or freedom), Professionals, Family Poverty Medication

Mental disorders within disability framework Identity as disabled – not always Madwaleni rural South Africa – did not refer to themselves as ‘disabled’ but described features of disability – functioning difficulties People with CMDs are not likely to identify as ‘disabled’ Disadvantage of disability – importance of including in disability agenda Recognition through terminology – psychosocial disability