Innovation summary

Reported levels of mental health and psychosocial problems rose during the 2014–2015 Ebola virus disease outbreak in Sierra Leone1. During the Ebola virus outbreak, the one specialist psychiatric hospital (serving a population of 7 million) in the setting was closed down to prevent further disease transmission, creating a strong need for accessible mental health services2.

As part of the emergency response, existing plans to create mental health units within the existing hospital framework were brought forward. A nurse-led mental health and psychosocial support service, with an inpatient liaison service and an outpatient clinic, was set up at the largest government hospital in the country. One mental health nurse trained general nurses in psychological first aid, case identification and referral pathways. Health-care staff attended mental well-being workshops on coping with stigma and stress.

Impact summary

From March 2015 to February 2016:

  • 143 patients were seen at the clinic; 20 had survived or had relatives affected by Ebola virus disease;
  • Half the patients (71) had mild distress or depression, anxiety disorders and grief or social problems;
  • 30 patients presented with psychosis requiring medication;
  • 14 non-specialist nurses received mental health awareness training;
  • Over 100 physicians, nurses and auxiliary staff participated in well-being workshops.

“The Ebola virus outbreak weakened an already-fragile health system and disrupted existing plans to develop mental health services across the country. However, the emergency response provided the opportunity, resources and focus necessary to create new mental health units. We hope that our experiences and the models applied will help others around the world successfully implement similar services within an emergency response.” 

- Dr Stania Kamara, KSLP volunteer from the King’s Centre for Global Health and Health Partnerships​

Innovation details

Mental health service provision in Sierra Leone is poor. In 2009 an estimated 2,058 people received some form of mental health treatment out of about 102,000 people (3% of the 3.4 million adult population) who had a severe mental disorder2. There is one specialist psychiatric hospital in the country, located in the capital Freetown, to serve the population of 7 million.

During the Ebola virus outbreak, the Sierra Leone psychiatric hospital was closed to admissions to prevent disease transmission. Existing government plans to create new decentralized mental health units3 across the country were brought forward as part of the emergency response. Mental health nurses who had received 12–18 months’ mental health training in 2012–2013 from a bespoke nursing curriculum were deployed to general hospitals in various districts4. This innovation describes the experience of establishing one of the new units ‒ a nurse-led mental health and psychosocial support service at Connaught hospital in Freetown, the largest government hospital in the country with approximately 300 beds.

The service was launched in March 2015 and was available to those living within the Freetown city area (about 1 million people) or anyone admitted to Connaught hospital. The partnership devised a standard operating procedure. Individuals of any age with a known or suspected mental health problem or psychosocial need met the referral criteria. A service level agreement with the Sierra Leone psychiatric hospital allowed transfers for inpatient care. In keeping with hospital protocol, a registration fee was levied and waived if service users were unable to pay. A single mental health nurse provided the service, with prescribing of medication carried out by a link hospital medical physician. A range of treatments were provided. Psychological interventions were the most common, comprising basic counselling and problem-solving therapy. The WHO Mental Health Gap Action programme (mhGAP) intervention guide informed the model of care used5,9. 

Key drivers

Partnership model was a success
  • Early engagement of participants and a partnership approach with clear roles and responsibilities for all parties was key to ensuring ownership of and commitment to the service.
  • Partnerships were established with service user groups (e.g. the HIV peer network), national and international non-governmental organizations (NGOs) providing livelihood support, child protection organizations and faith groups.
Integrating mental health into a physical health setting
  • The health ministry and the hospital management responded positively to mental health and psychosocial support services being incorporated into a general hospital.
  • Evidence of high use by abandoned patients (those with no relatives to provide care or financial support) led to a successful request for a social worker to be deployed to the hospital.
Supervision and monitoring
  • Shared supervision was essential for maintaining clinical standards, developing competencies and providing a support network for the mental health nurses.
  • Monthly updates to the hospital management encouraged service improvements
Responsiveness to the needs of service users during the Ebola outbreak
  • The service’s ability to adapt and respond to changing needs ensured that support for health-care workers could be provided as the impact of the Ebola disease workload became apparent.
  • The service provided care not only for survivors but for all those affected by the outbreak who had with psychosocial needs.

Challenges

Limited supplies of antipsychotic medications were available

  • Although limited supplies of antipsychotic medications were available in local pharmacies, some patients could not afford them.

High workload for single mental health nurse
  • The workload was high for a single nurse and the mental health nurse faced a risk of burnout and fatigue. Staff recruitment and training remain areas for development.
Low community uptake
  • Most referrals were from within Connaught hospital. We suspect community uptake was low because the service was new and the community had previous experience of mental health services at the hospital.

Continuation

The Ebola virus disease outbreak weakened an already fragile health system6 and disrupted existing plans to develop mental health services across the country. However, the emergency response provided the opportunity, resources and focus necessary to implement the innovation7. Plans for expanding the current program include:

  • The establishment of 14 other mental health units countrywide so far with the finding that the service is inclusive and accessible to the entire population.
  • Further developing the service to include integration into primary-care structures, increased community utilization and greater staff recruitment.
  • A service evaluation ‒ measuring outcomes, follow-up rates, barriers to access and service coverage ‒ is underway.

Partners

Funders
  • UK AID (Government of United Kingdom of Great Britain and Northern Ireland)

Evaluation methods

Monthly monitoring and evaluation data was collected manually from the clinic ledger and presented to the hospital and health ministry management teams.

Cost of implementation

The program evaluation included measures for estimating the costs of running the program, although this information is currently not publicly accessible.

The health ministry met the human resources costs while the hospital provided office and clinical space and funding for consumables. King’s Sierra Leone Partnership provided technical expertise, staff supervision and office equipment.

Impact details

Training and capacity building
  1. Mental health awareness training were provided to strengthen the skills of 14 non-specialist ward nurses.
    • Mental health awareness trainings were delivered by a mental health nurse and a KSLP volunteer
    • Training consisted of a half-day session on psychological first aid8 that explored successful approaches to case identification and referral pathways.
  2. Mental wellbeing workshops were held for nurses, auxiliary staff and physicians who worked at Connaught hospital, including those working within the Ebola holding unit.
    • These workshops were created and led by the mental health nurse and comprised a series of half-day sessions, for groups of 10‒15, on coping with stigma and discrimination, stress management and self-care. One-to-one counselling for staff requiring more support was also available.
    • Over 100 Connaught hospital nurses, auxiliary staff and physicians participated in mental wellbeing workshops.
    • The human immunodeficiency virus (HIV) and epilepsy services at Connaught hospital were also offered half-day mental health awareness training by the mental health nurse, and referral pathways were created across the services.
Innovation Impact
  1. Fourteen non-specialist nurses provided basic support on their wards and referred patients to the service.
  2. A total of 143 patients were seen within the first 12 months of the service from March 2015 to February 2016.
    • 96 patients (67%) were referred from another department at Connaught hospital and 7 (5%) were referred from Ebola clinics; 17 (12%) were self-referrals, or by family or other relatives. Approximately 30 abandoned patients were also referred to the service.
  3. The most common diagnostic category was mild distress or depression, anxiety disorders and grief or social problems.
    • Thirty patients (21%) presented with psychosis requiring medication.
    • Survivors and bereaved relatives presented with normal grief or mild depressive or anxiety symptoms and often reported being stigmatized or discriminated against within their communities.
  4. Seven of the patients (5%) had survived Ebola virus disease and 13 (9%) were relatives of the deceased or survivors.

References

  1. International Medical Corps (2014). Assessment of mental health and psychosocial support (MHPSS) needs and resources in the context of Ebola. Lunsar: International Medical Corps Sierra Leone [Link].

  2. Alemu W, Funk M, Gakurah T, Bash-Taqi D, Bruni A, Sinclair J et al (2012) WHO proMIND: profiles on mental health in development: Sierra Leone. Geneva: World Health Organization [Link].

  3. Mental health policy (2012). Freetown: Ministry of Health and Sanitation.

  4. Sierra Leone Mental Health Coalition (2011). Enabling access to mental health in Sierra Leone (EAMH-SL) Quarterly newsletter [Link].

  5. World Health Organization (2011). WHO mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings [Link].

  6. World Health Organization (2015). Health worker Ebola infections in Guinea, Liberia and Sierra Leone: preliminary report [Link].

  7. Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings (2015). Mental health and psychosocial support in Ebola virus disease outbreak: A guide for public health programme  planners [Link].

  8. World Health Organization (2014). Psychological first aid for Ebola virus disease outbreak [Link].

  9. World Health Organization and United Nations High Commisioner for Refugees (2014). mhGAP humanitarian intervention guide (mhGAP-HIG) for the clinical management of mental, neurological and substance use conditions in humanitarian emergencies [Link].

Research

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Country

Sierra Leone

Affiliated organizations

CBM
King's Sierra Leone Partnership
World Health Organization

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