Response to Ebola Crisis Will Require Attention to MH Needs: Psychiatric News: VoI49... Page 1 of 3

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Response to Ebola Crisis Will Require Attention toMH NeedsAaron Levin

October 16, 2014

The mental health needs of survivors, families, and health workers are already apparent in the midstof the Ebola outbreak, but resources are limited.

Hidden behind the scramble to halt the incendiary Ebola epidemic in West Africa are the early stages ofetforts to deal with the inevitable psychological consequences of a major disaster.

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An elderly resident of a village 30 miles north ofMonrovia, Liberia, is taken to an ambulance aftershowing signs of Ebola infection. \/vhile health careresources-including mental health care-in theimpacted countries were inadequate before theoutbreak, they can't begin to keep up wrth demand now.Some organizations are training health care workers inpsychological first aid and finding care forunaccompanied children.

AP Photo/Jerome Delay

Public health and infectious disease expertshave already noted the weakness of thepreexisting medical systems in the region.

'The Ebola crisis today is a reflection of long-standing and growing inequalities of access tobasic health care," wrote World Bank PresidentJim Yong Kim, M.D., and Paul Farmer, M.D.,cofounders of Partners in Health, in theWashington Post on August 31. The nationshardest hit by the outbreak-Guinea, Liberia,and Sierra Leone-lacked the staff, supplies,and equipment to battle the disease, they said.

The same is even more true of the options formental health care in those countries. Ebola hasproduced enlarging circles of victims beyond theinfected and the dead. Survivors, families,children, and health workers are dealing withthe stress and trauma left behind by thedisease.

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PS}CHIATRIf;'{EIVS"The totality of the response has been quite slow, and the mental | { f'}r\,q-flffhealth response has even been slower," wrote Benjamin Harris, xJ F* L'rf*t $ 6*M.D., in an emailro PsychiatricNews. Harris is an associate Psychiatric News update is a weekly

e-newsletter bringing you uFtoihe-professor and chair of the Department of Psychiatry at A.M. Dogliotti moment news abbu[me feid of psychiatryCollege of Medicine in Monrovia, Liberia. and much more.

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http://psychnews.psychiatryonline.org/doi/fulli10.I176lappi.pn.20l4.10b14 1t2st2016

aResponse to Ebola Crisis Will Require Attention to MH Needs: Psychiatric News: VoI49... Page2 of 3

The only two internal medicine specialists in Liberia, including thehead of the country's only postgraduate medical training program,have died from the disease, he said

"There is a psychosocial burden of the disease on the families ofhealth professionals," said Mardia Stone, M.D., M.P.H., who returnedfrom Liberja in August. Stone is an obstetrician/gynecologist and a

senior advisor to the Chester M. Pierce, M.D., of the Division ofGlobal Psychiatry at Massachusetts General Hospital and HarvardMedical School. "Families are becoming quite resistant to havingtheir loved ones go to work. Some people are even threatening todivorce their spouses. Nothing is being done to embrace thepsychosocial element of what the workers are encountering."

"fln Sierra Leone,l medical personnel are facing extremely long shiftsattending to too many patients, with a lack of resources, whilewitnessing their colleagues' deaths and working under lots of fearand stress," said Carmen Valle, Ph.D., project coordinator andmental health specialist for the Enabling Access to Mental Health(EAMH) program in Freetown, Sierra Leone, in an email. EAMH isrun by CBM, a Christian development organization based in

Germany.

There is another vulnerable group, said Harris.

"Children made orphans by Ebola is a very sad and tragicconsequence of the epidemic," he said. "As a result of the

increasingly widespread fear of infection, these children are being ostracized, stigmatized, and discriminatedagainst, ... partially driven by the low level of knowledge of disease transmission in the affected countries.Unless this situation is urgently addressed, these children will suffer adverse social and psychologicalconsequences for years to come."

ln response, orphanages in Monrovia are starting to accept some children. Olher groups are working tolessen stigma and reintegrate some of these children jnto their communities, he said.

ln Sierra Leone, the Ministry of Social Welfare is working with child protection specialists from UNICEF andSave the Children to register "unaccompanied and separated children," as lhey are termed, and find care forthem.

EAMH is providing training and continuing support for child protection practitioners, as well as the services ofmental health nurses, said Valle.

Access to mental health care was poor even before the epidemic struck and has been exacerbated by thetrauma it is causing.

Sierra Leone has just one working psychiatrist,and there is one, small, aging psychiatrichospital in Freetown, the country's capital, saidAyana Jordan, M.D., Ph.D., the chief resident inpsychiatry at Yale. She has visited Sierra Leonefrequently over the last four years, conductingpsychiatric epidemiology surveys on behalf ofthe medical nonprofit Wellbody Alliance.

"Elsewhere in the countryside, there are noestablished mental health services," said Jordanin an interview. "People with mood, psychotic, orsubstance abuse disorders are treated by

traditional healers."

The Ministry of Health and Sanitation issued itsfirst mental health policy and strategic plan in2012, said Valle. Since then, 21 mental health

nurses have been trained and now work in district hospitals. Another 130 staff members at local clinics havebeen trained in basic metal health knowledge so that they can detect and refer patients.

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The mental health response to theEbola outbreak in Liberia hasbeen slow, said the country's onlypsychiatrist, Benjamin Harris, M.D(lefi). The psychological burden isespecially is especially high onhealth professionals, said MardiaStone, M.D., M.P.H., ofMassachusetts General Hospitaland Harvard Medical School(right).

Haruard Medical School

Ayana Jordan, M.D., Ph.D., chief psychiatry resident atYale, pauses by a church in Koidu City, Kono District,Sierra Leone, during her epidemiological study ofmental health in the region.

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http://psychnews.psychiatryonline.org/doi/full/l 0.1 17 6lappi.pn.2014.10b 14 U2512016

Response to Ebola Crisis Will Require Attention to MH Needs: Psychiatric News: Vol 49... Page 3 of 3

Liberia faces similar conditions. "l am currently the only practicing psychiatrist in the country," said Harris."We have a small mental hospital that takes care of about 50 inpatients. Psychiatric drugs of all kinds are invery short supply, with shortages of basic drugs being faced on a regular basis.'

Given that background, any mental health response to the outbreak begins well behind the starting line, but atleast it is beginning.

Before the outbreak, the Carter Center had helped train about 1 00 nurses and physician assistants in Liberiato assess and manage basic mental health conditions, said Harris. "l am not aware of any medicalorganizations providing mental health-related interventions currently in Liberia."

The Mano River Union, a consortium of Liberia, Sierra Leone, and Guinea, is developing a psychosocialinitiative called the Social Protection Strategy, said Harris, who is working on the project. "Focus will beplaced on minors, unaccompanied children, orphans, and widows.'

Stone expects a demand for psychiatrists and psychologists once the outbreak is under control, but foreignspecialists will have trouble with local ethnic languages and cultural nuances even though the two countries'otficial language is English.

EAMH and other organizations working in Sierra Leone are training health workers in psychological first aidand providing backup support to mental health nurses in district hospitals, said Valle. "The goal is to helpthem with stress-management techniques and referral to psychiatric nurses."

A group of Sierra Leone expatriate mental health professionals is just beginning to organize to find ways toassist, Mandy Garber, M.D., of the VA Pittsburgh Healthcare System told Psychiatric News. The use ofquarantines and lockdowns to combat the spread of Ebola has meant that the few mental health workerscannot provide any individual therapy, so Garber's colleagues are considering ways to use mass media likeradio and lelevision to provide some kind of relief.

As with any disaster, the grealer part of the need for mental health evaluation and care will arise once theacute phase passes-whenever that might be. Stopping the virus is the great immediate priority.

"We need epidemiologists and oiher experls to help to minimize the spread of the infection in the variouscommunities," said Harris, praising the recent U.S. government decision to increase assistance.

'The main problem at this point is the lack of medical staff," said Valle. "This outbreak is much bigger than wecan control with the resources that we have. Many Sierra Leonean doctors and nurses are dying, and all theteams responding to the outbreak are ovenrvhelmed and need more equipment, more isolation units, andmore professionals.

"Unfortunately, mental health tends to come last in the provision of funds, and this outbreak is having terribleconsequences in a population already affected by a cruel civil war. We are committed to work, we havewonderful Sierra Leonean staff, but we need as much support as possible." r

The website for CBM'S mental health program in Sierra Leone can be accessed here. Two Boston-based nonprofitsare working in the epidemic zone. Wellbody Alliance lrains community health workers and provides medical care inKono, Sierra Leone; Last Mile Health works in remoter villages in Liberia.

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