South African Stress Research Articles

Creating Barriers to Mental Health Care in the Netherlands

Back to table of contents Previous article Next article LettersFull AccessCreating Barriers to Mental Health Care in the NetherlandsJohannes E. Hovens, M.D., Ph.D., and G. Johannes van der Ploeg, M.D.Johannes E. HovensSearch for more papers by this author, M.D., Ph.D., and G. Johannes van der PloegSearch for more papers by this author, M.D.Published Online:14 Jan 2015https://doi.org/10.1176/ps.62.9.pss6209_1106AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: The article in the July issue by Bruwer and colleagues (1) described attitudinal and structural barriers to mental health care and predictors of treatment dropout in South Africa. The study found that the most commonly cited reason for not seeking care was a low perceived need for treatment and that lack of health insurance was an important reason for treatment dropout. Similar results were found by Sareen and colleagues (2) in a study that compared the United States, Ontario, and the Netherlands. Remarkably, fear of stigmatization was not frequently cited as a reason for not seeking care in the studies. However, it should be noted that these studies did not include persons with more severe psychiatric disorders, such as psychosis.Currently, the Dutch government is planning what might be called a cynical experiment—to levy a considerable patient copayment for the treatment of mental disorders. Patients who are unable to pay may request financial compensation from the local council; however, under the current austerity policy, the councils have undergone severe budget cuts.It may be expected that structural barriers to care will increase in the Netherlands among persons with severe mental disorders, most of whom are on the verge of poverty and lack insight into their illness. Because only patients who are involuntarily admitted to the hospital are exempt from this copayment, such admissions can also be expected to increase.Other aspects of this austerity policy are the exclusion of adjustment disorders from coverage for treatment and a limit of five treatment sessions for persons with mental disorders in primary care. Such policies imply that these patients are simply whining and not suffering from a mental disorder. At the same time, several groups in the Netherlands have initiated campaigns against stigmatization of mental disorders.We understand that economizing cannot be avoided, but it is difficult to understand why patients with mental illness are regarded as separate from those with general medical conditions. Choosing which patients should receive treatment on the basis of their illness is nothing less than discrimination. For individuals who have some historical consciousness, it brings to mind the first steps in the annihilation of psychiatric patients in the 1930s because they were considered inferior.The authors are affiliated with the Teaching Department, Delta Psychiatric Center, Poortugaal, Netherlands.Dr. Hovens is also with Erasmus University, Department of Psychology, Rotterdam, Netherlands.References1 Bruwer B , Sorsdahl K , Harrison J , et al.: Barriers to mental health care and predictors of treatment dropout in the South African Stress and Health Study. Psychiatric Services 62:774–781, 2011 Link, Google Scholar2 Sareen J , Jagdeo A , Cox BJ , et al.: Perceived barriers to mental health service utilization in the United States, Ontario, and the Netherlands. Psychiatric Services 58:357–364, 2007 Link, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 62Issue 9 September 2011Pages 1106-1106 Metrics PDF download History Published online 14 January 2015 Published in print 1 September 2011

Barriers to Mental Health Care and Predictors of Treatment Dropout in the South African Stress and Health Study

This study used data from the South African Stress and Health Study (SASH) to examine both structural and attitudinal barriers to treatment initiation among South Africans with mental disorders and to investigate predictors of treatment dropout. Face-to-face interviews were conducted with 4,315 adult South Africans living in households or hostel quarters. The interview included a core diagnostic assessment of past-12-month mental disorders and assessments of disorder severity, service use, and barriers to treatment. Multivariate logistic regression models were used to determine predictors of not seeking treatment in relation to disorder severity and sociodemographic characteristics, as well as factors that were predictive of premature treatment discontinuation by participants who had received mental health treatment in the previous 12 months. Predictors of dropout were identified by cross-tabulation and discrete-time survival analysis. Of the 4,315 adults, 729 (16.9% weighted) met criteria for a mental disorder in the past 12 months. Across all levels of severity, the most frequently cited reason for not seeking professional treatment was a low perceived need for treatment. Among those who recognized the need but did not access treatment during the past 12 months (7.2%), attitudinal barriers to treatment seeking were reported more commonly than structural barriers (100% and 34%, respectively). Of the 182 respondents who received treatment (25% weighted), 20% discontinued prematurely. Various factors, such as substance use disorders and absence of health insurance, increased the odds of treatment dropout. Low rates of treatment seeking and high treatment dropout rates for common mental disorders among South Africans are a major concern. Public health efforts to improve treatment of mental disorders should consider the multiple influences on treatment initiation and discontinuation.

Barriers to Mental Health Care and Predictors of Treatment Dropout in the South African Stress and Health Study

This study used data from the South African Stress and Health Study (SASH) to examine both structural and attitudinal barriers to treatment initiation among South Africans with mental disorders and to investigate predictors of treatment dropout.Face-to-face interviews were conducted with 4,315 adult South Africans living in households or hostel quarters. The interview included a core diagnostic assessment of past-12-month mental disorders and assessments of disorder severity, service use, and barriers to treatment. Multivariate logistic regression models were used to determine predictors of not seeking treatment in relation to disorder severity and sociodemographic characteristics, as well as factors that were predictive of premature treatment discontinuation by participants who had received mental health treatment in the previous 12 months. Predictors of dropout were identified by cross-tabulation and discrete-time survival analysis.Of the 4,315 adults, 729 (16.9% weighted) met criteria for a mental disorder in the past 12 months. Across all levels of severity, the most frequently cited reason for not seeking professional treatment was a low perceived need for treatment. Among those who recognized the need but did not access treatment during the past 12 months (7.2%), attitudinal barriers to treatment seeking were reported more commonly than structural barriers (100% and 34%, respectively). Of the 182 respondents who received treatment (25% weighted), 20% discontinued prematurely. Various factors, such as substance use disorders and absence of health insurance, increased the odds of treatment dropout.Low rates of treatment seeking and high treatment dropout rates for common mental disorders among South Africans are a major concern. Public health efforts to improve treatment of mental disorders should consider the multiple influences on treatment initiation and discontinuation.

Prevalence and correlates of atypical patterns of drug use progression: findings from the South African Stress and Health Study

Atypical sequences of drug use progression are thought to have important implications for the development of substance dependence. The extent to which this assumption holds for South African populations is unknown. This paper attempts to address this gap by examining the prevalence and correlates of atypical patterns of drug progression among South Africans. Data on substance use and other mental health disorders from a nationally representative sample of 4351 South Africans were analysed. Weighted cross tabulations were used to estimate prevalence and correlates of atypical patterns of drug use progression. Overall, 12.2% of the sample reported atypical patterns of drug use progression. The most common violation was the use of extra-medical drugs prior to alcohol and tobacco. Gender was significantly associated with atypical patterns of drug use with the risk pattern varying by the type of drug. None of the anxiety or mood disorders were associated with atypical patterns of use. Atypical patterns of drug use were not associated with increased risk for a lifetime substance use disorder. Atypical patterns of drug use initiation seem more prevalent in South Africa compared to other countries. The early use of extra-medical drugs is common, especially among young women. Drug availability and social environmental factors may influence patterns of drug use. The findings have important implications for prevention initiatives and future research.

Race and Psychological Distress

We analyze data from the South African Stress and Health Study, a nationally representative in-person psychiatric epidemiologic survey of 4,351 adults conducted as part of the World Mental Health Survey Initiative between January 2002 and June 2004. All blacks (Africans, Coloreds, and Indians) initially report higher levels of non-specific distress and anger/hostility than whites. Access to socioeconomic resources helps explain differences in non-specific distress between Coloreds and whites and Indians and whites. However, only when social stressors are considered do we find few differences in psychological distress (i.e., non-specific distress and anger/hostility) between Africans and whites. In addition, self-esteem and mastery have independent effects on non-specific distress and anger/hostility, but differences between Coloreds and whites in feelings of anger/hostility are not completely explained by self-esteem and mastery. The findings contribute to the international body of work on social stress theory, challenge underlying assumptions of the minority status perspective, and raise a series of questions regarding mental health disparities among South Africans.

A model for community mental health services in South Africa

To provide a model to estimate human resource needs for community-based mental health services in South Africa. A situation analysis was conducted of current community-based mental health service provision in South Africa, which comprise outpatient and emergency services, residential care and day care. Service utilisation rates and staffing needs were estimated for two levels of service coverage, using data from the situation analysis, local epidemiological studies and consultation with key stakeholders. For a population of 100,000 people, 7.3-23.8 full-time equivalent staff would be required to provide services in outpatient services, 14.9-41.6 in day care and 11.5-23.0 in residential care at minimum and full coverage levels respectively. The model can facilitate rational planning by requiring transparency and accountability in the assumptions used. This method can be adapted to a range of countries, by entering relevant country data. The model fills a gap, particularly in low- and middle-income countries, where community-based mental health services are sparse, and decisions regarding allocations to them are hampered by a lack of good quality data. The results of the model are limited by the quality of data and the assumptions upon which the modelling are based.

Patterns of extra-medical drug use in South Africa: results from the South African Stress and Health Study.

Background. Historically data on substance abuse in South Africa has been limited. This paper describes patterns of substance use based upon recent, nationally representative data. Methods. Data were derived from the 2002-2004 South Africa Stress and Health Study (SASH). A nationally representative household probability sample of 4351 adults was interviewed using the paper and pencil version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Data are reported for lifetime use, socio-demographic correlates of use, and age of cohort predicting lifetime use for four classes of drugs. Results. The estimate for cumulative occurrence of alcohol use was 38.7%; tobacco smoking, 30.0%; cannabis use, 8.4%; other drug use, 2.0% and extra-medical psychoactive drug use, 19.3%. There were statistically significant associations between male gender and alcohol, tobacco, cannabis and other drug use. Coloureds and Whites were more prone to have used alcohol, tobacco and other drugs compared to blacks. Clear cohort variations existed in the age of initiation of drug use; these were most marked for other drugs and for extra-medical drug use. Use of all drug types was much more common in recent cohorts, with a similar cumulative incidence of tobacco, alcohol and cannabis use across age cohorts. Conclusions. These epidemiological patterns of alcohol, tobacco, cannabis, other drugs and extra-medical drug taking provide the first nationally representative data. New findings on race and exploratory data on time trends provide a foundation for future epidemiological work on drug use patterns across birth cohorts and population subgroups in South Africa.

Life stress and mental disorders in the South African stress and health study.

Although stressful life events (SLEs) are associated with psychopathology, the contribution from distal and proximal events and the specificity of their association with common mental disorders require further exploration. We examined the association of recent life events and past adversities to mood, anxiety, substance use and impulse control disorders in South Africa. Data were analysed from the South African Stress and Health study, a population-based study of mental disorders in a nationally representative sample of 4 351 adults. Psychiatric disorders were assessed with the Composite International Diagnostic Interview (CIDI). This included questions covering early and later SLEs (negative life events, relationship stress, partner violence, social strain and adverse events during childhood) and various sociodemographic variables. Logistic regression models were constructed for 3957 respondents (2371 female, 1586 male) with no missing covariate data, to assess life stress and sociodemographic predictors of 12-month and lifetime disorder. Recent negative life events and relationship problems were significant predictors of any 12-month disorder and any lifetime disorder. Physical partner violence predicted any lifetime disorder. There was evidence of specificity for the prediction of mood versus anxiety disorders, with childhood adversity specifically associated with mood disorders but not anxiety disorders. Single marital status was the strongest socio-demographic predictor of any 12-month and any lifetime disorder. Stressful life events, distal and proximal, contribute significantly and independently to the prediction of major psychiatric disorders among South Africans, underscoring the importance of screening adversities in adults with common mental disorders, and of providing appropriate adjunctive interventions.

The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders.

The South African Stress and Health (SASH) study is the first large-scale population-based study of common mental disorders in the country. This paper provides data on the 12-month and lifetime prevalence of these conditions. Data from a nationally representative sample of 4351 adults were analysed. Mental disorders were assessed with the Composite International Diagnostic Interview (CIDI). An extensive survey questionnaire detailed contextual and socio-demographic factors, onset and course of mental disorders, and risk factors. Simple weighted cross-tabulation methods were used to estimate prevalence, and logistic regression analysis was used to study correlates of 12-month and lifetime prevalence. The lifetime prevalence for any disorder was 30.3%, and the most prevalent 12-month and lifetime disorders were the anxiety disorders. The Western Cape had the highest 12-month and lifetime prevalence rates, and the lowest rates were in the Northern Cape. The SASH study shows relatively high 12-month and lifetime prevalence rates. These findings have significant implications for planning mentalhealth services.

Perceived discrimination and mental health disorders: the South African Stress and Health study.

To describe the demographic correlates of perceived discrimination and explore the association between perceived discrimination and psychiatric disorders. A national household survey was conducted between 2002 and 2004 using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate diagnoses of psychiatric disorders. Additional instruments provided data on perceived discrimination and related variables. A nationally representative sample of adults in South Africa. 4351 individuals aged 18 years and older. 12-month and lifetime mood, anxiety and substance use disorders. In the multivariate analyses, acute and chronic racial discrimination were associated with an elevated risk of any 12-month DSM-IV disorder when adjusted for socio-demographic factors, but this association was no longer statistically significant when adjusted for other sources of social stress. In fully adjusted models, acute racial discrimination was associated with an elevated risk of lifetime substance use disorders. Acute and chronic non-racial discrimination were associated with an elevated risk of 12-month and lifetime rates of any disorder, even after adjustment for other stressors and potentially confounding psychological factors. The association of chronic non-racial discrimination and 12-month and lifetime disorder was evident across mood, anxiety, and substance use disorders in the fully adjusted models. The risk of psychiatric disorders is elevated among persons who report experiences of discrimination. These associations are more robust for chronic than for acute discrimination and for non-racial than for racial discrimination. Perceived discrimination constitutes an important stressor that should be taken into account in the aetiology of psychiatric disorders.

The South African Stress and Health (SASH) study: A scientific base for mental health policy

This special issue of the South African Medical Journal is devouted to the South African Stress and Health (SASH) survey. This study is significant for a number of reasons. Firstly, SASH is the first nationally representative epidemiological survey of common mental disorders in South Africa, or indeed in Africa. Secondly, SASH used a similar methodology to other surveys in the World Mental Health Survey (WMHS), allowing comparison of local findings with those in a range of high-, low- and middle-income countries. Thirdly, SASH had a particular focus on psychological trauma, and so provides a unique perspective on this potentially important risk factor for mental disorder.

Twelve-month treatment of psychiatric disorders in the South African Stress and Health Study (World Mental Health Survey Initiative).

The proportion of people with mental disorders in treatment is relatively small in low and middle income countries. However, little is known about patterns of recent service use in a country like South Africa. A nationally representative household survey of 4,351 adult South Africans was carried out. Twelve-month DSM-IV disorders were determined using the WHO composite international diagnostic interview (CIDI). Prevalence and correlates of treatment were assessed among respondents with anxiety, mood and substance use disorders. One-fourth (25.5%) of respondents with a 12-month disorder had received treatment in the past 12 months either from a psychiatrist (3.8%), nonpsychiatrist mental health specialist (2.9%), general medical provider (16.6%), human services provider (6.6%), or complementary-alternative medical (CAM) provider (5.9%). Only 27.6% of severe cases had received any treatment. In addition, 13.4% of respondents with no disorder had accessed services in the past year. Blacks were significantly more likely than other racial groups to access the CAM sector while Whites were more likely to have seen a psychiatrist. The majority of South Africans with a 12-month mental disorder have unmet treatment needs. In addition to a greater allocation of resources to mental health services, more community outreach and awareness initiatives are needed.

Perceived discrimination, race and health in South Africa

To assess the levels of perceived acute and chronic racial and non-racial discrimination in South Africa, their association with health, and the extent to which they contribute to racial differences in physical and mental health, data were used from a national probability sample of adults, the South African Stress and Health Study (SASH). All Black groups in South Africa (African, Coloured and Indian) were two to four times more likely than Whites to report acute and chronic experiences of racial discrimination. Africans and Coloureds report higher levels of ill health than Whites, but acute and chronic racial discrimination were unrelated to ill health and unimportant in accounting for racial differences in self-rated health. In contrast, all Black groups had higher levels of psychological distress than Whites, and perceived chronic discrimination was positively associated with distress. Moreover, these experiences accounted for some of the residual racial differences in distress after adjustment for socioeconomic status. Our main findings indicate that, in a historically racialized society, perceived chronic racial and especially non-racial discrimination acts independently of demographic factors, other stressors, psychological factors (social desirability, self-esteem and personal mastery), and multiple SES indicators to adversely affect mental health.

Twelve-month mental disorders in South Africa: prevalence, service use and demographic correlates in the population-based South African Stress and Health Study

South Africa's history and current social conditions suggest that mental disorders are likely to be a major contributor to disease burden, but there has been no national study using standardized assessment tools. The South African Stress and Health Study was a nationally representative in-person psychiatric epidemiological survey of 4351 adults (aged 18 years) that was conducted as part of the WHO World Mental Health (WMH) Survey Initiative between January 2002 and June 2004. Twelve-month prevalence and severity of DSM-IV disorders, treatment, and sociodemographic correlates were assessed with Version 3.0 of the WHO Composite International Diagnostic Interview (CIDI 3.0). The 12-month prevalence of any DSM-IV/CIDI disorder was 16.5%, with 26.2% of respondents with disorder classified as severe cases and an additional 31.1% as moderately severe cases. The most common disorders were agoraphobia (4.8%), major depressive disorder (4.9%) and alcohol abuse or dependence (4.5%). Twenty-eight percent of adults with a severe or moderately severe disorder received treatment compared to 24.4% of mild cases. Some 13.8% of persons with no disorder received treatment. Treatment was mostly provided by the general medical sector with few people receiving treatment from mental health providers. Psychiatric disorders are much higher in South Africa than in Nigeria and there is a high level of unmet need among persons with severe and moderately severe disorders.

South African correctional official occupational stress: The role of psychological strengths

The objective of this study was to determine the dimensions of occupational stress of employees of the Department of Correctional Services in a management area of the Freestate Province of South Africa. A further objective was to investigate the role of psychological strengths, namely, work locus of control and affect, in the experience of occupational stress. A cross-sectional design was used. A simple random sample ( n = 157) was taken. The correctional officer stress inventory was developed by means of factor analysis, and the work locus of control scale and the affectometer 2 were administered. Results indicated that an external locus of control and negative affect contribute to the experience of occupational stress. The most severe stressors for correctional officials have to do with a lack of resources.

Quality promotion and capacity development - could they come to the aid of weary South African academics?

Whilst research on policy implementation concludes that 'the principles of equity and quality have been steadily internalised by institutions' (CHE 2003a), there has been a great deal of sometimes passionate dissent about how quality improvement should be implemented. In the South African context, stress and anxiety have developed within the higher education sector since the Higher Education Act of 1997. Quality improvement initiatives, like the adoption of ICTs or other systems, often fail for various reasons. Many difficulties arise due to the lack of trust and ownership of the system, which can be addressed by effective training, change management and implementation strategies. We contend that there is an immediate and urgent need for comprehensive quality promotion and capacity development programmes on a voluntary basis to support overburdened and quality-weary South African academics. Such initiatives would empower them to implement and assume responsibility for their own accountable quality assurance practices. South African Journal of Higher Education Vol.18(2) 2004: 5-15

The Development of a Stress Symptom Checklist

The development of a stress measure, and indications of its reliability and validity are reported in the present article. The human stress response and its deleterious consequences are discussed, including the fact that stress is a major problem in society at all levels of human interaction. South African stress levels are particularly high, and many lifestyle diseases, health-risk behaviours, suicidal behaviours, violence, trauma-producing behaviours, performance levels and difficulties in coping with change are stress-related, as are numerous medical, psychological and/or psychiatric disorders. Given this, a Stress Symptom Checklist (SSCL) was constructed as a user-friendly stress measurement. It was developed as part of a major stress research initiative. The aim was to produce an authoritative, reliable and valid stress checklist that can stand up to critical inspection, yet be an easy-to-use measure. It focuses on the respondent's stress level rather than on the stimuli leading to that stress. It is not intended to be a diagnostic tool that measures specific stress-related psychopathological conditions or disorders, but rather the intensity (or severity) of stress as reflected by an individual's physical, psychological and behavioural reactions. To date, the data show that the SSCL is a useful measure of non-pathological stress in the general population. Further refinements and validation studies are in progress.