1. 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

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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

9. 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,

10. 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

11. 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

12. 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