MSF psychiatrist and mental health adviser Greg Keane explains how and why our community-based approach to mental healthcare in Liberia works.
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 from illnesses like schizophrenia, bipolar disorder, severe depression or post-traumatic stress disorder.
Community-based care requires clinicians who have a foundation of 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 necessarily have to be doctors—they can be local nurses or clinical officers who are trained and supervised by experienced mental health professionals.
The power of community
One of the reasons our community-based care programme is working in Liberia is MSF's long history in the country and the collaborative relationship we have with the Ministry of Health, as well as the presence of other training initiatives focused on mental health in Liberia. Building on these, we are able to implement a best-practice model of community-based mental healthcare and outreach delivered by trained and supervised Liberians.
We have community health workers who go out into the community and meet people who may otherwise not manage to come and see us. One of the features of a condition like schizophrenia, for example, is that a person can be so disabled that they are unable to turn up to an appointment. Often they have reduced insight into their disorder, so they may also struggle to accept medication even if it is offered. This is partly why people suffer stigma.
With a community-based approach, you can get out and treat a person with this kind of severe condition and really improve their quality of life. Their families are really happy too, because the person can be more independent.
Without treatment, families often have to provide full-time care-giving. That means at least one person, full-time, who can't earn money to support the family. When families can't afford to have a person do the care-giving, and when one of the patient’s symptoms is violence or aggression, families may chain or rope up the sick member, lock them in their home, or leave them at a church, where other people physically restrain them. It is horrifying to see, but it is an understandable response to an extremely difficult situation and a lack of support.
With a community-based approach, you can get out and treat people and really improve their quality of lifeGreg Keane, MSF psychiatrist and mental health adviser
Seeing mental healthcare as a medical need like any other
We try to deliver mental healthcare in a primary healthcare setting, so people can access treatment as they would for any other health condition. The aim is to normalise mental healthcare. This is the first step towards reducing stigma and improving access.
In each clinic, we have one nurse trained in mental health, who can focus on medications and adherence therapy, and we have one or two trained mental health clinicians who – with support and supervision from MSF – assess patients and follow up on their condition, as a psychiatrist or general practitioner would in other contexts.
Epilepsy is not technically considered a mental health disorder, but it can be quite debilitating and we treat it as part of our programme. We saw one 18-year-old man who had epilepsy and a developmental disorder. He suffered frequent seizures and had never been to school because of his condition. His family believed he needed someone with him the whole time, because it can be dangerous to have a seizure if you are by yourself.
The community health workers identified this man in the community, educated his family about his condition, and brought him to the clinic. With medication, he is now free of seizures. The community health workers have also helped him go to school, by helping his teachers and fellow students understand his condition. When I met him, he was excited and felt a sense of purpose, while his family was relieved and grateful that they could do the things they wanted to do, and he could too.
It is a similar story for people with schizophrenia. We had a young man who had been chained up. He managed to escape and came to see us. We were able to start him on treatment, and he took us back to the church where other people with severe disorders had been put in chains. We are now helping them too. 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.