In Sierra Leone, Shining a Light on Pediatric Mental Health
PIH supporting country’s first mental health unit for children and adolescents
Posted on Aug 27, 2021
On a cloudy July morning on the lush green outskirts of Freetown, Sierra Leone, Dr. Elizabeth Allieu stands in front of a classroom of preteen and teen girls, encouragingly telling them that there are no wrong answers to the question she just posed:
“What is mental health?”
A few of the teens shyly offer some word associations: Frustration. Anger. Stress. Allieu leads the room in clapping for each girl who speaks up, then launches into her own explanation.
“When we say mental health, we mean the well-being of your mind,” Allieu, a pediatric specialist, says. “When you’re not well, what do you say? That you’re sick? Mental health can mean when your mind is sick.”
She then asks if any of the girls are familiar with Sierra Leone Psychiatric Teaching Hospital. Most say no. But when their teacher cuts in to revise the question—“Who has heard of Kissy Mental Hospital? The crazy yard?”—heads start nodding. The whole room knows about Sierra Leone’s only hospital dedicated to mental health care.
Based on how they still use the hospital’s decades-old nickname, however, they don’t know the extent to which the hospital has transformed. Since support from Partners In Health began in 2018, Kissy Mental Hospital has become Sierra Leone Psychiatric Teaching Hospital—a revolutionary change. For decades, the deeply stigmatized facility had no electricity, running water, or psychiatric medications. Members of the surrounding community feared Kissy’s patients, who often were chained to their beds by desperately under-resourced clinicians.
Now, Sierra Leone Psychiatric Teaching Hospital is a chain-free facility with modern amenities and stocked pharmacy shelves, where improved services are enabling clinicians to care for more outpatients than inpatients. Amid the fear, misunderstanding, and sometimes cruelty that surrounds people living with mental health conditions, the hospital is slowly but surely changing the face of mental health care.
Nonetheless, one group had been left out of this process: children. That is, until May, when clinicians at Sierra Leone Psychiatric Teaching Hospital opened the facility’s, and the country’s, first child and adolescent mental health unit.
The new unit was spearheaded by Allieu and is the reason for her visit to the girls, all of whom have suffered severe abuse and now live in a group home run by a local nonprofit.
“The child and adolescent mental health unit is for you, and it’s free of charge,” Allieu tells them. “Whenever you feel stressed, when you’re not feeling okay, when you have an illness in your mind, you go there. You talk to a teacher or someone very close who you trust, and come with that person to us. And we can help.”
After asking each girl her name and what she wants to be when she grows up, Allieu goes on to deliver the same message to two more classrooms of children and teens from the home, ensuring they and their caregivers know about this new resource for counseling and psychiatric support.
It’s part of Allieu and unit staff’s ongoing effort to reach as many schools, group homes, and orphanages throughout Freetown as possible. Their goal is to spread welcome news: In a country with the oldest psychiatric hospital in sub-Saharan Africa, yet with only two psychiatrists and extremely limited mental health services—none of which have ever been specialized for pediatrics—young people now have a dedicated place to go for their mental health needs.
“They aren’t meant to suffer”
Since she started medical school in her home city of Freetown, Allieu has been determined to care for children.
“I think one of the main things I like about children is they don't tell lies. They tell you exactly how they feel, and they don't pretend,” Allieu said. “I just see the need for them to have a healthy life. That's why I’ve always been working with them: I need to protect them. They aren’t meant to suffer.”
After training and working in pediatric departments in hospitals and health centers throughout Freetown, Allieu moved to London to pursue a master’s degree in advanced pediatrics. That experience, she said, is how she fell in love with pediatric mental health.
“My driving force was a paper I came across talking about Sierra Leone’s treatment gap for children living with mental health conditions. They noticed we had a 99.3% treatment gap,” Allieu said. “We’ve gone through a lot, from the civil war, to Ebola, to mudslides. Imagine what children have gone through.
“I kept the paper,” Allieu continued, “and said to myself, ‘When I come back home, I’ll try to do something.’”
In the fall of 2020, Allieu moved back to Freetown and began talking with Dr. Abdul Jalloh, the medical superintendent of Sierra Leone Psychiatric Teaching Hospital and one of the only psychiatrists in Sierra Leone, about the idea of the unit. He offered a space and the resources of the PIH-supported hospital. With additional private funding, the unit was quickly planned, staffed, and filled with books, toys, and inspirational murals. By May, it was ready to welcome its new young patients.
“I vividly remember the first meeting we had with Dr. Allieu and Dr. Jalloh,” said Chenjezo Gonani, PIH’s mental health program manager. “It was very, very clear that this is a matter of urgency, and we had no choice but to find the resources for this facility. With their enthusiasm and leadership, we were able to pull this facility through within a very short time.”
Low Information, High Stigma
As Allieu notes, trauma—experienced and inherited—plays a large role in shaping mental health for Sierra Leone’s population, children included. As she conducts more outreach visits to promote the unit, especially to high schools, she anticipates an uptick in patients arriving for care for depression, anxiety, and trauma.
Thus far at the unit, however, she’s mostly been observing the biology and genetics behind mental health conditions, as well as how extreme poverty, and its resulting lack of access to nutrition and education, can disrupt children’s cognitive development and emotional well-being. The majority of kids have been arriving with speech delays, ADHD, autism, and epilepsy (a condition that falls under the umbrella of mental health in Sierra Leone, and in much of sub-Saharan Africa).
While these roots are well-known, the exact burden of pediatric mental health conditions in Sierra Leone remains mostly a black box. With services long non-existent for the country’s youth, there has been no public platform that could provide data on the prevalence of mental health conditions among kids and adolescents. This lack of information obscures the exact need for pediatric mental health services and becomes part of a familiar cycle between lack of resources, lack of care, and stigma—which Allieu says is doubled for children.
“Mental health conditions don’t just affect the child; they affect the family, also,” Allieu said. “That’s what makes it worse: The family stigmatizes the child. They keep them out of school, at home, and don’t associate them with other children.”
Such stigmatization is often a form of protection. Given the lack of treatment available, and given deeply rooted cultural beliefs, most families opt to take their children to traditional healers in their communities when they exhibit signs of a mental health condition, which are commonly thought to result from witchcraft or demonic possession. When the child inevitably does not get better without clinical intervention, families often feel they have no choice but to bow to stigma and keep their children away from those who might misunderstand or hurt them, or their entire family.
Not only does Allieu want to provide direct care to families for whom treatment has never been available—in so doing, she also wants to begin developing a comprehensive understanding of what illnesses are affecting what children.
“That’s the question I want to answer: ‘What’s the real picture?’” Allieu said. “What’s the percentage of diseases? What’s the economic burden? Because we started this clinic, we’ll be able to collect some numbers—how many patients we have, their conditions—and tell the public that this is what we’re dealing with. Everything comes back to awareness.”
Gonani also noted the generational shifts the unit could potentially enact.
“We’re looking at the continuum—mental health from a young age, the developmental stages, up to the adult world,” Gonani explained. “If we create this base of services to respond to the mental health needs of young people, we will reduce the burden of mental health in the adult population. And we know the burden of mental health on adults trickles down to young people. So if we are able to strengthen this aspect of care, we can have a significant mark on the history of this country.”
Allieu knows this could be a slow process. In its first three months, the pediatric mental health unit has seen 21 patients, ages 3 to 16, with an average of four coming in each Wednesday, when Allieu provides checkups and new intakes. Much of Allieu’s week is dedicated to outreach visits to promote the unit and its unprecedented services. But she says the low patient volume does have an advantage: enabling her to spend adequate time on each case, especially as the only doctor in the unit.
Her approach to care is gentle and family-oriented. She avoids prescribing medications wherever possible, and emphasizes the power of knowledge, socialization, and parental involvement.
“If you notice, we don’t have inpatients,” Allieu said. “We’re trying to de-institute. I’m involving the parent more than I’m even involving myself. When a patient comes in, the first thing we do is psychoeducation. We explain to the family what the condition is, what they’re dealing with. I try to push a policy for families to not keep children at home—to send them back to school or to a special needs school. We do counselling. We teach parents techniques for some at-home speech therapy.”
With extreme poverty as the backdrop of many patients’ lives, Allieu makes referrals to PIH social support programs and works to provide opportunities for play, enrichment, and learning. She sends every patient home with a toy or book after their appointment, and is working to develop partnerships to introduce art and music therapy. She’s building a small playground inside the unit, complete with a swing set and AstroTurf. And soon she’ll establish an evening support group specifically for parents.
The goal, ultimately, is to set young people on a path to outgrowing their condition or easily managing it—a path many of Sierra Leone Psychiatric Teaching Hospital’s adult patients were never put on, especially with a lack of family support.
“Some mental health issues are not lifelong if they are treated early,” Allieu said. “In adults, it's rehabilitation; in children, it's reinventing, giving them new skills.”
It’s also to establish a model for child mental health in Sierra Leone.
“Not only is this a center of specialized mental health care for young people,” Gonani said. “It’s also a hub to build and strengthen child mental health services elsewhere across the country.”
“Today, she’s smiling”
Though there are no quick fixes when it comes to mental health, many patients of the unit have already seen their lives change with the ability to finally access proper care.
Shortly after the unit opened, 15-year-old Mabinty Mansaray arrived with a two-year-old struggle: Every time she got her period, she also experienced seizures. She hadn’t stepped inside her classroom ever since; amid the dangers of seizing at school, her parents kept her home. And amid suspicions of witchcraft from neighbors, her mother stopped her from leaving the house altogether.
Staying home all day, every day, Mansaray found herself in a hole of depression.
“She said she felt left out,” Allieu said. “I think that day she was even crying, that she can’t see her friends and she needed to go to school again.”
Allieu took her usual approach: psychoeducation, family involvement, and then medication, as well as counselling.
“The first thing was, she needed to understand what epilepsy was,” Allieu continued. “I told her that once she is on medication, she can go to school. She can do whatever she wants to do. There are people out there with epilepsy that are carrying on with their life.”
Mansaray’s sister had brought her to the unit, but Allieu quickly called her parents to come in to relay that same message, before beginning Mansaray on medication.
Finding the right dosages in accordance with Mansaray’s hormones required close monitoring. And convincing Mansaray’s parents of their daughter’s hopeful future required persistence.
“It was really a battle for her to take her medication,” Allieu said. “When we started the medication, her parents said they didn’t want her to go to school because they said she would always have seizures.”
But, Allieu continued, “They are all really happy now, because they notice that if she takes her medication, she doesn’t have a seizure.”
In mid-July, coming in for a check-up, Mansaray reported good news: She hadn’t had a seizure for a full month, and expected to re-enroll in school in September.
“She was really not smiling,” Allieu recalled of her first meetings with Mansaray. “Today, she’s smiling.”