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In times of economic uncertainty and political instability, healthcare costs and claims tend to increase, particularly with regard to anxiety and depression. It is clear that there is a co-dependency between mental and physical health. 

Recent studies show that over 17 million people in South Africa are dealing with anxiety disorders such as panic attacks, post-traumatic stress disorder and mood disorders. 

The WHO and the increase in mental disorders
In addition, statistics from a global study presented at a recent mental health summit in Johannesburg, revealed that mental disorders have increased by 22.7%. In South Africa around 30% of people report life-long psychiatric disorders, while 1 in 3 will be affected by a mental illness in their lifetime. 
According to The World Health Organisation (WHO), mental health disorders cover a broad range of problems with different symptoms. However, they are generally characterised by some combination of abnormal thoughts, emotions and behaviour. Examples include schizophrenia, depression, intellectual disabilities and disorders due to drug abuse. It says mental health can be seen as the centre of all health, characterised by integral relationships with a person’s physical, social and financial wellbeing.
The good news is that most of these disorders can be successfully treated. 
According to WHO, mental health care is indispensable within a holistic integrated care model, as inadequate mental health care leads not only to poor mental health outcomes, but also to co-morbid chronic illnesses such as diabetes and HIV. 

The way it is
The bulk of mental health care delivery in South Africa has historically been separated from general health care, relying heavily on psychiatric hospitals with little attention to mental health care in the primary setting. There are inadequate numbers of specialised health care workers to serve the population, which leads to poor access to quality mental health care of good quality and ultimately, complications and costly hospitalisations.

The costs
‘Mental health admissions are the third highest admission category in terms of hospital costs,’ says Gerhard van Emmenis, Principal Officer of Bonitas Medical Fund. ‘This cost continues to climb and is up 7% from the previous year. In 2016, there were a total of 5 791 admissions for mental health at a cost of R132 mil (3% of total Scheme costs). The average cost for a mental health admission is R23 000 and the length of stay is 11 days.’

The relationship between mental and physical health
‘Mental and other health cannot be separated,’ says Van Emmenis. ‘The presence of mental illness increases the risk of disability and premature mortality from other diseases. This is due to a number of factors including side effects of medication, unhealthy behaviours such as diminished physical activity and substance abuse as well as neglect of the patient’s physical health – by patients themselves, their families and their health care providers. Conversely, chronic illness like diabetes is increasingly recognised as a risk factor for the development of mental illness.

‘With such a strong link between health and mental health we have  introduced a new treatment optimisation model of care for mental health that aims to improve clinical outcomes and access to cost-effective care. This model is over and above the support and programmes that are already in place for mental health patients.’

So what’s new?  
The new Mental Health Programme aims to change the way mental health care is accessed. The model is informed by local and international clinical research, spearheaded by the WHO. Parallel to health care provider upskilling it uses specialised mental health managed care interventions to promote effective self-care by members suffering from moderate to severe mental illness.

Benefits of this model of care compared to usual care:
* Greater reduction in mental health symptoms
* Greater rates of care for mental health
* Improvement in quality of life
* Less functional impairment
* Lower total health care costs in the medium and long term
* Significant benefit-to-cost ratio for absenteeism and presenteeism offset against primary screening costs in the workplace.
* Person not disease-centred

By integrating mental health care into a person-centered (as opposed to disease-centred) primary care model, early screening and comprehensive management for those at risk for mental illness can occur, and vice versa for those with mental illness who are at risk of developing other chronic illnesses and complications. 

For many sufferers of mental illness who do present for care, the family practitioner is the first port of call, ideally placed at the coalface of primary care delivery to promote integration of care. 

Mental health care integrated into the primary care setting has a range of advantages over usual care, including:
* Improved clinical outcomes
* Cost-effective use of resources
* Improved doctor and patient satisfaction
* Patient convenience - which increases access and adherence to care
* Reduced stigma

Building on existing doctor-patient relationships
The Bonitas Mental Health Programme is built around the principle of offering support to family practitioners and members in order to promote delivery and access to good quality primary mental health care.  
Van Emmenis says, ‘We follow an internationally successful model of integrating mental health care into the primary care setting through effective collaboration between family practitioners, specialists and auxiliary caregivers and the introduction of a care manager to help coordinate the process.  This, along with family practitioner upskilling, creates the necessary structure to allow the busy family practitioner to deliver good quality, patient-centered care, which includes mental health care. Optimal outcomes are expected where there is a contracted family practitioner network to support the programme.’

Self-care is essential
Patient activation and support for self-care are other key components of the model to achieve the desired clinical outcomes. This is achieved through education of patients and their families, behavioural activation via the care managers, integration with workplace wellness initiatives and accessing community support groups

Supporting the General Practitioner (GP) 
Upskilling and supporting the GP is essential in the form of training, treatment guidelines, referrals, simple diagnostic and screening guidance. It includes specialist support with telephone and electronic case review by psychiatrists and access to specialist advice on difficult cases.  Members have access to a care manager who will monitor their as well as the Electronic Health Record (EHR) offering a platform for multi-directional information sharing.

Mental illness has direct consequences on behaviour, including help-seeking, self-care and treatment compliance. While patient activation and empowerment is becoming an important focus area in the management of other chronic diseases, this may be a particularly difficult achievement in the patient with a mental disorder.

Family support 
The programme also offers educational material aimed at family members supporting sufferers of mental illness, drug-and alcohol abuse and dementia. This includes 
the hosting of electronic forums for community support groups via the Care Manager.

Multidisciplinary care
Van Emmenis says, ‘A key component of an integrated mental health care model is effective collaboration between members of the multidisciplinary care team.  It requires co-ordinated care between the patients, their GP, specialist and allied health professionals as well as social support structures.’

* Kathy Malherbe is a freelance writer