The Sunday News
Dr Cherifa Sururu
Common mental disorders seem to rank lowest among the priorities in the health delivery system yet there is a huge need for these services in Zimbabwe.
This is so because Zimbabwe, like many African countries, has a heavy burden of disease. Communicable diseases such as HIV, tuberculosis, and malaria live side by side with interpersonal violence and trauma, maternal and childhood deaths and a growing number of non-communicable diseases such as hypertension and diabetes.
While the country has been trying to tackle this burden of disease, it has been constrained by resources which include scarcity of “appropriate skills mix” of health workers and a primary health care that may not have “evolved” comprehensively to address this heavy burden of disease.
Primary health care is where people engage with the health system for the first time.
Studies carried out in Zimbabwe show that the incidence of common mental health disorders range from 20% to 35% in different communities. People living with HIV (PLWH) have the highest prevalence of common mental disorders at more than 60%.
The socio-economic challenges the country experienced resulted in an increase in the number of people with common mental disorders.
Although it was a Government policy that all services be decentralised to outlying hospitals and health centres, mental health services are still concentrated in few psychiatric hospitals mainly in the big cities.
This situation leaves primary healthcare clinics to screen psychiatric patients and then refer these to psychiatric hospitals.
Unfortunately there seem to be low detection rates by health personnel in some primary and secondary care centres.
This week we look at the case of M whose history shows that he grew up at a farm in one of Zimbabwe’s poorest districts.
The community health centre and the district hospital serving the farm did not have mental healthcare wards and specialists’ nurses and psychiatrists.
He was raised by his aunt because his own parents lived in the rural areas in Malawi where opportunities were perceived to be much less. He was a quiet person. His aunt managed to send him and her own children to school up to Grade Seven due to financial difficulties.
M was determined to acquire further education for himself. He got employed as a gardener. He then managed to push himself up to O-level.
He was a hard worker and he spoke English eloquently. He was also very good with figures. This was noticed by his employer who also owned a bakery. He took him in to work in the bakery. He quickly rose through the ranks and soon he was the bakery manager. He became the envy of the entire farm.
When he visited the primary care clinic, he was noted to be mentally ill by the attending nurse. This was because of his abnormal behaviour, as he kept on talking to himself.
He was immediately referred to the district hospital. At the district hospital he was transferred to a central hospital.
The provincial hospital was bypassed because it did not have psychiatric facilities.
At the psychiatric hospital he was seen by a psychiatrist. He and the accompanying family members narrated how it all started. When coming from the local beer hall one night, he stepped on a broken clay pot that had a concoction of herbs and other stuff he could not see clearly that night. When he retired to bed he heard strange noises outside. He also saw a mysterious fire outside his bedroom.
Having grown up at the farm, he had a strong belief in witchcraft.
He strongly believed that his second in command at work, whom he did not “trust”, desperately wanted his position and had thus resorted to use of witchcraft to get him down.
His first marriage had ended, so had his second. Frustration with commitment relationships led him to resort to commercial sex workers. He also consumed large amounts of alcohol and he had also started to smoke marijuana.
His situation gradually spiralled out of control and his employer decided to give him time off to sort out his personal issues, since his performance at work had seriously deteriorated.
Although the whole family believed that he had been bewitched, everything they had tried to undo the witchcraft through traditional healers had failed. They had consulted many traditional healers without fruitful results.
He was instructed to buy an ox by one of the traditional healers. Rituals were conducted on the ox and a hundred dollar bill was tied by the ox’s neck and let out to roam in his neighbourhood. All members of his family including M had “magic” applied to their ankles in order to protect them from further “witchcraft” attacks and to bring healing to M.
These rituals did not bring relief to M. Like many Zimbabweans, M had been brought by the family to the medical health services as a last resort. He had been sick for more than six months by the time he was seen by the doctors. His symptoms had also worsened in the last six weeks before seeing the doctors.
On examination, the psychiatrist noted that he was seeing “things” and hearing “voices”. M and his family were told that the things he was seeing and the voices he was hearing were not real. These were visual and auditory hallucinations.
The doctors also noted that M had false belief that people were after his life. The psychiatrist told M and family that M was delusional. A delusion is a mistaken belief that is held with strong conviction even when presented with superior evidence to the contrary.
As pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, or some other misleading effects of perception. Since he felt that people were after harming him; this type of delusion is called “persecutory delusion”. He was then told that he was having psychosis. Because his symptoms had gone on for more than six months, he was then diagnosed with schizophrenia.
What is schizophrenia?
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), to meet the criteria for diagnosis of schizophrenia, the patient must have experienced at least 2 of the following symptoms: Delusions, hallucinations, disorganised speech, disorganised or catatonic behaviour, negative symptoms.
At least one of the symptoms must be the presence of delusions, hallucinations, or disorganised speech. Continuous signs of the disturbance must persist for at least 6 months, during which the patient must experience at least 1 month of active symptoms (or less if successfully treated), with social or occupational deterioration problems occurring over a significant amount of time.
These problems must not be attributable to another condition.
M was admitted at the psychiatric hospital for three weeks. He was told that his condition like many other Non-Communicable diseases, would require lifelong commitment to care and follow up. His symptoms gradually improved and he was able to be discharged and yes, he went back to his occupation.
Until we meet again, may God bless you all.
