LETTER

The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 49

Dear Colleagues                                                                     

In 2016 I was diagnosed with major recurrent depressive 
disorder (F33.2).

I used Citalopram and various evidence based non-
pharmacological treatments (psycho-therapy, mindfulness, 
exercise and an eating plan reducing my weight from 88kg 
[BMI = 27.8] to 78 kg [BMI = 24.6]). However my symptoms 
continued unabatedly, especially insomnia, daily suicidal 
thinking, poor concentration and decision making. 
Changing treatment to agomelatine (Valdoxan®) was equally 
unsuccessful. In mid-2017 I then changed to bupropion 
(Wellbutrin®) and a low dose of amitriptyline (12.5 mg) with 
marked improvement within 48 hours. Within a week I had 
positive thoughts, slept well and my cognition was back to 
normal.

In January this year I was appointed in a permanent position 
as academic staff with the Faculty of Health Sciences of 
the University of Cape Town. With this contract I was urged 
to join Discovery Health. When my pharmacist sent in the 
prescription of my psychiatrist to claim for my medication 
(bupropion and amitriptyline) we were informed that 
Discovery Health would not cover it in line with the Council 
of Medical Schemes regulations on covering a defined list of 
270 diagnoses and a defined list of 27 chronic conditions in 
terms of the Medical Schemes Act of 1998 (Act No. 131 of 
1998) and its Regulations.

As a medical practitioner in the public sector who treats 
people with depressive disorders almost on a daily basis it 
came to a shock to me that in the private sector it was not the 
choice of medication that was not covered but the diagnosis 
of depressive disorders (F32 and F33) per se was not regarded 
as a medical condition requiring pharmacological treatment. 

Can I draw your attention or remind you that in South Africa 
there is one suicide death every hour and between 20 and 
40 attempts.[1] The lifetime prevalence for attempting suicide 
in South Africa is roughly three percent.[2] Diminished sleep  
(< 5 hours/24 hours) increase the chance of suicidal 
attempts.[3] Depressive disorder increases the mortality 
risk from suicide attempts 20 fold.[4] Treating depressive 
symptoms may help suicide prevention efforts.[5] The WHO 
World Health Survey studied 

In South Africa, the lifetime and 12-month prevalence rates 
for major depressive disorder are 9.7% and 4.9% respectively, 
with less than a quarter of South Africans with major 
depressive disorder able to access services and receive 
treatment.[6] Pharmacotherapy should be tailored to 
the individual patient.[7] Depression is the single largest 
contributor to disability worldwide (contributing 7.5% of all 

years lived with disability in 2015).[8] Every US$ 1 invested 
in scaling up treatment for depression and anxiety leads 
to a return of US$ 4 in better health and ability to work.[9]   
Depression produces the greatest decrement in health 
compared with the chronic diseases angina, arthritis, asthma, 
and diabetes as found by The World Health Survey studying 
data from 245 404 participants from 60 countries.[10]

In the light of overwhelming evidence for the health burden 
and mortality caused by depression and the effectiveness 
of pharmacological treatment, with 27 antidepressants 
listed in the SAMF, and in light of national policy of health 
for all and the constitutional right of South Africans to health 
care can I urge you to revisit your regulations on covering 
pharmacological treatment for depressive disorders?

Can I also ask you who my children, my wife and my employer 
should hold accountable for my untimely premature death 
by suicide, should I die that route?

With kind regards

Dr Hermann Reuter 
MP 0384887

References
1. Schlebusch L. Risk factors in repeat non-fatal suicidal behaviour. 

S Afr J Psychol. 2005 Dec;11(3):72–4.
2. Joe S, Stein DJ, Seedat S, et al. Prevalence and correlates 

of non-fatal suicidal behaviour among South Africans. Br J 
Psychiatry. 2008 Apr;192(4):310–1. http://dx.doi.org/10.1192/
bjp.bp.107.037697

3. Goodwin RD, Marusic A. Association between short sleep and 
suicidal ideation and suicide attempt among adults in the 
general population. Sleep. 2008 Aug 1;31(8):1097–101.

4. Lépine JP, Briley M. The increasing burden of depression. 
Neuropsychiatr Dis Treat. 2011;7(Suppl 1):3–7.

5. Raubenheimer L, Jenkins LS. An evaluation of factors 
underlying suicide attempts in patients presenting at George 
Hospital emergency centre. South African Family Practice. 2015 
Feb: 1 http://www.tandfonline.com/loi/ojfp20

6. Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, 
Williams DR. The South African Stress and Health (SASH) 
study: 12-month and lifetime prevalence of common mental 
disorders. S Afr Med J. 2009;99:339-44

7. Thomas E, Seedat S, The diagnosis and management of 
depression in the era of the DSM-5. South African Family 
Practice 2018; 60(1):20

8. Thomas E, Seedat S, The diagnosis and management of 
depression in the era of the DSM-5. South African Family 
Practice 2018; 60(1):20

9. WHO. Depression: let’s talk. http://www.who.int/mediacentre/
news/releases/2017/world-health-day/en/ 2017 March

10. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun 
B. Depression, chronic diseases, and decrements in health: 
results from the World Health Surveys. Lancet. 2007 Sep 
8;370(9590):851-8. https://pdfs.semanticscholar.org/5915/
a079426dae3b59121ab9caa359ea9cd7de37.pdf

The cost of not covering payment of  
treatment for Depressive Disorders