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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.111 no.2 Pretoria Fev. 2021 



Mental illness: South Africa's blind spot



To the Editor: The articles by Odendaal et al.[1] and Pillay-van Wyk et al.[2] indicate poor recognition of mental illness and its complex interplay with physical health in South African (SA) research. While Odendaal et al.[1] screened for depression in pregnant women, the relationship between mental illness and persistent smoking was not explored and the possible need to tailor interventions to perceptual, cognitive or personality functioning was not discussed. Pillay-van Wyk et al.[2] include mental illness among 'other' comorbidities in COVID-19 deaths, but do not mention substance use. Furthermore, they do not discuss the low prevalence of these comorbidities among COVID-19 deaths, although it is an unexpected finding given the excess mortality associated with mental disorders.[3]

In pregnancy, mental disorders are associated with preterm delivery, low birth weight, hypertension, gestational diabetes and neonatal morbidity.[4-6] The extent to which these outcomes are mediated by smoking and/or social deprivation is unknown. Smoking is more prevalent among people with mental illness (PWMI) than in the general population, with more intense addiction and reduced response to population-level interventions.[7,8] Mental illness is also associated with social deprivation. The association between persistent smoking and social deprivation found by Odendaal et al.[1] is similar to that found in Canada among PWMI,[9] and is consistent with the well-documented mental health/poverty cycle[10] (related to social exclusion as well as social and/or occupational impairment).

While mental healthcare may improve socioeconomic outcomes among PWMI,[10] it alone does not reduce smoking. Neither does education. However, behavioural and pharmacological interventions may. Prochaska et al.[8] discuss the application of the Host-Agent-Vector-Environment (HAVE) public health model to smoking cessation among PWMI. The four domains of this application are:

'Host - tobacco user characteristics (e.g. biobehavioural, social/ cognitive, mental health).

Agent - tobacco product characteristics (e.g. nicotine content, delivery, flavourings).

Vector - tobacco industry efforts (e.g. research, development, advertising, distribution).

Environment - broader community and policy structures (e.g. taxation, smoking bans, insurance coverage, retailers).'[8]

In SA, collaborative biopsychosocial Host interventions are lacking.

Regarding mortality, compared with the general population, all-cause mortality is doubled among PWMI, with a 10 - 20-year reduced life expectancy.[3] Recent US database studies found, in their population, higher COVID-19 mortality rates among people with psychiatric[11,12] or substance use disorders[13] compared with those without such disorders. As with the study by Pillay-van Wyk et al., [2] their findings are dependent on accurate death records. While such accuracy is lacking for most conditions in SA, it is particularly so for mental disorders. During the investigation by the Ombudsman for Health in the Life Esidimeni tragedy, even unmissable, profoundly severe mental, neurological or intellectual disability was not considered an underlying cause of death by those completing certificates.[14] In a country where it is estimated that <10% of PWMI needing mental healthcare access it,[15] what is the possibility that comorbid mental illness was recorded in COVID-19 deaths?

In discussing costs of COVID-19 on our quadruple burden of disease, Hofman and Madhi[16] mention psychological ramifications, but not mental illness. This omission might be related to difficulty in quantifying mental illness, paucity of data or scant interrogation in physical health research. Perhaps mental illness is assumed to fall under non-communicable diseases, or maybe it is not perceived as integral to our disease burden. Nevertheless, omitting discussion on COVID-19 costs regarding incident mental illness; compromised access to maintenance treatment, increased relapse and hospitalisation; and the vulnerability of PWMI to substance use, assault, homelessness and mortality, keeps mental illness in our blind spot. How then will it feature in co-ordinated, collaborative research and healthcare planning?

Lesley J Robertson

Department of Psychiatry, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg; and Community Psychiatrist, Sedibeng District Health Services, Vanderbijlpark, South Africa



1. Odendaal HJ, Brink LT, Nel DG, et al. Smoking and drinking habits of women in subsequent pregnancies after specific advice about the dangers of these exposures during pregnancy. S Afr Med J 2020;110(11):1100-1104.        [ Links ]

2. Pillay-van Wyk V, Bradshaw D, Groenewald P, et al. COVID-19 deaths in South Africa: 99 days since South Africa's first death. S Afr Med J 2020;110(11):1093-1099.        [ Links ]

3. World Health Organization. Excess mortality in persons with severe mental disorders. 2015. (accessed 19 November 2020).         [ Links ]

4. Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016;3(10):973-982.        [ Links ]

5. Grigoriadis S, Graves L, Peer M, et al. Maternal anxiety during pregnancy and the association with adverse perinatal outcomes: Systematic review and meta-analysis. J Clin Psychiatry 2018;79(5):17r12011.        [ Links ]

6. Judd F, Komiti A, Sheehan P, Newman L, Castle D, Everall I. Adverse obstetric and neonatal outcomes in women with severe mental illness: To what extent can they be prevented? Schizophrenia Res 2014;157(1-3):305-309.        [ Links ]

7. Williams JM, Steinberg ML, Griffiths KG, Cooperman N. Smokers with behavioral health comorbidity should be designated a tobacco use disparity group. Am J Public Health 2013;103(9):1549-1555.        [ Links ]

8. Prochaska JJ, Das S, Young-Wolff KC. Smoking, mental illness, and public health. Ann Rev Public Health 2017;38:165-185.        [ Links ]

9. Dahal R, Bhattarai A, Adhikari K. Variation in characteristics of people with mental disorders across smoking status in the Canadian general population. Tob Prev Cessat 2020;6:61.        [ Links ]

10. Lund C, de Silva M, Plagerson S, et al. Poverty and mental disorders: Breaking the cycle in low-income and middle-income countries. Lancet 2011;378(9801):1502-1514.        [ Links ]

11. Wang QQ, Wong X, Volkow ND. Increased risk of COVID-19 infection and mortality in people with mental disorders: Analysis from electronic health records in the United States. World Psychiatry 2020.        [ Links ]

12. Li L, Li F, Fortunati F, Krystal JH. Association of a prior psychiatric diagnosis with mortality among hospitalized patients with coronavirus disease 2019 (COVID-19) infection. JAMA Network Open 2020;3(9):e2023282.        [ Links ]

13. Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: Analyses from electronic health records in the United States. Mol Psychiatry 2020.        [ Links ]

14. Office of the Health Ombud. Expert panel report for health ombudsperson on the investigation around the circumstances of deaths of patients at NGOs. 2017. (accessed 19 November 2020).         [ Links ]

15. Docrat S, Besada D, Cleary S, Daviaud E, Lund C. Mental health system costs, resources and constraints in South Africa: A national survey. Health Policy Plan 2019;34(9):706-719.        [ Links ]

16. Hofman K, Madhi S. The unanticipated costs of COVID-19 to South Africa's quadruple disease burden. S Afr Med J 2020;110(8):698-699.        [ Links ]

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