The chronic lack of mental facilities such as psychotherapy is a problem in a country where mental illness is heavily under-diagnosed, despite being a common phenomenon. According to the WHO mental health report for Sierra Leone, it is estimated that there are currently 715,000 people suffering from mental illness. Many reasons remain as to why mental illness is heavily under-diagnosed.
A few of them are: stigmatization due to a misunderstanding of what mental illness really is, lack of facilities and resources for treatment, and also the perception that depression and mental illness are foreign concepts or “western illnesses”. In 2020, depression will be the second leading cause of global burden of disease, according to the WHO mental health report. This means that in countries like Sierra Leone where mental illness is not supported by health care facilities, it will be difficult for patients to receive the help they need.
Mental illness is not perceived as an actual “illness”, and because of the stigma attached to it, families try to manage it at home. A 2008 ethnographic study in Sierra Leone found that families might take patients to traditional healers and herbalists to seek a solution. It is only when the patients then become violent that they resort to taking them to either the “kres yard” or City of Rest, a privately run Christian rehabilitation center. Finding a professional psychiatrist, psychologist or therapist, is impossible. They simply do not exist. As there is not enough information and education abut mental illness, patients and their families seek answers in church to find out the meaning of their psychosis. However, the churches are not always safe spaces for people with mental illness, which is often misunderstood as demonic possession by many evangelical churches. They face the same level of stigma and are categorized as “spiritually weak” since there is a myth that “good Christians” cannot be depressed or suffer from PTSD. Therefore churches cannot be used as a replacement for properly structured, sophisticated and professionally equipped mental health resources in Sierra Leone.
As a result of the crushing stigma associated with mental illness, there is unwillingness to report, research and fully address mental health issues in Sierra Leone. Many women are afraid to come out and say that they have some sort of anxiety or depressive disorder, and even the concept of psychosis is not easily understood. The term “kres yard” in krio literally translates into “crazy yard”, which could crassly be interpreted also as “the madhouse”. The stigma surrounding mental illness is heavily illustrated in the language used to describe it. Words such as “kres uman” (crazy woman) are derogatory and instill immediate fear of describing feelings of depression or psychotic behavior. There is very little investigation of post-partum depression, and premenstrual dysphoric disorder, which are staggeringly underdiagnosed and treated in Sierra Leone. Furthermore, Sierra Leoneans link mental illness only to the so called visibly mentally ill. These are people who display violent or outright abnormal psychotic symptoms. Non-visible mental illnesses such as mild depression and trauma are not considered as problems.
Women also face layers of obstacles, discrimination and stigma when seeking mental health resources. Traditional gender roles in Sierra Leone, which stress passivity, dependence and submissiveness in women increase susceptibility of mental illness. Women who have undergone sexual and domestic abuse also undergo high incidence rates of PTSD. Even though the International Rescue Committee together with the government of Sierra Leone, set up sexual Assault Referral Centers (SARC) also known as “rainbow centers”, which offer psycho social treatment for rape victims, some of these centers have closed down and the rest are under supported. However, issues such as domestic abuse and sexual assault still remain triggers for depression and anxiety among women. The high incidence of sexual violence against girls and women makes researchers suggest that this group make up the single largest group of those suffering from PTSD.
There needs to be a significant shift in the approach to mental illness in Sierra Leone. There cannot be adequate access to mental health resources for women if mental illness itself is not given the attention and support it urgently needs. There are steps to tackle mental illness, but they are not enough. Two psychiatric centers are not enough for 6.2 million people. 400 beds in the only government psychiatric wards are not enough for the 700,000 estimated people with severe mental illness and there not enough therapists (if any) and professional counselors to tackle a severely post-trauma society.
The government seems to be taking steps, but these steps are slow and the policies very insubstantial. The first mental health policy in Sierra Leone was adopted in 2010. As I perused the mental health policy document, and looked at the specific objectives, I realized that there was nothing really concrete or specific as the policy promised. A certain section mentioned that students at the College of Medicine and Allied Health Sciences would be encouraged to specialize in psychiatry. However, Dr. Nahim, the country’s only psychiatrist (technically retired but still on contract), mentioned that when he advised medical students to go into psychiatry, the response was usually laughter and jeering. This highlights the attitude towards mental illness in Sierra Leone- an unfortunate comical inconvenience.
In a consistently post-trauma society, Sierra Leone desperately and urgently needs a revamp of mental health services. The fragile country needs a well-funded and adequately resourced mental health system. There needs to be more solid and thorough research done concerning overall mental health, but also mental health and women in Sierra Leone.
