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. Linda1 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.
I can understand why it might be traumatic to be basically forced to learn a language, other than one’s own. But maybe God’s trying to end the Babylon problem, by giving people the gift of tongues? Maybe, the ungodly disrespect of people, for having a spiritual journey, by the psychological and psychiatric industries, should end? Just a theory, but maybe Patricia should be respected and listen to, when she is speaking in tongues, instead? Some Christian religions believe in that.
Please leave the people of South Africa alone, psychologic and psychiatric industries, since your DSM “bible” deluded religion has already been debunked as scientifically “invalid” and “BS.”
Report comment
What? The author said nothing about Patricia speaking in tongues. She peaks English, the language of the coloniser.
Report comment
By the way, the obvious reason why depression isn’t a word in the Zulu language is that it was a precolonial language and a very strong and powerful culture that even gave the colonists a run for their money, so they hadn’t yet been destroyed by trade and wage slavery and gun wielding enemies. Nature doesn’t tend towards depression you know! Only human societies characterised by domination, unfreedom or violence have this effect, including boredom which is the effect of having a life dominated and controlled by extraneous things rather then the expression of one’s nature and life instincts which is never boring. These things are so self-evident to me and I can’t believe they are not self-evident to you, only you don’t notice it because it’s drowned out by your stupefying theories and opinions, the vast majority of which were swiped from others. You have so much to learn from natural peoples of every kind, and it’s one of the few kinds of learning that could possibly save you.
Report comment
Agree 100%.
It’s maddening how seemingly easy it is for supposedly educated people to not fully appreciate the inevitable consequences of colonization.
Report comment
Thank you for sharing this information.
Report comment
Thank you MIA for highlighting the damaging effects of psychiatric colonialism. I love your plea to use the wisdom of the Zulu people when you say:” 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.”
However, the author leaves out the critical way that indigenous societies help restore wholeness: through community healing. Their healing ceremonies engage large segments of the community rather than locating the problem within the individual. Indeed two WHO studies, in 1979 and 1992, showed that indigenous healing ceremonies were more successful in treating psychosis ( the most severe severing of self from soul) than Western psychiatry. We persons with lived experience in Western world have developed emotional CPR as our way of healing our condition of disconnection. We are utilizing eCPR as an approach for restoring wholeness through emotional dialogue (www.emotional-cpr.org).
Report comment
It makes no sense to simply “reframe mental health treatment” in terms the Zulu can accept. We are barking up the wrong tree. We need to shut up and ask THEM what they think would be helpful, and change our model accordingly. But of course, that would mean scrapping our top-down, we-know-best, do-as-we-say approach, which would mean scrapping “mental health treatment” as we know it and starting over.
Don’t hold your breath!
Report comment
Agree 100%. It’s stupid to play from essentially the same playbook and expect better results.
Report comment
I thought you made a very good point and intended to reply to you, but accidentally replied to Tom. So I’m back to let you know I appreciated your comment and will be thinking about it, as well as the other comments in this thread.
Report comment
What a dogmatic, uneducated, deluded, racist, quasi-academic piece of excrement. The field of psychology will inevitably remain limited in its capacity to attain a comprehensive understanding of the complexities inherent in the human experience due to its infinite and evolving nature.
Report comment
Wow, Cat! I assume you are a big Cat! You make me want to say “Meow. Save me from psychiatry and psychology, Dear Leader, Ms or Mr Meow, or better, Growl.” You hit the nail on the head with more eloquence then any of us deserve, so you are a giver of undeserved gifts and we thank you and take our hats off to you. May we hear your remorseless and succinct assassinations of these MIA pages as as often as you can, for it will begin to fill us with such power we’ll be able to telepathically make psychiatrists go ‘psychotic’, as they call it, without any understanding of what they’re talking about. So thank you, Cat. If you could replace King Charles in our shithole country (the UK), I might contemplate the unthinkable and become a monarchist. Your Majesty Ms or Mr Cat. Long Live Meow Meow!
Report comment
thank you for this thoughtful piece which has a lot of parallels to the Aboriginal People of Australia and their interactions with the Mental Health industry under the Medical Model.
I wonder if SA has thought about incorporating the Friendship Bench idea – which is apparently very successful in Zimbabwe. Dr Dixon Chibanda, one of the handful of psychiatrists for the whole country, came up with the idea of using “grandmothers” older wiser women, who sit on the Friendship Bench in the grounds of hospitals, and who have some basic training in CBT type techniques but can provide practical and effective psychological therapy for at least two thirds of people who access their help.
Report comment
There are parallels, aren’t there? And people are definitely considering using the Friendship Bench in South Africa! There’s research underway right now, actually. I believe they’ve (local university Wits in conjunction with UC San Francisco) finished gathering data and are now preparing to publish. So that’s something to look forward to. Thanks for bringing it up. It’s a wonderful idea and should be perfect for the South African context – I’m holding thumbs for positive results.
Report comment
Thank you for an awesome article!
Catherine wrote:
“The authors suggest that a client’s social context, culture, biology, psychology, environment, and even their spirituality intersect to influence mental health.”
Surely the ONE thing that ALWAYS intersects…is our common spirituality, the common humanity we share, our collective consciousness?
‘They [the “authors” above] write,
“In this article, we aim to position mental illness within the African cultural context, acknowledging the existence of spiritual or supernatural dimensions that extend beyond the biomedical model. Our argument advocates for an integrative approach in South Africa, especially considering the indigenous population’s reliance on traditional healers. We propose that psychology as a discipline should not entirely shift away from current methodologies, but rather embrace an inclusive model that incorporates African-centred perspectives. The critical question we explore is: Are there possibilities of merging African and Western perspectives to effectively address serious mental illness? By integrating these diverse perspectives, we aspire to establish a holistic and culturally relevant framework for mental healthcare that resonates with the lived experiences and worldviews of African communities.”’
– from https://www.madinamerica.com/2024/12/ancestral-wisdom-meets-modern-medicine-in-african-mental-health/
If we are all spirits, spiritual, one in spirit, in Consciousness, well, ought not that always be our starting point?
If we are not, then is not all spirituality delusional, superstitious, insane, and hardly to be benignly condoned, humored or tolerated, and is not any and all “religiosity” “hyperreligiosity?”
So, just what are the odds we are indeed immortal spirits, beings, or Being, itself, rather than mere YOLO mortals?
We can do the math.
If either eternity or timelessness exists, or if both do, or, rather than existing, do whatever either does or both do, then the odds of any single one of us being alive for, say 100 years right, slapbang in the middle of all that infinitude of years is, obviously, 100 divided by one infinitude, which = one over infinitude.
The odds of 8.025 billion of us being here, if each only lived one life span of 100 years would be approximately one divided by infinitude to the power of 8.025 billion.
If, on the other hand, we all happened to be spirits, immortal spirits, the the odds of our all being alive at any point in eternity would shorten to one, or to 100%, if you like.
If you like to think of it this way, it may help put all our current woes in perspective, I think.
If we “inter-are” and, as scientists are now realizing of all subatomic particles, only exist in relation to one another, then Ubuntu,
https://en.wikipedia.org/wiki/Ubuntu_philosophy#:~:text=%22Ubuntu%22%20is%20sometimes%20translated%20as,sharing%20that%20connects%20all%20humanity%22. ,
may remind us we that Zulu traditional healers may have more of value to teach us Whites than any of us have to teach them?
“A very remarkable people the Zulus: they defeat our generals, they convert our bishops, they have settled the fate of a great European dynasty.”
– Benjamin Disraeli, British Prime Minister
[twice, https://en.wikipedia.org/wiki/Benjamin_Disraeli ], upon hearing of the death of Napoléon, Prince Imperial of the House of Bonaparte in Africa (1879); cited in James Anthony Froude, Lord Beaconsfield (1890), p. 213.
Mind you, the South African system, like that of the UK, and its careful, critical Western dissection, may also have much of value to teach us:
‘South Africa is not alone in opting for a wide definition of mental illness. South Africa has followed the United Kingdom in deciding that it is ‘unnecessary for the purposes of law to attempt to define the concept of “insanity”‘ and also that it is undesirable.35
The Rumpff Commission cited, in support of this option, the remarks of Lord Blackburn:36
“I have read every definition of insanity which I could meet with, and never was satisfied with one of them, and I have endeavoured in vain to make one satisfactory to myself. I verily believe that it is not in human power to do it.”
The Van Wyk Commission similarly recommended that the expression ‘mentally ill’ should be wide enough to include ‘all possible classes of mentally disordered or defective persons’.37 The failure to provide a specific definition of mental illness touches on the heart of the matter.
Brenda Hoggett comments:38
Defining mental disorder is not a simple matter, either for doctors or for lawyers. With a physical disease or disability, the doctor can presuppose a state of perfect or “normal” bodily health and point to the ways in which the patient’s condition falls short of that. A state of perfect mental health is probably unattainable and certainly cannot be denied. The doctor has, instead, to presuppose some average standard for normal intellectual, social or emotional functions, and it is not enough that the patient deviates from this, for some deviations will be in the better than average direction. Even if it is clear that the patient’s capacities are below the supposed average the problem still arises of how far below is sufficiently abnormal, among the vast range of possible variations, to be labelled a “disorder”. ‘
– from
https://www.csvr.org.za/wp-content/uploads/1993/02/The-Mad-Mrs.-Rochester-Revisited_-The-Involuntary-Confinement-of-the-Mentally-Ill-in-South-Africa.pdf
Thanks, again, for a terrific essay.
Ubuntu, Namaste, and wishing you mirth,
Tom.
Report comment
I accidentally posted a reply to Daniel here. Clearly it wasn’t for you, but I had been thinking about what you said.
It turns out I’ve not read a definition of insanity I’m happy with either! Let’s chuck it right out and remember it’s the world we live in that’s quite mad. : )
I appreciate your well wishes and positive feedback. I’m sending mirth back your way!
Report comment
Well noted, Daniel. Perhaps communal healing is worth its own piece? It does come up in the research cited but maybe there’s more to be said, more explicitly? I’ll give it some thought.
Report comment
“… Patricia only ever speaks English, the language of the British who colonized Zimbabwe, when she’s manic.”
This alone should tell you who the sick ones really are.
Report comment
Catherine, I would be glad to assist in a piece on communal healing. I and others with lived experience have developed a way to build communal healing through our training called emotional CPR (www.emotionsl-cpr.org)
Report comment