The mental health burden in northern Uganda By Sarah Tumwebaze

mhact_main_03A long the road to Gulu, it is clear that life has returned to normal. This is evidenced by children playing by the roadside, women riding bicycles loaded with produce from either the market or garden and men going on with their work mainly bicycle repair.
But as one of the Lord’s Resistance Army war survivors, Harriet Achiru said in an interview with this newspaper, “Forgetting is really hard as some people usually come across things that invoke memories” the effects of the war are still with the people in morthern Uganda and these include mental disorder among others.
Twenty-year-old Grace Acaa from Labonyka in Gulu District is one of the many people in northern Uganda that are suffering from this condition as a result of the war.

Types of mental disorders in the region
As she sits in the consultation room at the Mental Health Department at Gulu Regional Referral Hospital, she keeps murmuring disconnected words. Dr Canaan Katerega a senior clinical psychiatrist and the Head of Department Psychiatry Gulu Regional Referral Hospital says Acaa suffers from a mental condition called bipolar effective disorder.
Dr Katerega explains that her condition ranks the highest in the mental health disorders treated at the hospital in both male and female between 12 to 35.
“This is a mood disorder where a patient presents with excessive happiness and depression at the same time. It is one of the highest ranking psychotic illnesses admitted at the ward.”
Dr Nathan Onyachi, the executive director, Gulu Regional Referral Hospital adds that the other mental disorder seen at the hospital is post-traumatic stress disorder (PTSD).

Causes
Dr Onyachi explains that most of the PTSD cases they see are caused by the effects of the war. “The experiences these people went through during the Lord’s Resistance Army (LRA) war where many people were abducted, some were forced to kill their relatives while others saw many people die affected their minds. These effects manifest later on as aggressiveness and depression which are signs of PTSD.”
Dr Katerega adds that other causes of mental disorders in the region are desperation and poverty.
He explains, “Most of these people were in camps and while there, they were used to getting free things. But when they went back to their homes in 2007, they found that they had to fend for themselves and because they have failed to do it, this led to desperation which has contributed to PTSD.”
Dr William Odur another senior psychiatrist Clinical Officer at Gulu Regional Referral Hospital also says alcohol and other substance abuse which are high in the region have contributed to the mental disorder cases.
Additionally, Dr Onyachi says by way of African beliefs, people in the region believe that it is caused by witchcraft so they resort to traditional healers.
A 2014 research conducted by John Paul II Justice and Peace Centre in the Acholi and Lango Sub region reveals that most people in these regions believe that mental illness in this part of the country is as a result of witchcraft.

Number of patients they see
Dr Odur says on average, they see between 30 and 75 patients a day and in a month, they can see as many as 800 patients. “We have the biggest number of mental cases at this hospital.
People come from as far as Lira, Packwachi, Masindi, Acholi region, Adjumani, Moyo, Yumbe and South Sudan. So we are serving the whole northern Uganda population.”

Signs
Dr Katerega explains that most of these patients present with signs like irritability. “They become annoyed over small issues, they also become excessively happy, their speech increases, increased libido in women, some even get excited and give out property and they are very energetic.”

Effects of mental illness in the region
Dr Onyachi says because most people do not know how to manage the condition and yet they are normally neglected by people in the communities plus family members.
So, a number of them commit suicide.
He explains, “This region has the highest suicide rates in Uganda at the moment and this is related to the war because a background check on the victims always indicates a mental problem.”
He adds, “Many people who commit suicide are suffering from depression and when depression is not managed earlier, it will go to the extreme and that is how people end up taking their lives.”
Additionally, Dr Katerega says, “These cases are caused by underlying factors such as worthlessness, hopelessness, depression, PSTD. They are also found in alcoholics and those people who practice substance abuse. These cause people to believe that they are worthless so they think the only alternative is to end their lives. Such people hear voices commanding them to end their lives.”
A case in point is Grace Labeja’s husband. The widow explains that early this year, her husband became irritable. “He would get annoyed over small things and to deal with his frustrations, he resorted to alcohol.”
She adds, “On March 17 this year, he woke up and as usual, he was very irritable. He asked for some of the produce I had brought from the garden so that he could sell it and get money for alcohol.”
She refused to bow to his request. But it appears her husband was not amused by what the wife had done. “He started shouting at me at the top of his voice. But I had got used to his tantrums. Little did I know that that would be the last I see of him because when I went to the market, on my way back, they told me he had hang himself on the mango tree behind our hut,” she explains while wiping tears from her eyes.
Dr Odur says in the Out Patient Department, in about three days, they get one to three patients for incomplete suicide. “Some of these patients will have tried to hang themselves or taken drugs but were rescued before they died. These cases are among both male and female.”
Gulu’s police OC CID, James Asubu says nowadays they get at least two suicide cases a month.

Challenges
However, while the hospital has to grapple with the overwhelming numbers of mental cases, Dr Katerega says the medicine is not readily available. “At times we do not even have the important medication in the treatment of mental disorders.”

Way forward
However, to control the effects of mental disorders, Dr Odur says they have formed a community sensitisation committee through which they educate people.
“We hold seminars but the challenge is that most of the help goes to HIV and Malaria but NGOs like World Vision, Trans Cultural Psychosocial Organisation (TPO), Voluntary Services Overseas (VSO) and ACCORD have helped. We also hold a mental health meeting every month to assess the situation.”
He adds that they also have outreach programmes supported by TPO in conjunction with Gulu Regional referral Hospital. “Under this programme, we go out in the field, work with the community to identify people with mental problems, treating them and empowering the staff working in different health units to treat such patients so that we do not have the monopoly of treating mental patients. Other people in those units also have the ability to treat mental conditions so that we decongest the referral hospital.”

Message to government
Odur appeals to government to increase the number of drugs we receive because we are serving the whole of northern Uganda and part of South Sudan. “There is also need to increase staffing norms to meet the demand and also conduct community health sensitisation and hold radio talks to educate people.”

Government response
However, while the principal medical officer, Mental Health and Control of Substance abuse at the Ministry of Health, Dr Sheila Ndyanabangi agrees that Gulu Regional Referral Hospital is overwhelmed by mental health cases, she says the weakness lies with the other two referral hospitals in the region.
“Government budgets for Gulu hospital as a hospital to serve people in a specific region. The same applies to Lira and Kitgum. But since Gulu is the centre of business in the whole region, that is why most people go there.”
She adds, “The other two referral hospitals have failed to recruit staff and because people are not given the services they need when they go to these hospitals, the resort to going to Gulu. But our role as government is to come up with policies, standards and guidelines. The hospitals are supposed to implement what we give them.”
But all in all, mental health is one illness that needs to get as equal attention as HIV/AIDS and Malaria in Northern Uganda because its effects are clearly immense.

Psychiatry attendance financial year 2012 to 2013 (from July 2012 to June 2013)

·New attendants between zero to four years, 20 male and 27 female
·New attendants five years and above, 460 male and 511 female
·Returning attendants between zero and four years, 173 male and 115 female
·Returning attendants five years and above, 4434 male and 4996 female.
·Total patients seen in that financial year is 10,736

stumwebaze@ug.nationmedia.com