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The Culture of Mental Illness and Psychiatric Practice in Africa

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In many African countries, mental health issues, including the burden of serious mental illness and trauma, have not been adequately addressed. These essays shed light on the treatment of common and chronic mental disorders, including mental illness and treatment in the current climate of economic and political instability, access to health care, access to medicines, and the impact of HIV-AIDS and other chronic illness on mental health. While problems are rampant and carry real and devastating consequences, this volume promotes an understanding of the African mental health landscape in service of reform.

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1 A Historical Overview of Psychiatry in Africa

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EMMANUEL AKYEAMPONG

MENTAL ILLNESS IS a phenomenon in all societies. The predominance of preliterate societies in sub-Saharan Africa before the nineteenth century meant fewer written records on medical systems that could enable us to study mental illness in precolonial Africa and the efficacy of traditional African therapeutic systems. Diviners, priests, and healers (including herbalists) have a long tradition of healing in Africa, and their practice certainly predated the colonial encounter. Their skills were particularly indispensable in the case of mental illnesses, which many African societies even in the 1980s ascribed to supernatural causes such as witchcraft or offenses against the gods and ancestors (Odejide, Oyewunmi, and Ohaeri 1989, 709). It is, however, with the colonial encounter that we have our first studies of the African mind, usually by colonial psychiatrists and medical practitioners, and by extension of African healing traditions by curious Western medical men. The racial context of colonialism informed psychiatry, coloring psychiatric observations with racial prejudice and bias. Colonial psychiatry became not just a scientific interrogation of mental illness among Africans, but also an endeavor to explain the African psyche and cultures. Or, to be more precise, “African culture,” since key practitioners of colonial psychiatry, such as John Carothers, assumed a common African culture that had produced a generic African individual. Consequently, sweeping statements could be made about the African psyche, such as: “The psychology of the African is essentially the psychology of the African child. The pattern of his mental development is defined by the time he reaches adolescence and little remains to be said” (Carothers 1953, 106).

 

2 Common Mental Disorders in Sub-Saharan Africa: The Triad of Depression, Anxiety, and Somatization

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VIKRAM PATEL AND DAN J. STEIN

ANY UNDERSTANDING OF depression and anxiety in sub-Saharan Africa—indeed, in all developing countries, and in all probability in developed countries too—must highlight the fact that depression and anxiety more commonly occur together than separately, at least in community and primary health care settings. For example, the World Health Organization’s multinational study on general health care found that the comorbidity of depression and anxiety exceeded 50 percent (Goldberg and Lecrubier 1995), confirming previous observations made in primary care. Even if there are valid differences between depression and anxiety in terms of phenomenology, risk factors, and treatment, from a clinical and public health point of view there is significant utility in emphasizing the overlap between these two states of emotional distress. This overlap has prompted some psychiatrists to propose a return to the older concept of neuroses, albeit using new names such as “cothymia” (Tyrer 2001). In this chapter, we use the term “common mental disorders” (CMDs), first coined in 1992 (Goldberg and Huxley 1992). CMDs are a group of mental disorders that, according to the World Health Organization’s classification of mental disorders (World Health Organization, 1992), include depressive disorders, anxiety disorders, and disorders characterized by the clinical presentation of physical complaints where no obvious physical cause can be determined (labeled as “somatoform” or “somatic symptom” disorders). Evidently, this rubric is similar to the old category of neuroses. Although we do not discuss substance use disorders in this chapter, that omission is not intended to underplay the high prevalence and morbidity of these disorders, as well as that of a number of other psychiatric disorders.

 

3 Schizophrenia and Psychosis in West Africa

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URSULA M. READ, VICTOR C. K. DOKU, AND AMA DE-GRAFT AIKINS

IN PSYCHIATRY, THE term “schizophrenia” refers to a group of major mental disorders whose etiology is still unknown and that involves a complex set of disturbances of thinking, perception, affect, and social behavior (Barbato 1998). It is characterized by psychotic symptoms, known as “positive symptoms,” such as auditory hallucinations (hearing voices) and delusions, as well as by “negative symptoms” such as social withdrawal, blunted affect, and self-neglect. Schizophrenia has been viewed as the prototypical manifestation of madness. It can have a devastating effect on the person’s sense of self and ability to conform to social norms and to engage successfully in personal relationships. In diagnosing schizophrenia, the clinician distinguishes between the real and the hallucinatory, between subjective experience and a presumed objective reality. Thus, the diagnosis of schizophrenia is intimately involved with judgments concerning what it means to be a functioning member of society and what is considered to be within the normal range of behavior and belief. Such judgments are undoubtedly linked to cultural norms and expectations.

 

4 Mental Illness and Destitution in Ghana: A Social-Psychological Perspective

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AMA DE-GRAFT AIKINS

In several parts of the town [Accra] mentally deranged people, almost all of them men, are seen semi-clothed or naked, their hair and skin caked with dirt. This points to a need for greater institutional provisions. At present, unless such people become dangerous, they are left in the town where they sleep in the open, begging or stealing food.

—Ione Acquah, Accra Survey

THE AFRICAN LITERATURE on mental illness and destitution has limited itself to “vagrant psychotics.” A typical definition of a vagrant psychotic would be the one that guided Taha Baasher and colleagues in their work in Lesotho and Egypt in the 1980s: “A person who was without permanent accommodation, employment, money or regular sources of food and who lived a socially and geographically unsettled life. He should also manifest gross abnormality of behaviour in such a way that his general conduct, emotional reactions, or cognitive functions were such that a psychotic illness could clearly be established” (1983, 35).

 

5 Children and Adolescent Mental Health in South Africa

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This essay is dedicated by the remaining authors to the memory of Alan Flisher, our colleague, friend, and mentor, who passed away prior to its publication.

Prevalence studies of psychiatric disorders among children and adolescents in South Africa are characterized by small and unrepresentative samples and/or the use of diagnostic instruments that have not been validated in the local context. Nonetheless, estimates are necessary to inform the development of policies and plans for child and adolescent mental health services. In an effort to fill this information gap, Sharon Kleintjies and coauthors (2006) produced a set of prevalence estimates for children and adolescents in the Western Cape Province. The estimates were based on the results of relevant epidemiological studies, with greater weight being given to studies that were methodologically superior and more proximal geographically. Prevalence rates were adjusted to take into account risk factors particularly present in the South African environment: exposure to violence, maltreatment, and the stresses associated with living in households affected by HIV/AIDS.

 

6 Some Aspects of Mental Illness in French-Speaking West Africa

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RENÉ COLLIGNON

SINCE THEY FIRST blossomed in Europe in the nineteenth century, two scientific disciplines that take the concept of “difference” as an object of reflection—psychiatry and ethnology—have both been haunted by the question of “otherness.” In his study of the history of madness (1961), Michel Foucault showed how the identity of the modern rational subject, as subject of the contract, has been constructed in the West by contrasting it to a backdrop of a series of figures of otherness: the primitive, the savage, the child, the woman, the madman. Since before the period of colonization the African had already been given the role of one of these figures in the Western imagination: that of the primitive. How, then, could one conceive of a mad African, when his difference was already held to be radical on the colonial scene, a realm of power where the fiction of the contract does not hold for the “native” under guardianship? The very nature of the colonial relation helps explain some of the erring ways of colonial psychiatry. Megan Vaughan (1983, 1991) has suggested that the main focus of reflection of colonial physicians was not the construction of a mad African so much as a constant effort to reaffirm the irreducible difference between the African and the colonizer. And this, according to Vaughan, explains the broad consensus enjoyed in the 1930s by the theory of “deculturation,” which was believed to explain the mental pathology observed among the colonized who came into contact with civilization. The effects of the change wrought by colonization on the psyche were approached in terms of cultural and racial difference.1

 

7 Women’s Self-Reported Mental Health in Accra, Ghana

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ALLAN G. HILL AND VICTORIA DE MENIL

IN RECENT YEARS, interest in international comparisons of health across populations has grown considerably. So has interest in the concept of global health and the concern with measuring a country’s progress towards set targets, especially the Millennium Development Goals. The key assumption in tracking international progress towards such targets is that information on health can be collected in similar ways and compared on similar scales across countries. This makes good sense when dealing with objective measures such as height, weight, and blood pressure, but it becomes more questionable when dealing with conditions that are subjective, socially shameful, difficult to assess with simple physical examinations, and possibly intermittent or recurring. Most mental health disorders fall into this last category.

Nonetheless, a substantial literature has grown up around how best to compare self-reported health states, both physical and mental (Üstün et al. 2010). This literature addresses the development of reliable instruments and the introduction of better measuring approaches. These approaches include the replacement of categorical variables with visual analog scales and applying standardization techniques, including the “anchoring vignettes” for standardization used in several studies supported by the World Health Organization (Salomon, Tandon, and Murray 2004). The comparisons of test and self-report data around the world have largely focused on physical measures, often with confusing findings on the links between the two (Ploubidis and Grundy 2011; Halabi et al. 1992; Lawlor et al. 2002; Louie and Ward 2010; Zurayk et al. 1995). Many studies have found major discrepancies and inconsistencies in both level and distribution of outcomes, even when comparing so-called objective measures with self-reports on the same family of conditions. The conclusion to be drawn is that health states have several dimensions, and although many of them are complementary, it is difficult to collapse them all into any single summary measure.

 

8 One Thing Leads to Another: Sex, AIDS, and Mental Health Reform in South Africa

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PAMELA Y. COLLINS

SOUTH AFRICA, LIKE many other African countries, struggled with the reality of limited mental health resources as it entered the era of democracy. Under these circumstances, how did the mental health system address the specter of a growing AIDS epidemic? The development of public mental health policy and interventions is not always a linear process. Often, a chance collision of epidemiology (a devastating AIDS epidemic), politics (a society in transition to democracy), policies (changing health priorities), and people with overlapping interests catalyzes events and spurs systemic change. This chapter describes a series of HIV and mental health service research and policy activities that helped make the needs of people with mental illness more visible in the South African AIDS epidemic.

In 1998 in a small town in the Eastern Cape that was surrounded by rolling green hills dotted with thatch-roofed rondavels, a middle-aged black woman, her face made up with umcako (a white paste made from lime), captured the attention of a group of European and North and South American mental health service providers. The woman, a traditional healer, explained to the group how she had instituted a training program for healers, many of whom were young people with symptoms of mental illness. Of particular interest to the group was her explanation of how she distinguished between people with serious, persistent psychotic disorders (who needed to be evaluated and treated in the local hospital) and those whose symptoms could qualify them for apprenticeship as a traditional healer. She described an integrated approach to care: treatment in the formal mental health system accompanied by the rehabilitation and purification services she provided. A number of her students stood by, features obscured beneath their white make-up, listening to her and gazing at the group of foreigners. The leader of the group of Western mental health professionals, Melvyn Freeman, then head of South Africa’s National Directorate of Mental Health and Substance Abuse, explained the mission of his project: to explore how people might be discharged from the psychiatric hospital and cared for in the local community. The project marked another step on the path to mental health reform.

 

9 Health Care Professionals’ Mental Health and Well-Being in the Era of HIV/AIDS: Perspectives from Sub-Saharan Africa

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GIUSEPPE RAVIOLA

THE PHENOMENON OF the demoralization and burnout of health care professionals practicing in environments characterized by significant lack of resources and high numbers of patients with HIV/AIDS constitutes a major crisis for African medicine, its practitioners, and the patients they treat. This chapter presents a biosocial perspective on issues of medical professionalism and health care professionals’ distress and demoralization, both globally and in sub-Saharan Africa. That is, it seeks to examine such issues beyond the biological and clinical spheres, taking into consideration the social, political, and economic aspects of medicine as it is practiced in global and local contexts (Walton, Farmer, and Dillingham 2011). A stream of ethnographic research spanning the past decade, supplemented by research from other African medical milieus, has examined the moral and ethical dilemmas of public medical practice in East African teaching hospitals, illustrating the complexity of factors affecting health care workers’ well-being in African contexts (Good et al. 1999; Iliffe 1998 and 2006; Raviola et al. 2002).

 

10 The Role of Traditional Healers in Mental Health Care in Africa

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ELIALILIA OKELLO AND SEGGANE MUSISI

AFRICA HAS EXPERIENCED much strife in its recent history, especially south of the Sahara. Most of the continent’s countries are characterized by low incomes, high prevalence of communicable diseases, malnutrition, low life expectancy, and poorly staffed services (World Bank 1998). Mental health issues are often last on the list of priorities for policy makers. Health care in general is still poorly funded in most African countries, and mental health services are the least developed and most poorly funded of all health services. Indeed, the majority of African countries do not have a mental health policy, nor do they have mental health programs or action plans (Okasha and Karam 1998).

Traditional healers perform a valuable role in the lives of people in Africa, especially in rural settings. A traditional healer often serves as the primary health care provider for people living in low-income, rural communities. Approximately 80 percent of Africans use traditional healers, and traditional medicine provides a major source of health care for more than 66 percent of the world’s population (Kale 1995; Pillay 2002).

 

11 Improving Access to Psychiatric Medicines in Africa

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SHOBA RAJA, SARAH KIPPEN WOOD, AND MICHAEL R. REICH

THE WORLD HEALTH Organization (WHO) recommends a combined psychosocial and pharmacological approach to treating mental illness (2001). However, the limited availability of the essential medicines recommended by the WHO contributes significantly to the mental health treatment gap in most of Africa. The irregular supply of medicines seriously undermines intervention efforts, especially community-based mental health treatment initiatives. BasicNeeds is an international mental health organization that works with poor people with mental disorders in ten low-income countries in Asia and Africa. The organization does not generally provide direct treatment services, nor does it promote one form of treatment over another. BasicNeeds works through local partner organizations—often governments—to optimize the use of scarce medical treatment resources. Current governmental support for mental health interventions in Africa is limited, and it is largely allocated to pharmaceutical treatment. Limited access to psychiatric medicine therefore prevents many people in Africa from receiving any treatment for mental disorders. Accordingly, BasicNeeds has taken a considerable interest in studying the access and availability of psychiatric medicine in each country it serves. This chapter is based on four independent but simultaneous studies undertaken by BasicNeeds in 2007 in Ghana, Uganda, Kenya, and Tanzania. These studies investigated factors in government systems that contributed to shortages in psychiatric medicines as well as the perspectives of both caregivers and patients on how shortages and erratic supply of medicines affect them.

 

12 Child Soldiers and Community Reconciliation in Postwar Sierra Leone: African Psychiatry in the Twenty-First Century

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WILLIAM P. MURPHY

RECONCILING FORMER CHILD soldiers with their communities has become a central problem in contemporary African psychiatry. It is a dramatic problem because the goal is to heal the traumas of children who were victims and/or perpetrators of violence during a civil war, and to enable them to live peacefully and productively in postconflict communities. It is also a problem of scale. Since 1975 Africa has become “the epicenter of the problem, providing the largest concentration of both [civil] conflicts and child soldiers,” with estimates suggesting that “120,000 children, 40 percent of all child soldiers, were soldiering in Africa at the beginning of the twenty-first century” (Achvarina and Reich 2006, 130–31). In postconflict situations in Africa and elsewhere, rehabilitating former child soldiers is a central task of reconstituted governments and societies (see, for example, Boyden and de Berry 2004; Brett and Sprecht 2004, 129–36; Cohn and Goodwin-Gil 1994, chap. 5; Rosen 2005, chap. 10). In postwar Sierra Leone, a nation whose civil war ended in 2002 after more than a decade, this challenge is referred to as the “youth question,” a phrase often used by government officials throughout the rest of Africa to refer to the demography of a bulging youth population, leading to large pools of unemployed, disenfranchised youth vulnerable to the economic and psychological attractions of violent projects. In this government discourse, youth are viewed as a threat to society as well as an opportunity for national development. All the problems and possibilities attached to the “youth question”—such as urban youth, street children, HIV/AIDS orphans, and child labor—are condensed into the image of the child soldier. This image, however, creates a misleading equation of “youth” with “violent and dangerous,” an idea that overlooks the majority of youth during the civil war (and during postconflict rebuilding) who were not combatants (see Hoffman 2011).

 

13 Using Mixed Methods to Plan and Evaluate Mental Health Programs for War-Affected Children in Sub-Saharan Africa

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THERESA BETANCOURT

FEW CHILD AND adolescent mental health interventions have been proved effective in addressing the needs of war-affected children in sub-Saharan Africa. Such interventions are difficult to develop because of the absence of appropriate and valid measures of mental health problems and related constructs, as well as the practical problems of working in settings with few trained mental health professionals. Ethical issues also complicate research on children’s mental health in resource-poor settings. Research addressing these ethical, logistical, and methodological challenges is sorely needed. There is little empirical work that identifies the key ingredients needed to develop interventions or assesses which interventions are the most effective for addressing children’s mental health problems across the diverse settings in which children suffer extraordinary stress (Betancourt and Beardslee 2012). Yet there is a growing awareness in the field that new approaches must be developed for use in low-resource settings. This chapter argues for the application of a qualitative and quantitative “mixed methodology” approach as a way to more completely understand the mental health issues facing war-affected children and families. A mixed-methods model is presented for use in planning and evaluating mental health services in diverse cultural settings. Such integrated approaches can help address some of the challenges that have stymied progress in the field. Core issues are illustrated drawing from field research with war-affected children and families in Sierra Leone, Ethiopia, and northern Uganda.

 

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