Resourceful Young Children

Resourceful Young Children
Learning Brief

Perinatal Mental Health Project

Supporting those with common mental disorders in low resource settings – prevalence, detection, and treatment

Category: Resourceful Young Children | Comprehensive ECD package | 11 March, 2015 - 18:28



Common mental disorders such as depression, anxiety and substance abuse, are some of the most widespread and disabling conditions in South Africa. The perinatal period (from conception until one year after birth) is a time when women are especially vulnerable to common mental disorders. Yet, in South Africa few women get the care and support they need to cope with common mental disorders in the prenatal period, primarily due to a lack of resources and support service available to them.

A critical initial step towards providing care for perinatal women is to identify those most in need through screening services. There are a number of barriers to accurate screening in low resource settings including expertise, time, and local relevance of the questions that are used to screen.

The Perinatal Mental Health Project has tested several international screening questionnaires across South Africa in order to establish the shortest, easiest-to-use set of questions that accurately screen for valid depression and anxiety.

Background: Common Mental Disorders

Mental health disorders account for about 8% of the global burden of disease, and are the leading cause of disability worldwide. Common mental disorders include depression, anxiety, and substance abuse. Mental disorders affect people across a range of geographical, cultural, and financial situations, but are particularly associated with poverty and adversity. In South Africa, about 75% of people with these disorders do not get the care and treatment they need.

During the perinatal period, common mental disorders are particularly common. In South Africa, 35 – 42% of women experience depression at this time. The possible outcomes of untreated common mental disorders during this period are concerning because of the chance that the mother may be less able to care for her baby. This may have a negative long-term effect on child well-being and development.

There are a number of effective treatments for common mental disorders, ranging from community level support to specialist health services and medications. However, in South Africa there are many gaps in detection, treatment and care at primary health care level where there are too few specialist health and social workers for the needs of the population.

Where resources are scarce, one way of increasing access to care is to integrate mental health care into existing services, delivered by trained but non-specialist staff.  The Perinatal Mental Health Project believes that a useful entry-point to care is early detection of mental distress, through screening all women as a routine part of antenatal health care.

Challenges in screening for common mental disorders at health care facilities

Possible barriers and constraints to accurate screening at antenatal health care facilities include the following factors.


With the lack of mental health specialists in many primary care settings, there has been a call for primary health staff and community health workers to share tasks and routine activities, such as mental health screening. However, less qualified staff members at these facilities are likely to have lower levels of literacy and numeracy that may undermine administrative precision and the accuracy of scoring using complex screening tools. Any screening tools used in the South African environment need to be effective when delivered by those with low levels of education.


Public services are over stretched and under-resourced with their time. Staff members have little time to spend on individual clients, so any additional screening tool must be quick to administer and score so that it doesn’t add an extra burden.


The screening tool used must be able to detect women with symptoms of common mental disorders who are in need of additional care. However, it should not ‘over-detect’ and lead to false positive cases, which would overwhelm resources and lead to loss of credibility. Thus, it needs to be adequately sensitive and specific.

Local relevance

If the screen is to be accepted and effective, the screening tool’s wording needs to be easy to understand, culturally appropriate, and not offensive or stigmatising to the local population. Items might include risk factors and/or symptoms (mood or functioning).

Developing screening solutions

The Perinatal Mental Health Project set out to develop a solution to screening for common mental disorders at health care facilities by conducting research and a pilot screening process.

Our aim was to discover whether there was a brief and valid mental health screening tool for use in low-resource health and social work settings that could be administered by non‐specialist staff.

The study took place at the Midwife Obstetric Unit at Hanover Park Community Health Centre. We recruited 376 women who attended their first antenatal visit at the Midwife Obstetric Unit. The women were interviewed using a structured diagnostic interview to diagnose mood and anxiety disorders, suicide and substance use disorders. They were then assessed on 5 screening tools for common mental disorders and on 8 tools assessing risk for common mental disorders. The tools and individual questions were analysed against the diagnoses to establish which tools or questions accurately identified the need for a more in-depth assessment.

Four screening tools for symptoms were the best at predicting common mental disorders:

  • Edinburgh Postnatal Depression Scale (10 questions with a 4-point rating scale)
  • Kessler Psychological Distress Scale (10 questions with a 5-point rating scale)
  • Patient Health Questionnaire (9‐questions with a  4-point rating scale)  
  • Whooley Questions from the National Institute for Health and Care Excellence in the UK (3 questions, yes/no answers)

We found that the Whooley test performed similarly to the other longer, more complex screening questionnaires and provided reliable results and thus we used it as the basis for out new tool. The core questions establish whether the woman is experiencing low mood; inability to experience pleasure from activities usually found enjoyable; and whether she wants help with these feelings.

Consequently, we modified the Whooley screening questions somewhat to suit our contextual needs. The result was the development of the following three screening questions:

  1. During the past month, have you been bothered by feeling down, depressed or hopeless? (Yes/No)
  2. During the past month, have you been bothered by little interest or pleasure in doing things? (Yes/No)
  3. Is this something you feel you need or want help with? (Yes/No)

Women with a score of at least 2 out of 3 (i.e. respond ‘yes’ to two of the three questions) have a high probability of having depression or anxiety, and should be offered support.

Rolling out the screening processes

The way in which the tool is administered by staff members affects the way in which women answer the questions, especially with regard to accepting help for distress. Therefore, before screening takes place there needs to be engagement to provide psycho-education, to demystify and de-stigmatise mental health, and to encourage the development of mental health literacy. This may be done with groups of women in the waiting room. Screening should be voluntary, and delivered with care and empathy so as to encourage women to feel safe enough to express feelings that they may feel uncomfortable sharing.

Our research and service experience also shows that effective screening is feasible and acceptable when integrated into routine health procedures. However, screening is only ethical and of value if it offers an entry point to care. The screening tool must be used with a clear pathway to follow up services and support.

Providing services for those in need

Practical steps for supporting mothers in distress in low-resource settings include the following.

1. Act as advocates for change: Health and social care workers can be advocates for increasing mental health literacy and reducing stigma with colleagues and clients.

2. Provide appropriate referrals: Health and social workers in the state sector, as well as non-governmental organisations can play a crucial role in providing mental health care and support for families. The combination of common mental disorders and poverty makes it difficult for women to keep appointments. Some of the clinical features of common mental disorders also create barriers to health seeking. Culturally-adapted, psycho-educational interventions, implemented in local communities are effective in reducing common mental disorders and their effects.

Practical referral tips:

  • Establish relationships between referring centres and referral sources.
  • Know a person’s name and telephone number at the referral contact (not just the organisation’s name).
  • Nurture relationships with contacts by inviting them to events (e.g. staff teas, open days). Let them know that you are interested in attending their activities.
  • Display a map of organisations, contact names and regularly updated telephone numbers
  • Follow up: Ask referral organisations to report back; do the same when patients are referred to you.
  • Ensure your referral is feasible for the client. Consider the time/ place/ impact on her employment/ her willingness to attend the recommended service.
  • Have an open-door policy: Even if you feel frustrated by a mother defaulting, it is important not to judge her, to be angry or to punish her. When a mother returns by choice, she is more likely to adhere to her appointments and treatment.

3. Provide empathic care to the client: As part of the ordinary interactions with the client, health and social care workers have the opportunity to make a significant difference through the quality of their interaction. A genuine greeting, with an introduction and use of the client’s name shows that they are respected and important. Emphasising what the client is doing well, or has previously done well, can improve their self-esteem and sense of their own ability to be well. When busy and overwhelmed, staff can easily forget the power of gentleness and kindness in their interactions with vulnerable clients.

4. Help families access appropriate social support: Poverty is a major factor in common mental disorders. The South African Social Security Agency (SASSA) can provide support in the following ways to alleviate poverty and suffering:

  • Maintenance orders if a woman’s partner has left her
  • Child support grants for South African women who are the primary caregivers of a child
  • Urgent support grants for women who have applied for a grant but are yet to receive it. People in desperate need can apply for temporary assistance called Social Relief of Distress which is normally issued with a food parcel but can also be a voucher or cash payment.
  • A woman can apply for Indigency status for assistance with the cost of water, electricity and property rates.

5. Provide evidence based therapy: If resources allow for an additional service, there are several evidence based therapies that can be effective in low-resource settings, such as:

  • Cognitive behavioural therapy
  • Problem-solving therapy
  • Interpersonal therapy
  • Motivational Interviewing
  • Mindfulness techniques

Those providing these interventions need not be specialist mental health professionals. However, it is essential that their training is adequate and that they receive regular clinical supervision.

Developing the pathway to care

We suggest proceeding through the four following initial steps to developing the pathway to care.

  1. Establish the services that could be provided by your organisation, given your specific strategy and resources. Consider your core expertise, and identify your sources of funding and support.
  2. Map existing resources by considering the other agencies or organisations that exist in your area to support these women. List the services they offer, and how those services can be accessed, and what their client profile is.
  3. Common mental disorders are interconnected with a range of other issues, including HIV/AIDS, domestic violence, refugee status, teen parenthood, poor community cohesion and social networks, so it is important to look as broadly as possible at the support available.
  4. Establish the specific service your organisation will be able to provide in order to meet the needs. Do not duplicate services that are already available and accessible.


Common mental disorders are widespread in South Africa, and have a significant impact on the well-being and development of individuals and communities. Yet, in low resource settings, few have the expertise or time to conduct lengthy assessments.

The Perinatal Mental Health Project research has shown that three simple (yes/no) answers can accurately identify those mothers in need of additional support and treatment for common mental disorders. However, it is a waste of resources – and unethical – to screen without providing services for those identified as being in need.

Yet it is possible to respond to the needs of those with common mental disorders by providing limited extra resources. The attitude and approach of existing staff can make a significant difference to the care experienced by clients, and there are brief interventions that have been proved to be effective.

Perinatal Mental Health Project

Building B46 Sawkins RoadRondebosch

 021 685 9624

In Short

The Perinatal Mental Health Project has created a short, easy-to-use questionnaire that accurately screens for valid depression and anxiety in perinatal women. This brief explains the tool’s design and functionality for use in public health facilities, and highlights the benefits of public-private partnerships for delivering quality health care.

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