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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.99 n.5 Pretoria May. 2009




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



Dan J Stein; David R Williams; Ronald C Kessler



This special issue of the South African Medical Journal is devoted to the South African Stress and Health (SASH) survey. This study is significant for a number of reasons. First, SASH is the first nationally representative epidemiological survey of common mental disorders in South Africa, or indeed in Africa. Second, SASH used a similar methodology to other surveys in the World Mental Health Survey (WMHS),1 allowing comparison of local findings with those in a range of high-, low- and middle-income countries. Third, SASH had a particular focus on psychological trauma, and so provides a unique perspective on this potentially important risk factor for mental disorder.

The issue highlights some of the main findings from the survey, including the 12-month and lifetime prevalence of psychiatric disorders, and findings on the impact of mental disorders. There are also articles focusing on specific mental disorders (substance use disorders and major depression), as well as articles addressing key issues in the local context (stressors, perceived discrimination, perpetration of violence, HIV/AIDS). There is growing awareness of the economic and social impact of mental disorders,2 as well as of their early age of onset, and an interesting article notes an association between early onset of mental disorders and failure to complete secondary school. A range of other articles from the SASH study have been published or are under way, including many articles from the combined WMHS dataset, which includes SASH data.

Readers of the SAMJ need no reminder about the context within which this study took place; the survey was done in the first decade of our democracy, against a background of significant earlier political violence, and ongoing criminal violence. Key issues for the investigators were the historical legacy of apartheid with ongoing racial disparities in health (for this reason, race is reported in many analyses), the impact of past and ongoing stressors on mental health, and the growing HIV/AIDS epidemic. Some readers may, however, be less aware of the historical context of mental health services in South Africa – these have long been under-resourced, resulting in a gross lack of parity between general medical and psychiatric services.

Some of the findings reported here are therefore not surprising. In particular, the relatively high prevalence of 12-month and lifetime mood, anxiety and substance use disorders and the substantial burden of untreated mental disorders, although not previously documented in a nationally representative survey, are not unexpected. The data here are rigorous enough to persuade even the most sceptical of policy-makers that mental health services have been neglected. Data on the burden of mental disorders3 and on the cost-effectiveness of appropriate clinical interventions4 should help persuade such policy-makers that greater funding for mental health services is warranted.

When considered against the context of other surveys in the WMHS dataset, a number of features of SASH are particularly relevant. South Africa has a higher prevalence of mental disorders than many developing countries, but a lower prevalence than in many high-income countries.5 However, the prevalence of substance use disorders is particularly high in South Africa. This is consistent with a range of other data, including the extraordinarily high rates of fetal alcohol syndrome in the country.

There are many who remain sceptical about the basic constructs in psychiatry, arguing for example that DSM-IV (Diagnostic and Statistical Manual, 4th edition) diagnoses have poor cross-cultural validity, and noting that psychiatric symptoms fall into dimensions rather than into categories. It should be noted, however, that the WMHS made every effort to include a range of measures that allow deeper analyses of issues of this kind.6 There was a rigorous attempt to administer surveys in local languages, and categorical measures were supplemented with dimensional ones.7 Ongoing analyses of the WMHS data should be important in helping to revise current psychiatric nosology.

South Africa faces many health challenges, not least the HIV/AIDS epidemic. Nevertheless, the data discussed in this special issue remind us that there is 'no health without mental health'. We wish to acknowledge the sponsors of our research, particularly the National Department of Health in South Africa and the US National Institutes of Health, with gratitude. Many colleagues and students have contributed to the data analyses, and we are grateful for the tremendous amount of time and energy they have expended. We hope that the data here provide a scientific base for the development of future mental health policy in South Africa.


1. Kessler RC, Haro JM, Heeringa SG, et al. The World Health Organization World Mental Health Survey Initiative. Epidemiologia e Psichiatria Sociale – An International Journal for Epidemiology and Psychiatric Sciences 2006; 15: 161-166.         [ Links ]

2. World Health Organization. The World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva: World Health Organization, 2001.         [ Links ]

3. Lopez AD, Mathers CD, Ezzati M, Jamiso DT, Murray CJL. Global Burden of Disease and Risk Factors. New York: Oxford University Press and The World Bank, 2006.         [ Links ]

4. Chisholm D, Sanderson K, Ayuso-Mateos JL, Saxena S. Reducing the global burden of depression: Population-level analysis of intervention cost-effectiveness in 14 world regions. Br J Psychiatry 2004; 164: 393-403.         [ Links ]

5. Demyttenaere, K, Bruffaerts, R, Posada-Villa, J, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004; 291: 2581-2590.         [ Links ]

6. Kessler RC, Ustun TB. The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal Of Methods In Psychiatric Research 2004; 13: 93-121        [ Links ]

7. Harkness J, Pennell B-E, Villar A, et al. Translation procedures and translation assessment in the World Mental Health Survey Initiative. In: Kessler RC, Ustun B. The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders. Cambridge, UK: Cambridge University Press, 2008.        [ Links ]

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