Mental health in Sierra Leone
Sandra Zaeh writes on the the mental health challenges in Sierra Leone.
By any Western account, the mental health system in Sierra Leone is struggling.
With one trained government psychiatrist, little funding for psychiatric drugs and mental health facilities, and few opportunities for mental health care outside the capital of Freetown, the majority of mentally ill patients are beyond the reach of biomedical care for mental disorders.
To fill the void, Sierra Leoneans turn to alternatives like traditional healing and spiritual practices to address their mental health needs, options that even Western-trained experts consider crucial to maintaining the country’s mental health. And yet, the balance is tenuous - and, without an infusion of financial and human resources, may not be sustainable.
Mental health is far from the only problem facing Sierra Leone, which ranks at the bottom of the Human Development Index. (1) While the country has shifted from its post emergency phase to one of development since its 11-year civil war ended in 2002, it still faces daunting economic, educational and medical difficulties: nearly 75% of people live on less than $2 per day, the country has a literacy rate of 35%, and infant and maternal mortality rates are among the highest in the world. (2)
In light of these challenges, mental health may seem like a relatively minor problem, but experts at the World Health Organization (WHO) explain that there is “no health without mental health,”(3) and estimates suggest neuropsychiatric conditions are responsible for over 30% of the global burden of disease. (4) As Dr. K. Sheku Daoh, Director of Hospitals Services at Sierra Leone’s Ministry of Health (MOH) explains, mental health is intrinsically linked to many health issues. If we choose not to address mental health, there will be a “multiplying effect on the entire health system.”
Another concern for First Lady Sia Koroma is stability. If Sierra Leone fails to support individuals with drug-induced mental psychosis, she says, it is possible for them to “go to the guns again” and fight. Her concerns are particularly relevant given widespread opinion that a causal factor in Sierra Leone’s Civil War was youth discontent.
Despite the stakes, mental health remains a “neglected issue,” according to the First Lady, a trained psychiatric nurse. A nationally representative survey performed in 2002 suggested that the prevalence of depression within the population was 38%. Additionally, 7% of Sierra Leoneans were afflicted by substance abuse and 65% had suffered from trauma-related distress. (5) A recent longitudinal study of war-affected youth has documented similarly high rates of depression and anxiety disorders. (6)
Despite Sierra Leone’s pressing needs, the Western mental health system is vastly underdeveloped due to a lack of funding, its stigma, and little interest by medical professionals. Dr. Daoh explains that 75% of the minimal health budget is dedicated to reproductive and child health. While mental health is among the MOH’s priorities, he says, there is not enough money to make it a focus.
Dr. Edward Nahim, Sierra Leone’s lone government psychiatrist, expresses concerns that both Sierra Leoneans and Western trained physicians within the country do not see mental health as important health concerns. “They see mental health as something for the juju men,” he says. “They truly don’t understand it.”
The lack of attention paid to mental health in Sierra Leone has resulted in a mental health system which revolves around one man: Dr. Nahim.
On call 24 hours a day, 7 days a week, Dr. Nahim is in charge of Kissy Mental Hospital, the government’s only psychiatric institution, located in Freetown. The 108-year-old hospital, among the oldest psychiatric institutions in West Africa, has a 400 patient capacity, but recently cut its patient load to 150 due to a lack of personnel.
Throughout his tenure as government psychiatrist, Nahim has seen an increase in the prevalence of mental illness in Sierra Leone, mostly linked to an increase in drug abuse. Drug induced psychotic disorders, which used to account for 10% of the admissions to Kissy, now drive more than 80% of psychiatric admissions.
Despite the widening prevalence of mental disorders and limited capabilities of the biomedical mental health system, Nahim is convinced that the mentally needy are receiving the care they need.
“Eighty percent of all mentally ill patients are treated by people in the community - religious healers, spiritual healers, juju men, and black magic men,” he says. “They all do a very good job.”
Nahim argues that traditional healing is successful within Sierra Leone because many people believe their mental illnesses are externalized and associated with an “evil environment,” which can only be cured through traditional medicine.
Dr. Taylor Lewis, founder of the Sierra Leone Traditional Healer’s Association, also believes in the importance of traditional healers in order to achieve WHO’s goal of “health for all.” With over 2,000 traditional healers in Sierra Leone - compared to only 126 physicians - Lewis says that traditional healers provide a valuable resource if they are properly regulated. He sees traditional healers as important for patients who suffer from mental health disorders, as they can “cure mental ailments that Western doctors cannot treat” through traditional ceremonies.
In addition to traditional medicine, the mentally ill also seek spiritual healing. At the City of Rest in Freetown, Pastor N’gobeh leads a residential mental home and drug abuse center that employs biblical counseling and prayer to cure patients, without any psychiatric drugs. N’gobeh’s center is based on the philosophy that “there is no sickness that God cannot cure.”
Even with the use of traditional medicine and spiritual healing, however, there is widespread concern that gaps exist in patient care. Dr. Lewis believes the system is only 30% effective.
Thus, it is essential for the various actors involved to “work together” to build mental health capacity, says Dr. Lewis. In addition to making mental health part of all health initiatives, Lewis believes the first major step is to invest in human resources and increase the number of mental health workers.