in2mentalhealth

The conference: This 3rd annual Malawi Mental Health Research and Practice Conference took place on 22-23 April 2013 at the Saint John of God College of Health Sciences in Mzuzu, Northern Malawi. The event was organized by the St. John of God College, the Department of Mental Health College of Medicine Malawi University, and the Scotland-Malawi Mental Health Education Project (SMMHEP). The conference was funded by a Scottish Government Malawi Development Fund grant.

I was very happy to be able to attend this conference. It offered an excellent opportunity to talk with people of all cadres working in mental health care in Malawi and the surrounding countries. It was a great opportunity to talk about (and check) my endeavors in the global mental health field as well, like this website and the new SMS and email news update platform in2mhconnect.
About 100 people gathered for these 2 days in Mzuzu, few from overseas (Europe, USA, Canada), a couple from Zimbabwe and South Africa, one from Tanzania and the others from Malawi.

Malawi, Africa: The Republic of Malawi is one of the poorest countries in the World, with a population of almost 15 million, most living on farming in rural areas. Life expectancy by birth is 52 for males and 51 for females (WHO Mental Health Atlas 2011). There is currently only 1 Malawian psychiatrist working in the country, Dr. Felix Kauye, and there are 3 expat psychiatrists, Dr. Jen Ahrens, Dr. Selena Gleadow and Dr. Ellen Bosnak. Psychologists, social workers and occupational therapists working in mental health care are also very scarce, and number of psychiatric nurses in the country is about 30. There are projects running in order to increase the mental health capacity like the SMMHEP and from THET (Tropical Health Education Trust).
There are 3 mental health hospitals/clinics in Malawi, in Zomba, Blantyre and Mzuzu. The government is committed to strengthen community mental health care services in Malawi as a low cost solution the treatment gap in mental health care.

Note: With these 13 takeaways I try to give an impression of this conference. Unfortunately not all presentations could be included, it would be too much. I had to make choices. And I did not attend all sessions, since several were parallel. So if you are not mentioned here, it does not mean you did not well enough.
You can find the official 10 pages PDF report of the conference here.
The takeaways are written in order of appearance and are not a top 13.

1. Colleen Adnams, South Africa, ‘The determinants of intellectual disability and related mental illness in Africa’:
One-two percent of children Worldwide have intellectual disabilities (ID) and 90% of them live in developing countries. But only 10% of research on ID is done in the low income countries. About the cause of ID, the etiology, we don’t know very much yet.
Recognition of mental health illnesses in people with intellectual disabilities (PWID) is very low, but co-morbidity can be as high as 30-40%. For instance people with epilepsy can have a co-morbidity with an mental illness as high as 50-60%. But 10-20 % of behavioral problems in PWID exist without a mental illness, the so called ‘challenging behaviors’.
Adnams explored also the cycle between intellectual disability and poverty. Factors involved are not totally clear, but poor people and children born in poverty have so multiple disadvantages, like nutrition deficiencies, more infections, low education and poor cognitive, motor and socio-emotional development, under-stimulation, etc. So probably PWID have a bigger change to end up in poverty, and children in poor families can also have a higher chance to be born with an intellectual disability.
Therefore Adnams pleas for a human rights and public health approach in order to decrease the number of children born with ID and break these vicious cycles.
You can read more about intellectual disability in Africa from Admans a.o. here.

2. Gareth Nortje, South Africa, ‘The attitude of medical students towards psychiatry’:
The number of psychiatrists in low income countries (LICs) has decreased in the last 5 years. Nortje looked into 21 studies from LICs, which addressed the attitude of medical students towards psychiatry. He wanted to get a picture of the factors preventing medical students to go for a specialization in psychiatry.
Factors he find were: Stigma and cultural beliefs around mental illnesses, lack of status and career opportunities in mental health, lack of human resources and income, the duration and content of the study, shortage of infrastructure and services for people working in psychiatry, and no government priority.
What students need: curiosity rather than negative attitudes, positive patient contact, patients getting well, psychiatrists who can serve as a positive role model, relevant course material, opportunity to talk about the conflicting views (on psychiatry), career progression and prestige.
The conference described here will certainly contribute to what the attendees ‘need’ to keep their commitment for work/study/research in mental health.

3. Ms. B. Marimbe, Zimbabwe, ‘The perceived impact of a relative’s mental illness on the family members and their reported coping strategies and needs: a Zimbabwean study’:
Marimbe wanted to find out how caregivers did cope with the burden of the care for the person with a severe mental disorder. In her research 31 caregivers participated in a in-depth interviews and focus group discussions and were screened for common mental disorders (CMD).
Sixty eight percent of the participants were themselves at risk of a CMD. All experienced physical, psychological, social (stigma) and financial burden.
The financial burden could be the treatment and medication of the patient, the damage of property, and the time spend on the patient (and not able to generate income during this time).
Seeking spiritual assistance was the most commonly used way of coping.
Caretakers want support groups (like in AIDS care), more information and training, more support from the health care worker, and more financial support from the government to help them cope with their relatives illness.
Salient detail, which we heard more these 2 days, was that far more women than men were in the role of caretaker. This fact give rise to some hilarious discussions. Where are the fathers? Earning money or blaming the mothers for the problems of their child? Or just shunning these kind of difficult family circumstances?

4. Alister Munthali, Malawi, ‘A survey of alcohol use amongst the adult population in Malawi’:
Clear data about alcohol misuse in Malawi were unavailable. To fill this gap and to offer the Malawian government data which could be used to develop policy and interventions, Munthali a.o. did a quantitative study in more than 30,000 households in different areas of Malawi. They administered a short screening questionnaire to both heads and spouses in the sampled households and interviewed 70 people from the society/community about the subject.
Very worrying is the alcohol use in children and the availability of very cheap 30 ml sachets of high percentage alcohol, which especially effects the alcohol consumption of these children. The informal production of alcohol is huge and the country is in need of a better implementation and regulation of it’s rules.
Less than one in three adult males (30,1%) drank alcohol 12 months prior to the survey. A very small percentage of women (4,2 %) had been drinking. But people who use alcohol often drink a lot, especially in the Southern regions.
So, does Malawi have an alcohol problem? Yes, according to Munthali, the people who drink drink too much.

5. Orpheuse Chipata, Malawi, ‘Mental Health Users and Carers Association Malawi. One year on’:
The Mental Health Users and Carers Association Malawi (MeHUCA) is a patient advocacy organization and aims to improve the access to essential medications for people with a mental illness in Malawi, to sensitize the community regarding mental illnesses, to fight stigma and discrimination, to generate more support from the community and politicians and to establish peer support groups everywhere in the country.
It’s a young organization, but there are already some successes. There have been workshops and a luncheon with the president of Malawi, there are 3 peer support groups (although only in the Southern region), one service user was re-employed after being fired, and a lot of people with a mental illness now know their rights.
Challenges for the MeHUCA seem mainly financial at this moment, like money for an office, for travels to other districts, for a lawyer to help them with judicial proceedings, etc. But Chipata and colleagues seem very passionate and motivated to scale up the MeHUCA work and collaborate with other organizations in the Malawian mental health field.

6. Harris Chilale, Malawi, ‘Early Intervention Service for psychosis in Northern Malawi. Is it needed? Is it feasible?’:
Chilale assessed the average duration of untreated (first) psychosis (DUP) in Northern Malawi. He wanted to know whether DUP predicts outcome as it does in Ireland and other developed countries (from research: DUP in developed countries range from 12 to 24 months). And if special early intervention services for psychosis in Malawi are necessary.
The average DUP Chilale found in Northern Malawi was 51,7 months. Chilale saw significant improvements in the patients after 18 months treatment. The treatment provided in Chilales research included, along medication, psycho-education and basic counseling. But the DUP did not influence the clinical impact or outcome. This means that the time someone suffered from a psychosis before the treatment, did not effect his/her recovery from it.
The messages from this research seem that people with psychosis and their caretakers in this region wait very long before they seek professional help. That a person with a psychosis can improve a lot after sufficient treatment, even if he/she has been psychotic for years. This makes a special early intervention service in Malawi not a priority although Chilale made a very strong plea for radical changes in mental health services in Malawi. ‘Let them build their own houses’, ‘Involve the family’ and he could advocate for change and rehabilitation servives for hours more if we had let him.
More information about this research you can find here.

7. Simone Honikman, South Africa, ‘Integrating mental health care into maternity care: lessons from a decade’s work in South Africa’:
Another engaging and very inspiring presentation.
The prevalence of antenatal and postnatal depression is higher in low income countries than in high income countries (HICs). Figures from different research are for instance 10% or 13% in HICs and in South Africa 40%, 47% and 35%. In Malawi in one research 30,4% of the women suffered from perinatal (antenatal and/or postnatal) depression.
Honikman examines the risk and protective factors in mothers and the inter-generational cycle of the mother, to the child, in the society, to the child being a mother herself, to her child, etc. And the ‘cycle of healing and wellness’.
Honikman works at the Parinatal Mental Health Project (PMHP) in a slum area in Cape Town. Lessons learnt in the last 10 years are that:
One must ‘prepare the ground’ before starting a project like this: one has to build relationships at all levels (including the health care staff). One must identify the mental health needs of the women/patients as well as the mental health and other needs of the staff. One has to educate everyone from the mothers to the policymakers. One must look for ‘champions’ in order to give momentum to the project. One must invest in all the relationships continuously. The best trainings for staff include ‘care for the carer’ and are participatory. Supervision must be separated from monitoring, etc.
At this moment the PMHP has a small building just near the maternal ward. Honikman calls this a ‘one-stop-shop’: the patients don’t have to be referred to another place for mental health screening and support, they can just stay on the same site.
The PMHP offers routine screening to all mothers during the first antenatal visit. They are developing a brief, valid and easy to score screening tool with for instance 5 yes/no questions, assessing the mood and risk for mental health disorders. They offer individual and group counseling to the women.
In these ten years they screened nearly 18,000 women and 3,231 of them where referred for mental health care. The project provided 7,000 counseling sessions and only 140 women needed to see a psychiatrist.

8. Robert Steward, UK, ‘Maternal Mental Health in Malawi’:
In the 5 years Steward lived and worked in Malawi, he conducted a research in perinatal depression and child development, amongst other things. Studies in Pakistan and India showed that after a perinatal depression in the mother, the children were underweight, stunted and behind in their development.
In Malawi he screened for instance mothers on depression, anxiety and somatization with the SQR and measured their children at a age of 9 months on weight and stunting. Mothers with a high score (meaning having symptoms of a mental health disorder) and a stunting length in their children was significant, but not the weight of these children. He did a study in a nutritional rehabilitation unit for severe acute malnutrition, as well.
In Pakistan there has been a project were Lady Health Workers (LHWs, same as Community Health Workers) treated depressed mothers with a brief CBT (Cognitive Behavioral Therapy) intervention called ‘Thinking Healthy’ (see Lancet article). After a 2 day training and supervision the LHWs were able to provide these intervention and results were as follows: after 6 months 23% of the women in the CGT group versus 53% in the control group (no CBT) were still having symptoms of depression. This means that lay or low educated health workers can provide CBT interventions with positive results.
Other research in this area: AFFIRM in South Africa and SHARE in Pakistan.

9. Heather Gilberds, Canada, Farmradio, ‘An integrated approach to addressing youth depression in Malawi and Zambia’:
Farmradio is an international NGO using radio combined with other ICT to serve smallholder farmers and rural communities. They are active in 38 countries.
In Malawi and Zambia they are building a mental health literacy program for youth. It’s a research project; they want to know if radio and ICT communication can lead to behavior change. It’s the first of its kind in mental health worldwide. It’s called ‘Integrated Mental Health in Malawi and Zambia’ and you can find more about the project here.
Working with radio broadcasters, youth groups, schools and health care providers, this program will help youth in Malawi and Zambia understand depression and its symptoms, and learn how to talk about it and how to get help. The program on the radio will consist of 80% entertainment and 20% educational messages. During the radio broadcast they will run polls: people can answer questions (yes/no) without costs with their mobile phone using flashing (‘please call me back’ sign or service).
But how can you call depression in the local languages? ‘Matenda a nkhawa’ which means ‘disease of worries’?
Since I’m a passionate advocate for more use of ICT and mobile phones in Global Mental Health, I will follow the developments of this program closely in the months ahead.

10. Harry Kawiya, Malawi, ‘Mental Health Services at Zomba Central Prison’:
In the Malawian prisons there is no specialized mental health staff. Most mentally ill in the prisons stay untreated, although some severe cases are transported to the mental hospital and back. To fill this gap, Kawiya (medical officer working in the Zomba Mental Hospital) and colleagues started an assessment of needs in the Zomba prison, and extended the forensic mental health services for the inmates of this prison.
They screened 35 inmates, 34 men and 1 women on mental disorders. Most of them were known with a mental illness, a few not. The main crimes these 35 inmates committed were murder (38,9%), rape (22,2%) and theft (19,4%). The mental disorders they found were mostly schizophrenia (42,7%) and substance induced psychosis (30,6%).
First ‘preparing the ground’ (see 7) applied here as well: before starting the assessment and services Kawiya and colleagues trained the prison staff on mental health.
Results since July 2012: A reduction of referrals/transport to the mental hospital. Improvement of treatment and case management. Early assessment of people staying at the police station. Monthly forensic clinic in the prison. And due to these assessment and the services provided a couple of inmates were pardoned.
Among the challenges are: A very high workload. Not enough knowledge of forensic psychiatry. Inadequate documents. How to follow up? Or how to prevent that pardoned inmates commit another crime? People attending the conference seemed very worried about this last question too.
So still a long way to go, but a very brave project!

11. Chitsanzo Mafuta, Malawi, ‘Mental Health problems, a major risk factor for suicide?: evidence from Malawian Media’:
Suicide is number 16th cause of dead in Malawi with 2,269 cases a year.
Although international evidence shows a clear correlation between suicide and mental illness, in Malawi attempting suicide is still a crime. After surviving an attempt one can be convicted and sentenced to prison with hard labor for months or years.
In order to get some insight in the background of suicides in Malawi, Mafuta studied online media reports about complete and attempted suicides. These reports indicated that most of the suicides were committed by people who were stressed or challenged with social issues like family/relationship problems.
Quite strange that so much personal information about people in need are revealed on the internet. But for this purpose it’s maybe not 100% reliable but useful, since there are no other data about this topic available.
Mafuta asks: Is criminalizing suicide an answer to curb this problem in Malawi? And he proposes other pathways to follow by police, court, doctors and others involved in suicide attempts. In these pathways detection, prevention and care for these people with stress and mental problems are the main focus.

12. Mandala Mambulasa, Zambia, ‘Mental Health and Human Rights’:
Mambulasa explains the background and development of the United Nations Convention on the Rights of Persons with Disabilities (the CRPD). In 2006, the UN adopted the CRPD, and many governments and international development agencies are turning their attention to the goal of including persons with disabilities in development.
From a medical model to a social model, and disability regarded as an social problem. Or to put it in other words: the society must adapt/change in order to include people with disabilities.
Malawi rectified the CRPD and for Mambulasa the CRPD gives Malawi an obligation to promote community based care and support, amongst other things. Because community based treatment and support is cost effective and meets the human rights of people with disabilities, a government must invest in this kind of care.
Treatment against someone’s will is a violation of the CRPD, as is ECT (electro convulsive therapy), brain surgery and seclusion of people with a mental illness. In this view women with a mental disability, or other disability, have the right on fertility and children too. These statements of Mambusala gave rise to a lively discussion in the conference room.

13. Wamundila Waliuya, Malawi, ‘Mental Health and Human Rights’:
Waliuya is a lawyer and committed to help change to Malawian mental health legislation. Or in his words: ‘A call for review of the Malawian mental health treatment act and the mental health policy with emphasis on the rights of mental health professionals and users’.
The Malawian mental health act is overdue and needs review. International standards like the CRPD force a lot of governments to adapt their policies. And the national norms, values and reality of the people in Malawi have been changed too. So: ‘When the rhythm changed, the dance must change too’ (African proverb).
If African needs an own CRPD or that the UN CRPD is sufficient and applicable is a discussion as well as if empowerment and freedom of treatment is always beneficial for the wellness and health of a person with a mental illness.
Waliuya expressed his worries about the mental health of his fellow lawyers. Workload and other pressure can effect their health and somehow this conference seems to have make him aware of this. Maybe a mental health worker can attend the next Malawi lawyers meeting?

It were 2 very nice and inspiring days. I would like to thank all the presenters and attendees for their input, ideas and companionship. And the organizers and the generous sponsor as well.
If you stumble upon mistakes or inaccuracies in the text please let me know; I can still make corrections. Other comments are also very welcome.

Roos Korste, psychologist, international trainer, blogger