Reformation of psychiatric care

Abdul Jalloh was the only practicing psychiatrist in Sierra Leone when he took over the country’s sole psychiatric hospital on the outskirts of the capital. Now six years later, the young doctor is leading a transformation of mental health services in the West African nation.

He abolished the practice of chaining patients to their beds, and has worked hard to attract new talent with the help of a U.S.-based nonprofit that has invested millions of dollars, along with Sierra Leone’s government.

The hospital now has three fully qualified psychiatrists and seven doctors in a new residency training program, the first in the country’s history. The hospital has also added nine specialized mental health nurses, along with addiction professionals, clinical psychologists and occupational therapists for a total of 135 staff.

During a recent Associated Press visit, an Afrobeats song played during a young men’s football game in the courtyard. All were patients, many undergoing treatment for drug addiction.

The scene would have been unthinkable before Jalloh took over.

The hospital was once known among locals as the “Crase Yard,” or yard for crazy people. Now it’s known as the Sierra Leone Psychiatric Teaching Hospital. It has helped give the facility, the oldest of its kind in sub-Saharan Africa, a new reputation.

“We have been able to change the face of this infrastructure,” Jalloh said in an interview. “From a place that people were ashamed to bring their family members, a place that even health workers were afraid to come and work … to a place that the country is proud of.”

The transformation has been backed by the U.S.-based health nonprofit Partners In Health that has invested millions in rehabilitating the hospital including providing training, equipment and services. A new building opened in mid-June as a rehabilitation center for drug users.

But there is little professional medical help for those living in the rest of the country beyond Freetown. The Ministry of Health established units for mental health in all 14 districts of the country almost a decade ago, but few function as intended due to a lack of trained staff and other resources.

Many people still go to traditional healers or religious figures for help, as many mental health conditions are associated with spiritual or demonic forces.

Sierra Leone’s population is still scarred from a more than decade-long civil war that began in the 1990s. Widespread unemployment, poverty and other hardship also takes a toll on mental health, helping to contribute to soaring rates of addiction to a locally produced drug known as kush.

There are also wider systemic challenges to mental health services.

Joshua Abioseh Duncan, the head of the Mental Health Coalition of Sierra Leone, a group that advocates for mental health, said the long overdue review of the country’s 1902 Lunacy Act that stigmatizes mental health issues — and strips people of basic rights — is contributing to the low level of funding and resources.

“The current law treats people with mental health issues as deviants in society who should be kept out of sight,” he said.

Few medical students in Sierra Leone consider psychiatry because of the lack of training opportunities and the limited earnings associated with the career, he added.

The government is taking some steps in coordination with international organizations. The health ministry is implementing a World Health Organization training program that aims to help healthcare workers identify and manage common mental health problems like depression, substance abuse and post-traumatic stress. The first 50 workers took the four-day course in June.

Sierra Leone’s director of mental health at the ministry declined to comment to the AP.

“Transforming mental health is a long game, it takes time,” said Giuseppe Raviola, a director at Partners In Health, which also set up a mental help line in Sierra Leone last year for counseling and advice. “Part of what takes time is not only building local capacity, but also making sure services are aligned with cultural beliefs and practices, and that things are driven locally.”

Jalloh first came to the psychiatric hospital for training during his fourth year of medical school and was shocked by its conditions.

He told his friends he would become a psychiatrist, which they thought was a joke. The profession is known to make little money and often fails to treat its patients. But after three years, he returned to the hospital and vowed to turn it from a place of suffering to sanctuary.

Despite the transformation of the hospital, Jalloh said soaring rates of addiction had taken a toll on his own mental health. The hospital continues to face challenges including a lack of security personnel to stop patients from scaling the walls to buy drugs.

“As you can see me, I am not feeling well. There are a lot of challenges. We don’t have the capacity to handle the (kush) crisis, considering human resources, infrastructure, medication,” he said. “It’s a big challenge and a huge burden on us.”

Community mental health initiatives

Amidst these national-scale efforts, several community-driven mental health initiatives have begun to take root, offering hope and localized solutions. Grassroots organizations and local NGOs are playing pivotal roles in bridging the gap between urban and rural mental health care.

One such initiative is the Mental Health Coalition of Sierra Leone, founded by Joshua Abioseh Duncan. This coalition is pivotal in community-based mental health awareness campaigns, which include educational outreach in schools, churches, and local marketplaces. By integrating mental health education into everyday community activities, the coalition aims to normalize conversations around mental health and dismantle the stigma associated with it.

The coalition also hosts monthly support groups for families affected by mental health issues. These gatherings provide a safe space where individuals can share their experiences, receive peer support, and learn practical coping strategies. Duncan believes that empowering family members with knowledge not only aids the patient but strengthens the community fabric as a whole.

Another promising initiative is the collaboration between traditional healers and mental health professionals. In Sierra Leone, where many still turn to spiritual and traditional practices for healing, incorporating respected local figures into the mental health strategy has proven effective. Programs like the one led by Dr. Jalloh are training traditional healers to recognize the signs of mental illness and refer patients to medical professionals when needed. This symbiotic approach respects cultural practices while ensuring patients receive the care they need.

Women in Action for Mental Health (WAMH) is a women-led organization making substantial impacts at the grassroots level. They operate mobile clinics providing mental health services in remote areas where access to healthcare is particularly challenging. Their team includes trained counselors and social workers who conduct home visits to deliver therapy and medication management. Additionally, WAMH runs skill-building workshops intended to help women with mental health conditions regain their independence and contribute economically to their families.

Utilizing radio as a tool for mental health education has proven remarkably effective in Sierra Leone. Initiatives such as the “Healthy Minds” program, broadcast weekly, discuss various mental health issues, invite experts for live Q&As, and share recovery stories from community members. This not only raises awareness but also encourages those suffering in silence to seek help.

Furthermore, the youth of Sierra Leone are not left behind in this transformative wave. Clubs like Mind Matters have been set up in secondary schools and universities to foster a supportive environment for students dealing with stress, anxiety, and other mental health issues. These clubs offer peer counseling sessions, promote mindfulness activities, and organize events aimed at de-stigmatizing mental health.

These community-based initiatives, while promising, often face hurdles such as limited funding, cultural resistance, and infrastructure challenges. The leaders of these programs, however, remain optimistic. They believe that with continued collaboration, education, and support, they can build a robust community network that will transform mental health care from the ground up.

Challenges and future prospects

The transformation of mental health care in Sierra Leone is a commendable start, but the journey ahead is fraught with significant challenges. The soaring rates of addiction, particularly to the locally produced drug known as kush, exert immense pressure on the already stretched mental health services. Addressing this crisis demands an urgent and multi-faceted approach that goes beyond the capabilities of the existing infrastructure.

One of the glaring issues is the lack of security personnel at the Sierra Leone Psychiatric Teaching Hospital, which leaves staff and patients vulnerable. The hospital’s walls, often scaled by patients desperate to buy drugs, starkly highlight the need for enhanced security measures. Without securing the facility, it remains difficult to provide uninterrupted care to those battling addiction.

Infrastructure and Resources:

• Improving the physical infrastructure of mental health facilities across the country is crucial. Many district-level mental health units suffer from inadequate equipment and dilapidated buildings, which hamper the delivery of quality care.
• There is a critical need for more trained personnel. The scarcity of professionals such as psychiatrists, psychologists, and social workers means that many patients do not receive the comprehensive care they need.
• The supply chain for essential psychotropic medications is unreliable. Interruptions in medication availability can lead to relapses and worsen patient outcomes.

Refining these logistical and systemic issues will require sustained financial investment and international collaboration. The government’s recent moves, such as the partnership with the World Health Organization for staff training, are steps in the right direction but need to be scaled up to make a widespread impact.

Legislative and Policy Reforms:

The outdated 1902 Lunacy Act remains a shadow over Sierra Leone’s mental health landscape. Its dehumanizing perspective on individuals with mental health issues perpetuates stigma and discrimination. Modernizing this legislation is essential to ensuring that people with mental health conditions are treated with dignity and have their rights protected.

Enhanced legislation should also focus on integrating mental health into primary healthcare, guaranteeing that mental health services are accessible and equitable. Policies must mandate the inclusion of mental health education in medical and nursing curricula to cultivate a new generation of healthcare providers who are not only aware but also equipped to tackle mental health challenges.

Cultural Shifts:

Social stigma remains a formidable barrier. Despite the efforts of community initiatives, many people still associate mental health conditions with spiritual or demonic causes. Changing such deep-seated beliefs requires continuous public education and community engagement.

Technology and Innovation:

Leveraging technology can be a game-changer in bridging the gap between urban and rural mental health services. Mobile health units, telemedicine, and mental health apps can extend the reach of professionals to underserved areas, offering counseling and follow-up care remotely.

Continuous monitoring and adaptation of these solutions, aligned with local needs and cultural practices, will be essential for their acceptance and effectiveness.

Community Involvement:

Sustaining these improvements will fundamentally depend on active community involvement. Empowering local organizations, such as the Mental Health Coalition and Women in Action for Mental Health, ensures that transformations are grounded in community realities and thus more sustainable.

As these diverse elements are addressed, it’s important to recognize that transforming mental health care in Sierra Leone is not just about alleviating individual suffering but about nurturing the mental well-being of a nation. It’s a collective venture requiring patience, resilience, and unwavering commitment to a vision of holistic health for all.