ABSTRACT/BACKGROUND

In the city of Burao with 250,000 inhabitants, there were no psychiatric services until late 2008.  The mentally ill were chained in their homes; confined and often chained in the so called ”Elajs”; hospitalized in the psychiatric hospital in Berbera; or simply left to fend for themselves - as result becoming homeless, “Darbiyejiif”.

In March 2008, Dr. Ahmed Awad, a Somali physician from Germany, opened a day hospital for mentally retarded children and youths, many of which had been chained for years in their homes.  Dr. Ahmed and his German born wife Brigitte were doing the work through their NGO Medical Care Somalia (MCS).

                                        The Mental Health Center

Six months later an Outpatient unit for psychiatric patients opened in the center which was named “Mandhaye”.  Three Somali psychiatrists in Scandinavia (Dr. Yakoub Aw Aden in Sweden, Dr. Jama Yusuf Elmi in Norway and Dr. Fatuma Sheik Ali in Denmark) joined Dr. Ahmed’s efforts to improve the conditions of the mentally ill .The three psychiatrists and Dr. Ahmed established the Somali Psychiatric Network (SPN) hoping that other Somali health workers in Diaspora will join them.

TAF (Togdheer Abroad Foundation) in the UK joined the work by building an In-patient unit (with 10 beds for men and 5 beds for women) and paying the salaries of the staff for the next 2 years.  The In-patient unit was opened on February 2011.  Meanwhile, in 2012 TAF Norway overtook the responsibility from TAF UK and changed their name to the NGO Mandhaye Norway.

In Denmark Dr. Fatuma Ali, established the NGO Mental Health in Somalia (MHIS) and started working regularly at Mandhaye, bringing Danish professionals annually to work at the center on a voluntary basis.  MHIS also started fundraising in Denmark for Mandhaye.

In Denmark Dr. Fatuma Ali, established the NGO Mental Health in Somalia (MHIS) and started working regularly at Mandhaye, bringing Danish professionals annually to work at the center on a voluntary basis.  MHIS also started fundraising in Denmark for Mandhaye.

Through MHIS, a Danish NGO called Peaceware established tele-psychiatric facilities at the center and Dr. Yakoub and Dr. Jama started weekly Skype consultations with the Outpatients at Mandhaye.  Despite the fact that the Peaceware sponsorship has ended, Dr. Jama and Dr. Yakoub continue the tele-psychiatric services as members of SPN.

In 2013, the Ministry of Health of Somaliland recognized the work that was going on at Mandhaye by putting the staff on the payroll and giving Mandhaye status as a ward under the General Hospital of Burao.

DISCUSSION

Mandhaye’s patient data: Together with IOM and a Danish Doctor Hanne Christensen we are currently working on a comprehensive database which will give the possibility to specify all information on Mandhaye’s 7,532 Outpatients by Mid-2014.  For the overall number of patients treated at Mandhaye see Table 1.

Meanwhile, Statistics are available on the patients treated at the inpatient units [Table 2]; which is followed by the male to female patient distribution of diagnosis shown in Graphs 1 & 2.  

Table 2: Inpatient unit Male and Female diagnosis distribution

Most of the male patients are Schizophrenic (70%) and almost all of them have a current or previous massive Qat abuse. Qat abuse in the Somali society is a serious problem resulting in Acute Qat induced psychosis (38%) in patients seen at Mandhaye.  There are related family and community problems such as broken homes, children growing up in dysfunctional families, violence and crime.  The relationship between Qat abuse and mental illness (along with the related societal problems) has to be researched in order to get valid information and recommendations.

The current inpatient data only shows one patient as suffering from PTSD. Considering the history of civil wars and trauma we presume that a major number of PTSD patients will be found in the Outpatient population and that can be confirmed when we establish the results from the new Database in Mid-2014. 

The majority of the female patients treated were young women under the age of 35 with a large number of pregnancies and complicated deliveries.  Multiple child deaths and poor living conditions are some of the exacerbating factors that cause trauma which leads to Post Partum depression and psychosis.  It is interesting to note that out of 129 female patients only one had a history of Qat abuse. 

What makes Mandhaye’s services extraordinary and Mandhaye a unique Somali experience?

A service by Somalis for Somalis: First of all, Mandhaye is an institution created by Somali health professionals together with community activists in UK and Norway with the support of the local community in Burao.

International service standards: Mandhaye’s work is based on the WHO’s principle of developing community psychiatry, meaning that the mentally ill should be assisted where he or she resides.  The number of beds at Mandhaye is limited, but the level of activities in the community through the home visits, visits to Elajs and the City jails is enormous.

Holistic and continual services: The patient’s first point of contact at Mandhaye happens at the Outpatient unit.  There the patient gets a psychiatric assessment, is diagnosed and starts treatment if it is needed.  The patients are almost always accompanied to the center by family members who receive information about psychiatric disease, treatment procedures, how to communicate with the patient and so on.  If hospitalization is needed the patient will be referred to the Inpatient unit.  After a period of maximum three months, the patient will be discharged and referred back to the Outpatient unit.  Therefore, there is a continuity in the treatment, and the only way we can lose contact with the patient is if the patient or his/her family choose to stop the treatment at Mandhaye.  This can happen, as is the case when the family members believe the patient is possessed by evil spirits (Jinn) and choose to seek traditional treatment through Koranic interventions at local Elajs.

If a patient cannot come to Mandhaye, the families can ask for a home visit which is scheduled on a Thursday.  These home visits often result in patients getting referred for hospitalization at the Inpatient wards directly after a home visit.

The patients are always admitted accompanied by a family member.  The purpose of this is:

Friday morning the patients are taken home and they are back in the ward Friday evening (sunset).  The purpose of the day pass is to maintain the patient’s place as member of the family and community.  Finally, as mentioned earlier, when the patient is discharged from the ward, he or she will be referred to the Outpatient unit to receive follow up treatment.  The continuity of the treatment is guaranteed.

Policies and Ethics:  When each patient is admitted the family members sign a Mandhaye Center  Contract with allocates clear responsibility for property damage, residential patient care and continued rehabilitation and treatment (by carers) after discharge. 

We often receive patients in chains and most of these patients have been chained for years.  It is up to the Doctors/Staff of the ward when to remove the chains but this happens normally on the same day of admission or the day after.  We have never had cases of patients being returned to chains while at the wards.

Training and Development: Mandhaye Mental Health Center receives students from the nursing school for Psycho-education and practical training in mental health.  There are also plans for psychiatric training for the medical students from the relatively new Faculty of Medicine at the University of Burao.

The Future of Mandhaye: The ambition of Mandhaye Mental Health Center is to become the National Psychiatric Capacity Building Center that trains health workers nationally, and to implement Community Psychiatry services in the whole region of Togdheer. 

As we have seen in our clinical work Qat abuse is a major problem.  In the future, we have to focus more on preventing and treating this problem working with the decision makers such as the Ministry of Health and Ministry of Education. 

Another group to focus on in the future are the young women at risk of Post Partum psychosis and depression by supporting family planning and working with the various Mother Child Health Centers. 

A lot of hard work is waiting ahead such as research, advocacy, awareness and anti stigmatisation campaigns.  However, we are on the right track with the support of our community, carers and patients.