SA’s poor mental health pandemic made worse by high costs and scarcity of treatment

Nearly five out of ten South Africans suffer from stress and one in every four from some form of mental ailment, yet the costs of mental healthcare in South Africa are too high for the average worker to get therapy.

This means those in need of hospitalisation usually only get helped until their medical aid funds run out, while cheaper alternatives are few and far between, and often come with their own sets of challenges.

The Mental Health Price Index 2022, which shows the cost of mental health treatment and medicines, examined which countries have the best mental healthcare provisions and infrastructure.

With the US placed at number one, indicating they have the best mental healthcare facilities in the world, South Africa managed to place right in the middle, and ranked 25th out of 50 countries with a score of 76.55 out of 100 for mental healthcare provisions and infrastructure.

While Sweden was found to charge the highest for therapy, averaging R3 050 for an hour session, South Africans pay an average of just over R800.

The index found that out of every 100 000 people, 46 000 South Africans suffered from stress, followed by depression at 4 132 and 3 625 suffered from anxiety. 541 out of 100 000 people were diagnosed with bipolar disorder and 221 with schizophrenia.

Mental health conditions have worsened since the start of the Covid pandemic, including in children, said psychologist Dr Lerato Mokgethi.

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“There has definitely been an increase in patients lately. Since 2020, there has been a huge uptake in patients like issues of grief, loss, loss of income, a lot of mental difficulties across the board, including depression and suicidal ideation. Patients are getting younger and younger.

“School children face issues of bullying, which is a huge issue in schools, but there are also self-worth aspects due to social media, as children are exposed to a whole lot more due to online platforms. This includes pornography. Children are now watching pornography,” said Mokgethi.

Only one psychiatrist for every 100 000 South Africans

The price index shows alarming figures regarding the availability of mental health practitioners, with only 18 psychologists and 1.5 psychiatrists per 100 000 people.

This is due to the training demands for mental healthcare practitioners, with universities having a limit on the number of students who can complete a Masters’ degree to practice psychology, explained psychologist Dr Helena Niedinger.

“You only get selected once you do your Honours’ degree and, in that year, they do the selection for the Masters’ degree, which is a two-year degree. Universities which offer the Masters’ programme have a lot of applications and a bottleneck, and they only select very few. Some have studied for four years but can’t practice because of this,” she said.

Clinical psychologist Dr Charity Mkone, said universities often train a maximum of 13 psychologists and other mental health professionals annually, as it involves one-on-one training.

“This is because of the training demands. It is a one-on-one focused kind of training where for one training psychologist, they can train two psychologists in training,” Mkone said.

Therapy and rehab prices will drive you to drink

While the index has found that medication for anxiety and depression have decreased by 2.36% and 1.96% respectively, those who need an hour of therapy should expect to pay around R830 per session.

Even this figure is wishful thinking for most patients though, explained Mokgethi.

“Even that R830 is the least, and people are less likely to get that rate for a session with a psychologist,” she told The Citizen.

The high cost of mental healthcare and consultation is regulated by the Board of Healthcare Funders (BHF) and in line with the Health Professions Council of South Africa (HPCSA), which put a cap of a minimum of 50-minute-long sessions.

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Restrictions on healthcare practitioners exacerbate crisis

According to the regulations by the HPCSA, each psychologist can see a maximum of seven patients in a day for a one-hour consultation session, said Mkone, who is registered with both bodies.

“When you look at some of the restrictions that are placed on a psychologist, it is about practicing ethically in accordance with the HPCSA, as well as balancing that with the livelihood of a psychologist because of the number of people they can see. That is what has an implication on what is deemed as a high cost.”

“Unlike a general practitioner or a general doctor, who can see a large number of patients at a time, a psychologist is quite constrained because of the nature of the work they do with their patients,” said Mkone.

The same applies to psychiatrists, who take between 90 minutes to two hours for an initial assessment.

“That is a considerable amount of time because they need a thorough history in terms of dispensing medication to a particular patient. That is also a huge time constraint and the remuneration of a psychiatrist needs to be in accordance with the time spent with a patient,” she said.

Mental health patients discharged once medical aid funds run out

Those in need of psychiatric hospital admission can expect to fork out R832 per day, the index said, but according to Niedinger, a patient’s hospital stay is also dependent on their medical aid cover, and patients are often discharged once their funds run out.

“The average length a person stays is not long because medical aid determines when the patient has to leave – not the doctors or psychologists. The hospital would inform you after a few weeks. A patient seldom stays longer than a month. It is generally short admissions – about a week or two.

If someone needs to stay longer, they are going to have to go to a public hospital like Weskoppies or Sterkfontein psychiatric hospital. But medical aids generally won’t pay for more than three weeks, depending on the medical aid cover and benefits.”

Dr Helena Niedinger

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This is due to a multidisciplinary team who work on a patient, including psychologists, psychiatrists and sometimes dieticians, meaning hospitalisations could easily exceed the indexed R800 per day fee, said Mkone, as each practitioner is charged separately.

“The cost is astronomical when you think about it, because of the multidisciplinary team that needs to be remunerated in a private setting, separately. You have the nursing staff that assist, you have psychologists, doctors, psychiatrists. That multidisciplinary approach makes it quite a costly exercise because each of these professionals need to be reimbursed separately.”

Dr Charity Mkone

“The same level of care is what is ideally needed in a public healthcare setting, which is available, but the waiting lists are very long because of the demand versus the availability of the professionals that specify and can assist. Also, occupational therapists play a pivotal role in the rehabilitation of a mental healthcare user.”

Cheaper alternatives come with challenges

Despite public hospitals and clinics offering psychology and psychiatry treatment, as well as toll-free helplines being available for those in desperate need, challenges such as waiting lists and lack of long-term telephonic treatments are prevalent.

There also seems to be under-investment in mental healthcare from the health department, as the demand for mental healthcare in the public service far exceeds the availability of mental health practitioners, the experts said.

Even though South Africa scored 76.55 out of 100 for mental healthcare infrastructure, these services were rarely easily accessible in rural areas and townships, said Mokgethi.

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“The department of health does employ psychologists in clinics but they are few and far between, and we sometimes find that there is one who services ten clinics and the waiting list is insane. You sometimes find they go to a specific clinic once every three weeks.”

While toll-free helplines are available, they use a crisis approach and are mostly useful for suicidal patients who needed someone to talk to.

“They are not able, on that platform, to work with someone on a long-term basis with post-traumatic stress disorder or depression. With a number of sessions you need, you can’t get that on that platform. The toll-free lines do work and do help when you don’t have someone to talk to but can’t deal with a magnitude of mental health issues, like bipolar, where a patient needs both a psychologist and a psychiatrist,” Mokgethi said.

With 70% of the country relying on public healthcare services, government needed to step up as the protector of citizens, said South African Society of Psychiatrist board member and public sector psychiatry national convenor Dr Kagisho Maaroganye.

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“Psychiatrists are forced to discharge patients earlier than advisable, because there are not enough beds to accommodate patients long enough for their condition to improve optimally. The serious, countrywide lack of child an adolescent clinics and wards is a contributing factor to teenagers and young people turning to substance abuse to alleviate their mental distress,” he said.

rorisangk@citizen.co.za