The burden of mental disorder in Sierra Leone: a retrospective observational evaluation of programmatic data from the roll out of decentralised nurse-led mental health units

Abstract

Background In sub-Saharan Africa the treatment gap for mental disorders is high. In 2009, 98.0% of people with mental illness in Sierra Leone were not receiving treatment, partly due to the absence of public psychiatric facilities outside the capital. In response, the Ministry of Health and Sanitation rolled out nurse-led mental health units (MHU) to every district. This study aims to retrospectively evaluate the uptake of these services by examining the pathways to care, diagnosis, management, and treatment gap, to provide insight into the functioning of these units and the potential burden of mental health disorders in Sierra Leone. Methods We evaluated the roll out of MHU using summary data from all units between 1 st January 2015 and 1 st January 2017, to establish the burden of diagnoses among service users, pathways to care, treatments provided, and treatment gaps. Negative binomial regressions examine bivariate relationships between diagnoses, treatments, and medication inaccessibility with demographics (age and sex), location (Freetown vs the rest and Ebola endemic regions vs the rest) and year. Results We collected data from 15 MHU covering 13 districts in 24 months. There were 2401 referrals. The largest age category was 25–34 (23.4%). The prominent diagnoses were epilepsy (43.5%, associated with children) and psychosis (17.5%, associated with males). Reported depression (8.6%) and suicide attempts (33 patients) were low. Ebola endemic regions reported higher rates of grief, trauma, and medically unexplained symptoms. In 24.7% of cases where medication was required, it was not accessible. Conclusions Nurse-led MHU can have a modest effect on the treatment gap in resource constrained environments such as Sierra Leone, particularly in epilepsy and psychosis.

An analysis of age-standardized suicide rates in Muslim-majority countries in 2000-2019

“…The upward trend in suicide rates in Syria between 2006 to 2019 may be partly explained by the Syrian civil war which began in 2011 and was a factor contributing to between 16% to 84% of Syrians suffering from post-traumatic stress disorder, and 11% to 49% from depression [ 48 ]. Sierra Leone recorded an upward trend in suicide rates between 2015 and 2019, and this may be related to the increased incidence of grief, post-traumatic stress, depression, and unexplained somatic symptoms owing to the Ebola outbreak between 2015 and 2017 [ 49 ]. These may have stemmed from the social ramifications of the disease such as the loss of loved ones, and stigma and violence against those presumed infected, depriving affected individuals of the traditional social support needed to overcome the crisis [ 50 , 51 ].…”

Sexual Risk Behaviour Among School-going Adolescents in Sierra Leone and Liberia. A Secondary Analysis of the 2017 Global School Health Survey

“…In contrast to a Mozambican study [31] but consistent with a Ghanaian study [11] and in the Caribbean as well as Asian paci c island countries[16, 35,36], psychological distress was associated with sexual risk behaviours such as ever had sex, early sexual debut and non-condom use. High mental health burden has been reported among adolescents in Sierra Leone and Liberia, and such burden is linked with exposure to trauma during the civil war and Ebola outbreak in these two countries [22,26]. Psychological distress contributes to adolescents being vulnerable, leading to risky sexual behaviour, violence, substance abuse, partly caused by economic hardship, and parental loss [42].…”

“…Sierra Leone and Liberia are neighbouring countries that have shared unique history. Both countries populations have experienced civil war and, most recently, an Ebola disease outbreak leading to profound economic hardship, psychopathologies such as posttraumatic stress disorder, depression, and psychosis as well family disruption [20,[22][23][24]. These mental health morbidities and family disruption were more profound among adolescents and young people, making them vulnerable to indulge in at risk behaviours such as sexual risk behaviours like early sexual debut, having multiple sexual partners, and not using condoms [10,25,26].…”

Sexual risk behaviour among school-going adolescents in Sierra Leone and Liberia: a secondary analysis of the 2017 Global school-based student health surveys

“…In contrast to a Mozambican study [ 36 ] but consistent with a Ghanaian study [ 11 ] and in the Caribbean as well as Asian pacific island countries [ 16 , 40 , 41 ], psychological distress was associated with sexual risk behaviours such as ever had sex, early sexual debut and non-condom use. High mental health burden has been reported among adolescents in Sierra Leone and Liberia, and such burden is linked to exposure to trauma during the civil war and Ebola outbreak in these two countries [ 26 , 30 ]. Psychological distress contributes to adolescents’ vulnerability, leading to risky sexual behaviour, violence, and substance abuse, partly caused by economic hardship and parental loss [ 49 ].…”

“…Sierra Leone and Liberia are neighbouring countries that have a shared history. Both countries' populations have experienced civil war and, most recently, an Ebola disease outbreak leading to profound economic hardship and psychopathologies such as post-traumatic stress disorder, depression, psychosis, and family disruption [ 20 , 26 – 28 ]. These mental health morbidities and family disruption were more profound among adolescents and young people, making them vulnerable to indulging in at-risk sexual behaviours such as early sexual debut, having multiple sexual partners, and not using condoms [ 10 , 29 , 30 ].…”