Stories From the Field:

LIBERIA

Psychiatry in Liberia

Dr. Maithri Ameresekere, a resident at MGH McLean Adult Psychiatry Residency, was granted a Center for Global Health Travel Award to partner with Dr. Benjamin Harris at Doglotti Medical College in Liberia. Dr. Ameresekere travelled to Monrovia to understand psychiatric practice in post-conflict Liberia.

With the support and mentorship of Dr. David Henderson and Dr. Christina Borba of the Chester M. Pierce M.D. Division of Global Psychiatry at Massachusetts General Hospital, Dr. Benjamin Harris of A.M. Dogliotti Medical College at the University of Liberia and the MGH/McLean Psychiatry Residency program I had the opportunity to go to Monrovia, Liberia as a rising third year resident. The focus of my trip was manifold and included 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 medical students to go into the fascinating and underserved field of psychiatry. I returned to Liberia nearly twenty years after my first visit as a child when my mother was stationed in Monrovia working for UNICEF.

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 suicide. 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 spent the majority of my time in Liberia 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. I saw a variety of interesting neuropsychiatric presentations for which I had to adapt my training to fit the cultural context. Psychiatric presentations 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 of the most compelling concerns I heard 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. Also, 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. Similarly, patients are sometimes encouraged to stop taking medications by family or community members and often suffer from relapse of their affective or psychotic illnesses resulting in further damage to social and functional status. Having direct exposure to the profound influence of stigma as both an internal and external barrier to care has shaped my research interests and further fueled my desire to understand barriers to care both locally and internationally.

Lastly, over the course of my trip, I had the opportunity to both learn and share knowledge with medical students and mental health clinicians, through formal lectures and informal case presentations all while experiencing first hand the rewards and challenges of practicing psychiatry in post-conflict Liberia. A committed multi-disciplinary team of occupational therapists, psychiatric nurse specialists, social workers and other mental health staff work together to care for patients. Despite their commitment, however, the dearth of human resources remains a challenge. 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 given Liberia’s post-conflict past. I was heartened to hear that at least a few students were interested in pursuing further psychiatric training!
My trip to Liberia has been a profoundly educational experience for me. I hope to continue to support the efforts of the Division of Global Psychiatry at MGH in partnership with the University of Liberia and A.M. Dogliotti Medical College to encourage research and training efforts that will address the needs of those suffering from mental illness in Liberia and post-conflict communities elsewhere.

Many thanks to the Centers for Global Health for supporting my trip!