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Prioritising mental health is becoming more important than ever in the face of ongoing global health such as economic and social inequalities but addressing these problems can also make finding solutions seem like an insurmountable task, writes Bronwyne Coetzee and Maria Loades.
World Mental Health Day is observed annually on 10 October to raise awareness about mental health issues. Looking at the theme for 2022, 'Make mental health and wellbeing for all a global priority', one of the first thoughts that comes to mind is whether making mental health and wellbeing a priority for all is even possible, and if so, how? Where would we begin? Or rather, where would we need to focus or refocus our efforts?
Much attention has been placed in recent years on finding ways to destigmatise mental health problems and provide access to affordable mental health services and relevant and appropriate support. Given the ongoing global threats to mental health such as economic and social inequalities, public health emergencies, humanitarian emergencies and forced displacement, and the climate crises, prioritising mental health is becoming more important than ever. But addressing these problems can also make finding solutions seem like an insurmountable task.
Mental health globally
Even before the Covid-19 pandemic hit us in 2020, 2019 estimates showed that globally at least one in eight people were living with a diagnosable mental disorder, with anxiety and depression being the most common by far. One in eight people amounts to about 970 million people living with a mental disorder pre-pandemic, and about 82% were living in low-and middle-income countries. And the pandemic has certainly exacerbated the situation, with a Lancet report in 2021 (based on data collected from 204 countries and territories around the world) showing a significant increase in the rates of anxiety and depression during the pandemic. Among children and adolescents, global estimates show that 8% of children between five and nine years and 14% of adolescents between 10 and 19 years live with a mental disorder.
Mental health in SA
South Africans are disproportionately at risk of developing mental health problems given the many social, political, contextual and environmental factors that impact on daily life – referred to as the social determinants of mental health. The social determinants of mental health include factors such as climate change, poverty, food insecurity, violence, inequality, stigma, and discrimination that place individuals at a high risk of experiencing mental health problems.
National estimates of the prevalence rate of common mental disorders among South Africans are somewhat outdated, with the last data having been published in 2009. Those data were collected as part of the South African Stress and Health Study also referred to as the SASH study. These findings showed that the lifetime prevalence for any mental disorder was 30.3% and that at least 15.8% of those who participated in the study (out of 4351 adults) had an anxiety-related disorder and 9.8%, major depression.
Regrettably, the SASH study did not include estimates of the prevalence of common mental disorders among South African children. However, existing research based on international prevalence data and expert consensus suggests that about 17% of children in the Western Cape specifically are likely to be living with a mental disorder.
The available global and local estimates of the prevalence of mental health problems in society contextualises the burden of mental health. Yet, mental health is still not yet afforded parity with physical health or, indeed, other global priorities; hence, the theme for this year's World Mental Health Day is particularly salient.
Mental health treatment gap
But drawing attention to the growing burden of mental health problems also highlights the sheer lack of resources, support, and infrastructure required to provide services and treatment to those who need it. This is known as the mental health treatment gap.
Relative to higher-income nations, South Africa offers little in the way of scalable and affordable provision of mental health treatment. Those who manage to overcome many of the barriers to help-seeking and can ask for help often have difficulty accessing support, given few mental health specialists in the public sector and long waiting times.
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This help-seeking for mental health problems and obtaining access to mental health services and care is made even more challenging for children and adolescents who rely on the adults in their lives to recognise when something is wrong and to help guide them to appropriate support – whether these are parents, teachers or other caregivers. Failure to address the mental health needs of children and adolescents is linked to mental disorders in adulthood, school dropout, substance abuse, and criminal activity, all of which disrupts their adult lives.
Prevention and early intervention
But if we are going to ask where we should refocus our efforts to prioritise mental health and wellbeing for all, then we do need to look at the early years, and we do need to focus on promoting mental health in children and adolescents. A focus on prevention and early intervention is even more convincing if we consider that half of all adult mental health problems begin before the age of 14. And to do this effectively, we need to provide these mental health supports to young people where they already are.
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Schools can therefore be ideal settings for delivery of mental health programmes which aim to support resilience and to build life skills. School-based programmes aimed at mental health and wellbeing have shown to be effective in high-income countries – but we know less about whether they can be delivered in South African schools. Schools are considered ideal settings in that, in South Africa at least, almost all children of primary school-going age are in school and schools offer settings that are considered much less stigmatising than mental health services. Our team has explored the potential of offering universal school-based mental health support to learners in primary school settings.
Universal school-based mental health support
In 2018, we received funding from the Wellcome Trust to develop and pilot a classroom-based mental health programme for young teens. We started by asking learners, parents and caregivers, teachers and school counsellors what was needed from such a programme. We also looked at what had been used in other parts of the world. Based on what we found, we designed an eight-lesson programme to build life skills like believing in oneself, thinking that 'I can', managing feelings, and empowering goal-focused action. Each lesson includes large group discussions, small group activities and focuses on building and practising skills for life.
In 2021, we piloted this programme to see if it could work. We ran it in two schools in the Western Cape, for around 250 grade 5 learners (10-14 years old). Although it is too early to tell yet, based on this initial test, whether it is truly effective at reducing mental health problems, the feedback we had from all those involved was very encouraging indeed. Even if such programmes were available widely, some youngsters would still need more targeted and personalised support.
Community-embedded school-based solutions
Often a concern among stakeholders in the basic education sector, including teachers, principals, school governing bodies is the sustainability of these programmes, particularly who is expected to deliver them. While research has shown that mental health and wellbeing programmes can potentially be delivered by teachers, our findings showed that teachers and learners themselves prefer for these programmes to be delivered by individuals or organisations external to the school but are nonetheless embedded within the school and broader community.
One such non-governmental organisation (NGO) that is doing so rather successfully is Community Keepers in the Western Cape. Community Keepers provides learners in primary schools and high schools in the province with psychosocial support services and have in their staff complement a cadre of registered counsellors, psychologists and social workers. The NGO is currently located within 29 schools, and their recent report shows they have been able to offer resilience-based workshops to more than 30 000 learners.
Making mental health a global priority for all is possible and urgent, but it will require focusing our efforts on promoting mental health early ––possibly through schools which may have ripple effects throughout the community over time.
- Dr Bronwyne Coetzee is a senior lecturer in the Department of Psychology at Stellenbosch University. Dr Maria Loades is a reader in the Department of Psychology at the University of Bath.
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