In-depth: How are depression and bipolar disorder treated in the public sector?
It is estimated that “one in ten adults living in South Africa will have experienced major clinical depression at some point in their life but only 25% have sought treatment and care for their mental conditions, such as depression”. Although these estimates are based on the South African Stress and Health (SASH) study, last done in 2009, subsequent studies have also stressed the challenge of reducing this treatment gap.
Depression and Bipolar Disorder: The difference
Psychiatrist at the Department of Psychiatry and Mental Health at the University of Cape Town Dr Qhama Cossie says feeling depressed or down is a normal human experience, and this is different to feeling clinically depressed or having a major depressive episode.
In a major depressive episode, someone feels down or joyless every day, the majority of the day for a long period, and this impacts their ability to function in their day-to-day lives. This is also accompanied by other symptoms such as difficulty sleeping, lack of appetite, and withdrawal from social situations, Cossie explains. He says a major depressive episode can be caused by a range of things, including a physical illness, the use of substances like alcohol and sleeping tablets, as well as other psychiatric illnesses.
Bipolar disorder, on the other hand, according to Cossie, is a mood disorder that is characterised by a person going through either very low moods in the form of a major depressive episode or episodes of an elevated mood known as hypomania or a highly euphoric mood known as mania. These periods of unstable moods can impact a person’s day-to-day functioning.
For more detail see the American Psychiatric Associations (APA) definitions of major depressive disorder and bipolar disorders. The APA publishes the Diagnostic and Statistical Manual of Mental Disorders.
What we know about prevalence
Although there has been significant research on mental health conditions in South Africa, research on the prevalence of mental health conditions such as depression and bipolar disorders has been scant.
According to Cossie, the best estimates of major depression in the country are found in the South Africa Stress and Health (SASH) study published in 2009.
The SASH study found that the lifetime prevalence of major depressive disorder in South Africa was 9.7% and that women were at higher risk. “So, 9.7% of people in a lifetime will have a depressive episode at some point. The 12-month prevalence is just under 5% (4.9%) of people over a 12-month period will have major depression,” he says.
“For bipolar disorder, the local studies aren’t as robust. They’re not necessarily as large as what was done with depression, but the estimated prevalence is between 3 and 4% of people [who] will have a bipolar illness over their lifetime,” he says.
According to the Global Health Data Exchange, the estimated prevalence of major depressive disorder in South Africa in 2019 was 3.14%, and the estimated prevalence of bipolar disorder was 0.6% (but this is likely an underestimate).
From diagnosis to referral in the public sector
As is the case with other healthcare services, Cossie says that mental healthcare services in the public sector also have different levels of care.
A patient generally starts on the first level, which is community-based services. This is often where lay-persons such as community health workers, supervised by a nurse, help promote mental health and help people with adherence and reminders for appointments and follow-ups. The second level is community health centres. According to Cossie, this is where the majority of people who have “uncomplicated” depression are managed.
He says a mental health nurse can provide more specialised care at the clinic level and if a patient requires hospitalisation, they will be referred to a general hospital, and then, if needed, be referred to a specialist (mental) hospital. “But that’s a minority of people, so the vast majority of people are treated at the clinic level, by nurses and general practitioners,” he says.
What the guidelines say
According to Cossie, there are guidelines for nurses that tell them what to look for and when and where to refer patients, but he questions whether the guidelines are followed as strictly as they should be.
Professor Lesley Robertson, community psychiatrist in the Sedibeng District in Gauteng and Adjunct Professor in the Department of Psychiatry at the University of the Witwatersrand, says the guideline documents for recognising and treating mental illnesses are the Standard Treatment Guidelines (STGs) and Essential Medicines List (Primary Healthcare Level 2020) as well as the Adult Primary Care 2019/2020 guidelines (APC). For hospital-level care in the public sector, the guidelines can be found in the Standard Treatment Guidelines (STGs) and Essential Medicines List (EML) for South Africa (Hospital Level, Adults 2019).
Robertson serves on the PHC (Primary Health Care) and Adult Hospital expert review committee for the National Essential Medicines List.
She says that mental health illnesses like major depression and bipolar disorder should ideally be picked up at a primary healthcare level, and there has been a push for more screening efforts at that level.
In the APC guidelines, primary care nurses are advised to screen all patients for depression symptoms. If a patient meets the criteria for further investigation, nurses are referred to a page with more detailed questions to guide them in ruling out any other medical reasons, such as a thyroid problem that might be causing the depression symptoms. If these are ruled out, nurses are advised to monitor the patient’s symptoms and start interventions, such as advice on self-care and referral for social interventions.
The APC guidelines advise that the patient be reviewed every two weeks until their symptoms improve and then monthly until stable. If the patient does not improve after eight weeks or gets worse, then nurses are advised to refer them to a medical officer or doctor.
According to Robertson, nurses can make a preliminary assessment or have a working diagnosis of depression, and the medical doctor can confirm the diagnosis. She says the medications used to treat depression and bipolar disorder are Schedule 5 and above, which means they must be prescribed by a medical officer or doctor. The exceptions are some of the anticonvulsants used to treat bipolar disorder, which can be prescribed by a primary care nurse.
If the patient’s condition still does not improve after treatment, the next step is to send the patient to a specialist. This, Robertson says, is where there is a big barrier in terms of access.
The APC guidelines also outline some common symptoms of bipolar disorder under the section for diagnosing depression. If a patient meets at least three of the criteria, nurses are advised to refer the patient to a medical doctor and then to a specialist.
Robertson says it is more difficult to diagnose bipolar disorder than depression since the signs are usually non-specific, and only a medical officer or doctor can make the official diagnosis. “The Adult Hospital STGs recommend management in conjunction with a specialist, [but] because of the scarcity of specialists, such referral is often not possible. Also, referral to remote hospitals is often not acceptable to the patient,” she says.
What types of treatment are available
The Primary Care guidelines advise nurses to offer a choice between psychotherapy and medication to treat depression if psychotherapy is available. Since psychotherapy might not always be available due to a lack of psychotherapists in the public sector, patients can be referred to a counsellor instead.
Robertson says the treatment guidelines provide for general measures nurses can take, such as counselling and using the resources they have available to them at the facility, like social workers, physical therapists, occupational therapists, NGOs, lay counsellors or community health care workers. This, however, poses a problem when resources are constrained at a primary healthcare facility.
The first-line treatment for depression in the public sector is Citalopram and Fluoxetine, both Selective Serotonin Reuptake Inhibitors (SSRIs).
Robertson says that if someone does not respond to these, they can move to second-line treatment in the form of the anti-depressant Amitriptyline, although other options like Venlafaxine could also be considered, or in some cases specialist assessment of alternative diagnoses such as bipolar disorder.
The Hospital Level STGs outlines the same treatment approach as the Primary Care STGs and states treatment should be prescribed for a minimum of nine months and patients should be referred if they don’t respond to treatment, display a high suicide risk, or show psychotic features.
Robertson says for bipolar disorder, psychotherapy can be used in addition to medication, but there is no strong evidence that it can be used by itself to treat the disorder.
The first-line treatment for bipolar disorder in the public sector is Lithium. The second-line treatment option to treat someone in a manic phase of bipolar disorder is the anticonvulsant Valproate and the third-line is an anti-psychotic called Olanzapine.
For those in the hypomanic course of bipolar disorder, the second-line treatment is the anticonvulsant Lamotrigine and the third-line is the anti-psychotic Quetiapine. If someone is resistant to the third-line treatment, the last resort is Clozapine.
Robertson says the guidelines also provide for the use of Electroconvulsive therapy (ECT) treatment as a last resort for acute, severe bipolar depression where it is considered a life and death situation.
According to Cossie, there is a difference between the medication treatment options available in the private sector and the public sector as the public sector does not have a full range of medication, while the private sector does. But, he says, that for depression and bipolar disorder there is no one medication that works better than another and so the treatment options in the private sector are not superior to those in the public sector.
“The first-line drugs available from government are just as good as the first-line drugs available in the private sector,” he says.
Patients falling through the cracks
Weighing in on the guidelines, Director of the Knowledge Translation Unit at the University of Cape Town and Professor of Healthcare Delivery at Global Health Institute in King’s College, Professor Lara Fairall says, “While mental health has not enjoyed the same level of investment as other conditions, and there are no programmatic guidelines for mental health like there are for tuberculosis and HIV, and maternal and child health, there is provision in our primary care guidelines to provide inexpensive and highly effective treatments.”
However, Fairall points to two recent studies conducted in KwaZulu-Natal that show how patients with depression are falling through the cracks.
One study published in 2020 found that clinical nurse practitioners (CNPs) successfully detected depressive symptoms in just under half of cases. Of those detected, just over one-third were referred for treatment and of those referred, only one quarter received any depression counselling.
The other study published in 2021 found that very few professional nurses working at the primary healthcare level felt they had the necessary time to assess properly patients with depression.
According to Professor Inge Petersen, the director of the Centre for Rural Health in KwaZulu-Natal, and a co-author of both studies, they found in addition to insufficient time and a lack of confidence in making a diagnosis of depression, another common reason for low rates of diagnosis included a poor understanding of the symptoms of mental health conditions and treatment options.
“The optimal configuration is to have access to the evidence-based treatment in the form of counselling and first-line medication available at the clinic and providers who are competent and confident to provide these for patients,” says Fairall.
Petersen expands on this, saying that in the context of a shortage of mental health specialists working in the public healthcare sector, there is a need to adopt a task-sharing approach, where specialist tasks are shared with generalists healthcare providers like primary healthcare nurses and doctors. The Southern African Mental Health Integration project recently trialled a form of task-sharing when they trained HIV counsellors to perform mental health counselling services under the supervision of a mental health specialist.
A study published in 2019 estimated that there was an average of 0.31 public sector psychiatrists per 100 000 uninsured people, and 0.97 public sector psychologists per 100 000 uninsured people. There were an estimated 1.53 public sector occupational therapists, 1.07 public sector speech therapists and audiologists, and 1.83 social workers – all per 100 000 uninsured people.
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New treatments and guarding against ‘wishful thinking’
Robertson tells Spotlight any new treatment options that may emerge for depression and bipolar disorder will have to be thoroughly vetted through assessments and comparative studies before being considered.
She says two options that currently pique people’s interest are ketamine injections as an acute treatment option for depression as well as transcranial magnetic stimulation for treating depression.
However, Robertson says, so far there isn’t enough evidence to suggest that these two options will be tried in South Africa on a large scale in the near future. “I am not aware of there being such promising evidence that we can say at the moment that either of these would be definite things to roll out,” she says.
She also warns against “wishful thinking” in the form of treatments that will magically solve the problem. Instead, Robertson says that the focus should be on improving psycho-social interventions in the country. “You can’t fix discrimination with medicine. It doesn’t stop it. And what happens is the person comes in and the mood is unstable, and you just end up giving more medicine but actually (it should be) about changing our society,” she says.
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*This article is part of Spotlight’s special series on mental health.