Greg Keane, a Doctors Without Borders/Médecins Sans Frontières (MSF) psychiatrist and mental health adviser, explains MSF's approach to mental health care in Liberia.
In Liberia and other low-income countries, it can be extremely difficult for people with severe mental health disorders to access effective treatment. They and their families really suffer as a result, because caring for someone with a serious mental health condition can often be a full-time job.
However, we know that when you invest in community-based care, you can make a big difference in the lives of individuals who suffer illnesses like schizophrenia, bipolar disorder, severe depression or post-traumatic stress disorder. And what that requires is clinicians who have a foundation of some training, a strong system of supervision, and access to affordable, effective, safe medications. Depending on the laws and regulations of the country, these clinicians do not have to be doctors—they can be local nurses or clinical officers who are trained and supervised by experienced mental health professionals.
One of the reasons our program is working in Liberia is because of MSF's long history in the country and the collaborative relationship we have with the Ministry of Health, and other training initiatives focused on mental health in Liberia. Building on this, we are able to implement a best-practice model, which is community-based mental health care delivered by Liberians who are trained and supervised, with a community outreach aspect as well.
Working with the community
We have community health workers that can move out into the community and look for people who otherwise might not have been able to come and see us. One of the features of a condition like schizophrenia is that a person can be so disabled that they are not able to turn up to an appointment. Often they have reduced insight into their disorder, so they might struggle to accept medication even if it is offered.
This is partly why people suffer stigma, but with a community-based approach you can get out and treat people with those severe conditions, and you can really improve a person's quality of life. Families are really happy about that, because a person can be more independent.
Without treatment, families often had to do full-time caregiving. So that meant at least one person, full-time, who couldn't support the family by earning money. When families can't afford to have a person do the caregiving, and when one of the symptoms is violence or aggression, families may chain or rope up their family member, or lock them in their homes, or leave them at churches where other people physically restrain them. It is horrifying to see, but it is an understandable response to a difficult situation with a lack of support.
Reducing stigma
We try to deliver mental health care in a primary health care setting, so people can access their mental health care like any other health condition. We want to normalize it—it's the first step in reducing stigma and improving access.
In each of the clinics we have one nurse trained in mental health, who can focus on medications and follow-ups and adherence therapy, and we have one or two mental health clinicians with prior training. With the support and supervision of MSF, they can assess and follow up patients, as a psychiatrist or general practitioner would do in another context.
Epilepsy is not technically considered a mental health disorder, but it can be quite debilitating, and we treat it as part of this program. We saw one 18-year-old man who had epilepsy and a developmental disorder, with frequent seizures. He had never been to school because of his condition, and his family believed he needed someone with him the whole time, because it can be dangerous to have a seizure when you are by yourself.
The community health workers identified this man in the community, gave a lot of education to his family about his condition, and brought him to the clinic. With medication, he is seizure-free now, and the community health workers have also supported him in going to school, by helping teachers and students understand his condition. When I met him, he was excited and felt a sense of purpose, and his family was relieved and grateful that they could do the things they wanted to do, and he could do what he wanted to do.
It is a similar story for people with schizophrenia. We had a young man who had been chained and managed to escape and came to see us. We were able to start his treatment, and he took us back to the church where a group of people with severe disorders had been chained, and now we are helping these people as well. With the support of their families, we were able to treat them and move them back home, where their families can actually manage their conditions without such drastic measures.
