Psychiatry in Sub-Saharan Africa faces a unique set of challenges due to limited healthcare infrastructure, cultural stigmas surrounding mental illness, and a shortage of mental health professionals. Despite these barriers, certain rules of thumb and guidelines can provide a framework for improving psychiatric care in resource-constrained environments. In psychiatry, especially in the context of Sub-Saharan Africa, several principles or rules of thumb can guide clinical practice and care delivery due to unique cultural, social, and healthcare challenges. Here are some key considerations: Cultural Sensitivity: Understanding and respecting cultural beliefs, traditions, and norms is crucial. Psychiatry in Sub-Saharan Africa often involves integrating traditional healing practices with modern psychiatric care to enhance treatment acceptance and effectiveness. Community Engagement: Involving families, religious and community leaders in treatment planning and decision-making can improve adherence to treatment and reduce stigma associated with mental health conditions. Holistic Approach: Adopting a holistic approach that considers not only psychiatric symptoms but also social determinants of health, such as poverty, unemployment, and access to healthcare, is essential. Integration of Services: Integrating mental health services into primary care settings can improve access and reduce the treatment gap for psychiatric disorders in resource-limited settings. Stigma Reduction: Addressing stigma through public education campaigns, advocacy efforts, and empowerment of individuals living with mental illness is crucial for promoting help-seeking behaviour and reducing discrimination. Cultural Formulation: Using cultural formulation interviews to understand the impact of culture on illness experience, help-seeking behaviours, and treatment preferences. Task-Shifting and Capacity Building: Training non-specialist healthcare providers, such as nurses and community health workers, in basic psychiatric care can expand the workforce and improve access to mental health services. Resilience and Strengths-Based Approach: Recognizing and building on individual and community strengths and resilience can enhance treatment outcomes and recovery. Adaptation of Evidence-Based Practices: Tailoring evidence-based psychiatric interventions to fit local cultural contexts and healthcare resources to ensure relevance and effectiveness. Ethical Considerations: Upholding ethical principles in psychiatric practice, including respect for autonomy, beneficence, and justice, while navigating cultural and social complexities.

Rules of Thumb in Psychiatry

Author's details

Dr.Khashau Eleburuike
MBBS (Ilorin) MSc. Global Health Karolinska Institute.
Resident doctor in family medicine in Northen Sweden.

Reviewer's details

Maitanmi Moyosore Ifeolu.
Consultant psychiatrist, FWACPsych
Federal Neuropsychiatric hospital, Yaba, Lagos.

Rules of Thumb in Psychiatry

Background

Psychiatry in Sub-Saharan Africa faces a unique set of challenges due to limited healthcare infrastructure, cultural stigmas surrounding mental illness, and a shortage of mental health professionals. Despite these barriers, certain rules of thumb and guidelines can provide a framework for improving psychiatric care in resource-constrained environments.

In psychiatry, especially in the context of Sub-Saharan Africa, several principles or rules of thumb can guide clinical practice and care delivery due to unique cultural, social, and healthcare challenges. Here are some key considerations:

Cultural Sensitivity: Understanding and respecting cultural beliefs, traditions, and norms is crucial. Psychiatry in Sub-Saharan Africa often involves integrating traditional healing practices with modern psychiatric care to enhance treatment acceptance and effectiveness.
Community Engagement: Involving families, religious and community leaders in treatment planning and decision-making can improve adherence to treatment and reduce stigma associated with mental health conditions.

Holistic Approach: Adopting a holistic approach that considers not only psychiatric symptoms but also social determinants of health, such as poverty, unemployment, and access to healthcare, is essential.
Integration of Services: Integrating mental health services into primary care settings can improve access and reduce the treatment gap for psychiatric disorders in resource-limited settings.
Stigma Reduction: Addressing stigma through public education campaigns, advocacy efforts, and empowerment of individuals living with mental illness is crucial for promoting help-seeking behaviour and reducing discrimination.
Cultural Formulation: Using cultural formulation interviews to understand the impact of culture on illness experience, help-seeking behaviours, and treatment preferences.
Task-Shifting and Capacity Building: Training non-specialist healthcare providers, such as nurses and community health workers, in basic psychiatric care can expand the workforce and improve access to mental health services.
Resilience and Strengths-Based Approach: Recognizing and building on individual and community strengths and resilience can enhance treatment outcomes and recovery.
Adaptation of Evidence-Based Practices: Tailoring evidence-based psychiatric interventions to fit local cultural contexts and healthcare resources to ensure relevance and effectiveness.
Ethical Considerations: Upholding ethical principles in psychiatric practice, including respect for autonomy, beneficence, and justice, while navigating cultural and social complexities.

Rules of thumb

1. Management of Depression

Depression is a leading cause of disability in sub-Saharan Africa, but it is often underdiagnosed and undertreated.

Rules of Thumb

Screen for Depression in Primary Care Settings:

Depression is often somatised, with patients presenting physical symptoms like fatigue, pain, or sleep disturbances. Using simple screening tools like the Patient Health Questionnaire (PHQ-9) can help identify depression early.

Start with Low-Cost, Effective Therapies:

Given the limited access to mental health specialists, primary care physicians should be trained to initiate treatment with antidepressants (such as selective serotonin reuptake inhibitors—SSRIs) and brief psychosocial interventions.

Incorporate Community-Based Approaches:

Engage local leaders and community health workers to destigmatize mental health and provide support for those with depression.

Guidelines

WHO mhGAP Guidelines for Depression

Recommend integrating mental health services into primary care. Emphasize early identification, treatment with antidepressants, and community-based support.

National Institute for Health and Care Excellence (NICE) Guidelines on Depression

Focus on stepped care approaches, starting with low-intensity interventions like self-help and progressing to medication and psychotherapy depending on the severity of symptoms.

2. Management of Anxiety Disorders

Anxiety disorders are common but often overlooked in sub-Saharan Africa due to stigma and the focus on physical illness.

Rules of Thumb

Recognize the Somatic Symptoms of Anxiety:

Patients may present with physical symptoms such as palpitations, sweating, or dizziness. Addressing both the physical and psychological components of anxiety is crucial.

Use Low-Cost Treatments:

Non-pharmacological approaches, such as cognitive-behavioural therapy (CBT), relaxation techniques, and psychoeducation, are effective and can be provided by community health workers. SSRIs can be used when medication is necessary.

Involve Families and Communities:

Engage family members in treatment plans and educate them about anxiety disorders to reduce stigma and ensure support.

Guidelines

WHO mhGAP Guidelines for Anxiety Disorders:

Highlight the importance of integrating mental health into general healthcare services and recommend CBT and SSRIs as primary treatments.

American Psychiatric Association (APA) Guidelines for Anxiety:

Recommend a combination of pharmacotherapy and psychotherapy for moderate to severe cases, with an emphasis on access to care and follow-up.

3. Management of Psychotic Disorders (Schizophrenia)

Schizophrenia and other psychotic disorders are highly stigmatized in sub-Saharan Africa, with patients often facing social isolation and delayed care.

Rules of Thumb

Early Diagnosis is Key:

Psychotic symptoms like hallucinations and delusions may be attributed to supernatural beliefs. Educating communities and healthcare providers about the early signs of psychosis can facilitate timely diagnosis and treatment.

Start Antipsychotics Early:

Use low-dose antipsychotic medications, such as haloperidol or risperidone, to manage acute psychosis. Long-acting injectable antipsychotics can be used to ensure compliance in chronic cases.

Supportive Community Care:

Train family members and caregivers to provide ongoing support and supervision. Community-based rehabilitation can help reintegrate patients into society.

Guidelines

WHO mhGAP Guidelines for Psychotic Disorders:

Recommend early treatment with antipsychotics, along with psychosocial interventions and long-term follow-up.

NICE Guidelines on Psychosis and Schizophrenia:

Stress the importance of coordinated care, medication adherence, and psychological support, alongside regular monitoring of physical health.

4. Management of Bipolar Disorder

Bipolar disorder is often underdiagnosed in sub-Saharan Africa, with episodes of mania or depression being misinterpreted as other conditions.

Rules of Thumb

Differentiate Between Bipolar and Unipolar Depression:

A history of manic or hypomanic episodes is crucial for diagnosis. Mood stabilizers, rather than antidepressants, are the cornerstone of treatment in bipolar disorder.

Mood Stabilizers and Antipsychotics:

Lithium is a first-line treatment, but valproate or carbamazepine may be more readily available in some settings. Antipsychotics can be used to manage manic episodes.

Monitor for Side Effects:

Regular monitoring for side effects, such as lithium toxicity, is crucial in settings where laboratory resources may be limited.

Guidelines

WHO mhGAP Guidelines for Bipolar Disorder:

Recommend mood stabilizers such as lithium or valproate, with regular monitoring for side effects. Emphasize psychosocial support and long-term follow-up.

NICE Guidelines for Bipolar Disorder:

Advocate for a combination of pharmacotherapy and psychotherapy, with regular reviews of treatment plans and mood monitoring.

5. Management of Substance Use Disorders

Substance use, particularly alcohol and cannabis, is a growing concern in sub-Saharan Africa.

Rules of Thumb

Screen for Substance Use in All Patients:

Use simple screening tools like the Alcohol Use Disorders Identification Test (AUDIT) to assess for substance abuse in routine clinical care.

Brief Interventions and Motivational Interviewing:

Train healthcare providers in brief intervention techniques to address harmful drinking or drug use. Motivational interviewing can help engage patients in their own recovery.

Use Culturally Appropriate Interventions:

Tailor substance use treatment programs to the cultural context, involving traditional healers and community leaders when appropriate.

Guidelines

WHO Guidelines for the Management of Substance Use Disorders:

Recommend integrating brief interventions into primary care and using harm reduction approaches. For severe cases, referral to specialized care may be necessary.

Substance Abuse and Mental Health Services Administration (SAMHSA) Guidelines:

Emphasize the importance of evidence-based treatments like cognitive-behavioural therapy and pharmacotherapy (e.g., naltrexone or methadone for opioid dependence).

6. Management of Child and Adolescent Mental Health Disorders

Mental health disorders in children are often overlooked due to stigma, and services for this age group are scarce in sub-Saharan Africa.

Rules of Thumbs

Early Identification and Intervention:

Use simple screening tools to identify developmental delays, attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorders. Early intervention improves outcomes.

Involve Parents and Teachers:

Educate caregivers and teachers on recognizing signs of mental health disorders in children and involving them in treatment.

Non-Pharmacological Interventions:

Use behavioural therapies and psychoeducation as first-line treatments for many child and adolescent mental health conditions. Medications like stimulants for ADHD should be used cautiously.

Guidelines

WHO Guidelines on Child and Adolescent Mental Health:

Highlight the need for early identification and community-based interventions for children. Include recommendations for low-intensity psychological interventions and cautious use of medications.

NICE Guidelines on ADHD and Autism:

Recommend a multi-disciplinary approach that includes behavioural interventions, school-based support, and pharmacotherapy when necessary.

Conclusion

Psychiatry in sub-Saharan Africa is shaped by unique cultural, social, and economic factors. Despite the scarcity of resources, rules of thumb such as screening for depression in primary care, using low-cost therapies for anxiety, and ensuring early intervention for psychotic disorders can improve mental health outcomes. Integrating mental health services into primary care and utilizing community health workers can help bridge the treatment gap.

There should be synergism with faith-based institutions, seeing as they are the first point of reference for most psychiatric presentations. Educating faith leaders and creating an informal reference pathway for them to seamlessly refer/ get help for their followers who need help should also be an integral part of community engagement/outreach.

Implementing guidelines from organizations like the WHO and global psychiatric associations ensure that mental health care in sub-Saharan Africa aligns with best practices while being adaptable to local contexts. Long-term efforts to reduce stigma, improve access to care, and promote community involvement will be essential in transforming mental health outcomes in the region.