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!

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