Academic journal article South African Journal of Psychiatry

Where There Is No Psychiatrist: A Mental Health Programme in Sierra Leone

Academic journal article South African Journal of Psychiatry

Where There Is No Psychiatrist: A Mental Health Programme in Sierra Leone

Article excerpt

Mental disorders are an important cause of longterm disability and dependency, with the 2005 World Health Organization (WHO) report attributing 31.7% of all years lived with disability to neuropsychiatric conditions, [1] particularly unipolar depression (11.8%), alcohol-use disorder (3.3%), schizophrenia (2.8%), bipolar depression (2.4%) and dementia (1.6%). This significant burden affects both more-developed countries and those that are poorer and less well resourced. However, mental health remains a low priority in most low- and middle-income countries (LMICs), which tend to prioritise the control and eradication of infectious diseases, and reproductive, maternal and child health. [2] Investment in mental health is often perceived in these countries as having an unaffordable opportunity cost. As a result, there is an large treatment gap for people with neuropsychiatric disorders in LMICs. While at least two-thirds of all persons with mental illnesses go untreated worldwide, the figure for low-resource countries exceeds 90%. [3]

There is also a conspicuous lack of published literature evaluating the implementation of mental healthcare programmes in low-income countries. Fewer than 1% of identified trials worldwide that aimed to treat or prevent schizophrenia, depression, developmental disabilities or alcohol-use disorder were conducted in low-income countries, and of these about two-thirds come from China. [4] In the case of sub-Saharan Africa, the vast majority of published data from mental health research (nearly 70%) is focused on South Africa, [5] an emerging country that is not representative of the region as a whole. Sierra Leone, in the sub-Saharan area, occupies one of the lowest positions in the Human Development Index drawn up in 2008, [6] ranked 128th among 135 countries for which a Human Poverty Index was calculated. The proportion of its population below the poverty line of US$1.25 per day is estimated at 47.7%. The country has recently emerged from a brutal, decade-long civil war during which civilians were victims of widespread violence, including amputation of body parts, rape and forced labour. After this devastating conflict, the health system, like all public systems, was in tatters. Nevertheless, the country has managed to implement a free healthcare plan for pregnant women, breastfeeding mothers and children younger than 5 years, that has been proposed as an example for LMICs. [7] As countries such as Sierra Leone continue to rebuild after conflicts, the need to develop services for all from the ground up may offer a unique window of opportunity for the inclusion of persons suffering from mental disorders into the health system.

Reports on mental health initiatives in LMICs are crucial to provide more direct evidence regarding cost-effective interventions that may help low-income countries use their limited financial and human resources for mental health as effectively as possible. This article describes the results of a free outpatient mental health programme that was run in Makeni (Sierra Leone) between July 2008 and May 2012. The programme was delivered by trained non-specialist health workers integrated into the existing healthcare system.

Methods

Setting

Since 2011, there has not been a single psychiatrist in Sierra Leone; only occasionally is there input from foreign professionals via NGOs. The country has only one facility for treating mental health patients on a long-term basis using Western medicine, namely the Kissy Mental Hospital in Freetown, the capital of Sierra Leone. Makeni, located approximately 137 km east of Freetown, is the 5th largest city in Sierra Leone and is the economic centre of the Northern Province. It has a current estimated population of 109 112 and is the capital of the Bombali District, of which the estimated population is 439 319.

The Holy Spirit Hospital is linked to the University of Makeni, and both form part of the Catholic Diocese of Makeni. …

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