The statement “There is no health without mental health” made by the World Health Organization highlights the importance of taking care of both our mental and physical health. Health services in South Africa are improving for many physical health problems but remain weak and limited for mental health services.
Currently the majority of the budget for mental health services is spent on institutions catering primarily for severe mental disorders, such as severe mood disorders and psychosis. Providing services for all mental disorders at local health centres is urgently needed through an integrated service that is supported by a strong district mental health team.
The clinic-level services should include accurate screening and detection of problems such as depression, brief counselling interventions provided at clinic level, and an effective referral system from the primary to more specialised services when required. Provision of integrated and effective mental health services within a general health care service addresses a number of concerns. People with chronic conditions, such as HIV, diabetes and cardiovascular diseases, often have comorbid depression and/or anxiety affecting adherence to their treatment.
Providing mental health care services assists people to find ways to cope more effectively with their chronic conditions and can reduce poverty levels.
Furthermore, mental disorders are strongly associated with poverty. Providing mental health care services assists people to find ways to cope more effectively with their chronic conditions and can reduce poverty levels. Addressing mental health care needs will reduce the health and economic burden of mental health disorders. In South Africa, and other low- and middle-income countries, there are a growing number of efforts to integrate mental health into general health care. Examples include screening and counselling for depressed pregnant women, providing a brief counselling intervention for people with injuries related to alcohol and drug abuse presenting at emergency departments at hospitals in the Western Cape, and addressing mental health disorders of people attending chronic disorder clinics.
Read more about how the the Alan J Flisher Centre for Public Mental Health suggests mental health care should be integrated into primary healthcare settings in the South African Health Review 2016 here.
While working on this piece and discussing the idea of adolescent mental health with friends not working in the mental healthcare sector, it became clear that even for some of the most educated the idea of mental health is inherently about pathology.
This got me thinking about whether awareness efforts from the 1977 WHO Alma Ata declaration of “health as not merely the absence of disease, but a state of complete wellbeing” to the more recent, and more specific WHO-endorsed idea that “there can be no health without mental health,” have penetrated society sufficiently and what implications the somewhat automatic link to pathology has on adolescents’ (who we know are highly conscious of how they are perceived by others) views of mental health and their willingness access to care and treatment when necessary.
Young people overseen
Earlier this year, The Lancet launched the third in a series of reports from an expert commission on adolescent health. The key message of this commission is that contrary to the traditional approach of neglecting adolescence in global and public health policy (because young people are considered to be generally healthy), investment in the health of adolescents is critical, not only to the health of the young people themselves and their health as adults, but also to the health and wellbeing of society and future generations. 
The rapid biological, neurological, social, cognitive, emotional, and psychological changes taking place during adolescence can provide opportunities for positive civic engagement and transitions to adulthood, but can also leave adolescents and young people vulnerable. Health behaviours, cognitive strategies and psychological coping mechanisms established in adolescence lay the foundation for adult health and wellbeing. The health and wellbeing of adolescents are noted to be significantly impacted on by social factors.
Two of the biggest causes of morbidity and mortality among young people globally, and in South Africa are HIV and mental health problems.
AIDS still massive problem under youth
While there has been significant progress towards the global goal of ending AIDS by 2030 among adults and children, the epidemic continues at crisis levels among adolescents. AIDS-related illness is the leading cause of death among adolescents in Africa and adolescence is the only age group in which AIDS-related deaths are increasing and infection rates remain unacceptably high. In South Africa, there are an estimated 320000 adolescents (aged 10-19), living with HIV, 15 % of the global total. Adherence to treatment is critical to reducing AIDS morbidity and mortality but is a particular challenge among adolescents largely due to psychosocial factors including stigma, discrimination, concerns about disclosure and a lack of social support. Many adolescents living with HIV experience depression and other mental illnesses, which in turn is a risk factor for worse HIV outcomes. Many also are exposed to the various other factors which contribute to mental illness. Losing ground in the fight against HIV/AIDS in adolescents and young people represents a potential resurgence of the epidemic.
Globally mental illness is an increasing health burden, with detrimental health, social and economic consequences. In many parts of the world, psychological and psychiatric care is inaccessible, and even more so for children and adolescents. In South Africa, the statistics vary, but it is estimated that 1 in 3 people will experience mental illness in his/her lifetime, but 85% will not receive treatment. Prevalence of mental illness among adolescents in South Africa is estimated at about 17%, although the data is limited, and adolescent mental illness increases the likelihood of adult mental illness.
Vicious circle of ill health
Poor mental health, especially among young people is strongly related to other health and development concerns including living with a chronic illness; HIV infection; malnutrition; substance abuse; exposure to violence or trauma; death of a family member; multiple shifts in caregiving; lack of family support structure; academic failure; lack of resources at schools; lack of opportunity for future career and study; lack of financial security; bullying; and discrimination.
Given these risk factors, the high levels of inequality and poverty in South Africa, as well as our social history of racial discrimination, migrant labour, and inequitable distribution of resources, would likely predispose a significant proportion of young people in the country to poor mental health.
Adolescents living with HIV often face these general risk factors for mental illness, compounded by living with a highly stigmatised and chronic illness. Furthermore, access to support and healthcare may be extremely limited.
The Khuluma Project
In the context of scarce human and material resources for mental healthcare, Khuluma is part of an effort to develop low-cost and scalable mechanisms of making mental healthcare more accessible. The specific aims of Khuluma are to address the mental health and well-being needs of HIV-positive adolescents through promoting peer-to-peer support and bolstering mechanisms identified as protective against mental ill-health in adolescents.
These include supporting improvements in self-esteem; training in problem-solving skills; helping them to learn from one another’s experiences; helping participants to feel part of a community (connectedness to one another); connecting them to opportunities; connecting them to positive role models.
Khuluma provides facilitated and interactive support to closed groups of 10 to 15 participants. Participants are able to communicate amongst themselves and with a facilitator via mobile phone about a broad range of topics while remaining anonymous to one another. The Khuluma model allows young people to have a direct input into their treatment and provides them with the space to openly talk about the issues affecting them. Khuluma allows them to be part of the conversation.
Khuluma participants have at times expressed a sense of not having had the opportunity to express their feelings before joining the project, but most significant has been the sense of belonging to a community created through the groups.
South African adolescents are exposed to an uncertain and tumultuous environment, to be sure. In light of the university closures and #FeesMustFall protests, which have dominated over World Mental Health Month, a key message in one of the papers in The Lancet 2012 series on adolescent health caught my eye:
“The strongest determinants of adolescent health world-wide are structural factors such as national wealth, income inequality, and access to education.”
Whatever your position on the protests may be, one thing is clear, young people are ultimately protesting for their right to health and mental wellbeing and are demanding to be heard. Perhaps it is time we listened – and basic technology may be helpful here.
 Lund, C., Boyce, G., Flisher, A. J., Kafaar, Z. and Dawes, A. (2009), Scaling up child and adolescent mental health services in South Africa: Human resource requirements and costs. Journal of Child Psychology and Psychiatry, 50: 1121–1130. doi:10.1111/j.1469-7610.2009.02078.x
 Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: a global public-health challenge. The Lancet, 369(9569), 1302-1313.