For those who advocate with passion about the need to radically overhaul the practice of mental health in Ghana today, who argue in favor of the modern trend of community-based care, it is incredibly amazing the extent to which existing policies subvert that cause which they champion. Tied in very closely to the above observation is the subtle albeit pervasive issue of mental health funding which largely entrenches the obsolete practice of institutionalized care of the mentally ill. Connected indirectly to the twain is the issue of the lack of modern drugs that psychiatrists insist would have positively impacted the management and prognosis of their patients. In the ensuing paragraphs, I intend to draw heavily on great conversations with a young colleague who is in his early days of post-graduate medical education in the clinical specialty of psychiatry and a freshly graduated clinical psychologist from the University of Ghana. We shall examine somewhat the practical realities confronting the practicing psychiatrist, the roles if any of the clinical psychologist in the holistic management of the mentally ill and the impact of psychiatric illness on the family of the mentally afflicted. For these deep insights, I wish to express my profound gratitude to Dr Akwasi Osei, Acting Chief Psychiatrist, Dr Eugene Dordoye of Pantang Hospital and Miss Regina Enyonam Adatedu, Secretary of the newly-formed Ghana Clinical Psychologists Association. When psychiatrists and health practitioners insist that mental health is not covered under the NHIS (National Health Insurance Scheme), exactly what do they mean? If the modern trend in management is to move from keeping patients locked up in a psychiatric facility (institutional care) as opposed to encouraging greater community-based social interaction and integration, then what is it in current policy that steadily militates against community-based care and perhaps explains why some relatives prefer to keep discharged relatives suffering mental ill-health in the hospital as opposed to taking them home? Currently, Mental Health Care is designated by law as a free service. To a large extent, this is largely true when mentally ill patients are treated for psychiatric illness in psychiatric hospitals. Cash and carry is however very much in existence for the mentally ill in the non-psychiatric health facility. Prompt response is therefore urgently needed on the part of government officials and health authorities by way of financial reimbursement to keep the service in all Psychiatric Hospitals up and running. With the Chief Psychiatrist lamenting about feeding patients in Accra Psychiatric Hospital on credit, your guess is as good as mine as to how prompt this response has been. For the mentally ill however, the problem is more profound than the issue of feeding. Most tend to forget that like the rest of us, the mental patient is given to bouts of physical ill health. It is very normal then that a woman suffering severe depression may catch a bad pneumonia along the way or a young man being managed for drug and substance abuse may enter into a hostile tango with mission-minded and purpose-driven mosquitoes and come out the worse for it. What about the schizophrenic who is also a known asthmatic patient with frequent severe attacks? The above scenarios without doubt beg the question of what happens when physical illness sets in in today’s mental health care system. Now check this out. Today, when a patient is treated for mental ill health in a psychiatric facility, he does not pay. If such a patient were to be admitted at the same facility and while on admission fall physically ill e.g. an attack of malaria, his treatment would also be free of charge. If such a mentally ill patient were however to present at the out-patient-department of the same psychiatric hospital with the same malaria, he would be required to pay upfront unless he is registered under the NHIS. This is because the NHIS does not cover his malaria or physical illness. In a non-psychiatric facility, the mentally ill pays upfront irrespective of the presenting condition unless his relations have registered him under NHIS. His treatment is free only if it is limited to collecting “routine” psychiatric drugs. Realistically therefore, it can be safely summarized that treatment is free only when the illness and the hospital are both psychiatric! To corroborate this summary however, I speak to the relation of a psychiatric patient who is being cared for at home. Her answer proves even more revealing when she adds that “As for the psychiatric tablets, they are free but we pay for the monthly injections!” O well…so much so for free psychiatric care. At this point, I can’t help wondering what the fate of these “free” tablets would be if patients were to benefit from newer, more expensive and perhaps more efficacious tablets with less undesirable side effects as is being advocated by the psychiatrists. The outflow of this singular act is myriad, and disturbingly so. Already over-burdened but smart relatives quickly decipher that if they were to keep their mentally ill relation on admission even after they have been discharged, then in the event of their falling physically ill, they would be looked after free of charge in the psychiatric hospital. And so to prevent the stigma, the burden of caring for such a relation at home and the ensuing hospital bills, a third of the patients on admission at the Accra Psychiatric Hospital are in the category of those treated, discharged and ready to go home. Place your self for a minute in the shoes of the mental patient. Having grown so used to the caring attitude of the health professionals of the psychiatric hospitals who perhaps best understand and appreciate your situation, a psychiatric patient will instinctively go to the same psychiatric facility when he falls ill only to be told that “today because it is a respiratory tract infection and not Mania, you have to pay!” Just in case you think I raise the thorny issue of physical illness in the mentally ill as an academic exercise, permit me to quickly disabuse your mind of the notion. In Dr Dordoye’s words, in addition to all the ailments mentioned already, he has on numerous occasions handled serious epileptic attacks with the patients having continuous seizures where he has had to “manage” with what equipment and medication have been available. With a rueful shake of his head and a wry smile on his face, he recalls with deep regret how he lost two patients both to late presentation of complicated Diabetes mellitus. As to what tests he could do or could not do or what drug was available and which was not, the least said about it, the better! The web burrows deeper still. Since most psychiatric hospitals are not equipped to perform surgeries and as Psychiatrists themselves are Physicians and not Surgeons, when a Schizophrenic gets an obstructed hernia which requires surgical repair, he would have to go to the appropriate facility where he would be required to pay even if he was originally on admission in a psychiatric hospital. The point then is that ideally and practically, psychiatrists would prefer that treatment of all forms for the mentally ill ought to be free and borne by that state and whichever government that considers itself responsible, compassionate and foremost advocates of the rights and interests of the socially-disadvantaged in the Ghanaian society! This, perhaps is where the Mental Health Bill which is still lying down un-passed a whole year after completing the draft, comes in handy. In it whoever qualifies to be a mental patient can be clearly defined by psychiatrists. In addition, psychiatrists are prepared to discuss which specific ailments may benefit from this comprehensive inclusion in the NHIS and also how to tighten all the loose ends so as to prevent possible abuse. My dislike for the devil notwithstanding, as his temporary advocate, I take on Dr Dordoye. What is it that should make the Ghanaian state isolate the mentally ill for special consideration? What really prevents the relations of the mentally ill from paying their premiums under the NHIS so that like many others, they can enjoy the minimum benefit package? These lead us inevitably into what the relations of the mentally ill have to endure. My friend however ripostes with a powerful response of his known. Waxing eloquent about the social obligation that the state has to care for its citizens, he asks what considerations go into isolating people over 70 years and children under 18 years for special consideration under the NHIS. Furthermore, most of these mentally ill patients end up either being unemployed or being limited to low-paying jobs with their limited education. Where their relations are concerned, a whole pandora’s box is opened. Apart from the unrelenting social stigmatization of mental ill health that rubs off in equal measure on the family of the mentally ill, the family maintains responsibility for feeding, accommodation, some social support and also the health care needs of the patient. Taking the typical example of the young man abusing and addicted to alcohol, cocaine or cannabis, the crucial rehabilitative process in his management may include placing him in a job. This burden also falls squarely on the shoulders of the family in the absence of the very same abysmal lack of Ghanaian State support and responsibility. Then comes the issue of delegated care. Who looks after a mentally-challenged child or a depressed adult at home while the adult relation goes to work for the much-needed income? If we are to prevent say, real suicide in the severely depressed and damage to property while everyone has gone to work and left the mentally ill alone, then care would have to be delegated which means the relations may have to contract the services of a carer of sorts, never mind their qualification or lack of it. Talk of the mentally-ill child reminds me even more acutely how if the whole of Mental Health represents a dark world, then the sub-specialty of Child Psychiatry may well be hell itself! Who knows the thoughts of a normal child anyway, let alone those of the mentally ill? But really, who cares? Finally, what happens to the family of the mentally ill patient who once was the main breadwinner? Now more than ever, we may be better able to look appreciatively at the daunting circumstances of the mentally ill and the burden on their relations and not be too judgmental when they refuse to come for their discharged mentally-ill relations. In Dordoye’s words, “the burden is too much!” Simultaneously sad and interesting, after talking to Dordoye for a little longer, it readily becomes unclear for whom this heavy burden is too much-the patient, relative or the doctor?! This is because for the health care practitioner at Pantang Hospital, even as the country laments the current four psychiatrists in Ghana, he sees and manages far more than the mentally ill with Pantang having become a referral centre of sorts in the Ga East District. And so the doctors handle all the malaria, respiratory tract infections, gastroenteritis, diabetes mellitus and hypertension of the mentally sound from nearby health centers in Danfa, Madina and Abokobi etc! This brings me to the role of the clinical psychologists in psychiatric care. Each year, the University of Ghana graduates an average of about ten clinical psychologists. How many of these graduates are employed by the Ghana Health Service to contribute to the management of these psychiatric illnesses? Do Clinical Psychologists have any useful role to play anyway? A brief talk with some Psychologists does not fail to leave one with the distinct impression that matters of appreciating their roles and integrating their services into holistic patient care is easier said than accomplished. Generally, Clinical Psychologists aim to reduce psychological distress and enhance and promote psychological well being. They therefore work with people of all ages who experience mental or physical health problems by employing tools of psychological assessment and psychotherapy. Their services may cover anxiety and depression, serious and enduring mental illness, adjustment to physical illness, neurological illness, addictive behaviors and eating disorders. Other areas include behavior disorders, personal and family relationship problems and learning disabilities. There is now said to be preliminary empirical evidence that by promoting (Seligman’s) three components of happiness-positive emotion (the pleasant life), engagement (the engaged life) and meaning (the meaningful life), positive psychotherapy can decrease clinical depression. Now I am pretty sure that sounds all well and good till I tell you that Pantang Hospital has one clinical psychologist who owes his employment more to the fact of his being a medical doctor/psychiatrist with additional training than on his being a thoroughbred clinical psychologist. Technically, the Accra Psychiatric Hospital has no Clinical psychologists having “borrowed” 3 who are actually lecturers of the University of Ghana with a greater responsibility and focus on teaching than on attending to daily clinical needs of patients! Ankaful Psychiatric Hospital in the Central Region is said to have a returnee Clinical Psychologist who has been offering his services free of charge for over a year. In the words of the Chief Psychiatrist, “Thank God the Ministry is now taking steps to employ him.” Given that this is the situation in Pantang and Accra Psychiatric and Ankaful Hospitals; need I explore any further what pertains in the other Regions before zeroing in on the districts? Alas! Like many other items famous for their skewed distribution in favor of the capital, mental ill-health may perhaps be safely assumed to reside in Accra only! Dr. Akwasi Osei sums up the present situation thus, “Yes, the issue of clinical psychologists and the Ghana Health Service is really funny. The bottom line is the fact that somehow unconsciously, Mental Health does not feature in the scheme of affairs, though they seem to be making efforts to consider it a priority. The fact is that there is no post for clinical psychologists in the Ministry and the GHS. Those in the system are employed in different capacities. Thank God that in principle we have got them to now recognize the need but the bureaucracy of employing them is the problem. All these we hope to change if the Mental Health Law is passed, and therefore to me that has been the focus of a lot of my efforts-to have the law passed!” I end by reiterating an earlier impassioned plea to all journalists, civil society organizations and professional bodies including… no, I mean especially the Ghana Medical Association to gallantly take up the issue of Mental Health Reform without let or hindrance till the powers that be begin to listen. I once again advocate that we elevate the issue of Mental Health Reform to the status of a major campaign issue in the 2008 Presidential and Parliamentary elections in Ghana. While it may be important to understudy the winning strategies of advocacy in the passage of the Domestic Violence and the Disability Acts, we must aspire to go beyond the mere passage of a Mental Health Act and follow it immediately with robust, practical and meaningful implementation. It is time to find out who is on the side of the mentally ill. Source: Sodzi Sodzi-Tettey General Secretary Ghana Medical Association