Training nurses to treat common mental health conditions, not the right medicine

This is the South African Society of Psychiatrists‘ (SASOP) response to suggestions in the new Action Plan for HIV, TB and STIs (2023-28) that policies should be encouraged that will enable professional nurses to treat common mental health – and substance-abuse disorders in HIV and TB patients with the support of a doctor. 

According to the plan, this will be achieved through “standardising and implementing screening tools for anxiety, depression and harmful alcohol and drug use in primary care facilities” and then training and accrediting nurses to prescribe drugs such as anti-depressants, benzodiazepines as well as methadone as substitution therapy for opioid addiction.

But says Dr Mvuyiso Talatala, former president of SASOP and Head of the Department of Psychiatry at Chris Hani Baragwanath while the plan looks good on paper, it doesn’t take into consideration the realities of the state’s overwhelmed psychiatric services, the shortage of psychiatric nurses who can be trained to prescribe and dispense these medications, and the potential dangers of prescribing these drugs without proper psychiatric assessment and follow-up. Most importantly, the combination of HIV and mental illness is complicated to treat because of issues such as possible drug-drug interactions and the real reasons why HIV patients present with depression and anxiety – whether it is a symptom of the disease itself or a reaction to being HIV-positive and other stressors in their lives.

“That is why we have specialised HIV neuro-psychiatry clinics in the country to deal with mental illness comorbidities in HIV patients. I won’t expect a nurse to do that,” says Dr Talatala, adding that the Minister was not correctly advised when the proposal was drafted.

The focus on addressing the mental health crisis experienced in the country and the lack of timeous access to treatment in both the public and private sectors, he explains, should start with investment in mental healthcare at community level. Nurses should rather be trained as case managers to monitor and follow up with patients with serious mental conditions such as schizophrenia and bipolar disorder in the community to ensure that they take their medication and prevent them from relapsing and having to be readmitted to psychiatric wards and institutions.

“That will open up space in hospitals, relieve the pressure on psychiatry services at tertiary level, and release money to community-based psychiatric services. Currently, around 80% of the mental wellness budget is spent on in-hospital care for serious mental conditions with 20% of that amount going to re-admissions of patients who could have been managed at community level to prevent them from relapsing,” explains Dr Talatala.

According to him, this model should also be considered in the private sector where the rise in mental health conditions in the last couple of years has led to backlogs with patients often waiting up to three months to see a psychiatrist.

“We need psychiatric nurses who are capable of managing serious mental illnesses to follow up with these patients in the community under the supervision of a psychiatrist to prevent relapse and mental health conditions from becoming disabilities,” Dr Talatala elaborated.

Given the shortage of psychiatrists in the public sector, he proposes that the health department considers hiring some of the unemployed doctors with basic training in psychiatry to assist in treating and managing patients with common mental disorders.

“Training nurses to do it is not the solution to open access to mental health services. Our immediate problem is those patients with serious mental problems filling up casualty wards waiting for beds in psychiatric wards that are taken up by patients who have relapsed because of a lack of supervision and community-based care.”

Instead, he says nurses should rather be trained in administering depot antipsychotic injections prescribed by psychiatrists for conditions such as schizophrenia and psychosis at clinic level and following up on these patients to ensure that they come back for treatment and don’t relapse.

SASOP recently called on government to allocate more money to mental healthcare, particularly at primary care and community level in the face of what it called the country’s “mental health pandemic”.

According to SASOP ‘s public sector national convenor Dr Kagisho Maaroganye, one in three South Africans suffers from mental illness with 75% not being able to access treatment because the focus is skewed towards more severe mental health conditions that affect less than 1% of the population.

“South Africa’s mental healthcare budget, as a percentage of the overall health budget, is at the lower end of international recommendations for mental health spending, but it is also misdirected. Budget allocations are hospital-centric and reactive, with 86% of the budget allocated to inpatient care, and almost half of that on specialised psychiatric hospitals,” Dr Maaroganye said in a statement.

Proposals by SASOP to alleviate the pressure on psychiatric services include a strong emphasis on strengthening and funding community psychiatry by hiring psychiatrists, psychiatric medical officers and nurses and allied health professionals with expertise in mental health and facilitate the training of generalist clinical staff to manage patients’ mental illness with the support from psychiatric clinicians.