Saturday, June 29, 2013

Mental Health in Liberia - Maithri Ameresekere - The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital

As I reflect on my short trip to Monrovia, I am extremely thankful to have had the opportunity to go to Liberia with the assistance of the Partners Global Travel Grant. I saw a variety of interesting neuropsychiatric presentations which allowed me to experience first-hand the rewards and challenges of practicing psychiatry in post-conflict Liberia. I also had the opportunity to teach medical students and psychiatric nurses, through both formal lectures and informal case presentations. Psychiatric diagnoses such as bipolar disorder, schizophrenia, obsessive compulsive disorder, drug induced psychoses, and vascular dementia are often enhanced by cultural nuance and medical and neurological comorbidity. One particular patient stands out: He was a 19 year old man who presented with disorganization, agitation and was treated for malaria and typhoid on arrival. He later developed catatonia while on chlorpromazine with symptoms of mutism, waxy flexibility, and bizarre posturing, among other symptoms. The typical treatments for catatonia that I would use in the United States of lorazepam or ECT are not widely available in Monrovia. We therefore had to modify treatment and use diazepam instead, one of the only benzodiazepines available. With this intervention he gradually improved, but I wondered about his clinical course given a finite supply of medication.

This case is representative of a larger issue in Liberia: psychotropic medications are very limited and only chlorpromazine, haloperidol, fluphenazine, amitriptyline and diazepam are fairly regularly available. Supplies of risperidone, fluoxetine or paroxetine occasionally arrive but quickly run out and patients have to be transitioned to alternative agents. Mood stabilizers like valproic acid and carbamazepine are only intermittently available and other medications such as lithium are not available at all. Additionally, laboratory monitoring is very limited and the monitoring required for a medication like lithium may be prohibitive for continuous use, even if the drug was available. Additionally, medications that are commonly used in the United States like benztropine or diphenhydramine for prophylaxis of extrapyramidal symptoms are unavailable, making it challenging to prescribe high potency first-generation anti-psychotics like Haldol. Given the absence of a steady supply of anti-depressants, second-generation antipsychotics, and mood stabilizers, it is often a great challenge to balance treatment of psychiatric illness with tolerability of the medication and side effect profile. Limited availability of medications can also make it difficult to achieve continuity of treatment, leading to relapse, re-hospitalization, or morbidity and mortality associated with untreated psychiatric illness. 

Occupational Therapist - Conducts group therapy sessions in his office
            Additionally, substance abuse is a growing concern among young people Liberia. I was told that nearly one-third of patients admitted to Grant Mental Health are admitted for substance abuse treatment or substance-induced psychoses. A common drug in Liberia known as “Italian White” which is reportedly a derivative of cocaine and, per staff, is very commonly used by young males. I observed group sessions lead by the occupational therapist that focused on psychoeducation regarding substance abuse and provided strategies to avoid recurrent use in the future. Additionally, the clinical supervisor at Grant has been working with staff to use a cognitive behavioral therapy framework to help patients with these concerns. More support and training is needed, however, for staff to routinely use these psychotherapeutic techniques.

            The most compelling concerns when talking to patients and staff was the stigma associated with psychiatric illness. Often patients have been wandering the streets for many years prior to being brought to Grant Mental Health Hospital. Additionally, patients who are eventually brought to the hospital by family members are often not picked up at the time of discharge due to concerns that their conditions are communicable or the result of spiritual forces. Furthermore, patients are sometimes encouraged to stop taking medications by family or community members and often suffer from relapse of their affective or psychotic illnesses.
            Given all these challenges, I am struck by the dedication of the staff at Grant. A committed multi-disciplinary team of occupational therapists, psychiatric nurse specialists, social workers, and other mental health clinicians run the hospital. Despite their commitment, however, the dearth of human resources remains an obstacle. Inspiring clinicians to pursue specialized psychiatric training is critical to providing high-quality care for patients, minimizing burnout and developing culturally-relevant mental health interventions that address the unique needs of the Liberian population. During the course of my lectures and case presentations with students I aimed to encourage enthusiasm for the field while stressing the need for psychiatric care, particularly in this post-conflict setting. I was heartened to hear that at least a few students were interested in pursuing further psychiatry training!

5th year Medical Students prior to a lecture I gave
 on the Diagnosis and Management of Schizophrenia
            My trip to Liberia has been a profoundly educational experience for me. I hope to continue to support the work of the Division of Global Psychiatry at MGH in partnership with the University of Liberia and AM Dogliotti Medical College to encourage research and training efforts that will address psychiatric illness in Liberia.

Many thanks to the Partners Global Health Travel Grant for supporting my trip!

Tuesday, June 18, 2013

Hanni Stoklosa, Bangkok, Thailand, Post-Natural Disaster Human Trafficking Prevention in Thailand

Blog Entry #2: Hanni Stoklosa, Bangkok, Thailand, Post-Natural Disaster Human Trafficking Prevention in Thailand

Conducting interview

  With our strong team of researchers, we were able to interview a number of UN agencies, local Non-governmental organizations (NGOs), international NGOs, and Thai governmental agencies working in disaster response and anti-human trafficking. While analysis is ongoing, preliminarily we have seen some interesting trends.
Populations which are vulnerable to human trafficking at baseline include migrants from Burma, Cambodia, and Laos as well as Thai children and Thai minority groups. The flood water resulted in the closure of many factories where these marginalized groups typically work. As such, the floods caused major shifts in the labor market, leaving these already vulnerable groups open to exploitation, with reports of near-bondage labor conditions in some industries. Families were geographically fragmented. Undocumented status may have left certain groups further exposed to exploitation, as they were less likely to receive benefit from social safetynets available to the general Thai population. Communication via social media was a helpful, protective tool for many communities with access to internet. There were no mentions of explicit human trafficking prevention efforts among relief organizations during the flood time. While we continue to analyze our data, looking to the future, a population-level study based on the sample frames defined during this study will help to further elucidate the impact of disasters on human trafficking and thereby inform future prevention and protection measures.

Thai Red Cross
As my trip comes to a close, I want to thank the Harvard Humanitarian Initiative (HHI), the Asian Disaster Preparedness Center (ADPC), the Institute for Population and Social Research (IPSR) at Mahidol University, my residency program, Harvard Affiliated Emergency Medicine Residency, and the Partners Healthcare COE Global and Humanitarian Health Scholarship Program for making this important research on human trafficking in disaster contexts possible.
Members of our research team and partner organizations, HHI, ADPC & IPSR

Hanni Stoklosa, Bangkok, Thailand, Post-Natural Disaster Human Trafficking Prevention in Thailand

Blog Entry #1: Hanni Stoklosa, Bangkok, Thailand, Post-Natural Disaster Human Trafficking Prevention in Thailand


The United Nations defines trafficking as the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, or deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. 
Here I am training our Thai research assistants


The International Labor Organization and the U.S. Department of State have long recognized Thailand as a hub of trafficking in southeast Asia. Economic disparity in the region helps to drive significant migration into Thailand from its neighbors, presenting traffickers opportunities to exploit those desperate for jobs.  Trafficking is a serious risk that is heightened when people are displaced, families separated, children orphaned, and livelihoods destroyed. Specifically, natural and man-made disasters may increase the risk of human trafficking by increasing their vulnerability by these means.  

Map of Thai flood water progression from disaster response organization

I am here in Thailand to explore the relationship between the devastating 2011 Thai flood and human trafficking, thereby informing prevention and protection efforts against trafficking in future disaster scenarios.

Canal community affected by Thai flood

Through a partnership with Harvard Humanitarian Initiative, the Asian Disaster Preparedness Center in Bangkok, and the Institute for Population and Social Research (IPSR) at Mahidol University in Thailand I am leading a team of researchers in a qualitative research study on Post-Natural Disaster Human Trafficking Prevention in Thailand. Through rigorous semi-structured interviews with established disaster response and anti-human trafficking NGOs in Thailand, we will explore relationships between a natural disaster and human trafficking.


One of our partner organizations, the Asian Disaster Preparedness Center

Thursday, June 6, 2013

Mental Health in Liberia - Maithri Ameresekere -The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital

With the support and mentorship of Dr. Benjamin Harris of A.M.
 Dogliotti Medical College at the University of Liberia, Dr. David Henderson and Dr. Christina Borba of the Chester M. Pierce M.D. Division of Global Psychiatry at Massachusetts General Hospital, and the MGH/Mclean Adult Psychiatry Residency program I have had the opportunity to come to Monrovia, Liberia as a rising PGY3. The focus of my trip is manifold and includes understanding psychiatric practice in post-conflict Liberia, teaching medical students and mental health clinicians about psychiatric diagnosis and management, providing consultation for patients at Grant Mental Health Hospital and hopefully encouraging some students to go into the fascinating and underserved field of psychiatry. I have returned to Monrovia nearly twenty years after my first visit as a child when my mother was stationed in Monrovia working for UNICEF. Returning now many years later, the country seems both familiar and unfamiliar. Now I look at the city of Monrovia with a new set of skills as a psychiatric resident. My hope is to develop a more nuanced understanding of the challenges faced by both clinicians and psychiatric patients here in Liberia. The experiences I have had so far have provided immeasurable insight into the local Liberian context and will lay the ground-work for any future research endeavors regarding mental health service provision for this population.

Liberia has suffered from violent civil conflict from 1989 to 2003 with over 250,000 people killed in two Liberian civil wars and more than one-third of the nation’s inhabitants forced to flee their homes as refugees and internally displaced persons. Although there is limited data regarding prevalence of psychiatric illness in Liberia there appears to be high rates of mental illness including depression, post-traumatic stress disorder and substance abuse. Despite the high prevalence of psychiatric illness, individuals often face multiple barriers to accessing appropriate psychiatric care including lack of human resources, minimal access to psychotropic medications, and lack of culturally appropriate interventions or treatment settings. In fact, there is only one psychiatrist to serve a population of approximately 3.5 million! Additionally, lack of perceived need for treatment, the view that mental illness is a result of personal weakness, and stigma are also significant barriers to detection and treatment of mental illness.

I have spent the majority of my time thus far at Grant Mental Health Hospital, the sole psychiatric hospital in Liberia. It has a variable census ranging from 40-70 patients and is run by psychiatric nurse specialists and mental health workers. Patients are typically brought by the police, family or community members for concerning behavior, and often after many years of wandering the streets and/or visiting traditional healers for herbal treatments. In addition to patient consultations, I am working with the medical students to provide case-based teaching and lectures on the fundamentals of psychiatric diagnosis and treatment. I have also had the good fortune to work with Dr. Benjamin Harris, the only psychiatrist in Liberia, who, in addition to the students, nurses and patients have provided an invaluable educational experience for me regarding the practice of psychiatry in Liberia. 

Dr. Harris and myself listening to case presentations 
Grant Mental Health Hospital
5th year students on their Psychiatry Rotation