By Manoj K. Pandey, Vani S. Kulkarni and Raghav Gaiha
Canberra, Philadelphia and Manchester, Mar 20 2019 (IPS)

Depression is often distinguished from other non-communicable diseases or NCDs (e.g., cancer, diabetes, cardio-vascular diseases, hypertension) because of the stigma attached to it. Among other consequences, those suffering from depression are often denied access to medical care. Indeed, the latter is an outcome of interaction between supply of and demand for medical care. On the provider side, stigmatizing attitudes by service providers are identified as a barrier to access. On the demand side, stigma and low mental health literacy by community members are just as emphatically reported as barriers to accessing care.

Manoj K. Pandey

Many NCDs share common risk factors such as tobacco use, physical inactivity, and unhealthy diets that are associated with cardio-vascular diseases (CVDs), diabetes, and cancer. The South African adult population has high levels of these risk factors, and large proportions of the disease burden can be attributed to these modifiable risk factors. Mental disorders increase the risk of all these diseases, which in turn increase the risk of mental disorders (Patel et al.2018 a).

Our recent study focuses on the association from depression to other NCDs, based on a state-of-art analysis of the five waves of the National Income Dynamics Study (NIDS) panel survey data for South African adults (30 years and above) for 2008, 2010, 2012, 2014, and 2016/17 (Pandey et al. 2019). NCD outcomes are the dependent variable with depression in the initial year and other explanatory variables that vary with time or do not. Examples of the former include age, wealth, whether living alone and affiliation to social networks, and of the latter gender and ethnicity. Although much has been written on the association from NCDs to depression, the research on the reverse association from depression to NCDs remains patchy. Hence the focus here is on the latter.

There are robust associations from depression to other NCDs in South Africa. With controls for socio-economic factors, the initial condition of moderate and severe depression is robustly associated with NCDs such as high blood pressure, stroke, heart diseases, cancer, and at least one NCD in subsequent years. This result is also consistent for mental health conditions where poor baseline mental health condition increases the risk of NCDs later. Moreover, the risk of NCDs is higher when severe depression or poor mental health conditions are present (with or without NCDs)—with a slightly larger risk when severe mental health conditions co-occur with an NCD in the initial year.

Vani S. Kulkarni

Relative to the Africans, the Whites are less likely to suffer from diabetes but more vulnerable to heart diseases, cancer and at least one NCD. The Coloureds have higher risks of NCDs while the Asians/ Indians are more vulnerable to diabetes and heart related problems. At older ages, the proportion of black Africans is higher than it was previously which accounts for the decrease in lung cancer because black Africans have a lower rate of smoking than White and Coloured people. The South African Indian community is more insulin resistant than other ethnic groups and therefore at greater risk of diabetes type 2 and ischaemic heart disease.

The Lancet Commission on global mental health and sustainable development (2018) and WHO (2015) report adverse impacts on the health of the caregivers. Caring for a person with a chronic, disabling NCD or mental disorder, such as cancer or dementia, is stressful and associated with an increased risk of chronic health problems, including depression, hypertension, sleeping problems, and fatigue; increased use of psychotropic drugs; and premature mortality. Indeed, such indirect impacts on caregivers, who are often members of the patient’s household, result in sick households.

The Mental Health Care Act 17 of 2002 in South Africa requires that service users undergo a 72-h emergency management and observation period for involuntary admissions to designated general district and regional hospitals across the country, before they are referred to specialist psychiatric hospitals. However, implementation remains daunting, with inadequate infrastructure and specialist staff. Indeed, several studies are emphatic that this requirement has negatively affected the quality of care provided (Petersen et al. 2017).

Raghav Gaiha

A case could be made for substantially higher investment in primary health-care systems (Patel et al. 2018 b). On the supply side, these investments include greater accountability of services to local communities, enhanced sensitivity of providers to local conditions and beliefs, and provision of care to the needy. On the demand side, effective local services can address complex problems of patient access, offset the financial burden of adult chronic illness, and restrict unnecessary use of expensive private care. Although additional resources are needed, the magnitude is likely to be less than projected if the efficiency of investment in primary medical care is factored in.

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The proportion of persons 60 years and older is projected to almost double during 2000–2030 in South Africa. Credit: Jeffrey Moyo / IPS

By Manoj K. Pandey, Vani S. Kulkarni and Raghav Gaiha
Canberra, Philadelphia and Manchester, Feb 20 2017 (IPS)

Old age is often characterised by poor health due to isolation, morbidities and disabilities in carrying out activities of daily living (DADLs) leading to depression.

Mental disorders—in different forms and intensities— affect most of the population in their lifetime. In most cases, people experiencing mild episodes of depression or anxiety deal with them without disrupting their productive activities. A substantial minority of the population, however, experiences more disabling conditions such as schizophrenia, bipolar disorder type I, severe recurrent depression, and severe personality disorders. While common mild disorders are amenable to self-management and relatively simple educational or support measures, severe mental illness demands complex, multi-level care that involves a longer-term engagement with the individual, and with the family. Yet, despite the considerable burden and its associated adverse human, economic, and social effects, governments and donors have failed to prioritise treatment and care of people with mental illness. Indeed, pervasive stigma and discrimination contributes to the imbalance between the burden of disease due to mental disorders, and the attention these conditions receive.

The percentage of the population aged 60 years and above in South Africa rose from 7.1% in 1996 to 8 % in 2011, an increase from 2.8 million to 4.1 million individuals. The proportion of persons 60 years and older is projected to almost double during 2000–2030 because of (i) a marked decline in fertility in the past few decades; (ii) the HIV and AIDS pandemic contributing to this change in the population structure, with a higher mortality of young adults, especially women of reproductive age; and (iii) a rise in life expectancy to 62 years in 2013-– a staggering increase of 8.5 years since the low in 2005.

Four in ten elderly persons in South Africa are poor. More than a third make an average living, and the rich constitute about 27%. Provincial variations show that rural provinces have higher proportions of poor elderly persons compared to those residing in the urban provinces. Racial differences show that elderly Whites and Indians/Asians occupied a higher socio-economic status than black Africans and Coloureds.

Ours is the first study that offers a comprehensive analysis of depression among the old (60+ years) in South Africa, using the four waves of the National Income Dynamics Study (SA-NIDS) (2008, 2010, 2012 and 2014).

A self-reported measure of depression is used. SA-NIDS gives data on not depressed in a week, depressed for 1-2 days, 3-4 days and 5-7 days. We focus on those depressed for ≥ 3 days in a week. Referring to this as a measure of severe depression, its prevalence reduced from 15.3 % among the old in 2008 to 14.5 % in 2014, with a dip to 12.6 % in 2012.

Aging is a major factor in depression. Those in early 60s are generally more depressed than older persons in their 70s and 80s.

Old women were consistently more depressed than old men, as they are subject to violence. It is associated with conflicts over the man’s drinking, the woman having more than one partner, and her not having post-school education. Another factor is that women are typically much more likely to be overweight and obese, leading to non-communicable diseases (NCDs) and subsequently higher depression . A challenging aspect of obesity prevention among black South Africans is the positive perception that both women and men attach to a large body size.

Married men and women are less depressed than others. Marriage thus serves as a barrier to loneliness and a source of support during periods of stress for old persons. However, old persons in larger households without any other old person are more prone to depression. It is not clear whether larger households result in neglect of old persons or their abuse.

Ethnicity matters. The Africans are more prone to depression than the reference group of the Whites and Coloureds. There is limited evidence suggesting that Asians/Indians/Others are less likely to be depressed.

Pensioners are less likely to be depressed despite some evidence in the literature on pooling of pensions with other household resources and denying the pensioner any financial autonomy. Although this can’t be ruled out, it is evident that the favourable effect of pensions in preventing depression is robust.

Of particular significance are the results on multimorbidity (more than one disease at a time). Two combinations of NCDs (diabetes and high BP, and cancer and heart disease) are positively associated with depression. Equally important are the associations between disabilities in activities of daily living or DADLs (e.g. difficulties in dressing,bathing, eating, walking, climbing stairs) and depression. In many cases, both sets of DADLs are positively associated with depression. The relationship between depression and body mass index or BMI categories (underweight, normal, overweight and obese) is not so robust except that in some cases overweight were less likely to be depressed than the reference category of obese.

Shock of a family member’s death (in the last 24 months) was robustly linked to higher incidence of depression. There is some evidence suggesting that this shock had stronger effects on women relative to men.

As loneliness and lack of support during a difficult situation can precipitate stress leading to depression, we experimented with measures of social capital and trust as barriers to depression, and the mediating role of preference for the same neighbourhood.

Although social capital doesn’t have a significant negative effect on depression, social trust does. Besides, the mediating role of preference for the current neighbourhood is confirmed in most cases. An exceptional case is that of the Africans for whom neither social capital nor social trust is of any consequence except the mediating role of preference for the current neighbourhood.

The burden of depression in terms of shares of depressed in total depressed has risen in the more affluent wealth quartiles-especially that of the most affluent. However, likelihood of depression remained lower among the third and fourth quartiles, implying that the likelihood of depression was higher in the poorest (or the least wealthy). It is somewhat surprising that despite marked inequalities even among the Africans, there is no wealth effect on depression.

Although older people are in worse health than those younger, older people use health services much less frequently. These patterns of utilization arise from barriers to access, a lack of appropriate services and the prioritization of services towards the acute needs of younger people.

A larger ethical issue is rationing of health care to older people on the notion that health services are scarce and must be allocated to achieve the greatest good for the greatest number of people. WHO 2015 rejects this view on two counter-arguments: older people have made the greatest contribution to socioeconomic development that created these services; and they are entitled to live a dignified and healthy life.

Mental health care continues to be under-funded and under-resourced compared to other health priorities in the country; despite the fact that neuropsychiatric disorders are ranked third in their contribution to the burden of disease in South Africa, after HIV/AIDS and other infectious diseases. In fact, mental health care is usually confined to management of medication for those with severe mental disorders, and does not include detection and treatment of other mental disorders, such as depression and anxiety disorders.

From this perspective, the proposed National Mental Health Policy Framework and Strategic Plan 2013-2020 is a bold and comprehensive initiative.

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