“There’s No Word for Depression in Zulu”: Inside South Africa’s Mental Health Crisis

Research has found South Africa consistently ranks in the bottom three performing countries in terms of global mental health.

The first Mental State of the World Report released by The Global Mind Project, which has hosted online surveys examining global trends in mental wellness since 2020, found respondents from South Africa and the UK had the poorest mental health of the 64 countries represented.

The UK and South Africa shared lowest place in the 2021 report. In 2022 South Africa took the second-lowest position, with the UK ranking worst. In 2023 there was little change in most countries’ average scores, but 35.8% of internet-enabled South Africans were “distressed or struggling” according to a scale developed by the researchers.

The Mental State of the World Report measures the mental health of internet users only, making it limited in the South African context where close to one-third of the population isn’t online. It was also conducted in English, only one of South Africa’s 12 languages. Unfortunately, more far-reaching local research reveals equally troubling findings.

The 2004 national South Africa Stress and Health study, the first large-scale research project of its kind in the country, found the lifetime prevalence of any DSM mental health diagnosis to be 30.3%. In 2019 it was, arguably conservatively, estimated that one in six South Africans suffered from anxiety, depression, or substance-use disorders, while fewer than a third of them had access to mental health treatment. Further, 40% of pregnant women were found to be depressed and it was estimated that as many as 60% of South Africans could be suffering from PTSD.

The most recent local national survey, published in 2022, concluded that 25% of South African adults were likely depressed and that close to one-fifth suffered from anxiety. In more impoverished rural communities, those most likely to have been excluded from the Global Mind Project’s online surveys, the numbers reached as high as 38.8% and 29%, respectively. Additionally, just over 23% of respondents had suffered severe childhood adversity, having been exposed to four or more childhood stressors such as physical or emotional abuse and neglect.

It’s clear South Africa is in crisis. The reasons for the nation’s poor mental health are multifaceted and difficult to resolve, however. High levels of childhood adversity, known to affect mental and physical health across the lifespan, are influenced by and contribute to problems such as severe violent crime, poverty, and lack of access to education.

Limited treatment options compound the issue. South African allocates only 5% of its annual health budget to mental health, placing it at the bottom of international benchmarks of government spend on psychological well-being. As a result there are few services available at the primary healthcare facilities the majority of South Africans rely on when they’re unwell, and government isn’t in the position to prioritize the training of black psychologists who, speaking indigenous languages, would be able to reach the rural poor most neglected by the system.

Where treatment is available, pharmaceutical interventions are often all that’s on offer. Linda is a 20-year-old Zimbabwean refugee living in South Africa. Her mother Patricia has been diagnosed with bipolar I and is currently in hospital.

“My mom takes handfuls of pills,” she tells me. “For her heart, for her blood sugar, to help her sleep.”

Like many psychiatric patients, she’s concerned about the medicines’ side-effects and at times refuses to take them.

“I need to tell her every night, take your pills, but she doesn’t always.”

When Patricia doesn’t take her medicine Linda has to take time off work as a housekeeper to escort her to the local public hospital where they’re only able to stabilize her in the short-term. From there she’s usually sent to a bigger hospital with a psychiatric department but it’s in another city, almost two hours away by minibus taxi.

“The nurses laugh,” she tells me. “It’s you again!”

I ask her if her mother has ever seen a psychologist or a social worker. I ask if anyone has ever counselled her about her medication or suggested lifestyle changes to help reduce her dependence on them.

“No,” she says. “There’s nobody there. It’s just the doctors and the nurses.”

Without health insurance, known locally as “medical aid”, people living in South Africa are only guaranteed care for serious mental illness. A mere 15% of South Africans can afford to be insured, leaving tens of millions of South Africans without access to outpatient treatment – as well as severely limited access to in-hospital psychological help. The numbers are dire: it was recently estimated that there are only 0.97 public sector psychologists and 0.31 public sector psychiatrists per 100 000 South Africans without medical aid.

As a result the majority of psychiatric patients must rely on medication only, even when social or psychological interventions might help alleviate their suffering.

Unfortunately polypharmacy, the potentially dangerous use of a number of medications at once, is an increasingly recognized problem in South Africa. While it’s still under-studied, current research suggests Lynn isn’t exaggerating about how much medication her mother takes.

A 2022 paper examined the prescriptions of 250 outpatients aged 60 and over at a regional hospital, finding that men and women were prescribed a whopping average of 11.46 and 12.45 medicines respectively. The more medication one takes, the authors note, the higher the risk of adverse drug reactions as well as drug-drug interactions.

Psychiatric patients like Patricia, currently in her 60s, should be concerned.

Something else that worries her, as well as many other southern Africans, is the stigma associated with mental illness.

Cassey Chambers, director of non-profit advocacy group the South African Depression and Anxiety Group (SADAG), illustrates the extent of the problem:

“In isiZulu [one of South Africa’s 12 national languages], there is not even a word for ‘depression’ – it’s basically not deemed a real illness in the African culture. As a result, sufferers are afraid of being discriminated against, disowned by their families or even fired from work, should they admit to having a problem. There is still the perception that someone with a mental illness is crazy, dangerous or weak. Because there is often an absence of physical symptoms with mental illness, it is considered ‘not real’, a figment of the imagination.”

Black South Africans struggling with depression might express symptoms differently to white South Africans, due to discomfort around sharing emotional pain. They’re more likely to frame psychological distress in physical terms because sharing symptoms related to the outer self feels less threatening than sharing deep-seated emotional trauma, most especially with a potentially threatening stranger like a doctor or a psychologist. This, of course, leads to misdiagnosis by clinicians trained under a Western model. Incapable of asking questions that could help them better interpret reported physical complaints, they can’t provide appropriate care.

South African activists are working hard to develop a psychology more suited to the local context. An article recently published in Psychology in Society argues that the biomedical model of treating mental health is inherently unsuited to African ways of being. The authors suggest that a client’s social context, culture, biology, psychology, environment, and even their spirituality intersect to influence mental health. A holistic, truly African psychology, would combine the best of the Western system with the traditional healing methods favoured in many African countries.

New work by other local scholars is helping to formalize the psychology that already exists in South Africa’s indigenous knowledge systems. While Western psychology’s imported language and the cultural framework underpinning it might not make sense to a depressed black South African, a meaningful – and less stigmatising – local vocabulary already exists.

For example in the South African language isiXhosa, when someone is not feeling well they might use the phrase andiziva kakuhle, meaning the connection between the individual and their soul has been disrupted. This concept of illness relies on the belief that health, physical or mental, always has a spiritual component.

Where a Western psychologist might recommend journalling or mindfulness as a healing tool for clients, an isiXhosa-speaking psychologist could suggest the client take time to ukuzimemamela – to listen to themselves. The idea of needing time to listen to the self, common to other South African languages, is embedded in the indigenous worldview.

Reframing mental illnesses and treatments in ways that make cultural and linguistic sense to black South Africans would go a long way towards reducing stigma. Under this kind of framework, the goal of therapy would not be to “manage mental illness” but rather to return the client to wholeness (ukuziva kakuhle). The focus moves away from pathologizing the individual and towards physical, social, environmental, and even cosmological congruence.

A truly South African psychology would by necessity take the traumatic legacy of colonialism into account, acknowledging the painful disconnect between hyper-individualist capitalist ways of being and traditional understandings of what it means to be human.

It might listen better, noticing the way Patricia only ever speaks English, the language of the British who colonized Zimbabwe, when she’s manic.

In her home language she’s fine.