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Mental Health Services in Sierra Leone
- Victoria Adeyemi Williams, Dr Oyedeji Ayonrinde, Bethlem Royal Hospital, UK deji.ayonrinde@slam.nhs.uk (17 March 2008)
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A response to Psychosocial intervention for war - affected children in Sierra Leone
- Prof K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Dr.A.Hapangama MD , Lecturer in Psychiatry, Faculty of Medicine, University of Kelaniya,Ragama,Sri Lanka (22 May 2008)
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Sierra Leone Plan international /Unesco Project
- Gonzalo Retamal (2 December 2009)
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Victoria Adeyemi Williams, Psychiatric Nurse Visiting Psychiatric Nurse to Kissy Hospital, Freetown, Sierra Leone, Dr Oyedeji Ayonrinde, Bethlem Royal Hospital, UK deji.ayonrinde@slam.nhs.uk
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viyemi{at}yahoo.co.uk Victoria Adeyemi Williams, et al.
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Dear Editor We read with interest the paper by Gupta and Zimmer (1) highlighting the psychological impact of conflict on children in Sierra Leone. The war in this West African country lasted about 10 years ending in 2002, leaving many people with severe physical and emotional scars. The conflict not only eroded the previously limited health services but also increased the nation’s physical and mental health morbidity. It is noteworthy that nearly 10 years on from the study these children are now adolescents or young adults faced with further life challenges and responsibilities. We present a contemporary description of post-war psychiatric resources in Sierra Leone following a visit by co-author (VW) to her country of origin in 2007-2008. Sierra Leone has one specialist psychiatric hospital, the oldest in West Africa. Built in 1827 by the British colonial government, Kissy Mental Home was renovated and renamed Sierra Leone Psychiatric Hospital in December 2006. The 400-bed hospital has 10 wards of which one female and 3 male are currently in use. Admission, accommodation, food and medication are free (state subsidised) but sparsely resourced and supplemented by carers where possible. The Sierra Leonean population (approx. 6 million) is served by this specialist hospital, one consultant psychiatrist, two qualified psychiatric nurses and a pharmacist. There are no psychology, social work or occupational therapy staff. A WHO population survey (2) found 2% had psychosis, 4% severe depression and 4% substance misuse, 1% mental retardation and 1% epilepsy. The majority of hospital attendees have tried a number of other interventions such as faith healers, traditional doctors and herbalists prior or complementary to hospital care. Up to 75% of acute admissions are in the context of or with comorbid substance misuse, predominantly cannabis (“jamba”) and cocaine (“brown- brown”). Substance misuse is felt to be an escalating post-war public health problem inflicting further morbidity. About 25% of in-patients are long-term hospital residents of whom a number have no family. Some have been resident in the hospital for up to 25 years. Medication is predominantly the typical antipsychotics (chlorpromazine, haloperidol), benzodiazepines (diazepam) and tricylic antidepressants. Mechanical restraint with chains is not uncommon in the hospital with some patients chained to their beds or window frames. This reflects staff shortage, limited containment in the ward settings, challenges of tranquillisation and the allure of substance seeking by some patients. Access to the hospital on a steep hill is best with off-road vehicles. There is no direct electricity or water supply and is therefore supplemented with generators and boreholes. While there has been international interest in the Sierra Leonean mental health by foreign media, researchers and multi-national organisations sustained support is required. Mental health services in Sierra Leone are austere, stretched and sustained by a dedicated workforce. Anticipated increases in levels of psychological morbidity, PTSD, substance misuse, psychosis and affective disorders highlight the future mental health challenges ahead. With increasing demand and limited resource, mental health should now be a public health and international priority for post-conflict Sierra Leonean society. References 1. Psychosocial intervention for war-affected children in Sierra Leone Gupta L, Zimmer C, Br J Psychiatry 2008 192: 212-216 2. Jensen S. B Mental Health and Substance Abuse in Post Conflict Sierra Leone (2002) October. World Health Organisation |
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Prof K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka, Dr.A.Hapangama MD , Lecturer in Psychiatry, Faculty of Medicine, University of Kelaniya,Ragama,Sri Lanka
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lalithkuruppu{at}lycos.com Prof K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), et al.
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The article on Psychosocial intervention for war affected children in Sierra Leone by Gupta et al (BJP 2008) raises several important issues; which are relevant to war-torn countries like Sri Lanka. Many children and families in Sri Lanka are directly or indirectly exposed to war related trauma. They also frequently undergo the psychological impact of traumatic events such as ‘suicide bombers ‘or ‘claymore’ mine explosions which either kill or maim their relatives and or friends. It has been reported that indirect exposure such as viewing violent television programmes can precipitate PTSD in children (Ceylon Medical Journal 2000). Some schools in Sri Lanka portray photographs of students who died due to war related trauma. This may help to reduce the bereavement process as well as displace the anger and learn to combat the “terrorism” while on the other hand they may act as reminders of the traumatic process. In children who are exposed to the terror of shelling, there is evidence of an increase in aggressive attitudes which are expressed through increased patriotic feelings(Plunkett 1998) . Mental health professionals needed to be aware of different presentations of PTSD in children, the consequences of repetitive exposure to such events and the long term consequences. It is important to be aware of the long term consequences of such trauma as well as repeated exposure in addition to the dose of the traumatic experience. Repeated exposure can occur due to repeated broadcasting of traumatic incidents by the media such as television news coverage of combat and news footage of the sound of gunfire, injured people screaming and mutilated bodies. It has been noticed that reactivation of previous episodes of psychiatric illnesses can occur e.g. depressive illnesses, PTSD and substance misuse following traumatic events (Fullerton et al.World psychiatry 2002). It is note worthy that the clinical presentation and coping strategies of children may be different from that of adults. Children are cognitively not mature enough to understand the concepts and consequences of war related trauma and the vulnerability factors to develop psychiatric disturbances in children are multiple and additive. Apart from the vulnerability factors which are so often highlighted the societies in our part of the world also contain protective factors such as good family support and the society itself seeming to be more flexible in dealing with its losses. Culture, religion etc seem to shape these mediating and moderating factors and to alter the outcome associated with the trauma. Therefore professionals should acknowledge family and community resources as an intricate part when planning services and involve school teachers, parents and clergy men. Services should be innovative and locally appropriate depending on the available resources. Health care workers and policy makers in developing countries should be made aware of the culturally relevant factors when managing trauma affected children. Reference Gupta L, Zimmer C. Psychosocial intervention for war-affected children in Sierra Leone. British Journal of Psychiatry.2008; 192:212-216 Kuruppuarachchi K.A.L.A., Williams S.S, Gadambanathan T. Post- Traumatic stress disorder after watching scenes on televion. Ceylon Medical Journal.45;(4)177-178 Plunkett M. C.B, Southall D.P. War and Children. Arch Dis Child. 1998;78:72-77 Fullerton C.S, Ursano R.J. Mental health intervention and high-risk groups in disasters. World Psychiatry2002; 1(3):157-158 |
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Gonzalo Retamal, Senior Research Fellow International Bureau of Education. Geneva
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gretamal{at}literacyexchange.com Gonzalo Retamal
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Congratulations for the article , it comes as a positive surprise. The Sierra Leone experience continues to be unique, in the sense that there continues to be a profound vacum in the area of systemstic research and evaluation of the impact of emergency curricula in situations of complex emergencies . It would be important to repeat this experience in other programmes similar to the Rapid Ed methododology being at the moment implemented in several emergency situations by UNICEF and other partners . The work of Mrs. Gupta I believe should continue to be implemented beyond the first pilot and unique experience in Sierra Leone . |
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