New research shows Australian healthcare practitioners are often prescribing medicinal cannabis for psychiatric conditions where the evidence for effectiveness is unclear. But researchers who looked into the prescribing data believe that perhaps something has been overlooked, possibly leading to new avenues for treatment. The findings come University of Sydney researchers and are published in Frontiers in Pharmacology.
“These data confirm many Australians have unmet needs around their mental health and that medicinal cannabis is now frequently being trialled as an alternative to conventional therapies,” said study leader Dr Elizabeth Cairns.
“Medicinal cannabis is not typically prescribed as a first-line therapy, so those using it for conditions such as anxiety and depression likely have not had success with other treatments.
“This provides us with new leads for our clinical trials that will hopefully produce high-quality evidence to support or discourage current patterns of use.”
Dr Cairns and colleagues analysed the complete record of medicinal cannabis prescribed through Special Access Scheme B (SAS-B), using data supplied by the Australian Therapeutic Goods Administration (TGA) going back to the drug’s legalisation there in 2016, which allowed a diverse range of CBD and THC products to be legally available for medical use.
Prescriptions through this scheme have been increasing annually since the drug made its way into Australia’s pharmaceutical market in late 2016. From February 2021 the number of prescriptions started to boom, leaping from 100 000 to 300 000 by September the following year.
After treatment for chronic pain, analysis by the Lambert researchers shows anxiety is the second most common condition being treated with prescribed medicinal cannabis in Australia. However, evidence for the effectiveness of medicinal cannabis products in treating anxiety is surprisingly poor.
There is also increasing prescribing for conditions such as depression, ADHD and autism where an “evidence gap” exists around effectiveness.
Psychiatric prescriptions, used to treat mental, emotional, developmental and behavioural disorders, make up 33.8% of total approvals.
“Despite prescribing for a variety of different psychiatric indications, there is limited published high-quality evidence of efficacy to support this prescribing,” Dr Cairns said.
“The key here is not that the evidence shows cannabis products don’t work, more that high-quality studies supporting current prescribing just haven’t been done.”
Medicinal cannabis has been approved for anxiety disorders far more than any other psychiatric condition, making up 22.6% of all SAS-B prescriptions, and the type of medications used to treat anxiety caught the interest of scientists at Lambert.
“The anxiety data are really interesting because more than three quarters of the products prescribed contain THC (tetrahydrocannabinol), but THC is often thought of as anxiety-inducing, with cannabis use sometimes associated with paranoia and social anxiety,” Dr Cairns said.
“It makes you think, is there something about THC that we’ve missed historically?”
Dr Cairns suggested more priority research funding is needed to examine the effectiveness of medicinal cannabis products at improving mental health and quality of life.
The researchers said healthcare professionals often struggle to find reliable information about prescribing the hundreds of medicinal cannabis products available, and whether THC or CBD products are best used for different psychiatric conditions.
Reaching for a high-calorie snack is a common reaction when stressed – but this could be driving a vicious circle. Australian scientists report that stress combined with calorie-dense ‘comfort’ food creates brain changes that drive more eating, boost cravings for sweet, highly palatable food and lead to excess weight gain.
A team from the Garvan Institute of Medical Research reported in the journal Neuron that stress overrode the brain’s natural response to satiety, leading to non-stop reward signals that promote eating more highly palatable food. This occurred in a part of the brain called the lateral habenula, which when activated usually dampens these reward signals.
“Our findings reveal stress can override a natural brain response that diminishes the pleasure gained from eating — meaning the brain is continuously rewarded to eat,” says Professor Herzog, senior author of the study and Visiting Scientist at the Garvan Institute of Medical Research.
“We showed that chronic stress, combined with a high-calorie diet, can drive more and more food intake as well as a preference for sweet, highly palatable food, thereby promoting weight gain and obesity. This research highlights how crucial a healthy diet is during times of stress.”
From stressed brain to weight gain
Most people will eat more than usual during times of stress and choose calorie-rich options high in sugar and fat. To understand what drives these eating habits, the team investigated in mouse models how different areas in the brain responded to chronic stress under various diets.
“We discovered that an area known as the lateral habenula, which is normally involved in switching off the brain’s reward response, was active in mice on a short-term, high-fat diet to protect the animal from overeating. However, when mice were chronically stressed, this part of the brain remained silent – allowing the reward signals to stay active and encourage feeding for pleasure, no longer responding to satiety regulatory signals,” explains first author Dr Kenny Chi Kin Ip.
“We found that stressed mice on a high-fat diet gained twice as much weight as mice on the same diet that were not stressed.”
The researchers discovered that at the centre of the weight gain was the molecule NPY, which the brain produces naturally in response to stress. When the researchers blocked NPY from activating brain cells in the lateral habenula in stressed mice on a high-fat diet, the mice consumed less comfort food, resulting in less weight gain.
Driving comfort eating
The researchers next performed a ‘sucralose preference test’ – allowing mice to choose to drink either water or water that had been artificially sweetened.
“Stressed mice on a high-fat diet consumed three times more sucralose than mice that were on a high-fat diet alone, suggesting that stress not only activates more reward when eating but specifically drives a craving for sweet, palatable food,” says Professor Herzog.
“Crucially, we did not see this preference for sweetened water in stressed mice that were on a regular diet.”
Stress overrides healthy energy balance
“In stressful situations it’s easy to use a lot of energy and the feeling of reward can calm you down — this is when a boost of energy through food is useful. But when experienced over long periods of time, stress appears to change the equation, driving eating that is bad for the body long term,” says Professor Herzog.
The researchers say their findings identify stress as a critical regulator of eating habits that can override the brain’s natural ability to balance energy needs.
“This research emphasises just how much stress can compromise a healthy energy metabolism,” says Professor Herzog. “It’s a reminder to avoid a stressful lifestyle, and crucially – if you are dealing with long-term stress – try to eat a healthy diet and lock away the junk food.”
A new UK study has found that fatigue is the most significant symptom for long COVID patients, and can affect quality of life more than some cancers. The research, published in BMJ Open, examines the impact of long COVID on the lives of over 3750 patients who were referred to a long COVID clinic and used a digital app as part of their NHS treatment for the condition.
Patients were asked to complete questionnaires on the app about how long COVID was affecting them – considering the impact of long COVID on their day-to-day activities, levels of fatigue, depression, anxiety, breathlessness, brain fog, and their quality of life.
The researchers, from UCL and the University of Exeter, found that many long COVID patients were seriously ill and on average had fatigue scores worse or similar to people with cancer-related anaemia or severe kidney disease. Their health-related quality of life scores were also lower than those of people with advanced metastatic cancers, like stage IV lung cancer.
Overall, the team found that the impact of long COVID on the daily activities of patients was worse than that of stroke patients and was comparable to that of patients with Parkinson’s disease.
Dr Henry Goodfellow, who co-led the study alongside the late Professor Elizabeth Murray (both UCL Institute of Epidemiology & Health), said: “Up to around 17% of people who get COVID go on to develop long COVID *. However, the impact of the condition on patients’ day-to-day lives isn’t fully understood.
“Our results have found that long COVID can have a devastating effect on the lives of patients – with fatigue having the biggest impact on everything from social activities to work, chores and maintaining close relationships.”
Not only does long COVID negatively impact the lives of patients on an individual level, the researchers also believe that it could have a significant economic and social impact on the country.
In order to be referred to a long COVID clinic, a patient must have had symptoms in keeping with long COVID for at least 12 weeks after an acute infection.
Over 90% of long COVID patients using the app were of working age (18-65) and 51% said they had been unable to work for at least one day in the previous month, with 20% unable to work at all.
Meanwhile, 71% of patients were female. As working-age women make up a majority of the health and social care workforce, the impact of long COVID on their ability to function may add additional pressures to already stretched services.
Dr Goodfellow said: “We hope that a greater understanding of the symptoms and impact of long COVID in these patients will help the NHS and policymakers to target limited resources by adapting existing services and designing new ones to better meet the needs of patients with long COVID .”
Alongside fatigue, long COVID patients typically experience breathlessness, anxiety, depression and brain fog. This is the first study to report on the impact of the condition on day-to-day functioning and health-related quality of life in patients who have been referred for specialist rehabilitation in long COVID clinics across England.
Dr Goodfellow said: “Our findings show that fatigue should be an important focus for clinical care and the design of rehabilitation services.
“Post-COVID assessment services should consider focusing on assessing and treating fatigue to maximise the recovery and return to work for sufferers of long COVID .”
Being obese significantly increases the chances of also developing mental disorders. This applies to all age groups, with women at higher risk than men for most diseases, as a recent study of the Complexity Science Hub and the Medical University of Vienna shows. The results were published in the specialist journal Translational Psychiatry.
“We analysed a population-wide national registry of inpatient hospitalisations in Austria from 1997 to 2014 in order to determine the relative risks of comorbidities in obesity and identify statistically significant sex differences,” explains Elma Dervic of the Complexity Science Hub. Consequently, it became evident that an obesity diagnosis significantly enhances the likelihood of a wide range of mental disorders across all age groups – including depression, nicotine addiction, psychosis, anxiety, eating and personality disorders. “From a clinical point of view, these results emphasise the need to raise awareness of psychiatric diagnoses in obese patients and, if necessary, to consult specialists at an early stage of diagnosis,” says Michael Leutner of the Medical University of Vienna.
First diagnosis: obesity
“In order to find out which illness typically appeared prior and subsequently to the obesity diagnosis, we had to develop a new method,” explains Dervic. This allowed the researchers to determine if there were trends and typical patterns in disease occurrence.
In case of all co-diagnoses, with the exception of the psychosis spectrum, obesity was in all likelihood the first diagnosis made prior to the manifestation of a psychiatric diagnosis. “Until now, physicians often considered psychopharmacological medications to cause the association between mental disorders and obesity as well as diabetes. This may be true for schizophrenia, where we see the opposite time order, but our data does not support this for depression or other psychiatric diagnoses,” explains Alexander Kautzky from Department of Psychiatry and Psychotherapy of the Medical University Vienna. However, whether obesity directly affects mental health or whether early stages of psychiatric disorders are inadequately recognised is not yet known.
Women more impacted
Surprisingly, the researchers found significant gender differences for most disorders — with women showing an increased risk for all disorders except schizophrenia and nicotine addiction.
While 16.66% of obese men also suffer from nicotine abuse disorder, this is only the case in up to 8.58% of obese women. The opposite is true for depression. The rate of diagnosed depressive episodes was almost three times higher in obese women (13.3% obese; 4.8% non-obese). Obese men were twice as likely to be affected (6.61% obese; 3.21% non-obese).
Early intervention is key
Since this study now also shows that obesity often precedes severe mental disorders, the findings reinforce its importance as a pleiotropic risk factor for health problems of all kinds. This is especially true for young age groups, where the risk is most pronounced, and for whom the researchers strongly recommend obesity screening.
A registry-based study on cannabis users in Denmark spanning 39 years found that young males were more than twice as likely to develop schizophrenia as young females. The researchers, who published their findings in Psychological Medicine, estimated that about 15% of schizophrenia in this population group is due to cannabis use.
Previous research suggests an increase in schizophrenia population attributable risk fraction (PARF) for cannabis use disorder (CUD). However, sex and age variations in CUD and schizophrenia suggest the importance of examining differences in PARFs in sex and age subgroups.
Moreover, cannabis potency measured by the percentage of delta-9-tetrahydrocannabinol (THC) (main psychoactive component of cannabis) has increased dramatically, eg from 13% in 2006 to 30% in 2016 in Denmark. CUD has also increased markedly – past-year CUD rose significantly from 4.9% in 2014 to 5.9% in 2018 among US 18–25-year-olds.
A growing body of evidence suggests that the relationship between CUD and schizophrenia may differ by sex. Male sex and early heavy or frequent cannabis use are associated with earlier onset of psychosis.
The researchers conducted a nationwide Danish register-based cohort study including all individuals aged 16–49 at some point during 1972–2021, identifying CUD and schizophrenia status.
The researchers examined 6 907 859 individuals, with 45 327 cases of incident schizophrenia during follow-up. Males had slightly higher risk for schizophrenia with CUD (142%) than females (102%). But among 16–20-year-olds, the risk for males (284%) was more than twice that for females (81%). They also found that during the 39-year study period, the annual average increase in PARF for CUD in schizophrenia incidence was 4.8% among males and 3.2% among females. In 2021, among males, this risk fraction was 15%; among females, it was around 4%.
Conclusions
The researchers concluded that “Young males might be particularly susceptible to the effects of cannabis on schizophrenia. At a population level, assuming causality, one-fifth of cases of schizophrenia among young males might be prevented by averting CUD. Results highlight the importance of early detection and treatment of CUD and policy decisions regarding cannabis use and access, particularly for 16–25-year-olds.”
It has been believed speed of information transmitted among regions of the brain stabilised during early adolescence. A study in Nature Neuroscience has instead found that transmission speeds continue to increase into early adulthood, which may explain the emergence of mental health problems over this period. In fact, transmission speeds increase until around age 40, reaching a speed twice that of a 4-year old child.
As mental health problems such as anxiety, depression and bipolar disorders can emerge in late adolescence and early adulthood, a better understanding of brain development may lead to new treatments.
“A fundamental understanding of the developmental trajectory of brain circuitry may help identify sensitive periods of development when doctors could offer therapies to their patients,” says senior author Dora Hermes, PhD, a biomedical engineer at Mayo Clinic.
Called the human connectome, the structural system of neural pathways in the brain or nervous system develops as people age. But how structural changes affect the speed of neuronal signalling has not been well described.
“Just as transit time for a truck would depend on the structure of the road, so does the transmission speed of signals among brain areas depend on the structure of neural pathways,” Dr Hermes explains. “The human connectome matures during development and aging, and can be affected by disease. All these processes may affect the speed of information flow in the brain.” In the study, Dr Hermes and colleagues stimulated pairs of electrodes with a brief electrical pulse to measure the time it took signals to travel among brain regions in 74 research participants between the ages of 4 and 51. The intracranial measurements were done in a small population of patients who had electrodes implanted for epilepsy monitoring at University Medical Center Utrecht, Netherlands.
The response delays in connected brain regions showed that transmission speeds in the human brain increase throughout childhood and even into early adulthood. They plateau around 30 to 40 years of age.
The team’s data indicate that adult transmission speeds were about two times faster compared to those typically found in children. Transmission speeds also were typically faster in 30- or 40-year-old subjects compared to teenagers.
Brain transmission speed is measured in milliseconds, a unit of time equal to one-thousandth of a second. For example, the researchers measured the neuronal speed of a 4-year-old patient at 45 milliseconds for a signal to travel from the frontal to parietal regions of the brain. In a 38-year-old patient, the same pathway was measured at 20 milliseconds. For comparison, the blink of an eye takes about 100 to 400 milliseconds.
The researchers are working to characterise electrical stimulation-driven connectivity in the human brain. One of the next steps is to better understand how transmission speeds change with neurological diseases. They are collaborating with paediatric neurosurgeons and neurologists to understand how diseases change transmission speeds compared to what would be considered within the normal range for a certain age group.
Frequent users of YouTube have higher levels of loneliness, anxiety, and depression according to researchers from the Australian Institute for Suicide Research and Prevention (AISRAP). Published online in MDPI, their study found that the most severely impacted were those under age 29, or who regularly watched content about other people’s lives.
Lead author Dr Luke Balcombe said the development of parasocial relationships between content creators and followers could be cause for concern, however some neutral or positive instances of creators developing closer relationships with their followers also occurred.
“These online ‘relationships’ can fill a gap for people who, for example, have social anxiety, however it can exacerbate their issues when they don’t engage in face-to-face interactions, which are especially important in developmental years,” he said.
“We recommend individuals limit their time on YouTube and seek out other forms of social interaction to combat loneliness and promote positive mental health.”
Dr Balcombe said the amount of time spent on YouTube was often a concern for parents, who struggled to monitor their children’s use of the platform for educational or other purposes.
In the study, two hours per day of YouTube consumption was classed as high frequency use and over five hours a day as saturated use.
In addition, the study determined more needed to be done to prevent suicide-related content being suggested to users by YouTube algorithms.
While ideally, people shouldn’t be able to search for these topics and be exposed to methods, the YouTube algorithm does push recommendations or suggestions based on previous searches, which can send users further down a disturbing ‘rabbit hole’.
Users can report this type of content, but sometimes it may not be reported, or it could be there for a few days or weeks and with the sheer volume of content passing through, it’s almost impossible for YouTube’s algorithms to stop all of it.
If a piece of content is flagged as possibly containing suicide or self-harm topics, YouTube then provides a warning and asks the user if they want to play the video.
“With vulnerable children and adolescents who engage in high frequency use, there could be value in monitoring and intervention through artificial intelligence,” Dr Balcombe said.
“We’ve explored human–computer interaction issues and proposed a concept for an independent-of-YouTube algorithmic recommendation system which will steer users toward verified positive mental health content or promotions.
“YouTube is increasingly used for mental health purposes, mainly for information seeking or sharing and many digital mental health approaches are being tried with varying levels of merit, but with over 10,000 mental health apps currently available, it can be really overwhelming knowing which ones to use, or even which ones to recommend from a practitioner point of view.
“There is a gap for verified mental health or suicide tools based on a mix of AI-based machine learning, risk modelling and suitably qualified human decisions, but by getting mental health and suicide experts together to verify information from AI, digital mental health interventions could be a very promising solution to support increasing unmet mental health needs.”
Scientists have developed two new drug candidates for potentially treating addiction and depression, modelled on the pharmacology of a traditional African psychedelic plant medicine called ibogaine. At very low doses, these new compounds were able to blunt symptoms of both conditions in mice.
The study, published in Cell, took inspiration from ibogaine’s impact on the serotonin transporter (SERT), which is also the target of selective serotonin reuptake inhibitor (SSRI) drugs, such as fluoxetine. A team of scientists from UC San Francisco and Yale and Duke universities virtually screened 200 million molecular structures to find ones that blocked SERT in the same way as ibogaine.
“Some people swear by ibogaine for treating addiction, but it isn’t a very good drug. It has bad side effects, and it’s not approved for use in the US,” said Brian Shoichet, PhD, co-senior author and professor in the UCSF School of Pharmacy. “Our compounds mimic just one of ibogaine’s many pharmacological effects, and still replicate its most desirable effects on behaviour, at least in mice.”
Dozens of scientists from the laboratories of Shoichet, Allan Basbaum, PhD, and Aashish Manglik, MD, PhD, (UCSF); Gary Rudnick, PhD, (Yale); and Bill Wetsel, PhD, (Duke) helped demonstrate the real-world promise of these novel molecules, which were initially identified using Shoichet’s computational docking methods.
Docking involves systematically testing virtual chemical structures for binding with a protein, enabling scientists to identify new drug leads without having to synthesise them in the lab. “This kind of project begins with visualizing what kinds of molecules will fit into a protein, docking the library, optimising and then relying on a team to show the molecules work,” said Isha Singh, PhD, a co-first author of the paper who did the work as a postdoc in Shoichet’s lab. “Now we know there’s a lot of untapped therapeutic potential in targeting SERT.”
Optimising a shaman’s cure
Ibogaine is found in the roots of the iboga plant, which is native to central Africa, and has been used for millennia during shamanistic rituals. In the 19th and 20th centuries, doctors in Europe and the US experimented with its use in treating a variety of ailments, but the drug never gained widespread acceptance and was ultimately made illegal in many countries.
Part of the problem, Shoichet explained, is that ibogaine interferes with many aspects of human biology.
“Ibogaine binds to hERG, which can cause heart arrhythmias, and from a scientific standpoint, it’s a ‘dirty’ drug, binding to lots of targets beyond SERT,” Shoichet said. “Before this experiment, we didn’t even know if the benefits of ibogaine came from its binding to SERT.”
Shoichet, who has used docking on brain receptors to identify drugs to treat depression and pain, became interested in SERT and ibogaine after Rudnick, an expert on SERT at Yale, spent a sabbatical in his lab. Singh picked up the project in 2018, hoping to turn the buzz around ibogaine into a better understanding of SERT.
It was the Shoichet lab’s first docking experiment on a transporter – a protein that moves molecules into and out of cells – rather than a receptor. One round of docking whittled the virtual library from 200 million to just 49 molecules, 36 of which could be synthesised. Rudnick’s lab tested them and found that 13 inhibited SERT.
The team then held virtual-reality-guided “docking parties,” to help Singh prioritise five molecules for optimization. The two most potent SERT inhibitors were shared with Basbaum and Wetsel’s teams for rigorous testing on animal models of addiction, depression and anxiety.
“All of a sudden, they popped – that’s when these drugs looked a lot more potent than even paroxetine [Paxil],” Shoichet said.
Manglik, an expert with cryo-electron microscopy (cryo-EM), confirmed that one of the two drugs, dubbed ‘8090,’ fit into SERT at the atomic level in a way that closely resembled Singh and Shoichet’s computational predictions. The drugs inhibited SERT in a similar way to ibogaine, but unlike the psychedelic, their effect was potent and selective, with no spillover impacts on a panel of hundreds of other receptors and transporters.
“With this sort of potency, we hope to have a better therapeutic window without side effects,” Basbaum said. “Dropping the dose almost 200-fold could make a big difference for patients.”
Researchers have released positive topline data from a trial evaluating microdoses of lysergide, commonly known as LSD, in the treatment of major depressive disorder (MDD). The investigator-initiated Phase 2 trial was led by Prof Matthias Liechti and Dr Felix Mueller at University Hospital Basel (UHB) and the University Hospital of Psychiatry, and supported by Mindmed.
Lysergide is a potent semi-synthetic hallucinogen that has gained some notoriety as an illicit drug but in recent years has been investigated as a treatment for MDD, alongside other psychedelic drugs. The new trial compared lower and higher doses of lysergide, though at still small doses. Previous research also showed benefits in treating anxiety.
The topline data demonstrated significant, rapid, durable and beneficial effects of lysergide and its potential to mitigate symptoms of MDD. The high dose lysergide regimen in which 28 patients received 100µg at their first dosing day and 200µg at their second dosing day (separated by four weeks) resulted in statistically and clinically significant improvements on the primary endpoint, which was the change in clinician-rated depressive scores 6 weeks after the first administration as compared to control (whether or not the patient received a second administration). The 27 members of the control group received a lower dose regimen of 25µg on both treatment days. Both groups had improvements compared to the placebo group. Data from the secondary endpoints were also encouraging, and the investigational drug was generally well-tolerated, as indicated by reported adverse events, changes in vital signs and laboratory values.
“We continue to be encouraged by the positive results being generated on the clinical activity of lysergide by our collaborators at UHB,” said Robert Barrow, Chief Executive Officer and Director of MindMed, the company behind the trial. “The statistically and clinically significant improvements observed in this study reinforce preliminary findings that have shown the clinical potential of lysergide in anxiety, depression and other brain health disorders. These positive findings are particularly relevant to our MM-120 program in generalized anxiety disorder, given the high degree of comorbidity of GAD and MDD. I would like to congratulate and thank our collaborators at UHB for once again generating high quality clinical data that continue to support the progression of our pipeline.”
Prof. Matthias Liechti, co-primary investigator of the trial, commented, “Historical studies of lysergide in MDD demonstrated rapid, robust and sustained improvement in depressive symptoms. We also observed improvement in depressive symptoms in patients with anxiety disorders in another of our recently published trials. We believed it was necessary to confirm the historical studies with ones using modern methods. Hence, we designed this randomised-controlled trial to assess the benefits of lysergide treatment in MDD. Importantly, an active small dose of lysergide was used as the control. We are extremely encouraged by the results we presented today, which demonstrate the strong, rapid and enduring improvements of this compound in patients suffering from MDD. We look forward to publishing the completed results in a peer-reviewed journal along with additional analyses. Our lab will continue investigating the therapeutic potential of lysergide and other psychedelics.”
MindMed supports the UHB Liechti Lab in conducting investigator-initiated trials for lysergide and other novel therapies and has exclusive access and rights to the data generated by these studies.
South Africa’s long-awaited new National Mental Health Policy Framework and Strategic Plan 2023 – 2030 has been published. The policy framework was presented at the SA mental health conference this week. PHOTO: DOH/Twitter
But even though there has been a gap from 2020 to 2023, speaking to Spotlight at the conference, Minister of Health Dr Joe Phaahla said that it doesn’t mean there was a gap in terms of updating. “Every either three or five years, we revise the policy. So, it is not that there has been a gap. There has been a policy, which has been guiding,” he said.
“But as things change, and in each cycle of the strategy and planning, we have a particular timeframe so that we can evaluate. And so now we have evaluated, and that’s why we are adding [additional things], as we learned from the previous implementation.”
Phaahla said that gaps in the country’s mental health services are not because of a lack of policy and plans but due to implementation issues and sometimes the shortage of resources and psychiatrists.
“If you look at the area of psychiatrists, it is just the two-tier system of our health service, which makes it very difficult because what psychiatrists can earn providing the services to more of the insured patients – it is something we can’t really match with the public sector salaries generally,” he said. Phaahla said that psychiatrists, who mostly work in the private sector, were typically trained at public-sector teaching hospitals. “But once they’re qualified, they stay for one year or so, then they are attracted by better income,” he told Spotlight.
According to Phaahla, to deal with the shortage of psychiatrists in provinces such as the Northern Cape where there are only three psychiatrists, the department plans to contract psychiatrists from other provinces. “We can have part-time psychiatrists, maybe take some from Gauteng where the majority are and in Western Cape and contract them to provide services in Northern Cape. Even if it’s on a weekly rotation,” he said.
Concerns over delays
While several mental health experts have welcomed the new policy framework and agree with Phaahla about the importance of implementation, they are not happy about the delays.
“We’re now sitting in 2023, three years late,” said Cassey Chambers of the South African Depression and Anxiety Group (SADAG). What that means, she said, is that civil society did not have a working document with which to engage government at provincial or district level.
Bharti Patel of the South African Mental Health Federation expressed similar concerns. “As the Federation for mental health, we are disappointed that it has taken this long for the policy to be reviewed, given the fact that the initial policy was launched in 2013,” said Patel.
“We had a crisis during that period from 2013 to 2020. We have witnessed mental healthcare users losing their lives during Life Esidimeni. The [Health] ombud report, the South African Human Rights Commission Report, have all given recommendations,” Patel said. Patel argues that those recommendations should have informed policy and implementation more quickly.
Implementation problems
Chambers described the previous strategic policy framework as a “very good document”. Then, she said, the problem came in the implementation. “And I think perhaps this is [why there was a] delay in having an updated document that is now running from 2023 to 2030. It is because the document was good, the policy was good. However, how it was implemented was not happening,” she said.
Speaking to Spotlight, Professor Crick Lund, Co-Director, of the Centre for Global Mental Health at King’s College London, explained that there are a number of factors that create implementation challenges. “The one is ignorance on the part of senior decision-makers about mental health, ignorance about the scale of the problem, and ignorance about the fact that something can be done about it,” he said.
According to Lund, the new policy framework has stronger implementation monitoring mechanisms and implementation can be tracked in a much clearer way over time.
For the new policy framework to work better than the previous one, Lund believes there is a need to create greater public awareness about mental health and about the mental health policy. He says, “We need to get all the sectors involved working together – the Department of Health, Education, Social Development, the criminal justice system, and also the NGO sector.”
Along similar lines, Patel stressed the importance of getting more government departments involved. “While the policy is developed at the national level, the National Department of Health is responsible for training the provinces and not only the Department of Health; they need to train all government departments within the province who have bought this policy,” she said. “You can’t have the Department of Health alone implement a policy. This is a policy that requires inter-sectoral collaboration so that different departments can also put budgets towards implementation.”
Lund said that there is a lot of common agreement on what the priorities are and a lot of energy going forward. “So I’m hopeful that we can move things forward.”
Budgets and human resources
While there seems to be consensus on the need for more training and getting wider buy-in, there is also a shared awareness that successful implementation will depend on the availability of sufficient funds and human resources.
“We need to see structured action plans in the provinces with budgets allocated so that we can hold the government departments accountable,” said Patel.
Chambers agrees that in order to get implementation of the new policy framework right, we will have to get the budgets right. “You need to allocate a budget in order to help with the implementation plan, especially knowing that our previous policy framework was not implemented. So, we have to overcompensate for that now, which is concerning because this year, the health budget has been reduced. Therefore, meaning that the national mental health budget has been reduced,” she said.
According to the new policy framework, the case for investing in mental health is strong. It states that at a societal level, lost income associated with mental illness far exceeds public sector expenditure on mental healthcare – in other words, it costs South Africa more to not treat mental illness than to treat it. The impact of mental illnesses such as depression and anxiety has been estimated to cost the economy more than US$3.6 billion (R61.2 billion) in lost earnings per year. Certain conditions such as perinatal depression and anxiety have lifelong cost consequences. For example, it is estimated that the lifetime costs of perinatal depression and anxiety in South Africa amount to US$2.8 billion (R47.6 billion) per annual cohort of births.
Chambers also stressed that we are facing shortages of human resources and appropriate facilities. “We don’t have the human resources or the capacity to fulfil that implementation plan and that’s a worry and a concern,” she said.
NHI and provincial plans
According to the new policy framework, mental health will be financed according to the principles adopted for all health financing in South Africa, and people will be protected from the catastrophic financial consequences of mental ill-health.
According to the policy framework, in the financing of the National Health Insurance (NHI) system, mental health services will be given parity with other health conditions, in proportion to the burden of disease and evidence for cost-effective interventions. NHI will specifically include packages of care for mental health, in line with the evidence for the most cost-effective interventions. The policy framework states that private medical aid schemes should be required to provide similar parity between mental health and other health conditions.
“Budget will be allocated to meet targets set for the implementation of the policy and regular discussions will be held with provinces to discuss strategies and monitor progress with implementation. At provincial level, mental health budgets will be reviewed annually to align mental health with national priorities, for each of the areas for action in 2023 and annually thereafter,” the policy framework reads.
The policy also says that all provinces will develop provincial strategic plans for mental health, in keeping with national policy, which outlines specific strategies, targets, timelines, budgets, and indicators in 2023 and annually thereafter, informed by specific unique local challenges.
