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The Royal College of Psychiatrists Improving the lives of people with mental illness

Ethiopia - Alexander Adams

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28/04/2014 12:26:27

Mental Health in Ethiopia

Nurse led psychiatric clinics, rural health centres and data collection in and around Butajira.



After flying into Addis Ababa from Heathrow I was almost instantly whisked away to Butajira - a reasonably large town about 2-3 hours drive south of the capital. Butajira has a general hospital where a group of psychiatrists such as Dr Abebaw Fekadu and Prof Atelai Alem have a cohort of psychiatric patients who they have been following for 15 years. A lot of data has come out of this which is valuable not only for the Ethiopian governments plan to scale up their mental health care, but also for other low income countries where the reality of providing mental health care is very different to high income countries such as the U.K.

Village, Ethiopia

The hospital itself caters for around 3 million patients coming from up to 300km away...

Butajira itself is much like many other Ethiopian towns - strung out along the main asphalt road with a couple of bumpy dirt roads spreading out from there. The general hospital is a small cluster of buildings set around several open-air courtyards. The psychiatric clinic consists of two rooms off a corridor. The psychiatric nurses who run the clinic (none of Ethiopia's 40 or so psychiatrists work here) can see up to 80 patients a day. The hospital itself caters for around 3 million patients coming from up to 300km away although psychiatric patients have been known to come from up to 700km away as the clinic has a very good reputation. However the majority of patients with mental health care problems will never be seen here. This is because most people will see a traditional healer first. If that then doesn't work a small proportion may seek help from a western style service – if accessible. Others, who can't afford medicines, don't believe they work or just do not know they exist may be chained up by a family who can't cope and have no other options. That or land may be sold to pay for services meaning when the patient is better they may not even be able to work.

Nibret, one of the psychiatric nurses, at the nurse led clinic in Butajira General Hospital.

Others, who can't afford medicines, don't believe they work or just do not know they exist, may be chained up by a family who can't cope


Some of the stories I heard were incredible, and the nurses were doing all they could with the limited resources of first generation antipsychotics, amitriptyline and phenobarbitol (the clinic also treats epileptic patients.) A woman who was abducted on the way home from school, raped and forced to live with her captor for several months, a suicide attempt relating to a acrimonious family relationship, and several women with psychosis after returning from working in the middle east were some of the cases I saw. In short consultations the psychiatric nurse would prescribe medications, attempt to offer counseling and act as a family mediator. Obviously this meant there were limitations - histories had to be targeted to diagnosis, the choice of medications was scarce and sometimes inappropriate drugs were used as there was no other choice. Often relatives attended for ill family members who could not make the journey due to transport costs, work or being too ill and medication had to be prescribed without the patient being there. With no mental health law covering treatment another problem occurs when patients lack insight. In-fact one of the psychiatric nurses told me he actually gets a “danger” pay allowance on top of his salary.

Rural clinic, Ethiopia

There is some suggestion by researchers and the WHO that perhaps people in lower income countries with schizophrenia have better outcomes due to factors such as reduced stigma, a more agricultural subsistence economy and better family support. However in low-income countries, such as Ethiopia where services are so scarce, human rights abuses can occur and there is a fragile subsistence economy - the reverse could actually be true.


The problem with the evidence for this is that it relates to a cohort of people presenting to services - but the majority of people do not end up presenting to services. This is why research such as that conducted in Butajira - which recruited people from primarily rural communities using local data collectors is useful.





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Alexander Adams

  Alexander Adams

I am a final year medical student studying at Cardiff University hoping to specialise in psychiatry. I became interested in mental health, particularly globally, after doing an intercalated BSc in Psychology and Medicine. I spent 8 weeks experiencing the clinical and research sides of mental health in Ethiopia for my elective. I am due to start my foundation year training at St Mary’s/Charing Cross in London in August.

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