Tag Archives: Mental Illness

Remodel to rehabilitate – The need for mental health aftercare and rehabilitation treatment in Malawi

A build or remodel is not typically what the doctor ordered to stave off chronic stress and depression; the process risks construction anxiety and expense and according to Walter A. Brakkelmans, an associate clinical professor of psychiatry at UCLA, “on a scale of 1 to 10, 10 being the death of a child and 1 a fender-bender, a remodel rates a 6 in terms of stress.”

But in Malawi there is a shortage of doctors with orders, and for Flomina Mawindo, a single mother of five in Che Mboma village, rebuilding a dilapidated house is her best shot at ensuring her own rehabilitation to home life after being discharged from Zomba Mental Hospital.

Mawindo was admitted to Zomba Mental Hospital after familial and financial stresses set off a downward spiral into anxiety, insomnia and ultimately mental illness – she struggled with a husband who, until his death in 2004, encouraged thieves to steal from her to ensure she did not have the means to divorce him, in-laws who cursed her and her children and a son who stole from other villagers and skipped town leaving her to answer to the authorities and pay outstanding debts.

She began walking the streets at night, talking to herself and became increasingly violent when her children attempted to restrain her, and after initially being turned away from the Queen Elizabeth Central Hospital primary health care facility in Blantyre was admitted to the mental hospital in November of 2011.  She was discharged in February of 2012, and is able to recall, with a shaking voice and haunted eyes, her experience at the hospital as one of “trouble and pain.”

“In the first ward, it was not good at all,” Mawindo remembers.  “There were four or five patients in one room.  The others would bite me, abuse me, and grab my food.  I could not protect myself.”

Mawindo said the problems that made the hospital “like a prison” were caused by a shortage of doctors and nurses, an issue that was confirmed by a nurse at the hospital who said “the nurses are always there, but for example today we are only two nurses, and we have got 53 patients… For one or two nurses to look after 50 patients and provide the quality of care that they need?   It’s impossible.”

Due to the shortage of doctors and nurses, psychological treatment has not been institutionalized and instead the provision of drugs takes priority.

Mawindo has been prescribed sodium valproate, a mood stabilizer which causes side effects which include fatigue, shaking and sedation and are immediately obvious in Mawindo.  She is no longer strong enough to walk to the market to do business and has not returned to work since being discharged.  Her eldest daughter Tadala absconded from primary school to care for the family until the Jacaranda School for Orphans stepped in and hired a caretaker.

Beyond the caretaker and maize meal donations provided by Jacaranda, Mawindo said she is not aware of any community-based services to help support her and her family.

 

In the absence of government-funded community-based aftercare and rehabilitation services, Mawindo said she plans to make repairs to a dilapidated house on her property and open it to renters or turn it into a chicken farm.  She said with the supplementary income she will feel less stress about paying debts and providing food for her family.

 

She derives her motivation from the time spent at the mental hospital – not from therapy and positive learning but the fear of return.

“I was going through trouble and pain at that hospital,” she said.  “I’ve decided I will never go back there again.”

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According to Draft III of the Malawi Health Sector Strategic Plan for 2011-2016, in March of 2011 when the plan was published there were no mental health activities at community level, primary health care units did not provide mental health services, the treatment services provided by tertiary institutions were mainly for people with severe or acute mental health problems and the provision of psychological rehabilitation was limited.

The same report found that in 2011 only 1.5 percent of the national health budget was being spent on mental health and except for one or two districts, most districts spent none of their budget on mental health services apart from the procurement of drugs.

Barriers to mental healthcare in Ghana’s Northern Region

Mami Sandow started hearing voices when she was nine years old.

“She used to roam, talking anyhow, climbing some kind of trees, ” says her brother, Fatawu Sandow. ” You asked her to stop, but she wouldn’t stop. She would just run and hit anything [and fall] down. ”

Mami is 16 years old now and is being treated for epileptic psychosis at Tamale Teaching Hospital She pulls down the left shoulder of her screen-printed dress to show deep scars on the shoulder blade. Her left ear is mangled; the lobe tattered and hanging loosely. Her injuries are self-inflicted; when she hears voices she throws herself at walls to get them to stop.

Seven years ago, when Mami first started exhibiting unusual behaviour, her family thought she was just misbehaving, says Fatawu. The severity of her symptoms increased until they realized she needed medical treatment.

“We thought it was jokes [but] it came to a time, we had to send her to the hospital,” says Fatawu.

Psychiatric drugs in Ghana

Some of the drugs prescribed to psychiatric patients at the Tamale Teaching Hospital.

When Mami first became sick, the family sent her to a hospital in Bolgatanga, about 150 km north of Tamale. A private hospital, her treatment cost over 3,000 GHC ($1,500 CDN). To pay the hospital fees, the family had to sell off property and rely on remittances paid from siblings in Accra.

“We sold everything, just to take care of her,” says Fatawu.

Mami needs around-the-clock attention, to prevent her from injuring herself or others. Fatawu is the sole caregiver, because his mother and father are too busy to help. Staying at home as come at a personal sacrifice to Fatawu.

“It’s even effected my education,” he says. “I was attending [the Tamale Islamic Senior High School] … but because of the sickness, I must come home to take care of her.”

Mami’s epilepsy is treated as a psychiatric illness because of the stigma attached to her behaviour, explains community health nurse David Agyarwa. He says poor understanding of mental health issues stops patients from getting treatment.

“Most people think that when somebody suffers from mental illness it is due to sin an individual committed or the individual is demon possessed,” says the native of Accra.

Agyarwa says there is a great need for psychiatric care in Tamale, yet the hospital does not have a ward. Today he’s conducting interviews in examination room 52; an overcrowded room that houses urological, pediatric and orthopaedic appointments on different days of the week.

“We are compelled to sit at any place [in the hospital] that we can get and do our [patient] history taking,” he says.

Agyarwa says this is problem for psychiatric patients with delicate temperaments. Also, if appointments are conducted in open waiting areas, it violates patient privacy.

The Tamale Teaching Hospital unveiled a new wing on April 30, with maternity, intensive care, neo-natal, radiology and surgical wards, but no provisions for psychiatric care. The $54 million CND building took two years to build and was funded by the Dutch and Ghanaian governments.  Psychiatric patients will be housed somewhere in the new facility, says the hospital’s public relations officer Gabriel Nii Otu Ankrah.

“Because of the importance we attach to psychiatric care, the space will be created for them in the new building, temporarily,” says Ankrah. “[But] the original plan didn’t include space for the psychiatric unit.”

The Ghanian government is prioritizing mental healthcare after the March 2 passage of the country’s Mental Health Bill. The bill promises to de-centralize treatment from the three mental hospitals in southern Ghana, to community hospitals across the country.

Unaware of the government’s new mandate on mental healthcare, Fatawu is simply grateful for his sister’s new course of treatment. Mami hasn’t had a psychotic attack for one week, he says.

“Now it’s good [since] we started coming here, collecting the drugs,” he says. “Now [the illness is] no more [affecting] her, so now she is free.”

Growing mental health awareness in Malawi calls for more trained medical professionals

About half of the world’s population resides in a country where there is one psychiatrist or less to serve 200,000 people on average, according to the World Health Organization (WHO).

However, in Malawi, there are only two psychiatrists and two psychologists who are registered with the Medical Council of Malawi and serving a country of over 13 million people.

Without access to trained mental health care professionals, the mental health issues facing Malawians remain largely untreated and access to mental health facilities with trained professionals is arduous.

“The situation for mental health in Malawi is something that really requires a lot of attention,” says Dr. Chiwoza Bandawe, one of the registered clinical psychologists in Malawi, on the topic of the 1 to 6 million psychologist to patient ratio.

Until the field of mental health started growing, Bandawe speaks of his experience being the only clinical psychologist in Malawi for about 10 years upon his return to Malawi in 1995 from studying at the University of Cape Town. He attributes the lack of psychologists in the country to the lack of attention mental health previously received.

The current state of mental health is expected to change as Bandawe adds that the Malawian government has recognized mental illness in the Essential Health Package which “will help tremendously towards putting mental health right in its necessary spotlight.”

Henry Chimbali, Spokesman for the Ministry of Health in Malawi, told The Daily Times that government is adapting to the growing needs for mental health treatment.

“Mental health is one of the priority areas that have been included in the new health sector strategic plan and requires more attention than before,” he said.

Chimbali, however, suggests mental health still requires adequate budget allocation by government. He claims an assessment made in 2008 on funding to the sector found that only 0.9 percent of the total health budget was assigned to mental health.

Faced with scarce resources and a growing need for treatment, two of the country’s main forces behind mental health, Dr. Felix Kauye and Dr. Chiwoze Bandawe both agree that tremendous challenges remain which must be overcome in the field, beginning with addressing the need for more mental health professionals.

“There are a lot of challenges which I face in my career. The main challenge which I am currently facing is the workload,” says Kauye, who is one of the country’s two registered psychiatrists and also holds the title of Director of Mental Health Services at Malawi Government.

His skills are so highly relied on that his role within Malawi is increasingly more multifaceted. Kauye undertakes clinical work at Zomba Mental hospital, where he has four business ward rounds and one academic ward round in a week. He is also a clinical lecturer for the College of Medicine and involved in the training of post graduate students who are training to be psychiatrists. Additionally, Kauye is the head of the management team of Zomba Mental Hospital and is involved in the administration of the hospital.

But his role still does not end there, “Lastly but not least, I am involved in the drafting and implementation of national mental health programs like integration of mental health in primary care in Malawi and supervision of district mental health services,” says Kauye.

Bandawe’s responsibilities are just as demanding. At the present time, Bandawe is employed by the College of Medicine as the Dean of Students. He says his challenge, like other mental health care professionals, is not being available to as many people as he would like.

“.…I hardly see clients or patients at Queen Elizabeth Hospital and the need for psychologists is growing. People are coming to realize and appreciate the need for speaking with a psychologist,” he says.

Bandawe sums up the current problem of lack of qualified staff by saying that “there is a growing recognition and appreciation, so the challenge is as that recognition and appreciation grows, so do the demands on me grow. It becomes quite taxing at times.”

He attributes this, in part, to the fact that “the government has been so caught up with infectious diseases, which are important, but mental health has never been considered a priority,” he says.

Even without the resources to conduct community based data, Kauye is aware of the causes of psychological distress, as “the proportion of people who suffer from mental illness does not differ across cultures.” These causes include genetic factors, physical illnesses like HIV, daily life events like loss of employment, giving birth and substance abuse.

Kauye explains that there is currently a severe shortage of mental health professionals in Malawi and Bwaila unit in Lilongwe is currently run by nurses with no clinician working there. This affirms the WHO research finding that nurses represent the most prevalent professional group working in the mental health sector.

The nurses at Zomba Mental Hospital were unavailable for comment, but Kauye says, “With the shortage of staff and poor district mental health services, the team works under a lot of pressure because if we do not treat and discharge our patients quickly, the hospital becomes overcrowded and difficult to manage.”

This is particularly important in the cases where there is an over reliance on the tertiary hospitals since district hospitals are in poor condition, increasing the strain on the professionals in these settings.

Bandawe suggests that there are posts in the government for psychologists, but training and filling those posts have not been a priority. He attributes that lack of response to the stigma associated with mental health, a stigma that means those who suffer from mental illness are often ostracized from society and fail to receive the care they require, according to WHO.

“When most people talk of mental health in Malawi, they usually refer to people with severe mental illness who are in most cases unkempt and disheveled,” but mental illness has many faces, Kauye says, and this is just being realized.

Both doctors suggest that this stigma be addressed through creating mental health education and awareness, which is one of the methods that will enable every individual’s right to enjoy the best attainable state of physical and mental health under Article 16 of the African Charter on Human and Peoples’ Rights.

With the Malawian government seeking solutions to mental health care issues, there is a new hope that the future of mental health in Malawi will bring about positive change and the perceptions surrounding mental health will adapt to the growing need for mental health care professionals.

Charity and M'Adyoa

Mental illness still widely misunderstood in Ghana

This past week was a bit of a learning experience.

I learned that in Ghana, many children with mental disabilities are thought to be ‘water babies,’ or demon-possessed witch children.  I learned that most parents will leave such newborns at orphanages or children’s homes, though occasionally, kids are simply taken into the bush and left to die.  I learned that education about mental disabilities in Ghana is still relatively basic, and I learned that the current state of affairs can only improve if there is an improvement in public awareness.

I also learned that there is hope.  Operation Hand in Hand was started in 1992 by a Dutch doctor named Ineke Bosman as a shelter for mentally disabled orphans.  It’s now a permanent care home to 65 kids and adults and 31 caregivers.  Leah and I had the opportunity to visit and stay overnight at the shelter’s guesthouse in Nkoranza this past weekend, and it gave us a glimpse, albeit fleeting, into the world of 65 people who have been abandoned by their families, but adopted into a new one.  To see more of the Operation Hand in Hand community, check out Leah’s video blog here.

Operation Hand in Hand have seen many mentally disabled children pass through its front gates.

What we saw at Operation Hand in Hand was inspiring, but also a painful reminder of the challenges that still face mentally disabled people in Ghana.

“People are afraid of these children,” said Samuel Beffo, Operation Hand in Hand’s project director.  “When they have children like this, they send them to the hospital and then run away so [hospital authorities] can’t trace the family.”

The kids, who come from all over the country, are affected by a variety of illnesses, most commonly Down’s Syndrome or autism.  Beffo said the majority of cases are sent to Operation Hand in Hand by either the Department of Social Welfare or Health Services.  However, he stresses that merely sending mentally disabled kids to the community is not enough.

“Ghana is not helpful to the mentally handicapped,” said Beffo.  “The government simply [doesn’t] care.  Even the funds we are using to support this place, none come from the Ghanaian government.”

Instead, Beffo said the camp is funded by donations from all over the world, including Germany, Holland, and the United States, and the children are sponsored by “adoptive families” who send about $50 a month.  The kids’ caregivers are comprised of both international and Ghanaian volunteers.

Charity Asabea belongs to the latter group.  The 31-year-old Nkoranza native was originally hired at Operation Hand in Hand in 2003 to be a receptionist.  Asabea admitted that at first, she had reservations about working at a shelter for mentally disabled children.

“Before I came here, I had never seen such a child before,” said Asabea, “but one of my friends told me, ‘Just come and try it. If you don’t like it, you can leave.’”

Clearly, Asabea liked it, and eight years later, she is still at the shelter, where she is the head hostess and also the caregiver to a child, 16-year-old M’Adyoa.

“She calls me ‘Mommy,” said Asabea of M’Adyoa, who suffers from autism and epilepsy.  “I just call her M’Adyoa.”

When I asked her M’Adyoa’s last name, Asabea smiled.

“Bosman,” she said.  “All the children here are named after Dr. Bosman, because when they came, they were orphans.  Now, they have joined a family.”

Charity and M'Adyoa with big smiles for the camera!