Understanding South Africa’s Mental Health Act

The Mental Health Care act no 17 of 2002, which replaced the Mental Health Act of 1973, has brought with it a new set of regulations and new focus. In particular, the Act has a stronger human rights orientation than the previous act, which means that it is more patient-centric with greater respect for the civil liberties of patients. The downside is more checks and balances, which means more paperwork and administration, which, in turn, translates to longer waits for government healthcare services.

According to the new Act, the State has a duty to ensure the provision of mental healthcare services and it must protect the rights and interests of patients. Patients have, amongst others, the following rights:

  • Only tertiary health establishments or psychiatric hospitals may provide tertiary level (intensive) mental health care to patients.
  • Treatment can only be given to patients if they have agreed to it if it has been authorised by the Mental Health Review Board (MHRB), or if a delay in treating a patient may result in their death or injury or the injury of others.
  • Patient’s information may not be revealed to anybody, unless it would be harmful to the patient or other people to withhold it. In this case only the head of the health establishment would be able to disclose the information.
  • Patients may not be unfairly discriminated against because of their mental health status.
  • All mental health patients must be informed of their rights before they are given treatment, unless a delay could result in either death or injury to the patient or death or injury to another person.
  • Healthcare establishments have to provide the appropriate level of care and they may not give psychiatric medication to a patient for more than six months, unless it has been authorised by a registered mental health care practitioner.

The Act requires that mental health care users be treated in the least restrictive manner possible with the least discomfort and inconvenience, and are treated as close to home as possible. However, in practice this is not always the case, treatment is dependent on the beds that are available, which in return is dependent on resources and funding.

Notably, the Act has also introduced a 72-hour assessment period, which takes place at a general hospital prior to further involuntary treatment and the Act has also provided for the establishment of Mental Health Review Boards (MHRB), which is primarily to protect the rights of people with mental illness.  Under the old legislation, South African Police Service (SAPS) members would take a mentally ill person who needed involuntary admission to a magistrate; this is no longer the case. Instead, if a mentally ill person is apprehended by a SAPS member, they must be taken to a health establishment that has assessment facilities for an assessment by a mental health care practitioner. 

In the guidelines, the Act stresses that use of seclusion and physical restraint, should only be used as a matter of last resort.  It also notes that violent patients should only be physically restrained for short periods, while medicine to control the violence is being administered. It also stresses that physical restraint should not be used to punish patients. 

In particular, the Act regulates access to services for categories of mental health care patients: voluntary, assisted, involuntary and emergency.  How they are treated will depend on their status.

Procedures for patients

The procedures are as follows:

Voluntary patients:  the person is competent to make an informed choice and may give consent. This is the preferred admission procedure for all concerned. The person may be admitted to a private or State facility that is registered as a hospital, where they are entitled to appropriate care. They may not receive sleep therapy.

Assisted patients are persons with a mental illness, not capable of consenting to voluntary treatment as a result of their illness, but who do not refuse treatment.

  • In this case, a relative or person close to the patient or mental health practitioner applies in writing for admission and treatment on behalf of the person.  They must have seen the person within the previous seven days of making the application.
  • The person may be admitted to a private or State hospital that is licensed to give electroconvulsive treatment and to admit patients who aren’t able to give consent. Any treatment must be approved by the head of department.
  • The person must be examined by two medical care health practitioners and a physical examination must be conducted. If the practitioner’s findings don’t concur then a third medical practitioner must examine the person.
  • The application will only be approved if the person is believed to be suffering from mental illness or profound disability and they are thought to be incapable of making their own decision about care or treatment.
  • If assisted care is necessary, the person must be admitted within five days.
  • The relevant review board will look into the case within 30 days and decide whether the person should continue treatment at the hospital or be discharged. The patient can appeal within this 30 day period.

An involuntary patient may be admitted without consent. The patient must pose a danger to him or herself and to others or care and treatment rehabilitation is necessary for the financial interests or reputation of the patient.

  • Involuntary treatment may only be considered if a person is suffering from a mental illness in line with accepted psychiatric diagnostic criteria. 
  • An application for involuntary admission must be made to the head of a health establishment by a spouse, next of kin, partner, associate, parent or guardian; they must have substantial contact with the person and have seen them in last seven days. If none of the people are available or willing to make and application. It can be made by a medical professional. Application forms can be obtained at clinics, hospital admission rooms and police stations.
  • A patient can only be admitted to an institution for a period of 24 hours. A mental health care user may be treated involuntarily at a health establishment on an inpatient basis under very specific regulations that serve to protect the users’ rights as much as possible. 
  • If the head of the health establishment approves the application then two mental health care practitioners (MHCP) must do independent assessments of the patients. If their findings don’t correlate then a third MHCP must do an assessment.
  • If involuntary admission is recommended and approved by the head of a health establishment then, within 48 hours the mental health care user must be admitted to a health establishment.
  • The Act then provides for a 72 hour assessment to take place before further involuntary care can take place. The 72 hour period is the maximum that a person can be admitted on an involuntary basis for the purpose of psychiatric examination. Once a person has an involuntary examination and the 72-hour period expires, they cannot undergo a further consecutive 72 hour assessment.
  • If it is decided that the person does need inpatient treatment, a written report must be submitted to the Review Board.
  • If the Review Board grants the request then they submit documents to the High Court.
  • The patient, their spouses, next of kin, parents, associates, partners or guardians, may lodge an appeal within the first 30 days. The Review Board will investigate.

Untreated depression can endanger more than your mental health

You may brush it off as a case of the blues or something that will resolve when your circumstances improve, or you may not want to get help because of the stigma attached, but leaving depression untreated can harm more than just your ability to enjoy life.

Untreated depression has a wide range of effects, some physical, some mental, some relational – many can create long-term or life-threatening problems.

In fact, the World Health Organisation lists depression as the leading cause of disability worldwide, which underlines its seriousness. Worldwide, there has been a 20 percent increase in depression in the past 20 years. Almost 75 percent of people with mental disorders remain untreated in developing countries, a problem shared by South Africa, where mental health is not prioritised.

Although depression symptoms can vary, the most common are persistent sadness, irritability or anxiety, trouble sleeping, a loss of interest in normally enjoyable activities and an inability to carry out daily activities for two weeks or more. Untreated, the symptoms of depression can last for months or even years.

Depression and Suicide

The most dangerous risk of untreated depression is suicide. It is estimated that two thirds of all suicides are caused by depression. In South Africa, there are thought to be at least 23 suicides a day due to depression. One in four teens in South Africa have attempted suicide. If you have suicidal thoughts or intentions, get help immediately. It is not the only way out.

Depression and Substance Abuse

Symptoms rarely go away if they are not treated. This means people with depression often turn to drugs or alcohol to treat their symptoms. This can worsen depression symptoms and increase the chances of getting addicted to the substances. Alcohol, drugs and depression are a dangerous combination, which is why it is so important to get help.

Depression and reckless behaviour

Depression increases the risk of risky behaviour. When people are feel hopeless, angry or down they are less to worry about the consequences of their actions. They are more likely to put themselves in risky situations with potentially dangerous outcomes, for example, driving drunk or unprotected sex.

Depression and impaired cognitive performance 

Untreated depression can make it very difficult to keep to a normal work schedule or to get through tasks at school or work. This is because depression actually impairs cognitive function; it impairs the ability to concentrate as well as memory. For some people, even getting out of bed is can be difficult.

Relationship Problems

Depression can cause relationships to suffer. It can leave people exhausted emotionally, mentally and physically, so it becomes hard to interact positively with friends and family.

Health Concerns 

Depression can become an unhealthy cycle. Because people with depression lose interest in many things, they may find it difficult to take care of themselves in terms of healthy eating and exercise, which ultimately leads to them feeling worse or being vulnerable to other illnesses.

A number of studies have been done on depression and physical health and there is mounting evidence that clinical depression can have a serious effect on physical health, for example:

Depression and Heart Disease: studies show that depression can lead to heart disease, worsen it or make it difficult to recover after complications of heart disease. Depression and stress are closely related and chronic stress put your body in a constant state of emergency which can cause blood vessels to tighten. This can lead to heart disease over time. Poor lifestyle habits that often go along with depression such as poor diet, drinking or smoking are also bad for heart health. 

Depression and Diabetes: The same bad habits can also increase your risk for type 2 diabetes, or make it difficult to manage diabetes. Depression plays a significant role in appetite and nutrition. Some people with depression may overeat and some may lose their appetite altogether. Overeating can lead obesity-related illnesses, such as type 2 diabetes.

Depression and Obesity: There is a higher risk of obesity if you are depressed and if you are obese there is a higher risk of being depressed. This is, in part, because eating is a form of self-medication when feeling depressed. Depression may also cause stress and stress hormones have been shown to promote belly fat.

Depression and immune system: Some studies show that depression may have a negative effect on the immune system, which can make people more vulnerable to infections and diseases and encourage faster tumour growth in cases where people have cancer.

Depression and Mental Decline: Studies have shown that long-term depression can add to the loss of brainpower, especially in elderly people. Brain scans of elderly people show greater shrinkage in certain parts of the brain in people with depression, compared to elderly people without depression.

Depression and Pain: Pain and depression can perpetuate an unhealthy cycle. Depression can make pain harder to treat and pain may make depression worse. For example, if you have chronic depression you are three times more likely to experience migraine headaches. 

Just as there are many negative consequences to leaving depression untreated, there are many benefits of early and appropriate treatment. Early detection and intervention decreases the risk of major depression, promotes remission, helps

prevent relapse and reduces the emotional and physical consequences of the disease. 

 


Bronwyn Harries-Jones is a journalist with 22 years’ experience in the field.  She has freelanced  as both a journalist, advertising copywriter, editor and communications manager for many years, working for publications such as The Sunday Times and consumer magazines, with communication’s clients including Old Mutual, South African Tourism and Verizon. She has a particular passion for mental health research, having suffered from post-natal depression for two years after the birth of her first child.