Mental health services in Liberia: building back better
As many as 1 in 5 Liberians suffer a mild to moderate mental disorder, according to WHO estimates, yet the country has only one registered psychiatrist and, until recently, the vast majority of health workers had a limited understanding of mental illness.
This is changing however, as WHO and partners are helping to equip health workers across the country with the skills to provide front-line care for people with mental illness.
Roland M Dolo, a registered nurse from Lofa County in the north of Liberia, is one of 380 health workers who have received intensive training from WHO in the management and treatment of mental disorders such as psychosis, depression and epilepsy.
Now, when someone comes to his clinic with symptoms of mental distress, he knows how to differentiate between different mental disorders. More importantly, he no longer stigmatizes these people. “I now know that these people can be treated, get well and play meaningful roles in their families, communities, and society at large,” he says.
The week-long training that Dolo received also covers post-traumatic stress disorder, grief and psychological first aid. The need for treatment for all of these conditions is heightened during emergencies such as the recent Ebola outbreak.
Training for primary health workers scaled up during Ebola response
Dr John Mahoney, Head of Mental Health and Psychosocial Services at the WHO office in Liberia, has been coordinating the training, which was funded by USAID. “Paradoxically, the Ebola outbreak provided an opportunity to scale up mental health services in Liberia, thanks to the funds that flowed into the country,” he says. “In a country that has just one psychiatrist, and where the needs are so great, training that enables generalists to provide first-line support to people in mental distress can be the difference, in many cases, between life and death.”
"Training that enables generalists to provide first-line support to people in mental distress can be the difference, in many cases, between life and death."
Dr John Mahoney,
Head of Mental Health and Psychosocial Services at the WHO office in Liberia
WHO plans to train 1300 health workers in this programme by the end of 2016.
A focus on ensuring care in the community
In addition, The Carter Center, a United States nongovernmental organization, has established and scaled up mental health training for nurses and physicians’ assistants, in partnership with the Ministry of Health.
After graduating from the 6-month course, graduates return to their former mid-level positions in primary care clinics as mental health clinicians who can help integrate mental health services into the larger health-care system. The Center has already trained more than 160 people and plans to train a further 100 in child and adolescent mental health. Care in the community is a cornerstone of The Carter Center’s mental health work in Liberia.
WHO has also been supporting care in the community through Community Healing Dialogues. The purpose of this initiative, which was introduced in Liberia by partner organizations during the height of the Ebola outbreak, is to provide Ebola survivors with a forum to share their daily struggles during and after the Ebola outbreak and to help one other to rebuild their lives. Through this initiative, WHO trained mental health clinicians and community health directors to run the sessions, subsequently taking on a supporting role. Over 80 groups have been set up across Liberia. Many of the groups are deciding to continue with the sessions when the initial 12-week period is up.
Nongovernmental organizations can help reduce stigma
To help address the stigma that is still often associated with mental illness, the nongovernmental sector plays an important role. So far, there is just one nationally-registered mental health consumer organization in Liberia, Cultivation for Users’ Hope, set up in July 2015 by Reverend Bill Jallah, who has bipolar disorder. Together with his friend and colleague Sidney, Reverend Jallah runs training courses in rural areas of Liberia for staff in health posts, and for community leaders and law enforcement officers.
The purpose of the training is to improve understanding of mental disorders and to break down myths that are still an obstacle to treatment in many parts of the country. The team is also starting to set up support groups to train people with mental illness in income-generating activities such as soap-making. Says Reverend Jallah: “There is still a commonly-held view that people with mental illness cannot hold down jobs. As a result, we often have to be creative and create our own.”
Severe shortage of medicines an ongoing challenge
While training programmes are expanding access to care, the lack of a sustained supply of medicines for mental health treatment is an ongoing challenge. According to John Mahoney at WHO: “Medication and the funds for it are severely lacking. There has never been a functioning supply system for psychotropic medicines. On occasion, the country receives donated medicines, but often these are close to their expiry date or have even expired.”
The lack of medicines is keenly felt by Mamuyan Cooper, the Administrator of Liberia’s only psychiatric hospital, E.S. Grant. She says: “The lack of psychotropic medicines in the facility is a huge problem. If all the people staying here received the medication they needed, the average stay would be much shorter than it is now.”
The reasons given for the lack of a sustained supply of medicines for mental disorders across the country are several: the lack of a supply system and funds; unwillingness to import medicines; and hesitation among health staff to prescribe. The Ministry of Health is taking leadership in identifying appropriate strategies to address the underlying causes of this shortage of medicines for mental disorders.
New 5-year strategy for mental health
Buoyed by recent progress, the Government of Liberia, with the support of WHO and partners, is developing a Mental Health Strategy for 2016-2021. The Strategy includes detailed plans for a strong and comprehensive system of mental health care, with robust community-based services, clinicians, nurses, social workers and community volunteers trained in mental health, and a sustained supply of psychotropic medicines. Funding, however, is needed to put these plans into action.