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Wednesday, April 7, 2010

Mental Health and Development: Does the mind of the nation matter?

*By Dr. T. P. Manus Ulzen

It is about time and President Mills has shown great courage and caring by recently visiting the Accra Psychiatric Hospital. This institution and others for the care of the mentally ill in our nation are suffering severely from legislative, moral, financial neglect and the severe stigma against mental illness which is causing great pain and suffering for mentally ill patients and their families, who carry a very heavy burden.

Mental illnesses are not spiritual conditions. They are chemically rooted diseases of the brain and advances in neurosciences over the last 50 years have had such a great positive impact on millions patients the world over. Though psychological stressors may be contributory most severe conditions are rooted in the (neuro) biology of the brain. In Ghana we have failed to date, to pass a mental health law which will protect the rights of the mentally ill and guarantee them access to modern effective treatments comparable to what is available for diseases of other organs of the human body.

The Accra Psychiatric Hospital needs to be completely re-designed and rebuilt into a modern facility with amenities that will aid the recovery of patients who are treated there. There are 3 psychiatric hospitals in the country. Two are in the Greater Accra Region and the other in the Central Region. There are no north of the coast. While this dearth of psychiatric services is present, the answer does not lie in building more psychiatric hospitals. The direction for the future involves resources to treat most patients in community based outpatient facilities and the development of inpatient psychiatric units at all regional hospitals. That is, in the integration of care.

We need to invest in training nurse clinicians, social workers and clinical psychologists to form the resource base for providing the varied services that patients with psychiatric illnesses require over time. This is very necessary because in spite of our collective denial of reality of mental illnesses, they are indeed very common. More severe illnesses like schizophrenia occur in 1 per 100 of the population worldwide. This means that in the Greater Accra metropolis of about 4 million people, we can expect to have 40,000 individuals with this illness alone. Likewise there will be 60,000 individuals with bipolar illness (manic depressive psychosis). Other disabling conditions like anxiety and major depression are more common and occurring at a modest estimate of 10% would afflict almost a million people in the region.

The fact is 25% of us will have a mental illness requiring some professional attention over their lifetime. I have not included childhood psychiatric conditions, alcohol and substance abuse or mental retardation in this calculation. I hope the president’s visit is an exercise in highlighting the need to address these problems in a forthright and just manner over time with a sustainable plan. We have no real data on suicides, which are a frequent outcome of severe mental illnesses. The fact that we have no data does not mean the problem does not exist. Given the numbers I have shared, it is unlikely that there is anyone whose family is not touched by mental illness or addiction in some way, yet we persist in portraying a 19th century attitude to these very severe and disabling illnesses.

Development aid has largely ignored psychiatric illnesses and the need to develop mental health services for the growing population. There are no global initiatives to support the promotion of good mental health, prevention of mental illnesses and their treatments in the developing world. We take sound mental health, which is the foundation for all our daily actions for granted. It is as if we consider ourselves a mindless people. A robust mental health law would provide a solid foundation for building the services needed to salvage the otherwise productive minds which have fallen victim to severe disease. Many of the major illnesses of the mind are now as manageable as hypertension or diabetes. After all, they are chemically rooted illnesses of a central organ of the human body – the brain; just as hypertension resides in the cardiovascular system and diabetes is a functional disorder of the pancreas.

There is no mystery here. Of course, if your brain is affected by an illness, it will affect how you think, feel or behave. It is only logical. We need to join the 21st century understanding of diseases of the brain and begin to return many of our disabled citizens to productivity and a fuller life, instead of discarding them into institutions which have no ability to aid their rehabilitation because they are not funded, not supported by legislation and are seen as a source of shame rather than places where hope should spring anew for the very sick.

The other imperative is an economic one. Data from the WHO consistently shows that Major Depressive Disorder (a common and major psychiatric illness) is second only to cardiovascular disease as the condition that carries the greatest degree of disability or burden to sufferers. Many afflicted patients certainly stop working and this absenteeism of otherwise skilled and productive individuals comes at great cost to the nation. Even more costly is presenteeism, which describes those who manage to drag themselves to work without treatment but remain underproductive. With adequate treatment, many are able to return to economic productivity to everyone’s benefit.

A great deal of community engagement and education is crucial to developing a mental health system to suit our needs. Many functions can be performed by non-specialists and outside of hospital settings. We need to build the system's capacity for delivering community – based mental health services, by supporting and training front-line health workers particularly and by raising awareness of mental disorders and patients' rights among the general population.

Over the last few years an organization of Ghanaian born psychiatrists, the Ghana Mental Health Educators in the Diaspora (GMHED) has been supporting the teaching of Psychiatry, principally at the University of Ghana Medical School and at the School of Medical Sciences at KNUST. This group of psychiatrists, of which I am a founding member, donate up to a month of professional services without pay every year to advance education in mental health within our health services. Each of these citizen volunteers provides this help at a cost in lost income, exceeding over $10-20,000 per person for each teaching trip to Ghana.

Members of this group are dedicated to advocacy for the mentally ill, improving medical education in the field of psychiatry at both undergraduate and postgraduate levels and in the training of nursing professionals in the field of mental health. We are particularly concerned about the lack of a sound legal basis for the administration of mental health in Ghana. The Ghana Health Service needs to be re-organized to protect funding for psychiatric services and the service should adapt to create appropriate designations, including one for Clinical Psychologists to support primary care physicians who bear the brunt of ambulatory but disabling mental illnesses at the district and regional levels.

Another frontline group in need of education on how to respond to psychiatric emergencies in the community is the police service. Decisions made at the point of first contact with a distressed and mentally impaired person at hand, shape the final outcome for the person and their family. Without a clear Mental Health Law which empowers the police to seek mandatory psychiatric evaluations by trained professionals of acutely ill individuals under the protection of the law, it is unlikely that acutely distressed individuals will get the care they need. Without this, suffering patients will not have the equal protection guaranteed to all citizens by the constitution. Many disturbed individuals end up in the criminal justice system instead of the health care system because of the lack of education and preparedness of our first responders.

There is nothing to fear from mentally ill individuals. They are often in severe emotional pain and extremely distressed as a result of neuro-chemical changes in the brain. They need treatment, which thanks to the recent advances in the neurosciences, is currently available. President Mills has taken a bold first step against stigma and it is an indication of mature leadership. I hope what he learnt will cause him to advocate for a Mental Health Law once and for all, to provide a framework for a 21st Century approach to mental illness in Ghana. Raising the profile of mental health requires advocacy, not just locally, but with the global experts who set the health agenda for the developing world. The president must be commended for his leadership and it is hoped that his advocacy will put Ghana on a path to lead the way in providing excellent services for our mentally ill citizens.

Donor countries and organizations in failing to include psychiatric priorities on their collective agendas are ignoring a major component of the healthcare concerns of developing countries like ours and are showing a complete disregard for longstanding data showing that improved mental health services can only serve to support development by removing a major source of disability and days lost from productive work in developing economies like ours.

Dr. T. P. Manus Ulzen


The author is Professor & Chair, Department of Psychiatry and Behavioral Medicine, University of Alabama School of Medicine, (Tuscaloosa Campus), Alabama, USA and a founding Member of Ghana Mental Health Educators in the Diaspora (GMHED).

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