Mental health implications of suicide rates in South Africa

Abstract

Mental health challenges are a severe issue that could lead to suicide if not properly addressed. South Africa has a significant burden of mental health issues, which contributes to the soaring rate of suicide. Adequate mental health-care provision could reduce the high suicide rate in South Africa. Since the apartheid regime, the country has made a series of efforts to improve mental health. This study aimed to review and examine available literature on mental health and suicide issues in South Africa and demonstrate the policy implications. This study adopted a narrative review approach. Electronic databases (PubMed, Scilit, Google Scholar and Semantic Scholar) were used to identify published articles in the English language with crucial search terms that included mental health, South African mental health policy, South Africa, suicide and policy. Literature suggests that at the provincial level, there are no adequate mental health policies, and the implementation of the country’s mental health policy is faced with many challenges, such as a shortage of professionals and finances. The review also showed that task sharing and counselling have been pilot-tested and shown to be effective methods for the prevention of mental illness and promotion of positive mental health. This study concludes that the mental health treatment gap still exists in South Africa, and this needs to be tackled using effective, multi-level counselling interventions and policy initiatives. Adequate mental health-care provision and effective implementation of mental health policy could reduce the high rate of suicide in South Africa.

Key Words: Counseling; Mental health policy; Suicide; South Africa; Task-sharing

Core Tip: A mental health challenge is a severe issue that could result in suicide if it is not addressed correctly. Mental health issues are prevalent in South Africa, contributing to the increasing suicide rate. Currently, South Africa still has a mental health treatment gap that ought to be addressed through effective, multi-level counseling interventions and policy initiatives to reduce the high suicide rate.

INTRODUCTION

A high suicide rate is seen as a global concern that needs to be controlled, especially in low- and middle-income countries. It has been documented that Africa’s mental health is gloomy and if not adequately solved, could lead to a health emergency[1]. Suicide is seen as death caused by injuring oneself with the intent to die[2]. It is a significant cause of mortality worldwide, accounting for 800000 deaths each year all over the world[3]. Suicide is responsible for 11% of non-natural deaths; the youth suicide rate is 9.5%, almost as high as the adult suicide rate[4]. It was also observed that suicide is the second leading cause of death among youth all over the world, with low- and middle-income countries accounting for 78% of all suicide rates[5]. People who sometimes get discontented with issues around them and who lose hope commit suicide by jumping from high places, burning, hanging, overdosing, using sharp objects, gassing, drowning, poisoning, electrocutions, and shooting, among others[4].

Many factors predispose people to suicide. People exposed to violence are at risk, and people who have access to health-care have less chance of committing suicide[3]. Violence exposure among adolescents can result in exposure to other types of violence, implying that experiences of victimization could amass over time[6]. When people face a series of troubles, social isolation, and anxiety, they may slip into depression and begin to think of terminating their lives. This study aimed at reviewing and examining available literature on mental health and suicide issues in South Africa, and further demonstrating the policy implications thereof.

Mental health in South Africa

Mental health disorder is a severe problem in South Africa. Mental illnesses such as depression, anxiety disorders, mood disorders, and substance abuse disorders are most prevalent in South Africa[7]. A person-centered approach to mental health-care in the country involves building rapport, rekindling hope, empathic listening, and empowering patients to cultivate their own social and internal resources for recovery[8]. However, mental health is influenced by the interplay of many factors, including genetic, biological, environmental, economic, political and socio-cultural[9]. Mental illness affects all strata of the South African population – the pregnant, prisoners, adults, children, adolescents and occupational groups[10,11]. Studies report high levels of mental disorders among different components of the population. For instance, high rates of mental disorders were detected among South African prisoners^[11]. A study on the mental health of pregnant women showed that most of them in South Africa are at risk of mental illness[10].

South African adolescents are at increased risk of psychological maladjustment. This is a result of the country’s alarmingly high rates of crime and violence, which may lead to suicidal thoughts and suicide, hence the need for mental health interventions[12,13]. The mental health of students at universities is considered one of the most pressing public health areas in South Africa[14]. According to study estimates, one out of every three South Africans will suffer from a mental illness during their lifetime, an incidence that is greater than that of most nations with low and middle incomes[15]. In addition, about 75% of individuals with mental illness in South Africa may not receive sufficient mental healthcare[16].

Mental disorders predict the onset of suicide ideation[17]. Hence, there is a need to investigate the connection between trauma and suicidal thoughts, particularly in low-income nations where traumatic disorders seem to be more pervasive than in developed nations[18]. Also, despite the fact that mental health is recognized as a public health priority in South Africa, mental health-care remains largely underfunded[19,20]. Research shows that one of the most efficient and cost-effective methods to expand access to mental health care in South Africa is to integrate it into existing health systems[15].

MENTAL HEALTH POLICY AND STATE OF MENTAL HEALTH-CARE IN SOUTH AFRICA

The Minister of Health often seeks input from various stakeholders when developing national health legislation and policy in South Africa. Implementation plans with clearly defined indicators, targets, timelines and budgets are prepared by the provincial Departments of Health[21]. Since the end of the apartheid reign in South Africa, the country has made several efforts to promote mental health, which led to the promulgation of the 2004 Mental Health-Care Act. According to the South African Ministry of Health, 2004 was a significant departure from the past apartheid health policies. It set out to expand access, place primary health-care as the first point of contact of mental health-care with the health system, and facilitate the incorporation of mental health-care into general health services and the establishment of community-based services.

The adoption of the Mental Health Policy Framework (MHPF) for South Africa and the Strategic Plan 2013 – 2020 by the National Health Council, emerged from a series of consultations, including provincial and national mental health summits. A progressive agenda was set with the first national MHPF, the “National Health Policy Guidelines for Improved Mental Health in South Africa”, drafted in 1997. The policy considers mental health issues to be an integral part of general health-care issues. It was South Africa’s first officially endorsed national mental health policy, with the country previously relying on instruments such as White Papers to inform policy choices[22]. The mental health policy was based on several existing policy and legislation mandates in South Africa, including the White Paper for the Transformation of the Health System in South Africa, 1997; the National Health Policy Guidelines for Improved Mental Health in South Africa, 1997; the National Health Act, Act 63 of 2003; Mental Health-Care Act, Act 17 of 2002; Prevention of and Treatment for Substance Abuse Act, No. 70 of 2008; and Child and Adolescent Mental Health (CAMH) Policy Guidelines, 2003[23,24].

Despite the formal adoption of the CAMH policy, a comprehensive CAMH policy implementation plan is still lacking across the South African provinces[21]. In South Africa, there is poor mental health even when individuals show depressive symptoms as risk factors for future suicide attempts and have attempted suicide in the past[25,26]. Mental health policy implementation has not been effective due to lack of adequate attention, limited staff for policy and planning and neglect of responsibilities by some provincial authorities for driving implementation[27]. The South African children and adolescents still suffer from poor mental health, and this group seems to be neglected according to a study conducted on CAMH[21]. Furthermore, facilities in most psychiatric hospitals are outdated, mental health professionals are limited in number, and community mental health and psychosocial rehabilitation services are still undeveloped, which makes them inefficient and less functional[22,28]. It is also worth noting that there is a significant gap in the screening and treatment of maternal mental disorders due to the lack of collaboration between providers of maternal health services, child health services, and mental health services in primary care[10].

The responsibility for health-care lies with the South Africa national department, whereas, using the public health-care model, the provinces administer and oversee comprehensive health-care via district delegation[29]. The South Africa Human Rights Commission’s report on the mental health-care status clearly states that there were significant challenges in the implementation of the national policy. These challenges included insufficient funding for mental health-care services, limited human resources or disparities in the allotment of mental health personnel across the private and public sectors, and urban and rural communities, and lack of collaboration between government departments[22,30]. This shows that a lot of work is still required in our schools. It is therefore necessary to promote mental health in South Africa to curtail the high suicide rate. Although there have been significant developments in mental health policy and legislation in South Africa, the inequality between provinces in available resources for mental health-care remains an issue[14].

SUICIDE IN SOUTH AFRICA

Suicide is a leading cause of death in South Africa. In a 2018 study, the female suicide rate in South Africa was 4.5 per 100,000, and women reported twice as many suicide attempts as men[25]. However, a 2020 study on Trends in Suicide Mortality in South Africa reported a higher proportion of suicide rates among South African men[31]. This study conducted in 2020 did not observe an overall decline in suicide mortality despite the high rate of decline in suicide rates in other parts of the world[31].

It is important to note that the high incidence of suicidal behavior in South Africa has significant implications for mental health facilities[4]. In consensus with research data from most countries, mental disorders are highly predictive of suicidal behavior[17]. As a result, it is not surprising that the suicide rate in South Africa is high due to increasing mental illness. The adolescent experience of revictimization can cause mental stress that may result in suicide[6]. Youth social stress was significantly associated with suicide attempts[5].

Some regional suicide prevention initiatives exist, including the South African Depression and Anxiety Group, Life Line Southern Africa, and the South Africa Federation for Mental Health. The others are the Mental Health Information Centre of South Africa, and the International Association for Suicide Prevention[4]. However, that significant progress has yet to be made in the planning and implementation of coordinated, targeted suicide prevention interventions in South Africa[8].

OBSERVATIONS BASED ON LITERATURE ANALYSES

This study adopted a narrative review approach, and electronic databases (PubMed, Scilit, Google Scholar and Semantic Scholar) were used to identify published articles with crucial search terms that included mental health in South Africa, South African mental health policy, and South Africa and suicide rate. The inclusion criteria for articles in Table 1 were articles on suicide and mental health outcomes in the South African context, whereas those articles focusing on other regions of the world were excluded. The outcome of the literature search and analyses are presented in Table 1.

Table 1 Summary of suicide-related and mental health studies in South Africa.

Ref.	Objectives	Methodology	Participants	Results
Goldstone et al[8], 2018	To explore mental health-care providers’ context- and population-specific suggestions for suicide prevention when providing services or PWSUDs in the Western Cape, South Africa	Qualitative data were collected via in-depth, semi-structured interviews with 18 mental health-care providers providing services to PWSUDs in the public and private health-care sectors	18 mental health-care providers were interviewed	Effective treatment of substance use disorder and other psychiatric conditions would significantly decrease suicidality, transforming the mental health-care system and training in suicide prevention for mental health-care providers help to prevent suicide
Naidoo et al[11], 2012	To determine the prevalence of severe mental disorders in a prison population in Durban, South Africa	This was a cross-sectional point prevalence study	193 prisoners were interviewed, and questionnaires were administered	There is a high prevalence of mental disorders among prisoners in the prison population in Durban, South Africa
Jack et al[15], 2014	To identify and review research from South Africa and sub-Saharan Africa on the direct and indirect costs of mental, neurological, and substance use disorders and the cost-effectiveness of treatment interventions	Narrative overview methodology		Reviewed studies indicate that integrating mental health-care into existing health systems may be the most effective and cost-efficient approach to increasing access to mental health services in South Africa
Khasakhala et al[17], 2011	To examine the relationship between lifetime mental disorders, subsequent suicide ideation, and suicide attempts in South Africa	A national survey of 4185 South African adults who were interviewed	4185 South African adults	There is a relationship between several mental disorders and suicidal behavior
Mokitimi et al[21], 2018	To examine the current state of child and adolescent mental health policy development and implementation in the nine provinces of South Africa and to perform a policy analysis of all CAMH-related policy documents	In order to identify all publicly-available policy documents related to CAMH, two search strategies were used	Health website searches	No South African province had a CAMH policy or identifiable implementation plans to support the national CAMH policy
Vawda et al[25], 2018	To establish what percentage of females admitted following a suicide attempt to a government tertiary hospital were pregnant and to establish associated clinical and sociodemographic factors	A retrospective review of medical and psychological charts of all female patients admitted to a tertiary hospital in Durban following a suicide attempt over one randomly chosen year (January 01, 2014 to December 31, 2014)		Participants diagnosed as having an MDD had also made previous suicide attempts while pregnant; no mental health help had been sought even when they showed a prior history of suicide attempts and depressive symptoms, which are risk factors for future suicide attempts
Petersen and Lund[32], 2011	To identify progress and challenges in mental health-care in South Africa and future mental health services research priorities	A systematic review of mental health services research. Literature searches were conducted in Medline, PsychInfo, and Sabinet databases	Of 215 articles retrieved, 92 were included	There is a paucity of intervention and economic evaluation studies. Common mental disorders remain primarily undetected and untreated in primary health-care
Steyn et al[33], 2013	To examine a possible link between PTSD and suicidal ideation and to examine whether any specific posttraumatic symptoms predict suicidal ideation	A cross-sectional survey design on South African police officers assessed utilizing the Posttraumatic Diagnostic Scale and a short version of the Adult Suicide Ideation Questionnaire	217 South African police officers	Hyperarousal was the primary predictor of suicidal ideation
Orri et al[34], 2022	To investigate childhood risk factors for suicidal ideation in adolescence and young adulthood	A longitudinal study used data from the largest and longest-running birth cohort in Africa, the Birth to Twenty Plus (Bt20+) study in South Africa Bt20+ cohort	Mothers and their singleton children born during 7 wk in 1990 in Soweto, South Africa	Prevalence rates peaked at age 17 and decreased continuously until age 28. Prevalence rates were higher among females than males; there are sex differences in the association of childhood individual, familial, and environmental factors with youth suicidal ideation
Bantjes et al[35], 2016	To investigate the 2-wk prevalence of suicidal ideations and their associations to symptoms of posttraumatic stress, depression, and anxiety among South African university students	Hierarchical regression analysis was used to investigate the relationship between suicidal ideation and symptoms of posttraumatic stress, depression, and anxiety	Data were collected from 1337 students between May and August 2013	Rates of suicidal ideation are higher among university students in South Africa than among the general population of the country and student populations in other parts of the world
Khuzwayo et al[36], 2018	To investigate key demographic factors and behaviors associated with planning and attempting suicide among high-school learners	A cross-sectional study in uMgungundlovu District, KwaZulu-Natal Province, South Africa	All Grade 10 learners (n = 1 759) at these schools completed a self-administered questionnaire	The suicide attempt prevalence rate is high in South Africa. The risk of planning suicide increases with age
Burgess et al[37], 2022	To pilot and evaluate the effectiveness of a complex intervention – Courage-Plus on symptoms of depression in Gauteng, South Africa	This pilot study used a non-randomized, repeated-measures design	47 depressed women	Courage-Plus was highly effective at reducing symptoms of depression across the spectrum of severities in this sample of women facing adversity in Gauteng, South Africa

CAMH: Child and Adolescent Mental Health; PWSUD: People with substance use disorder; PTSD: Posttraumatic stress disorder.

The literature shows that mental illness, which could lead to suicidal thoughts and behavior, is a significant concern in South Africa, and there have been limited interventions and policies aimed at addressing this issue[32-37]. It has been reported that South Africa is far from implementing the right to health for individuals with mental health challenges[38]. Studies show that common mental health disorders in South Africa include substance use disorders and depression[39]. Therefore, it is clear that to reduce the suicide rate in South Africa, efforts should be targeted at effective treatment of substance use disorders, depression and other mental conditions. Reviewed studies further showed that challenges are hindering mental health-care in South Africa, including too few state-run substance rehab services and staff shortages, and lack of budget from the federal and provincial governments, particularly for mental health services. As a result, mental health services are funded through general health budgets, which makes them inefficient[8].

To promote citizens’ mental health, counseling is seen as an essential tool. Counseling is considered an acceptable form of intervention for perinatal depression. Additionally, up to 3–4 sessions of counseling interventions can improve depression and alcohol outcomes among patients in South Africa[40,41]. A study on mobile phone intervention for mental health in South Africa reported that using digital mental health interventions using social media platforms is one way to assist young people with mental health in South Africa through psychoeducation. Among the benefits of this program is that it improves mental health literacy and teaches individuals how to cope with mental illness[42]. In addition, Courage-plus, which is a 13-wk intervention, has been pilot-tested among women as an effective group intervention for depression in South Africa[37]. This counseling intervention incorporates collective narrative counseling with training and support in the treatment process. It is also worthwhile for the components of a suicide prevention program to include the provision of emotional and social support from family, members of the community, and friends[8].

It has been documented that mental illness may not often be best treated with medication, but interventions outside the biomedical model may be more appropriate and effective[43]. Researchers further note that task shifting is a feasible option, especially in rural South Africa, where there is a lack of appropriately trained medical staff. Many other studies support the task-shifting or sharing model. For instance, Kathree et al[44] reported that the training of primary healthcare workers in diagnosing, reporting, and treating depression within a collaborative task-shared model promoted the use of co-located or facility-based counselling by mental health workers who are not specialists in mental health. This helped facilitate the implementation of integrated, accessible mental health care services. Task sharing promotes mental health-care, especially where there is a lack of mental health experts and programs. Community health workers can be trained to perform the task of a professional mental health expert. This is the result of a study by Myers et al[45], which showed that patients who have mental challenges were willing to receive counseling from trained community health workers whose primary duty was not to counsel patients with mental challenges.

Furthermore, a study of caregivers revealed that a group cognitive–behavioral intervention was feasible, acceptable, and effective in reducing depression among this population in Latin America[46]. The study contributes to the increasing body of knowledge concerning the effectiveness of this form of treatment intervention among culturally and socioeconomically diverse population. In light of South Africa's culturally and socioeconomically diverse population, group cognitive-behavioral interventions with cultural components may be appropriate for South African men and women. This is crucial given that in South Africa, there are no adequate guidelines for suicide prevention within local contexts despite the existence of the national mental health policy document[47].

CONCLUSION

Many people, including South Africans, are exposed to violence, which predisposes them to experience serious mental health challenges. Mental health challenges are a grave issue that could lead to suicide if not properly addressed. South Africa has a significant burden of mental health issues, which contributes to the high suicide rate. Implementation of the country’s mental health policy faces many challenges, such as a shortage of professionals and finances. As a result, the mental health gap still exists in South Africa, and this needs to be tackled using multi-level counseling interventions and task sharing. Adequate mental health-care provision and effective implementation of mental health policy could reduce the high suicide rate in South Africa.