MHM Magazine

Issue 5 | 2025 | MENTAL HEALTH MATTERS | 7 MHM assessment including: - a neurocognitive assessment (social, cognitive, and motor development); and - a social skills assessment (routines, roles, values, interests, environment, attitudes, motivation, activities of daily living (ADL), family and relationships) and - an occupational functioning or educational assessment; and - an assessment of socioeconomic status. • Relevant laboratory investigations are included in the PMB. This assessment could take a few sessions to finalise the diagnosis and is all covered under PMB. • Regular outpatient consultations to monitor medication efficacy, side effects, and metabolic health is included in the PMB. • 16–21 sessions of psychosocial therapy or group- based interventions such as cognitive behavioural therapy (CBT), psychoeducation, and social skills training. - Psychosocial interventions include psychotherapy and social interventions. It is delivered by qualified therapists as adjunctive therapy to pharmacological or medication treatment. It includes individual cognitive behavioural therapy (CBT), cognitive remediation therapy and psychoeducation. • 10 family therapy sessions per year, occupational therapy, social work, physiotherapy, and dietician assessments — all to improve functional, physical, and psychosocial well-being. These sessions can be delivered as single- family or multi-family group interventions. • Social work interventions that include family psychoeducation and support, family aided acceptance and commitment therapy (ACT) and case management. • Physiotherapy that encourages a healthier lifestyle choices and physical activity, assesses movement disorders and develops a physical therapy care plan as part of the multidisciplinary team (MDT). The benefit available should follow the equivalent number of sessions that is available to patients in the public sector. • A mental health nurse to assist with the treatment of patients in and out of hospital. • Assessment by dieticians regarding nutritional status and recommend appropriate diets to improve physical health and assist with metabolic problems patients often face. The benefit available should follow the equivalent number of sessions available to patients in the public sector. • Coverage for 12 electroconvulsive therapy (ECT) sessions per year. Access to a comprehensive list of medications, including both oral and long-acting injectable antipsychotics, as well as adjunctive treatments for treatment-resistant schizophrenia is part of the PMB. Some medical schemes approve some of the medications, including the long- acting antipsychotic injectables, but only pay a small portion of the total fee. Schemes must reimburse in full the cost of the medication listed as PMB. The following are medications listed as PMB: Medications now listed in the PMB definition guidelines, classified as PMBs are: • Oral Antipsychotics: - Haloperidol, Chlorpromazine, Risperidone, Olanzapine, Quetiapine, Amisulpride, Aripiprazole and Ziprasidone. - Clozapine is listed for treatment-resistant schizophrenia. - Anticonvulsants in combination with antipsychotic medication. • Depot Antipsychotics: - Flupentixol, Zuclopenthixol. • Long-Acting Injectable Antipsychotics (LAI-AP) - Aripiprazole, Paliperidone, Risperidone. Bipolar Disorder Similarly, patients diagnosed with bipolar disorder are entitled to 21 days of in-hospital care for acute episodes or 15 outpatient psychotherapy sessions per year, depending on how the care is utilized as per the DTP PMBs. Additional benefits as also specified under the CDL PMBs, the CMS guidelines include: A full diagnostic assessment by a multi-professional team, including the following: • a full psychiatric and medical history including a mental state and physical examination • a psychosocial assessment including a personal functional assessment. psychological assessment • an occupational functioning or educational assessment; and • an assessment of socioeconomic status. This assessment could take a few sessions to finalise the diagnosis and is all covered under PMB. • Relevant laboratory investigations are included in the PMB. • 6 outpatient consultations for medication monitoring and physical health assessments. • 16–21 psychosocial therapy sessions above and beyond the 15 sessions already mentioned and listed under the DTP section - Psychosocial interventions include psychotherapy and social interventions. It is delivered by qualified therapists as adjunctive therapy to pharmacological or medication treatment. It includes individual cognitive behavioural therapy (CBT), cognitive remediation therapy and psychoeducation. • A minimum of 10 planned MHM | 2025 | Volume 12 | Issue 5 | Challenges in Implementing the Council for Medical Schemes PMB Definition Guidelines for Schizo- phrenia and Bipolar Disorder in South Africa MHM