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Tuesday
May072013

The mental health policies of Ghana, South Africa, Uganda and Zambia

Assessment of mental health policy in Ghana, South Africa, Uganda and Zambia: Faydi et al.  Health Research Policy and Systems 2011, 9:17

This month’s article is interesting but it’s quite ‘high level’, however, don’t worry as next month’s summary will be more topical and all about Ghana again.  This paper assesses the mental health policies of Ghana, South Africa, Uganda and Zambia. 

Before you read the summary bear in mind that as mental health professionals we’re all stakeholders in the mental health system and when it comes to producing policies we should make ourselves available and be willing to be fully involved.  However, we most of us are not experts on producing policies so we might need training.  We should identify who are our leaders on this and support their education as policy developers.   We should keep abreast of latest guidelines and be ready to adapt to new ways of working as policies evolve. As frontline staff , we know the needs of our patients and we should not be afraid to take up leadership roles to coordinate their care.  As you will see, the country policies inspected in this survey could have been better.  It’s in our hands to help improve this for the future.  In fact when the new Mental Health Act implementation comes on, which won't be long now, each Region and District will require mental health leads so some of you might need expertise in this sooner than you were expecting.

SUMMARY

Countries that would like to improve their mental health services need a mental health policy.  The World Health Organisation (WHO) has a Checklist to assess the strength of health policies and this research paper uses the checklist to assess the mental health policies of Ghana (1994), South Africa (1997), Uganda (2000-2005) and Zambia (2005).

The study notes that country level mental health policies would be expected to cover;

  • community based services
  • integration of mental health into general health care
  • promotion of mental health and rehabilitation
  • prevention of mental illness
  • protection of human rights
  • use of an evidence based approach

A key strength of the WHO Checklist is its generalizability as it takes into account best practice in low, medium and high income countries.

 The results were;

According to the Checklist, all the policies had quite a lot of weaknesses.  Common failings were;

Data to support the policy

  1. Those drafting the policies  relied too much on local knowledge rather than robust surveys.
  2. There was a lack of evidence and data overall .

Consultation and sanctioning

  1. Service users (patients) weren’t consulted enough.
  2. There wasn’t enough formal approval by senior health officials and government bodies despite them seeing the policies.
  3. There wasn’t enough political support.

Integration

  1. There was not enough linking of mental health policies to overall national policy and legislative frameworks.

Writing and content

  1. Not describing the key vision, values and principles.
  2. A lack of internal consistency of structure and policy content .
  3. No clear action plan and no one to make sure actions get completed.

Financing

  1. No clarity on who will finance the policy if it is put into action.

A positive point was a strong emphasis on community based care.

The recommendations were

  1. Key stakeholders (and policy makers) should take part in education on how to produce policies.
  2. Policies should be seen as dynamic and they should be kept amended and adjusted.
  3. Policies should be linked together and co-ordinated to prevent wastage of resources.

This is a link to the full article

These summaries are produced by;

Dr Olusola Awonogun, Specialist Registrar in Psychiatry, Hampshire, UK

Dr Mark Roberts, Consultant Forensic Psychiatrist, Hampshire, UK

Professor JB Asare, Psychiatrist, Accra, Ghana.

Saturday
Mar022013

Characteristics of Suicidal Behaviour in Contemporary Ghana

Epidemiologic Characteristics of Suicidal Behaviour in Contemporary Ghana. Mensah Adinkrah. Crisis 2011: Vol.32(1):31-36

Suicidal behaviour is a crime in Ghana and if unsuccessful it can result in arrest, prosecution and criminal penalties.

In contrast, support and help is offered to an individual who has attempted suicide and failed in the United Kingdom.

Dr Mensah Adinkrah, Professor of Sociology and Criminal Justice at Central Michigan University, USA, explored the characteristics of individuals who committed suicide in Ghana by looking at all cases of suicide recorded on the police database between 2006- 2008.

He found out that 243 individuals committed suicide in those 3 years while 44 individuals tried but failed. Despite these numbers, Ghana still has a low rate of suicide compared to the western world because suicide is perceived as a social and religious taboo.

More males than females attempted and successfully committed suicide. The rate in males was 20 times higher than in females.

The gender distribution for attempted suicide in Ghana is different from those of industrialized countries where the rates are higher in females. This difference maybe because Ghanaian women are religious and this is a strong protective factor against suicide.

Motherhood is also a recognized protective factor and most women in Ghana have several children. They are also more likely to seek help and speak about their problems. Women have limited access and knowledge about the use of guns.

Suicidal behaviour was more common in the age group 20-29 years and 30-39 years.

The individuals who completed suicide were mostly from a low socioeconomic background. The commonest method used was hanging followed by shooting with firearms and ingestion of insecticides and acid.

In cases of unsuccessful suicide attempts, the most common method was cutting with a sharp object followed by poisonous ingestion.

Suicide commonly occurred in the home or near it.

There was a higher rate of suicide between July and September possibly due to an economic downturn around this time because of heavy rainfall.

The rate of suicide was lowest in December possibly due to Christmas celebrations and end of the year festivities but the rates increased in January possibly due to austerity from overspending in December.

Dr Adinkrah recognized that he may not have captured the complete data due to poor reporting practices.

By law all cases of death outside a medical facility in Ghana must be certified by a medical doctor and reported to the police and a coroner if the cause of death is unclear. A post-mortem must then be done by a pathologist. It is expected that with this rigorous process the police database will be accurate but this is not always the case.

There is always the chance that some suicides will be misclassified as accidents, illnesses or unexplained deaths especially as there is a shortage of pathologists in Ghana to carry out autopsies on suspicious deaths.

Some families and suicidal individuals know that suicide is a criminal offence and often attempt to avoid detection. Others are unaware of their responsibities regarding reporting to the authorities and so do not do so.

In the absence of a body, the death could be recorded as a missing person case. The absence of a suicide note also contributes to the low detection rates.

Other factors include stigma and the fear of being blamed or accused of murder. Also, it can be a costly venture to commute to a police station for those individuals who live in the remote villages.

With this knowledge, health care practitioners who come in contact with bereaved families or individuals who have attempted suicide and failed should actively encourage them to report the incident to the authorities.

When assessing a patient, we should apply the results of this study by considering that a young male, from a poor socioeconomic background ,who has easy access to firearms i.e. a farmer, has no religious affiliations and is putting on a “brave “ face is at higher risk of completed suicide. We should offer as much support as our resources will allow.

Perhaps we should also test out the theories and assumptions in this research as to true suicide rates and the differences between men and women thus increasing our overall knowledge on this important topic. . Sadly, the rate of suicide and attempted suicide is high in the UK and one wonders whether the increasing commercialization and urbanization occurring will lead to similar increases in Ghana.

The full article can be downloaded from: http://www.psycontent.com/content/d6642grn63254834/

The full article can be downloaded from: http://www.psycontent.com/content/d6642grn63254834/  but it's not free and it can't be accessed from Africa via Hinari either.  If you would like to try asking the publishers if they would let you have a free copy you could try via their email address customerservice@hogrefe.com 

 

Sunday
Feb032013

Medication side effects in Ghana

The article was published by Dr Ursula Read in Transcultural Psychiatry: Read, U. (2012). ‘‘I want the one that will heal me completely so it won’t come back again’’: The limits of antipsychotic medication in rural Ghana.Transcultural Psychiatry, 49438–460.

The full article can be found at http://tps.sagepub.com/content/49/3-4/438

We have also posted the summary on our Facebook page, tweeted it and sent a link by SMS to practiintioners in Ghana

The aim of this is to honour mental health research in Ghana, to assess it, help familiarise everyone with it and to see how the findings can be used to help patients and practitioners.

''I want the one that will heal me completely so it won't come back again'': The limits of antipsychotic medication in rural Ghana by Dr Ursula Read

There has been a big focus on the development of appropriate mental health services in low income countries using the models practiced in developed countries which emphasises medication as a huge part of the treatment of mental illness.

In doing this it seems that campaigners, prescribers and all those that offer “medical” treatment of mental illness do not discuss the limitations and perhaps the side effects of these medications with the patients and their families and certainly do not appear to acknowledge that it does not “heal completely”.

This lack of transparency seems to encourage non-compliance with treatment and strengthens the notion that mental illness is a spiritual illness and as such it cannot be cured completely by medical treatment.

“Health “is clearly defined by WHO (1948) and this definition is universally acceptable but in practical terms it means different things to different people. One of the factors that influence a person’s concept of health is their economic power hence the concept differs between low income and high income countries.

In Ghana and other such countries , health equates to strength- strength to wake up at the break of dawn, clean one’s surroundings, walk for miles to work, do intensive jobs such as farming , earn a living and look after one’s family.

Experiences such as visual and auditory hallucinations are not deemed to be particularly troublesome as they can occur even in the absence of mental illness. In any case it is not uncommon for people who attend churches and traditional places of worship to have visions in the absence of mental illness.

It was side effects of medication such as tiredness and the subsequent reduction in productivity that is deemed to be most troublesome for the individual and for their families. As soon as these individuals realise that medication could not deliver their desired outcome of “health = strength “they refuse to tolerate it despite the immediate positive effects.

It is therefore not surprising that there would be a preference to seek “healing “from spiritual churches and traditional healers whose treatment is perceived to be “side-effect free and long- lasting”.

Dr Read looked into the experiences of people with mental illness and their families in rural communities within and around Kintampo in Ghana.

These individuals had long standing mental illness which had led to a severe disruption of social functioning and frequently displayed behaviours such as talking nonsensically, acting aggressively, roaming around, and dressing in dirty clothing.

She recounted the story of Ibrahim- A promising young man who had recurrent episodes of mental illness characterized by hostility and aggression and who had to be chained to a log of wood by his family due to his uncontrollable behaviour.

He took antipsychotics which calmed him down considerably and helped him reintegrate into family life but he chose to stop his medication due to the unacceptable side effects. He “chose” to seek treatment elsewhere.

This article also proposed that people with mental illness and their families do not necessarily attend hospital when all else has failed. Sometimes they choose to do this at the start of the illness but may revert to traditional healers and spiritual churches due to unbearable side effects and/or after a relapse.

In African countries such as Ghana ,there is a strong belief in the supernatural- witchcrafts, gods etc and it is believed that orthodox medicines cannot cure illnesses caused by supernatural powers. The belief is that a spiritual illness is any illness which is recurring or prolonged.

Basically the rule is that if it is a medical illness, use medication and if supernatural or spiritual = church, mosque or traditional shrines. 

Mental illness by nature is reoccurring and this weakens the argument that mental illness is not a spiritual illness. That medication does not cure it further enforces this belief system.

It is also common for Ghanaians to believe that only God can heal. They are willing to “wait and see” knowing that no-one method can guarantee a result. They start to mix and match treatment.

In concluding, the study showed that Ghanaians are aware of the existence of mental health services and how to access this service.

They choose when they want to engage and if they want to. Sometimes they mix this various modalities of treatment in a bid to find a “cure “ and “recover “ which is defined as getting back into a social role and being able to work.

When patients choose to seek medical help and it is helpful, they may still end their engagement because of side effects of medications and the lack of long term therapeutic effects. This is similar to the pattern in high income countries including the UK.  However, in the UK there are other initiatives and alternatives such as community treatment, psychological therapy, wellbeing centres and wellness recovery action plans which provide a safety net for patients who choose to reduce or stop their medications.

What are the implications of Dr Read’s findings to us?

As the present and future work force, we need to ensure that we have transparent discussions with our patients about the limitations of antipsychotics, educate their families about the illness and address their expectations. Now that it is clear that social functioning is THE desirable outcome measure, we should start thinking about social reintegration, work opportunities, trade workshops etc for our patients right from the time of their first presentation to us.

We should also keep ourselves up to date about relevant local initiatives to signpost our patients as appropriate.

In order to gain and maintain the trust of our patients and their families, we must strive to provide the best possible care for our patients by maintaining an adequate depth and range of knowledge, reading and commenting on articles such as this one and accessing training whenever possible.

 

 

Friday
Jan042013

Drug abusers in Accra 

Here is a short summary of a scholarly article: Socio-demographic Characteristics of Substance Abusers Admitted to a Private Specialist Clinic, by JJ Lamptey.  Ghana Med J. 2005 March; 39(1): 2–7.

The article was published in the Ghana Medical Journal 39(1): 2–7 in March 2005 and is free online via any search engine (e.g. Google). It can also be downloaded by following this link:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1790802/

We have also posted the summary in facebook here http://www.facebook.com/groups/400750166671553/ 

The aim of this is to honour mental health research in Ghana, to assess it, help familiarise everyone with it and to see how the findings can be used to help patients and practitioners.

SUMMARY

Since time immemorial people have eased themselves of the stresses of daily life by using drugs, herbs and potions but at what cost ….and who become the addicts ?     Young males mostly become the addicts and the author of this research suggests it might be because being male is associated with aggression, violence, independency and adventurism, which are potent factors in the initiation of substance abuse.  The author suggests the protection of the extended family is giving way in Ghana to the nuclear family with bad consequences and broken homes are the worst thing especially if a young man is left with only his mother.

The study conducted in 2005 by JJ Lamptey compared characteristics of 87 substance abusers admitted to a 28 bed private clinic in the Accra Metropolis of Ghana between 1997 and 2002, compared with 87 randomly selected non-drug using students and staff of Legon University.

Lamptey found:

 

  • Most abusers started their drugs between ages 15- 24 years.
  • They were usually age 20-29 years before being admitted to the clinic as they didn’t seek help until 4-5 years after starting drugs.
  • Most were males
  • Their parents were often divorced, separated or never married.
  • Losing a father was worse than losing a mother
  • Religion had no effect on the chance of using drugs.
  • Most drug abusers felt that the attitudes of their families towards them were either warm or normal.
  • Starting treatment was often triggered by parents and relatives.

 

So perhaps losing a parent or both parents through death or long separation negatively impacts on a child especially where there is no appropriate substitute and lack of paternal authority or role model can be especially bad.

All the findings are similar to those found in other countries including the United Kingdom.

Interestingly, the study found no link between religious affiliation and becoming a drug abuser. One wonders why this is the case when a good proportion of the main religions practiced worldwide teach young people to stay away from “sin” and drug  abuse is frequently labelled as a sinful act.

So how should we put these findings to use in our day to day practice as mental health workers ? 

We reccomend you see our facebook post to join in the conversation http://www.facebook.com/groups/400750166671553/ 

The summary was written by Dr Olusola Awonogun, senior psychiatry trainee and Dr Mark Roberts, Consultant Forensic Psychiatrist, both of Southern Health NHS Foundation Trust, Hampshire, UK.  

Thursday
Nov012012

Common understandings of women’s mental illness in Ghana

We hope you enjoy our short summary of a research paper published by Dr Angela Ofori-Atta and colleagues in 2010.  We hope you find it useful.

There is worldwide evidence that women have higher rates of depression and stress related illnesses than men. This is also the case in Ghana. Dr Ofori- Atta conducted research exploring the beliefs local people have about why this was the case.  She found out that the participants thought women suffered more from depression and anxiety related illnesses because:

a. They thought women are naturally weaker than men and were less capable of solving their own problems. They also thought it could be because women internalise all their problems and have emotional disturbances as a consequence of their monthly menstrual periods or menopause.

b. The participants thought that women who were involved in witchcraft could bring mental illness upon themselves or other people in the community and as most witches were thought to be women there is the higher likelihood of mental illness among the female gender.

c. Being a female could predispose a woman to domestic and sexual abuse. It could also mean that if she does not have a personal source of income then she is dependent on the same man who is abusing her for food, clothing and shelter and is trapped in the relationship.

A woman married to a polygamist or unfaithful husband is also thought to be at an increased risk of mental illness due to the insecurities this will cause.

We suggest it is therefore important that all mental health workers are aware of these factors which could trigger and maintain mental illness in women. It may be that we have to proactively screen for the factors suggested in (c) and perhaps reflect on our own beliefs about (a) and (b) which are not held worldwide. It is also worth thinking about why people in Ghana hold these beliefs.

It may be helpful to be aware that a woman who has been accused of been a witch will be filled with a sense of shame and would be less inclined to disclose this. Her family will also appear unsupportive for the same reasons.

This article was published in the International Review of Psychiatry in December 2010 and is free online via any search engine (i.e. Google). It can also be accessed by clicking onhttp://www.dfid.gov.uk/R4D/PDF/Outputs/MentalHealth_RPC/Ofori-atta_etal_IntRevPsy2010.pdf

The full article reference is; Ofori-Atta, A., et al (2010). Common understandings of women’s mental illness in Ghana: results from a qualitative study. International Review of Psychiatry, 22(6): 589–598