David M. Ndetei: Improving mental health in Africa

Though it receives little attention in the West, access to mental health care is one of the most critical health issues in Africa, says a Kenyan psychiatrist.

With only 83 psychiatrists serving a population of more than 40 million, Kenya has a critical shortage of people trained to provide mental health care services. Yet the prevalence of mental illness there is little different from that in the United States and elsewhere in the West, says Dr. David M. Ndetei, professor of psychiatry at the University of Nairobi.

"It would take a hundred years before we would have enough psychiatrists," said Ndetei, founding director of the Africa Mental Health Foundation. "There is a demand for services now, not tomorrow."

NdeteiCreated in 2004, the foundation conducts research about mental health issues and the delivery of mental health care in Kenya.

Though other issues have captured the attention of mission groups and the general public in the West, mental health is just as critical to the future of Africa, he said.

"We know depression or mental illness is directly related to issues of poverty. Improve mental illness, you improve the health of the people, you improve the productivity of the people."

Ndetei visited the Duke Global Health Institute recently to talk about mental health care in Africa and spoke with Faith & Leadership. The following is an edited transcript.


Q: Tell us about the Africa Mental Health Foundation.

We started the foundation to find how best to address mental health issues in Kenya. Mental health care cannot be solely the responsibility of psychiatrists and psychologists in Kenya. There are very few of them. We have 83 psychiatrists in Kenya for a population of more than 40 million.

It would take a hundred years before we would have enough psychiatrists. But the prevalence of mental disorders and mental health issues in Kenya is similar to that in this country. There is a demand for services now, not tomorrow.

But we have shortages of human and financial resources and of everything. So we have to be innovative.

Kenya already has community health centers that deliver care for things like nutrition, malaria, HIV/AIDS, tuberculosis, childhood communicable diseases and immunizations. They are staffed by clinical officers with three to four years of training after high school and community health workers who act as a link between the clinical officer at the health facility and the family in the community.

So the structures in Kenya are already in existence. What we need to do is to find a strategy to include mental health in those structures. These are the issues we do research on -- using not only medical people like clinical officers and community health workers but also people like teachers or preachers. Can they and others be used to screen and perhaps even treat mental health disorders?

Q: People in the United States and the West hear about illnesses such as malaria, tuberculosis and HIV/AIDs in Africa, but not mental health. Why?

Even in Kenya we don't think about mental health. We are beginning to think about it, and to see it as an issue.

You can't really blame anybody. They simply do not know about mental illness. Mental illness is highly stigmatized. People think it means "madness."

When somebody is psychotic and hears voices when no one is around, people say they must be hearing the voices of either God or demons. People call them mad.

That kind of mental illness is a small percentage of the spectrum of mental disorders. Many people are depressed, but they don't know. They might think they have malaria or some other disease, or that it's just the way life is.

Often, the doctors don't even know.

Back in the 1970s in Uganda, a doctor found an interesting way to diagnose depression.

He would weigh the patient records. And then he would look through the records for the diagnoses. Maybe today they come with this condition; tomorrow they come with that condition. They would have been examined and given all kinds of treatment, but the doctors couldn't find anything.

When he went and interviewed the patients whose records weighed the most, he found that they were depressed.

But the doctors did not even know.

We recently studied depression among patients in the biggest referral hospital in eastern central Africa -- patients with cancer, diabetes, hypertension and other conditions. We interviewed them and found that 47 percent on average had depression severe enough to need clinical intervention. Yet in only 4 percent of the cases did the physicians suspect depression.

This is why it's important to do research.

Q: How does the intersection of religion and psychiatry play out in Africa, especially considering the rapid growth of the church there?

The church is very active in Africa, and it's growing exponentially. Many people, if they have family issues and they feel overwhelmed, the first person they get in touch with is the preacher or priest.

My suggestion is that we educate that preacher, increase his understanding of mental health issues, so he understands that these are medical conditions that can be treated.

There are also traditional faith healers. If we could reach them and the preachers and educate them on very simple things like how to recognize depression, it would have a tremendous impact.

Q: What effect does modernization, urbanization and economic development have on mental health in Africa?

A huge effect. Nairobi is very busy. People are very fast. They have no time for each other. They are too busy; they want to do A, B, C, D, and do it as quickly as possible.

When you move to a big city, you can be very lonely and have nobody to share issues with.

In the rural areas, everybody cares for everybody. But as much as they care for each other, their knowledge is limited.

Q: Many mission groups and organizations are doing work in Africa in a variety of areas, but I can't recall one involved with mental health. Why?

Well, there's a problem.

Talk about malaria, and Bill Gates, for example, will be very excited. Talk about HIV/AIDS, he will be very excited. Talk about vaccines, he will be very excited. Talk about mental health, he doesn't want to hear.

I think Bill Gates is one of the most wonderful people who ever lived. But I was trying to answer your question.

What about all these organizations? Take UNICEF, the United Nations body specializing in children. In Nairobi, when we approach them about doing mental health work with children, they say, "No, we're interested in immunization, malaria and things like that." They don't want to talk about mental health.

Q: Is mental health as important as these other issues?

Yes. It's very, very important.

We know depression or mental illness is directly related to issues of poverty. Improve mental illness, you improve the health of the people, you improve the productivity of the people.

But we need not only mental health workers; we need anthropologists to be able to understand better some of these issues; we need health economists to be able to quantify the economic impact of what we are doing.

That's the way we need to move.