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December 15, 2018

'No health without mental health': Kenya's mentality

Mentally ill people outside their wards at Mathari hospital in Nairobi during a visit by the National Assembly Health committee, February 23, 2016. /MONICAH MWANGI
Mentally ill people outside their wards at Mathari hospital in Nairobi during a visit by the National Assembly Health committee, February 23, 2016. /MONICAH MWANGI

Bizarre incidents have become commonplace across Kenya. Bizarre because they range from suicides by children, wild attacks during arguments over minor matters and crimes of passion reminiscent of movie scenes.

Ruth Kamande, for instance, has been termed Kenya's "hottest convict" for winning the 2016 Miss Lang’ata Women’s Prison pageant. She is a real ‘slay queen’. On September 19, 2015, Kamande allegedly stabbed her boyfriend 22 times sending him to an early grave.

She allegedly got enraged when she found out that her 24 year old boyfriend, Farid Mohammed was still keeping love letters from his high school girlfriends. She was also angry that he had hidden his HIV-positive status from her and attempted to force her to have unprotected sex. Bizarre? Yes. Was her mental health status questioned at the time of the crime? Yes.

Ruth Kamande poses for a photograph after winning the 2016 Miss Lang’ata Women’s Prison pageant.

Incidents of people attacking and even killing their families are common and usually, only the most bizarre incidents get reported in the media. For example, on May 2017, a 33-year-old casual labourer stabbed his wife to death in a fight over a small serving of ugali.

On January 15, 2018, a quarry broker murdered his wife and their three children before dousing himself and the house in petrol and starting a fire. Relatives and friends attribute his action to financial troubles. He was also accused of having an affair.

Men and women have also shot their lovers to death - at close range and sometimes multiple times - or beaten them to death on suspicion that they were unfaithful. In October 2016, an officer of the elite Recce Squad shot his lover 53 times after she reportedly  told him she was leaving him to marry someone else. He then turned the gun on himself.

A SHAKY FOUNDATION

Some of those who have committed ‘unthinkable’ offences have blamed the devil or spoken of hearing voices that convinced them that their actions were in order.  In May 2014, Joel Olusala told a Nakuru court that "the devil led him to sodomise his five-year-old son for more than a year". He also explained that his wife had left him and taken their child. Mental checks were ordered, as is often the case in any court case.

According to Harvard Health Publishing, auditory hallucinations occurs in about 60 per cent to 80 per cent of patients with schizophrenia. "These voices tend to be unfriendly or hostile, offering unwelcome commentary about the patient or a situation. Less often, the voices may command the patient to do something." Patients say they can be similar to the voices of their friends or relatives.

Mental, neurological and substance use disorders are a leading cause of the burden of disease in Kenya. According to the Global Burden of Disease 2010  study, these disorders account for 16 percent of the burden - more than HIV, which accounts for 15 percent.

Neurological disorders alone account for 11 percent of the burden of disease in Kenya. Among mental disorders, unipolar depression accounts for the highest burden of disease — 45 per cent — according to a research paper Providing Sustainable Mental Health Care in Kenya, by Professor David Ndetei of the University of Nairobi and Dr Ana-Claire Meyer.

Other disorders include anxiety (16 per cent), self-harm (15 per cent) bipolar affective disorder (seven per cent) childhood behavioural disorder (five per cent) pervasive developmental disorders (five per cent) schizophrenia (five per cent) idiopathic intellectual disability (one per cent)  and other mental and behavioural disorders (one per cent).

 

 

 

 

Mental disorders pose an increasing challenge to the global health care system. According to the World Health Organization (WHO), the prevalence of lifetime mental disorder globally ranges from 18.1 to 36.1 percent. This means that more than one-third of the world's population has at one time or another suffered from mental disorders of varying severity.

According to a study on the global prevalence of mental disorders commissioned by the WHO, slightly more than three-quarters of severe cases in the low- and middle-income world went untreated. Sub-Saharan Africa has a huge burden of mental disorders.

In addition, the vast majority of Kenyans believe that mental illness is caused by evil spirits. Many believe that those who develop mental disorders do so to atone for sins committed against ancestors or as a result of being bewitched. Those suffering from mental illness face stigma which hinders them, their families or relatives from seeking medical attention.

Despite the high burden of disease due to mental, neurological and substance disorders, there is a dramatic shortage of mental health specialists and neurologists. There are only about 100 psychiatrists in the country with most of them based in Nairobi.

Outside of the capital city, there is approximately one psychiatrist per one million people. There are only 12 neurologists with most of them practising in Nairobi, Kisumu, and Mombasa.

Still, for many Kenyans suffering from mental health, the promise of accessible and affordable mental health services remains just that as the Mental Health Bill 2014 is yet to be enacted into law.

LITTLE AWARENESS

Joan, a 62-year-old, does not think there is anything wrong with her and her behaviour that worries her children is simply part of old age.  But her son Jack says “She is not the same. She does not care about much,” adding that loneliness following the separation from her husband and her retirement from her day job make matters worse. Joan spends most of her time at home as she did not opt for another job after retiring.

A diagnosis has not been made about Joan yet. She has not seen any specialist.

Jack, however, suspects she is suffering from a bipolar disorder. “Her moods fluctuate, leaving her unreasonably angry sometimes. She also repeats stories to her children forgetting  that she had already told them the same stories,” he observes.

Jack, who has been reading on mental illness out of concern for his mother adds: “She also has a strange group of friends. They are not her peers. It’s almost as if she wants to control them.”

In a phone interview on March 23, Dr Catherine Mutisya, a psychiatrist, said there is no health without mental health as wellbeing of any person should be all round and not just physical.

Dr Mutisya proposes mental health education at primary, secondary and college levels of learning and the same be replicated on mainstream media to involve the larger audience.

“Almost everybody goes to school … and with the revision of the curriculum I am hopeful that mental health studies will be included,” she said.

Members of the National Assembly Health committee address mentally ill people at Mathari hospital in Nairobi during a visit on February 23, 2016. /MONICAH MWANGI

NEGATIVE ATTITUDES, LACK OF INTEREST

In the case of Jennipher (real name withheld), anxiety is killing her but she cannot talk about it neither to her friends nor family.

“They would not understand me. They would dismiss it for ‘a white person's problem’,” she says. So when she has anxiety attacks, she applies all the tricks she has mastered to calm herself.

“My case is not as bad as those of other people. But I cannot talk about it so I often wonder if I am overreacting.”

According to Harvard Health Publishing, "anxiety is a reaction to stress that has both psychological and physical features. In the short term, anxiety prepares us to confront a crisis by putting the body on alert. But its physical effects can be counterproductive, causing light-headedness, nausea, diarrhea, and frequent urination.

And when it persists, anxiety can take a toll on our mental and physical health. To deal with these attacks, options include therapy that includes talking to a specialist and taking drugs as well as joining support groups, whether physically or through social media.

In Kenya, much like in many parts of Africa, little attention is paid to mental health and in instances where mental instability manifests itself, traditional methods of dealing with the problem are applied. As it is, unless someone is violent, most ‘mad’ people are ignored and the matter is not treated seriously. People with mental illnesses are also shunned and sometimes declared, outcasts and in villages where access to mainstream doctors is a problem, mental illness does not receive the prominence it deserves.

In April 2016, Aljazeera reported a story of Kenyan brothers Hussein Abdi and Abdirahman Abdi, whose family started asking traditional healers to pray for them after they exhibited signs of mental illness. "Many Kenyans view mental illness as a spiritual problem rather than a medical one, causing them to turn to religious leaders or traditional healers for a cure," the agency said.

Dr Mutisya is of the view that many Kenyans do not understand mental disorders. She notes that specialists are limited to urban areas so people who need help in rural areas simply cannot find it.

“Every hospital should be able to handle mental disorders. The problem is not necessarily the number of institutions but whether they can diagnose the illness, start treatment and make referrals,” she said.

Dr Macharia Njoroge from Users & Survivors of Psychiatry in Kenya (USP-K), says mental health is not a laughable illness. He advocates for better understanding and the need to challenge the cultural, religious, racial and ethnic stereotypes about mental health.

“There also is need to empower persons with mental disabilities to tell their stories and be able to challenge the discriminatory attitudes in society. The media also has to be empowered to tell stories of mental health in a different way,” said Dr Njoroge.

SEVERAL CAUSES FOR WORRY

Another case that shook Kenya was that of serial killer Philip Onyancha, whose trial is ongoing. In a chilling videotaped confession presented in court during a 2015 hearing of the case, Onyancha detailed how over a five year period, he lured unsuspecting women and killed them before he was arrested in 2008. He was charged with strangling two women and a nine-year-old boy before drinking their blood.

Onyancha did not sexually assault any of his victims. Onyancha had been found to be mentally competent to stand trial. When concluding his submissions, the trial prosecutor senior assistant DPP Moses Omirera asked the court to commit Onyancha to life in an asylum for the criminally insane. On April 5, the court ordered a fresh trial saying Onyancha should have been charged as a mentally ill person.

A file photo of serial killer Philip Onyancha.

Dr Njoroge says cases of suicide, mass substance abuse and cases of self harm are also symptoms of mental illness but which go largely unreported or treated. Befrienders Kenya does not give statistics but says self harm is most common among people aged 11 years to 25 years and that cases are fewer among people older than 25 years. The forms include scratching, cutting, pulling hair, picking skin, taking toxic substances or swallowing objects.

In October 2014, a story of a mentally ill man in Kericho county swallowed about 30 metal particles, including small nails, bottle tops, bolt nuts, metal springs and padlock. The 21-year-old was treated at Kapkatet District Hospital.

Dr Mutisya notes that mental wellness is three-part; the ability to deal properly with stressors, the ability to contribute to society and the ability to relate well with others.

She cites increased cases of depression, domestic violence and substance and alcohol abuse as some of the reasons for worry and advises that people look out for changes in moods, behaviours and thoughts.

In May 2016, the-then Health Minister Dr Cleopa Mailu reported that at least one in four Kenyans had a mental illness but did not know it. The high rate presents another cause for worry - whether the country is sufficiently equipped to tackle mental health.  

At that time, Dr Mutisya said Kenya had only 80 psychiatrists and 427 psychiatric nurses.

“We need to ensure those in need have access to treatment that is affordable and put more effort in education,” she says.

She noted the need to manage stress levels and offer counselling and medication as a preventive measure rather than waiting to cure an illness when it is at its worst.

Dr Njoroge advises that people should look out for withdrawal from duties and responsibilities, lack of appetite, excess fear or anxiety, delusions and lack of self care as some of the symptoms to a mental illness.

AN INADEQUATE BUDGET

Dr Njoroge says Kenya is yet to allocate enough money to comprehensive mental health care. The main goal of the 2015-2030 policy is to attain the highest standard of mental health by strengthening leadership and governance, ensuring comprehensive access to care, implementing strategies for promoting mental health and strengthening systems but it “lacks enough financial commitment”.

The policy does not give figures but says Kenya will stick to the World Health Organisation (WHO) standards of financial allocations at national and county levels. Mental health did not feature prominently in the budget summary for the 2017/18 financial year but health as a whole was allocated Sh54.9 billion.

Dr Njoroge also notes the need for the Mental Health Bill to be reviewed since it does not conform to the international best practices in regard to the treatment and handling of a person with a mental health condition.

Alongside financial allocations, Users and Survivors of Psychiatry-Kenya recommends the following:

  1. Fast-tracking enactment of Mental Healthcare Bill 2014 and ensuring it is compliant with  The Convention on the Rights of Persons with Disabilities (CRPD).

  2. Increasing funding for mental health services and providing alternatives to medical treatment. This includes recognition of interventions such as peer support groups.

  3. Counselling for users and survivors, and peer-led respite centres.

HOPE

Increased access to mental health care services, and public awareness campaigns particularly targetting people in rural areas, can help in reducing stigma associated with mental health disorders.

Media campaigns similar to those that have been successfully applied in the fight against stigma associated with HIV/AIDS would be useful as would making information readily available to people suffering from mental disorders.

They would be able to learn about their conditions and alleviate possible feelings of self-blame and guilt.

Involving traditional and faith healers play in the provision of mental health care presents an alternative since Kenya does not have adequate resources to deal with the problem. A study on Traditional healers and provision of mental health services in cosmopolitan informal settlements in Nairobi revealed that traditional healers are consulted for mental disorders by members of the community.

They are able to recognise some mental disorders, particularly those relating to psychosis but they are limited especially for common mental disorders. But they need to be educated to recognise different types of mental disorders and make referrals when patients are not responding to their treatments.

Dr Njoroge says: “The best practice would be to respond to mental disorders like one would to any other emergencies such as accidents. The person, however, should be handled with dignity and adequate information about them provided.”

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