Tackling mental health in Sierra Leone

A pilot scheme has recently introduced basic mental health care to a remote area of west Africa that has never before received orthodox mental interventions. The organisers of the scheme, Lynne Jones and Joe Asare, describe its structure and assess its results

Despite the emphasis on mental health in the World Health Report of 2001, and the subsequent revolution in mental health care in many countries, the citizens of some countries in Africa have little or no access to mental health care.

The west African state of Sierra Leone went through a civil war lasting 15years that ended in 2002. With only one psychiatrist, two trained psychiatric nurses, and a population of four million, the country was in a weak position to deal with the mental health needs of its population during the years of reconstruction.

A survey by the World Health Organization in Sierra Leone in 2002 found that 2% of the population was psychotic; 4% had severe depression; 4% had substance misuse; 1% had mental retardation; and 1% had epilepsy. WHO advocated the creation of community based mental health services.

As a result, the International Medical Corps, a global humanitarian charity, applied and got funding from the Bureau of Population Refugees, and Migration, of the US State Department, to pilot a community based mental health project in the remote rural area of Kailahun, on the border with Liberia and Guinea.

Kailahun is a district of about 300 000 people in eastern Sierra Leone. The area was held by rebels engaged in conflict throughout the war and was last to be disarmed in 2002. Most of the population have either been displaced in refugee camps in neighbouring countries for periods as long as 15 years or have actually been caught up in prolonged periods of fighting. Many people are unemployed and impoverished. In addition, there are a large number of former combatants who are adjusting to a new way of life.

A preliminary mental health assessment exercise in January 2004 conducted in Kailahun by Lynne Jones, mental health adviser to the International Medical Corps, found an unexpectedly high number of people suffering from serious mental health problems or substance misuse. Many of these patients had been ill and untreated for years as a result of which they were already on the downhill path of self neglect, social exclusion, and stigmatisation. Tragically, most patients were young men, either returning refugees from Guinea or Liberia or former combatants. As they were untreated they were likely to be drawn back into conflict and criminal activities. These men remained an easy target for rerecruitment and added to the instability of the community.

The main objective of the pilot project was to establish a sustainable community based mental service at Kailahun through community education and increasing the number of workers in primary health care.

The country's Ministry of Health and Sanitation identified community health officers as the most suitable paraprofessionals to be trained. These officers are health workers who have received three years training in primary health care and public health before running primary health care posts throughout the country.

An officer was chosen by interview and given practical and theoretical training in mental health for six months, so that he could become the focal mental health person at the district hospital. Four outreach outpatient clinics were established, which were used for training. By the fourth month, the person who had been chosen for mental health training, who had become known as the community mental health officer, was able to hold clinics on his own with little supervision.

The programme sought strong collaboration with traditional healers, who allowed reciprocal visits to their healing consultations and who attended the outpatient sessions and training workshops. After this collaboration, many of the healers were prepared to adapt their own approaches to a more humane and non-restrictive treatment than that which they had previously used.

In addition to training a community mental health officer, the charity organised eight days of training for the health workers in charge of what are known as peripheral health units. These units, of which there are 52 in Kailahun, are manned by community health officers. Fifty of the people who ran them were sent to four two-day workshops, where they were trained in the recognition of common psychiatric conditions, management and referral of difficult cases, use of simple psychotropic medication, and mental health promotion. After the training, these people could identify and manage epilepsy, depressive illness, and psychotic cases. The nurses at the district hospital were also given orientation on psychiatric emergencies and their management.

Stigmatisation is probably the major problem in the area of mental health, and it affects every aspect of the work done by the International Medical Corps, including attendance at clinics, compliance with medication, and particularly the availability of social support for people who are mentally ill. Brief surveys showed that most of the community believed mentally ill people to be evil, violent, lazy, stupid, unable to marry or have children, and unfit to vote.

The International Medical Corps held regular public education workshops with community leaders and police and found that they were able to shift attitudes towards a more positive approach regarding the need for social support and a less nihilistic approach to treatment.

The Community Health Training School that produces community health officers at Bo, in southern Sierra Leone, had never, until recently, included mental health lectures in the curriculum. Psychiatrists from the International Medical Corps helped in developing mental health education at the Community Health Training School through lectures and curriculum development.

In addition, the charity worked with Edward Nahim, Sierra Leone's sole psychiatrist, to help the Ministry of Health create a mental health task force to coordinate and push forward a strategy for developing mental health services throughout the country.

In the pilot project in Kailahun, a total of 204 cases were seen within six months. The number would have been higher if patients had been seen on demand rather than been given appointments. An appointment based system (that quickly produced a waiting list) allowed time to be devoted to the training of staff after each appointment, but of course meant that fewer patients could be seen in any given clinic. Of these 204 cases, 64% suffered from epilepsy; 24% from psychosis; 4% from depression, 4% from depressive illness, and 1% from schizophrenia.

The organisers of the project believe that the technical experts at the ministry of health now accept that the decentralisation of mental health services is possible and that similar projects could be adopted in the other 11 districts of the country. The pilot programme might also serve as a model for other conflict affected areas of west Africa, they believe. The newly established task force reached a consensus that the government in Sierra Leone has pressing need to develop a mental health policy and to change the law to take account of the changes in the philosophy and new direction of mental health services in Sierra Leone.

World Health Report 2001, Mental Health: New Understanding, New Hope, is available at www.who.int/whr/2001/en.

Dr Joseph Asare is clinical supervisor in the International Medical Corps community based mental health programme in Aceh, Indonesia. Dr Lynne Jones is a consultant child and adolescent psychiatrist and the technical adviser in mental health for the International Medical Corps. She is also senior research associate at the Centre for Family Research at Cambridge University.