The Central African Republic (CAR) has experienced decades of turmoil and instability, marked by civil unrest, military coups and conflict. The last five years have seen the development of a humanitarian crisis of immense proportions, with over 680,000 internally displaced people (IDPs) and over 543,000 refugees. Almost 2 million people are in need of humanitarian assistance.+United Nations Office for the Coordination of Humanitarian Affairs, Central African Republic (CAR), http://www.unocha.org/car
Over the last decade, International Medical Corps, a non-governmental humanitarian organisation, has run programmes in six of the CAR’s 16 prefectures, working with healthcare providers and providing emergency relief and protection services. In Haute Kotto prefecture in the east of the country, International Medical Corps has been implementing mental health and psychosocial support (MHPSS) activities since 2015, with a focus on providing direct consultations and building the capacity of local staff to meet mental health needs. These activities are supported by funding from the Bêkou Trust Fund.
International Medical Corps’ mental health and psychosocial support
Conflict and displacement lead to increased mental health needs. When combined with a dearth of qualified medical providers to meet these needs, the effects on a country’s health system can be acute. According to World Health Organisation (WHO) estimates, the prevalence of mild and moderate mental disorders can increase from a baseline of 10% to an estimated 15–20% in the context of humanitarian crises. The prevalence of severe mental disorders can increase from 2–3% to 3–4%.+World Health Organization & United Nations High Commissioner for Refugees, Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Humanitarian Settings (Geneva: WHO, 2012).
In CAR, where the latest wave of violence began in May 2017, lack of access to and availability of appropriate care can be the difference between life and death for some people affected by mental disorders. Fearful for the safety of relatives affected by mental disorders, families see little choice but to restrain the individuals affected. In Bria, a city in Haute Kotto prefecture, one of the epicentres of the recent violence, one 22-year-old man with mental illness was kidnapped by an armed group unfamiliar with the area. Unsettled by the man’s incoherence and inability to answer their questions properly, the group held the main for five days, during which he was beaten. On his release his family tied him up to ensure that he did not put himself or others at risk, leading to wounds and infection from the ropes. In another case, a five-year-old child was physically restrained by his family and locked up inside the home whenever they went out. Countless others are affected by mental health issues compounded by conflict, displacement and insecurity.
International Medical Corps’ intervention in Haute Kotto aims to build the capacity of general healthcare providers in the identification, management and treatment of common mental health concerns. It includes training and supervision of prescribers (health assistants, nurses and doctors) and non-prescribers (first-aid workers, traditional birth attendants and community health workers) using the WHO mhGAP-Intervention Guide, which entails the provision of care and access to psychotropic medication for people with mental health problems, and the integration of mental health in primary care sites, in this case six health facilities, two mobile clinics and the hospital in Bria.
In humanitarian settings, it is critical to adapt the approach to meet the needs of the community and to adjust plans as the operational context changes with changing security and access conditions. While training and supervision to build local capacity was the primary pillar of the original approach, capacity-building was delayed as insecurity in the region deepened and potential trainees fled to safer areas. The strategy was reoriented to focus on direct consultation by International Medical Corps MHPSS staff, including our programme psychiatrist and a Central African nurse with mental health experience, until formal training and subsequent supervision of prescribers could take place.
Another adaptation was necessitated by geographical constraints. Since May 2017, Bria has experienced massive displacement, with more than half of the city’s population relocating to the PK3 IDP site. As a result, the population of PK3 increased from approximately 2,500 residents in 2017 to over 39,000 by February 2018. While PK3 is only three kilometres from Bria, movement between the two is limited by instability and the presence of armed groups along the road between the two locations. As a result, people with mental disorders from PK3 are unable to seek treatment at the hospital in the city. Beginning in July 2018, consultations are planned at multiple locations including Bria hospital, a nearby health facility at Bornou and two mobile clinics at PK3 and Gobolo, where large concentrations of IDPs are present. It has not been possible to provide consultations in peripheral health facilities due to insecurity on the roads. In some cases entire villages have been abandoned, reducing the need to provide consultations at nearby health facilities. Pillaging and looting have rendered two health facilities completely non-operational.
Treatment and care
Community-based mental health services and treatment approaches are tailored to individual needs. Clients with moderate and severe disorders can be treated by staff with skills and knowledge in appropriate mental health diagnosis and treatment, which sometimes includes medication. Unstable and agitated patients, or patients who have been abused in their homes or communities, are often hospitalised for up to a week under surveillance and psychotropic treatment. Each is then assigned to a community health worker, who makes home visits to assure adherence to medical treatment, to identify the challenges clients face, to monitor living conditions and to conduct sensitisation activities with a clients’ families.
Capacity-building: training and supervision
International Medical Corps has held two training sessions since August 2017, with a total of 13 non-prescribers and eight prescribers taking part. After completing the course, each participant is then supervised by an International Medical Corps psychiatrist and nurse to ensure development of skills for proper diagnosis, referral and prescription. Trainees who are prescribers spend one month shadowing an International Medical Corps psychiatrist or nurse providing consultations, and then spend at least two months providing consultations under supervision. International Medical Corps MHPSS staff intervene only when absolutely necessary, and provide feedback to the trainee after a consultation is completed.
Between March 2017 and February 2018, 1,489 mental health consultations were provided at Bria hospital and other health facilities and mobile clinics across Haute Kotto prefecture. Of those, 762 were new and 727 follow-up clients. Males comprised 53% of the clients seen, and females 47%. Of the total consultations, 880, or 59%, were provided in the PK3 IDP site. The four most common conditions seen were depression, epilepsy, psychosis and Post-Traumatic Stress Disorder (PTSD). Together, these four conditions accounted for 690, or 91%, of all new diagnoses during this period.
The profile of diagnosis distribution has changed over time, probably due in large part to International Medical Corps’ capacity-building training course. As shown in Figure 1, which presents the distribution of the top four morbidities over time, epilepsy was the leading cause of new admissions from March 2017 to July 2017. However, following training on the identification of mental disorders in August 2017, depression became the most commonly diagnosed morbidity among new clients. Diagnoses of psychosis and PTSD have also increased.
Before the specialised training in August 2017, the majority of people with mental disorders were self-referred, and epilepsy – which is easier for general healthcare providers to identify than conditions such as depression – was the most common diagnosis at admission. After International Medical Corps training, the ability of general healthcare staff to appropriately identify and diagnose various mental disorders improved. This training, combined with community sensitisation to raise awareness of mental health issues and the availability of free care, served to increase the identification of morbidities other than epilepsy. This is especially important given the links between psychological distress linked with conflict and adverse experiences and presentation of conditions, such as depression, PTSD and psychosis.
Barriers to identification and treatment
While the mental health programme has produced many positive outcomes, there have been challenges. Many are inherent to working in CAR, and would have been a factor in any part of the country. However, in certain cases they have been exacerbated by the conflict in Haute Kotto.
The lack of primary healthcare staff trained in mental health is a significant barrier to high-quality, community-based mental health services. This is true for CAR as a whole, but the situation is particularly dire in Haute Kotto. Currently, only three Ministry of Health staff in Bria and its surroundings are qualified to provide mental health treatment. This is a critical obstacle to planning for the eventual transfer of activities from International Medical Corps to the Ministry of Health.
There is still a strong perception within these communities that some mental disorders are caused by sorcery or disrespect of tradition, leading to a reluctance to seek treatment. Seeking help from traditional healers or using spiritual healing are the preferred coping methods, further delaying appropriate care and, at times, aggravating the condition. For example, in a religious centre in Madomale, in Ouaka prefecture, people with mental disorders are bound by chains and made to fast for a week at a time, after which the congregation prays to rid them of the disorder. For one man this process was repeated over seven months, most of which he spent in chains.
Continuous population displacement and the presence of armed groups makes adherence to treatment extremely difficult, as travelling from home to the nearest point of care presents a security risk to both clients and care providers. Armed groups have looted and pillaged health facilities, forcing clients to travel even further to receive care. Movement restrictions limit not only access to care, but also household visits and case identification by community health workers. Disruption of community structures and access to basic services and community support may also contribute to poor treatment adherence.
Implementing mental health programmes in an emergency context requires preparedness and flexibility, as continual adjustments have to be made to ensure that high-quality services are available in a way that takes into account insecurity, cultural context and existing and arising challenges. Programmes, as well as the donors that fund them, must allow for a high level of flexibility in implementation, including building in the possibility of modifying mechanisms of training, supervision and service delivery that can be adapted as appropriate as conditions change on the ground.
Holistic approaches to the provision of relief and services should also be considered in order to increase adherence to mental health treatment. During conflict and displacement, meeting basic needs like food and water may eclipse other priorities, including seeking mental health care. Thus, food assistance or income-generating activities for clients and/or their families should be considered in future programming, as should distribution of non-food assistance to assure the basic dignity of clients who do not have access to basic personal items. As noted above, the disruption of basic services was a significant barrier to effective mental health services, so programming that addresses these basic and interconnected needs should also help to increase access and adherence to services.
Cultural context must be respected and carefully considered in programme planning. Local authorities, religious leaders, traditional healers and community influencers must be engaged in the programme at all stages, from planning to implementation to handover. These stakeholders can help inform programme design by ensuring that the cultural context is taken into account, and they can help increase patient referrals and treatment adherence, inform community members of services, reduce the stigma around mental health issues and ensure appropriate treatment is provided. The importance of mental health and psychosocial programmes, particularly in conflict-affected communities, cannot be overestimated. Mental health care is essential and lifesaving, and efforts must be made to ensure that high-quality mental health programmes are integrated into all health system interventions in crises.
Davin Mpaka Mbeya is International Medical Corps Psychiatrist, CAR. Natalya Kostandova is CAR Program Coordinator. Ashley Leichner is International Medical Corps Senior Global MHPSS Officer in Washington DC. Rebecca Wener is an International Medical Corps MHPSS Intern. The authors would like to thank Christian Mulamba, Bobo Makoso, Emilie Mignot, Emile Ollivier and Inka Weissbecker for their support and contributions to this article.