Conducting Mental Health Researches in Africa: Challenges and opportunities

Experience from Ethiopia

Teshome Shibre Department of Psychiatry, School of Medicine, College of Health Sciences, AAU and Zewditu Memorial Hospital, FMoH

Presentation outline

• Brief background about mental health researches in Ethiopia

• Challenges of conducting MH research• Opportunities to conduct MH research in low income countries, Ethiopian experience

Top 10 subject areas published in biomedical journals (Shibre 2009, unpublished)

R. No Subject area

1 HIV/AIDS & Tuberculosis

2 Nutrition

3 Malaria

4 Mental disorders

5 Maternal health

6 Upper Respiratory Tract Infection

7 Diarrheal Disease

8 Injury (Physical)

9 Leishmaniasis

10 Schistosomiasis

MH researches before 1990 • Clinical and community based studies, instrument validation

studies (R. Giel, F. Kortman, F. Workneh)• Suicide and DSH studies (,L. Jacobsson, A. Bekrey)• Suicide (A. Alem, Kebede, Desta, Araya)• Studies among Children and adolescents (Tafari)

Transition

Advance in Mental Health Research after 1990• Internal & External collaboration for research and capacity building• International grants (SMRI, SIDA/SARCE)• TAAPP collaboration• Epidemiological studies• External grant• Validation of research tools

• SRQ , CIDI, DICA, IPDE, SCAN, SF-36• Use of innovative case detection methods (e.g. KI)

Focus of post-1990 researches• Butajira Study

• Psychotic disorders (Schizophrenia and other psychotic disorders, and bipolar disorder)

• Suicide • Epilepsy• Alcohol and Khat• Focus on special population• Disorders in children• Depression

Focus of the Butajira study• Prevalence of priority disorders including maternal depression

both in Butajira and other population groups • Course and outcome of priority disorders• Impact of priority disorders• Studies on special( population )

Reports on priority disorders: prevalencePriority disorder Lifetime prevalence (%)

Depression 5.0

Schizophrenia 0.5

Bipolar disorder 0.5

Suicide 8/100,000/year

Epilepsy 1.0-2.0

Alcohol dependence 1.0-1.5

Cannabis abuse 1.5% (Urban)

Disorders in children 17.7%§

§-Tadesse B, Kebede D, Tegegne T, Alem A. Childhood behavioural disorders in Ambo district, Western Ethiopia. I. Prevalence estimates. Acta Psychiatrica Scandinavica 1999; 100:92-97

Service utlisation data

• For those with schizophrenia and bipolar disorder: proportion who have ever received psychiatric treatment is < 10%

(Kebede et al 2003; Negash et al 2005)

• For those with some depressive symptoms: proportion who attend for general medical attention because of these symptoms: ~40%-80% (Fekadu et al 2007 and 2008)

Impact of disorders

• Described course and outcome (Kebede 2003, Alem 2009)

• High level of unemployed and unmarried among those with schizophrenia

• Level of general day to day disability very high• High level of stigma perceived by family (Shibre et al 2003) and

perceived by patients (Assefa et al 2010, unpublished)

• High level of family burden (Shibre et al 2003)

• High level of economic burden (Zergaw et al 2009)

Impact of disorders

• Significantly higher under nutrition (Lijalem et al, Unpublished)

• Maternal depression associated with infant diarrhoea disease (Hanlon et al 2009 )

• Schizophrenia, bipolar disorder and depression all associated with almost threefold higher risk of premature death compared with the general population

Impact of studies• Ethiopia is recognised as a centre of excellence in mental

health research in sub-Saharan Africa • The only population based studies on bipolar disorder in Sub-

Saharan Africa (possibly developing countries) • Study results are internationally recognised and have

challenged some of the major dogmas on the outcome of psychosis

• Important data for policy makers• Established service programmes in research sites• The Butajira project runs a model outreach service• Capacity building—PhD training (9 completed—8 currently in

country)

Criticisms on Mental Health Studies from low income countries (Alem & Kebede 2003)

• The studies conducted do not address priority problems • They have been donor driven • The quality of research in many instances is low• Information generated from the research have not been

well documented • Dissemination of results is poor

Challenges 1. Working environment

• Work load and extremely difficult situations• Lack of training to plan and implement research projects• Poor culture for mentoring and grooming young researchers• Low salary of researchers• High rate of brain drain• This has forced many people who had dreamt to be researchers

and scientists to devote their time to income-generating activities such as

• Private clinical practice or

• The Consultancy syndrome (Alem 2007, AAPAP meeting)• Market driven education

Challenges 2. Institutional factors• Insufficient training of staff in research

• protocol development• fund soliciting • project execution and • financial management

• Lengthy ethical clearance process at different levels• Long buearocratic process to utilise funds • Lack of system for remuneration from research grants to

complement their salaries• Lack of the required literature• Poorly developed lab facilities• Shortage of basic scientists • Lack of strong demand for publication by Universities

* Difficulty to publish in high impact factor journal

Challenges 3. Intrinsic nature of psychiatric research • Instruments are not validated for use in all cultures

• Absence of vital event registration system• Recall for important life events and past episodes of

illness in Illiterate society is very difficult • • Retrospective data collection suffers from recall problems

especially with illiterate subjects • Resources and logistic difficulties related to Longitudinal

studies • The obligation to treat those persons identified as cases

through the research activity (< 10% of the Butajira cohort had access to modern psychiatric

care)

Opportunities 1. General• Low cost• Possibilities for large population studies• Existence of wide cultural and genetic diversity to study

• Willingness of people to participate in research• Many unexplored areas, cultures and values• Growing number of professionals

Opportunities 1. General …

• Favourable conditions for capacity building through exchange programs for researchers and residents

•Service related research in traditional society is not explored e.g.

• factors influencing integration•Explore family based care system• Etiological researches e.g infectious causes

Opportunities 3. Political commitment

• Political commitments to integrate MH into existing health care system and supporting research

• National MH Strategy• 2- HEW per smallest admin unit (total over 34,000)

• Commitment to developed health infrastructure at all levels

Opportunities 4. University commitment• Dramatic improvements in the University academic undertakings and

commitment to research• Expansion of regional universities and commitment of Postgraduate

education (MSc and PhD level trainings)

Opportunities 5. Department• Excellent track record in International Collaboration• Increased donor’s interest • New Ph.D program in Mental Health Epidemiology• Experienced research team• Availability of validated instruments• Improved Research infrastructure - Guesthouse, Office

Conclusion• Challenges to provide service and conduct mental

health research in Africa are many

• But there are also many opportunities to make a difference in mental health of our people in the continent and improve research collaboration.

Thank You