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 International  Bipolar  Foundation  –  Kenya  Brief  Compiled  by  Kanyi  Gikonyo    Mental  disorders  have  only  attracted  limited  attention  in  global  efforts  at  alleviating  poverty  through  investment  in  health,  despite  evidence   of   their   impact.   Substantial   and   enduring   improvements   in   mental   health   services   require   an   integrated   policy   and  strategy,   including   systematic   educational   interventions   to   equip   service   providers   with   necessary   knowledge   and   skills,   public  education  to  raise  awareness  of  the  importance  of  mental  health  and  mental  disorders,  combined  with  organizational  reforms  to  enable   interventions   to   be   embedded   in   the   health   system   and   in   routine   care.   Unlike   the   large   scale   investments   in   vertical  communicable  disease  programs,  there  have  only  been  very  limited  investments  in  mental  health,  mental  disorders  and  other  non-­‐communicable  diseases.  The  attention  to  vertical  program  delivery,  and  use  of  non-­‐public  health  sector  actors  and  infrastructure  has  diverted  attention  and   funds  away   from  basic   strengthening  of  public  health   care   systems   in  Africa,   so   that  despite   considerable  investment,   there  are   still  only  1  or  2  nurses  and  clinical  officers   for  10,000  population   in  Sub-­‐Sahara  Africa.  Where  available   for  mental   health,   donor   funding   has   usually   been   short-­‐term,   uni-­‐sectoral,   and   focused   on   vertically   implemented   projects,   with  inadequate  attention  to  sustainability.  (Kiima,  Jenkins  2010  Medical  Journal)  

Mental  health   inequalities  have  contributed  to  profound  suffering  and  death  worldwide   largely  because  people  cannot  access  the  treatment   they   need.   Estimates   for   untreated   serious  mental   disorders   in   developing   countries   range   from   75%   to   85%   (WHO,  2004).  Over  80%  of  people  suffering  from  mental  disorders  (e.g.  epilepsy,  schizophrenia,  depression,   intellectual  disability,  alcohol  use   disorders   and   those   committing   suicide),   live   in   developing   countries   (Bertolote,   Fleischmann,   De   Leo  &  Wasserman,   2004).  Untreated  cases  range  from  32.2%  for  schizophrenia  (including  other  non-­‐affective  psychosis)  to  56.3%  for  depression,  to  78.1%  for  alcohol  and  drug  use  disorders  (Kohn,  Saxena,  &  Levav,  2004).    

In   Kenya,   for   example,   the   number   of   unidentified   cases   of  mental   illness   attending   a  National   Hospital  was   40%   (Makanyengo,  Othieno,  &  Okech,  2005);  with  unidentified  cases  of  depression  between  53%  and  66.2%  at   the  sub-­‐district  and  district  hospitals,  respectively.   Almost   a   quarter   of   patients   attending   general   health   facilities   in   Kenya   have   undiagnosed   alcohol   abuse   problems  (Ndetei   et   al.,   2009).   Rural   areas   in   developing   nations,   as   in   economically   established   countries   (Roberts,   2007),   are   especially  affected  by  mental  health  disparities.  

The  mismatch  between  the  global  burden  of  mental  disorders  and  availability  of  mental  health  resources  is  alarming.  According  to  WHO,  there  is  less  than  one  psychiatrist  for  every  100,000  people  in  much  of  south-­‐east  Asia,  and  less  than  one  psychiatrist  for  every  1  million  people  in  sub-­‐Saharan  Africa  (Jacob  et  al.,  2007;  WHO,  2005b).  Nigeria,  for  example,  has  100  psychiatrists  for  its  population  of  114  million  (Gureje  &  Lasebikan,  2006).  Globally,  only  2%  of  national  budgets  are  devoted  to  mental  health  (WHO,  2005b).  About  70%  of  African  and  50%  of  south-­‐east  Asian  countries  devoted  less  than  1%  of  their  health  budget  on  mental  health  (Jacob  et  al.,  2007).    Given  the  scarcity  of  mental  health  providers  in  developing  nations,  the  few  psychiatric  hospitals  that  exist  are  often  understaffed,  crowded,  and  may  not  provide  the  quality  of  care  needed.  Most  psychiatric  hospitals  are  located  in  urban  settings  and  away  from  family  members,  which   further   increases   the   social   isolation   and   cost   for   families.   In   some   countries,   these   hospitals   are   simply  ‘warehouses’  where  patients  are  kept  from  the  rest  of  the  society  because  of  limited  resources  and  capacity  to  manage  effectively  their  conditions.  In  developed  nations  (e.g.  USA),  deinstitutionalization  of  people  with  mental  illness  results  in  many  patients,  mostly  racial/ethnic   minorities,   being   incarcerated   because   of   limited   access   and   availability   of   basic   mental   health   services   in   the  community.  

In  Kenya,   the  economic   loss  associated  with   institutionalization  of  mental  and  behavioral  disorders   is  about  $13  million   (Kirigia  &  Sambo,  2003),  a   large  amount   in  a  country  where  over  half  of   the  population   live  on   less   than  a  dollar  per  day  and  have  no  safe  drinking   water   (UNDP,   2000).   Unmet   mental   health   needs   can   create   social   problems   (e.g.   unemployment,   substance   abuse,  poverty)   that  may   increase  crime  and  political   instability.  Sen  observes   ‘there   is  plenty  of  evidence  that  unemployment  has  many  far-­‐reaching   effects   other   than   loss   of   income,   including   psychological   harm,   loss   of   work   motivation,   skill   and   self-­‐confidence,  

 

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increase   in   ailments   and   morbidity   (and   even   mortality   rates),   disruption   of   family   relations   and   social   life,   hardening   of   social  exclusion  and  accentuation  of  racial  tensions  and  gender  asymmetries’  (Sen,  1999,  p.  94).  In  many  developing  nations  these  social  problems  are  further  compounded  by  poor  governance,  corruption  and  social  morbidity  due  to  natural  and  manmade  disasters  (e.g.  wars)  which   increase  mental   health   problems,   erode   social   cohesion   and   capital,   and   limit   economic   growth   (Dewa  &   Lin,   2000;  Njenga,  2002;  WHO,  2002).

Given  the  scarcity  of  mental  health  providers  in  developing  nations,  the  few  psychiatric  hospitals  that  exist  are  often  understaffed,  crowded,  and  may  not  provide  the  quality  of  care  needed.  Most  psychiatric  hospitals  are  located  in  urban  settings  and  away  from  family  members,  which   further   increases   the   social   isolation   and   cost   for   families.   In   some   countries,   these   hospitals   are   simply  ‘warehouses’  where  patients  are  kept  from  the  rest  of  the  society  because  of  limited  resources  and  capacity  to  manage  effectively  their  conditions.  (Recent  CNN  Highlight  of  conditions  at  Mathari  Hospital.)  

Psychosocial   (mental   illness)   and   Intellectual   disabilities   are   the   most   stigmatized   disabilities   in   Kenya.   Unlike   other   types   of  disabilities;  strong  social,  religious  and  cultural  stigma  is  associated  with  both  psychosocial  and  intellectual  disabilities.  As  a  result,  those   living  with  mild   intellectual   and   psychosocial   disabilities   live   under   cover-­‐up   due   to   fear   of   being   stigmatized.   Under   such  cover-­‐up,  their  rights  are  diminished  and  subjected  to  a  life  full  of  misery,  resulting  from  silent  suffering.  Parents  and  caregivers  of  those   living   with   severe   and   profound   intellectual   and   psychosocial   disabilities   also   fear   open   association   with   these   two   most  stigmatized  disabilities.  As  a  result,  the  voices  of  those  demanding  for  their  rights  have  remained  weak,  therefore  easily  ignored  by  policy  makers  and  legislators.  

There  is  urgent  need  to  empower  human  rights  groups  and  advocacy  networks  in  Kenya,  on  the  plight  of  persons  with  intellectual  and  psychosocial  disabilities  in  order  for  them  to  mainstream  their  special  needs  in  all  human  rights  activities.  It  is  also  urgent  that  persistent   and   vibrant   initiatives   be   implemented,   aimed   at   addressing   the   deep   rooted   cultural,   social   and   religious   stigma;  currently  associated  with  psychosocial  and  intellectual  disabilities  in  Kenya.    

People  with  mental  health  conditions,  particularly  those  with  long  term  chronic  conditions,  need  to  be  targeted  by  development  programs  for  several  reasons.    They  often  are  not  given  the  opportunities  by  communities  and  governments  to  reach  their  potential  as  contributors  to  both  micro-­‐  (personal)  and  macro-­‐  (societal)  economic  prosperity  and  well-­‐being.  This  leads  to  deeper  economic  and  social  marginalization.  Second,  people  with  mental  health  conditions  habitually  are  excluded  from  participating  fully  in  society,  and  they  are  not  empowered  to  change  that  which  oppresses  them.  Development  assistance  that  helps  improve  participation  is  likely  to  lead  to  improved  psychological  and  material  well-­‐being.  Third,  development  implies  the  improvement  of  the  lives  of  all  people  in  a  country  or  community.  Development  that  only  improves  the  lives  of  some  people  –  while  others  remain  as  badly  off  or  even  worse  off  than  before  –  is  fundamentally  deficient  in  nature.  Improving  the  lives  of  the  most  vulnerable  can  be  considered  as  the  very  reason  for  development.    Although  the  idea  of  health  without  mental  health  sounds  absurd,  mental  health  is  perhaps  the  most  neglected  aspect  of  health  in  developed  and  developing  nations.  Addressing  mental  disorders  often  appears  to  be  an  afterthought  in  health  and  social  policy  development,  added  to  existing  ‘more  important  health  issues’  rather  than  a  part  of  individual  and  population  overall  health  and  wellbeing.  In  defining  health,  the  WHO  clearly  articulated  the  importance  of  mental  health  by  including  it  with  overall  physical  and  social  well-­‐being.  By  putting  it  in  between  the  state  of  ‘physical’  and  ‘social’  well-­‐being,  this  definition  symbolically  shows  how  mental  health  ties  physical  health  and  social  wellbeing  together.  Neglect  of  mental  health  needs  in  health  policies  often  translates  to  neglect  in  research,  funding,  services,  and  infrastructure  (e.g.  the  development  of  competent  mental  health  workforce)  especially  in  poor  and  underserved  communities  (WHO,  2001a,  2001b).  Mental  health  is  vital  to  our  understanding  of  health  and  economic  development  and  must  be  prioritized  in  health  planning,  resource  allocation  and  fully  integrated  with  other  primary  care  services.    

 

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In  2008,  as  part  of  the  establishment  of  the  new  coalition  government,  with  a  consequent  doubling  in  the  number  of  ministers,  the  Ministry   of  Health   split   into   two  ministries,   the  Ministry   of  Medical   Services  which   is   responsible   for   health   delivery   at   national,  provincial   and   district   level,   and   the   ministry   of   public   health   and   sanitation   which   is   responsible   for   health   delivery   in   health  centers,   dispensaries   and   the   community.   These   changes   have   resulted   in   duplication   of   administrative   posts   at   provincial   and  district  levels,  and  confusion  amongst  staff  as  to  reporting  lines,  accountability  and  planning  routes.  In  addition,  until  recently  there  were  72  districts,  with  an  average  catchment  population  500,000;  but  these  have  recently  been  reconfigured  first  to  149,  with  an  average  catchment  population  of  around  250,000,  and  now  to  around  250,  with  a  catchment  population  of  around  150,000.  The  required  expansion  of  staff  numbers  is  greatly  straining  a  public  system  where  there  is  insufficient  trained  human  resource.  

Mental  health  care  in  Kenya  is  predominantly  government  funded.  Budgets,  originally  centralized  in  the  Ministry  of  Health  (MOH),  were  decentralised  in  2008  to  local  district  councils  as  part  of  Treasury  reforms,  leaving  the  MOH  with  its  core  technical  functions  of  policy  formulation,  legislation  formulation,  standards  and  guidelines  for  service  delivery,  regulation,  strategic  planning  coordination,  performance  monitoring  and  evaluation,  funds  sourcing  and  mobilization.  All  the  health  facilities  have  been  gazetted  as  audit  units  under  the  Exchequer  and  Audit  Act,  empowering  them  to  receive  funds  directly  from  the  exchequer,  treasury  and  account  for  them.    

Kenya  has  its  own  self  sustaining  training  program  for  psychiatrists  at  the  University  of  Nairobi,  producing  around  6  new  psychiatrists  per  year,  and  the  numbers  have  expanded  from  16  psychiatrists  in  the  public  service  in  2001,  to  46  in  2009.  In  addition,  there  are  24  psychiatrists  working  in  private  practice  In  Kenya  and  another  20  outside  the  country.  A  further  five  trained  in  Kenya  have  already  died.   The  psychiatrists   in   the  public   service  are  deployed   to   the  national  hospital  Mathari   (4  plus  1  on   long   term   sick   leave),   the  Ministry   of  Health   (MOH)  Headquarters   (3   plus   1   on   secondment   to   the  World  Health  Organization   (WHO)   country   office   plus   1  provincial   director   of   medical   services   in   Nairobi),   the   University   of   Nairobi   (10),   Kenyatta   Hospital   (6),   Kenyatta   University   (2),  Armed   forces   hospital   (1),  Moi  University   (6),   Provincial   hospitals   (6   -­‐Garissa   has   none),   plus   5   placed   in   the   district   hospitals   of  Machakos  (1),  Thika  (1),  Muranga  (1),  Meru  (1),  and  Kisii  (1).  (Kiima,  Jenkins  2010  Medical  Journal)  

There   are   418   trained   psychiatric   nurses   in   Kenya   of   whom   only   250   are   currently   deployed   in   psychiatry   (the   other   250   are  deployed  in  general  medical,  surgical  and  obstetric  services  or  in  HIV  centers),  70  are  in  Mathari  National  Hospital,  leaving  180  in  the  districts  and  provinces,  resulting  in  only  less  than  1  psychiatric  nurse  per  new  district  or  2-­‐3  psychiatric  nurses  per  old  district.  Many  psychiatric  nurses  have   retired,  died,   left   the  country  or  work   in  NGOs,  especially   linked   to  HIV  activities,   and  new  applicants   for  mental  health  nurse  training  are  dwindling.  Thus  2009  will  see  the  production  of  only  1  new  psychiatric  nurse  for  Kenya.  There  is  1  medical   social  worker   in  each  province  but  none  at  district   level,   and   there  are   social  workers   in  prisons,  probation   services,   the  children's  dept  and  the  ministry  of  Social  services.  There  are  a  handful  of  psychologists  in  university  or  private  practice  in  Nairobi.  

Thus  it  can  be  seen  that  the  majority  of  the  psychiatrists  are  in  Nairobi,  and  that  the  effective  psychiatrist-­‐population  ratio  outside  Nairobi  is  1  psychiatrist  per  province  of  3-­‐5  million  people.  North  Eastern  Province,  an  extremely  challenging  environment  adjoining  Somalia,  currently  has  no  psychiatrist  or  psychiatric  nurse.  At  the  current  rate  of  production  it  will  take  about  100  years  to  produce  enough  psychiatrists  to  have  one  in  each  district,  taking  account  of  retirement,  and  assuming  no  further  brain  drain.  The  University  of  Nairobi  has  also  started  training  clinical  psychologists  since  2000  (currently  37  students)  and  psychiatric  social  workers  since  2005  (currently  1  student).  There  is  also  a  new  post  graduate  diploma  in  substance  abuse  with  2  students.  (Kiima,  Jenkins  2010  Medical  Journal)  

The  specialist  service  for  nearly  all  regions  and  districts   is   largely  delivered  by  extremely  overstretched  mental  health  nurses,  who  have   had   no   access   to   continuing   professional   development   throughout   their   careers.   This   lack   of   human   resource   and   the  continued  limited  funding  of  mental  health  services  both  severely  curtail  access  to  specialist  care,  and  this  situation  will  rapidly  get  worse  unless   urgent   action   is   taken   to   train  more  psychiatric   nurses.   The  Ministry   of  Health   is   planning   to  offer   10  bursaries   for  training  mental  health  nurses  next  year,  but  if  the  numbers  are  to  expand  rather  than  simply  replace  losses,  that  figure  will  need  to  double.  The  production  of  other  specialist  cadres  would  also  benefit  from  support.  

The  health  service  is  broadly  structured  into  six  levels;  the  national  referral  hospitals  (level  6),  provincial  general  hospitals,  (level  5),  district  general  hospitals  (level  4),  health  centers  (level  3),  dispensaries  (level  2)  and  volunteer  community  health  workers  (level  1).    Level   2-­‐6   are   now   receiving   funds,   sent   electronically   from  Treasury,   chanelled   through   the  MOH,   to   the   facilities.  Districts   have  

 

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therefore   lost   their   earlier   role   of   distributing   funds   to   health   facilities,   but   they   have   their   own   funds   raised   from   cost   sharing  revenues  for  running  various  activities  (Clients  are  asked  to  pay  a  small  fee  for  each  consultation.  This  fee  goes  to  the  cost  sharing  fund  of  each  facility  where  it  is  used  for  service  developments).  Considerable  capacity  building  is  required  and  is  underway  to  ensure  accountability,  transparency  and  proper  utilization  of  public  funds.  

 

Level  I:  Community  level  –  the  community  to  be  empowered  with  information  and  skills  .  

Level   II   &   III:   Dispensaries,   clinics,   Health   Centers   and   Nursing/Maternity   Homes   –   to   provide  mainly   promotive   and   preventive  health  care  with  some  curative  health  care.  

Level  IV  –  VI:  Primary,  secondary  and  tertiary  hospitals  –  to  provide  mainly  curative  and  rehabilitative  health  care.  

According  to  the  census  statistics  of  2009,  the  population  of  people  with  disabilities  in  Kenya  is  about  1.3  million,  accounting  for  3.5  percent  of  the  total  population  (KNBS,  2010).  However,   it  should  be  noted  that  the  census  data  gave  this  as  a  conservative  figure,  owing  to  the  fact  that  only  the  traditional  areas  of  disability  were  considered  (physical,  mental,  hearing,  visual  and  speech),  and  only  ‘conventional  households’  were  asked  this  question.  Of  those  with  disabilities,  51  percent  were  female,  while  49  percent  were  male.  The   largest   proportion  was   physical   and   self   care   disabilities   (31percent),   followed   by   visual   disabilities   (25percent)   and   hearing  disabilities   (14percent).   However,   it   is   important   to   mention   that   other   estimates   do   vary   considerably   across   documents.  International   Labour  Organization   (ILO,  2004:9)  has  noted   the   lack  of   reliable  data  on   the   situation  of  persons  with  disabilities   in  Kenya.      Another  government  document  (GOK,  2005)  suggests  that  25  percent  of  children  with  disabilities  are  of  school-­‐going  age  (between  6-­‐18  years).  According  to  the  National  Survey  on  Persons  with  Disabilities  in  Kenya  (GoK,  2008a),  3.6  percent  of  youth  between  ages  15  to  24  years  had  disabilities  out  of  which  visual  and  physical  impairments  had  the  highest  prevalence  at  1.1  percent  each.  Amongst  persons   aged  between  25-­‐   34   years   the  prevalence  of  disability  was  4  percent.   In   this   group  physical   disabilities  had   the  highest  prevalence  of  1.3  percent  followed  by  visual  disabilities  at  1.1  percent.    Although  most  donor  and  development  agency  attention   is   focused  on  communicable  diseases   in  Kenya,   the   importance  of  non-­‐communicable  diseases  including  mental  health  and  mental  illness  is  increasingly  apparent,  both  in  their  own  right  and  because  of  their   influence  on  health,  education  and   social   goals.  Mental   illness   is   common  but   the   specialist   service   is  extremely   sparse  and  primary   care   is   struggling   to   cope   with   major   health   demands.   Non   health   sectors   e.g.   education,   prisons,   police,   community  development,  gender  and  children,  regional  administration  and  local  government  have  significant  concerns  about  mental  health,  but  general   health   programs   have   been   surprisingly   slow   to   appreciate   the   significance   of  mental   health   for   physical   health   targets.  Despite  a  people  centred  post  colonial  health  delivery  system,  poverty  and  global  social  changes  have  seriously  undermined  equity.  

The  public  sector  is  the  largest  provider  and  financier  of  health  services  and  operates  health  care  facilities  throughout  the  country  accounting  for  about  52%  of  all  facilities.      

 

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In  the  Vision  2030  Master  Plan,  several  structural  changes  are  envisaged  to  improve  and  expand  the  existing  health  sector  in  both  public   and   private   spheres   to   address   the   challenges.   The   government   has   therefore   invited   the   private   sector   to   join   it   in   the  delivery  of  health  care  services  in  line  with  the  spirit  of  the  Public  Private  Partnership.  

Funds  for  mental  health  remain  extremely  limited,  and  strategic  advocacy  is  required  for  adequate  prioritization  of  mental  health  in  each  district  and  province.  

There  have  been  increased  reported  cases  of  police  officers  turning  their  guns  against  their  fellow  officers,  their  families,  public  and  also  against   themselves.  This   is  most   likely   in   the  context  of  mental  health   issues   in   the  officers   themselves  which  have  not  been  channeled    to  professional  help  either  because  the  officers  do  not  realize  that  they  have  a  mental  health  issue  or  feel  constrained  to  talk  about  them  for  fear  of  victimization  or  being  stigmatized.  The  price  for  this  is  either  death  or  severe  incapacitation.  Therefore,  there  is  need  to  address  the  mental  health  needs  of  the  police,  check  on  their  stress  levels  and  situations  that  predispose  them  to  the  same,  how  it  affects  their  families,  their  colleagues  and  the  public  and  how  it  affects  their  work  performance.  

Rogue  officers  become  killers    

• February  10,  2011:  A  drunk  GSU  officer  shoots  dead  his  boss  and  a  colleague  in  Mombasa  • November  6,  2010:  AP  Constable  Peter  Karanja  shoots  eight  people  and  two  officers  in  Mbeere.  • May  7,  2010:  An  officer  commits  suicide  after  killing  a  colleague  in  Borabu  District.    • January  31,  2008:  Eldoret  traffic  police  officer  Andrew  Moeche  kills  a  former  girlfriend  and  an  MP  in  a  love  triangle.  • July  26,  2005:  Corporal  Christopher  Muli  kills  Chief  Inspector  Josephat  Mitau  at  Spring  Valley  Police  Station,  Nairobi.  

 Initiatives  and  strategies  to  address  health  must  systematically  incorporate  mental  health  as  a  key  part  of  overall  health.  Application  of  the  human  rights  and  social  justice  frameworks  in  mental  health  require  concerted  effort  and  commitment  to  address  the  underlying  determinants  of  mental  health  problems  including  fair,  equitable,  and  ethical  distribution  of  resource  distribution  (e.g.  treatment),  inclusive  mental  health  and  primary  care  policies,  and  strengthened  legal  and  human  rights  protection  for  people  living  with  mental  disorders  and  their  families  (Ngui,  Ndetei,  Khasakhala  &  Roberts,  2010)    The  projected  burden  of  mental  health  disorders  is  expected  to  reach  15%  by  the  year  2020,  where  common  mental  disorders  (depression,  anxiety,  and  substance-­‐related  disorders  including  alcohol)  will  disable  more  people  than  complications  arising  from  AIDS,  heart  disease,  traffic  accidents  and  wars  combined.  Almost  one  third  (28%)  of  disability-­‐adjusted  life-­‐years  in  2005  were  attributed  to  neuropsychiatric  disorders  (e.g.  unipolar  affective  disorder  (10%)    (Murray  &  Lopez,  1996).    Mental  health  inequalities  are  strongly  associated  and  embedded  within  the  broader  social  and  economic  context.  An  inverse  relationship  between  socio-­‐economic  status  and  mental  disorders  has  been  documented  (Dalgard,  2008;  Hunt,  McEwen,  &  McKenna,  1979;  Kessler  et  al.,  1994).  In  almost  all  nations  the  poor  are  at  a  higher  risk  of  developing  mental  disorders  compared  to  the  non-­‐poor.  Poverty,  is  both  a  ‘determinant  and  a  consequence  of  poor  mental  health’  (Murali  &  Oyebode,  2004,  p.  217).      Mental  disorders  increase  the  likelihood  of  living  in  poverty,  perhaps  because  of  their  influence  on  functionality  and  ability  to  get  or  sustain  employment.  Conversely,  poverty  increases  the  likelihood  of  developing  mental  disorders  (Bostock,  2004;  Das  et  al.,  2007;  Murali  &  Oyebode,  2004).    The  consequences  of  mental  health  inequalities  include  continued  unnecessary  suffering  and  premature  deaths,  increased  stigma  and  marginalization,  lack  of  investment  in  mental  health  workforce  and  infrastructure,  and  limited  or  lack  of  treatment  for  people  suffering  from  these  conditions.  In  many  developing  nations  with  mental  health  policies,  scarce  resources  and  infrastructure,  ineffective  advocacy  and  the  lack  of  political  will  limits  effective  mental  health  legislations  and  interventions  (WHO,  2005b).  These  nations  often  lack  effective  mental  health  champions  who  can  galvanize  communities  and  policy  makers  to  address  mental  health  needs.      

 

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Families  of  people  with  mental  health  problems  are  often  marginalized  and  are  limited  in  their  ability  to  champion  for  mental  health  issues  due  to  the  stigma  associated  with  these  disorders.    Unique  Challenges  Experienced  by  Persons  with  Psychosocial  Disabilities  (Mental  illness/disorders)  in  Kenya    

1. A  demand  to  prove  disability  in  legal  and  judicial  systems  yet  no  specialized  services  are  provided  to  support  identification  of  the  presence  of  special  needs  in  an  individual  during  the  court  process.        

2. Insensitive  administrative,  legal  and  judicial  personnel  who  are  completely  uninformed  of  the  special  needs  of  persons  with  disabilities.      

3. Unrecognized   and   poorly   exercised   supported   decision   making   process   often   abused   by   parents   and   guardians   when  persons  with  severe  and  profound  disabilities  are  involved.      

4. Lack  of  recognition  of  self  representation  of  persons  with  psychosocial  and  intellectual  disabilities  with  the  support  of  their  human  readers  or  aide.  Unlike   in  the  developed  countries,  a  self  confessed  person   living  with  psychosocial  or   intellectual  disability   is  denied  recognition  as  a  capable  individual  to  effectively  represent  persons  with  disabilities   in  decision  making  forums.      

5. Lack   of   legal   recognition   of   suitable/qualified   aide   to   accompany   persons   with   severe/profound   psychosocial   and  intellectual  disabilities  in  decision  making  forums  e.g.  policy  and  legislation  forums.  In  developing  countries,  recognition  of  such  aides  or  human  readers  are  limited  to  parents/guardians,  despite  their  inability  to  contribute  effectively  towards  the  multidisciplinary  issues  of  psychosocial  and  intellectual  disabilities.        

6. Effects  of  unmonitored  guardianship  and  substituted  decision  making,  among  persons  with  severe  and  profound  disabilities  which  result  to  denied  ownership  and  management  of  property.    

7. Misused  privacy  rights   in  homes  and   institutions  where  persons  with  severe  and  profound  disabilities  are  caged,  chained  and  isolated  under  the  home/institutional  privacy  rights.    

8. Inadequate  education  rights   that   limits  education   facilitation  to   teachers  and   learning  materials.  This  has  denied  persons  with  psychosocial   and   intellectual  disabilities   their   rights   to  access   suitable  multidisciplinary  approach   to  education,   care  and  rehabilitation.  Such  multidisciplinary  approach  would  include  the  rights  to  access  other  crucial  specialized  services  from  the  multidisciplinary  team  that  include  materials,  equipments  and  therapeutic  drugs.  

9. Abuse  of  religious  and  cultural  rights  through  performance  of  rituals  and  other  unorthodox  practices  e.g.  exorcism  of  evil  spirits  from  persons  with  psychosocial  and  intellectual  disabilities  practiced  in  Kenya  among  other  African  countries.      

10. Denied  access   to  specialized  basic   intervention  services  needed  by  persons  with  psychosocial  and   intellectual  disabilities.  This   is   often   the   case   in   developing   countries   due   to   extreme   poverty   and   scarce   resources.   NB   -­‐   Access   to   basic  intervention  services  remains  the  backbone  of  the  ability  to  exercise  an  individual’s  disability  rights.  In  Kenya,  lack  of  access  to  crucial  basic  intervention  services  by  children  with  disabilities further incapacitates their ability to exercise their disability rights.  

Treatment  and  management  of  Bipolar  Disorder  in  Kenya  

As  previously  stated,  there  is  no  targeted  approach  or  mechanism  to  cope  specifically  with  Bipolar  Disorder,  it’s  a  seldom  understood  condition  even  amongst  some  non-­‐psychiatric  doctors.  

 

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Personal  Experience  Treatment  Bipolar.  

1. Establish  contact  by  scheduling  appointment  with  a  Psychiatrist  (USD  30  per  session)for  diagnosis  (usually  with  a  close  friend  or  family  member).    Family  history  usually  taken  at  this  stage  (Depending  on  severity  of  case  on-­‐the-­‐spot  admission  to  mental  health  facility-­‐private  if  can  be  afforded  by  patient)  

2. Prescribed  medication  or  what  we  refer  as  the  maintenance  dose  of  anti-­‐depressants  with  regular  review  for  feedback  to  either  cut  back  increase  or  maintain.    A  new  variety  can  be  added  incase  the  current  prescription  is  not  effective  

3. Access  to  hospitalization  is  dependent  on  availability  of  health  insurance  (only  valid  if  at  time  of  taking  policy  bipolar  wasn’t  pre-­‐existing)  or  family  can  put  up  a  cash  deposit  to  reserve  occupancy  and  rehabilitation  (USD    50  –  120  per  day)  

4. Hospitalization  involves  daily  routine  monitoring,  art  therapy,  group  therapy  and  individual  counseling  therapy  when  required  

5. Once  discharged  from  hospital  the  switchover  is  not  so  easy  as  the  commercialized  services  of  art  therapy  and  group  therapy  are  no  longer  available  –  a  recovered  individual  back  to  a  similar  if  not  more  hostile  (lack  of  understanding  &  support)  environment  

6. The  Psychiatrist  can  recommend  a  psychologist  for  talk  therapy  (dependent  on  financial  capacity  of  patient/family)    for    sessions  –  10+  depending  on  case  by  case  charges  at  KES  3,000  –  9,000  or  USD  30  –  100  (spot  rate  today  1USD=KShs.  97)  

7. Currently  piloting  user-­‐led  peer  support  group  with  volunteer  NGO  (allied  disorders  not  purely  bipolar)    People  suffering  from  bipolar  disorder  in  Kenya  (along  other  allied  conditions)  tend  to  be  excluded  from  access  to  insurance  due  to  discriminatory  practices.    Upon  the  employer  finding  out  that  one  has  bipolar  and  they  connect  that  it’s  a  mental  illness,  termination  of  employment  or  by-­‐pass  to  career  advancement  is  the  common  practice.    Labor  &  economic  participation  a  great  challenge  when  considering  a  holistic  rehabilitation  of  a  person  with  bipolar  back  into  a  productive  member  of  society.