Wednesday, December 15, 2010

On the pathway to care: Schizophrenia and social-cultural fallacies

Schizophrenia only affects 1 to 1.5% of the general population (in Lagos). The only thing is that it has a devastating effect that tends to run a deteriorating course in the life of the people concern.”

Most misleading views about mental disorder are rooted in social-cultural beliefs. As a result, especially in this part of the world, most people suffering from mental illness experience dehumanizing conditions before they are eventually taken to a Psychiatric Hospital for treatment.

Schizophrenia, one of the major mental disorders, is commonly misunderstood to be split/personality disorder. In a more critical stage, people suffering from it are regarded as “possessed” by demons or witchcraft. In this chat about the prevalence of mental illness in Lagos, Dr. Olugbenga Owoeye and Dr. Richard Ademola Adebayo, both consultant Psychiatrists and a Clinical Psychologists at Federal Neuro-Psychiatric Hospital, demystify some of the social-cultural fallacies associated with Schizophrenia. They also elucidates on some of the cultural factors that delay or limit the treatment of mental disorder and recommend ways to better curb the illness.

According to Dr. Olugbenga Owoeye, “Schizophrenia is one of the major Psychiatric disorders. It is a disorder of the mind. But in a layman’s definition, it is like a Psychological condition in form of a shattered mind. Just like how a shattered glass looks. It is a chronic recurrent major psychiatric condition that tends to deteriorate with time. As a result of which the individual will not be able to function socially and emotionally.

There are different types of Schizophrenia. There is the paranoid Schizophrenia, which is the commonest and affects people in their 20s and 30s; Epiphrenic Schizophrenia and the simple Schizophrenia. “With these ones, if you are not a professional Psychiatrist you may not know that they are sick. The only sign is that they may not be socially active but in their dressing they look normal and make no trouble with anyone. But they lack the ability to move up in life, they lack motivation, they refuse to associate with people and are unable to function socially and occupationally. They may not aspire to set up their own family, they just eat and live.” Said Owoeye. Another type is the Catatonic Schizophrenia. “Those are the ones that may be reckless or aggressive and hyperactive on one hand and be socially withdrawn and mute on the other hand.”

Explaining some of the factors that instigate such conditions or precipitate mental illness, Owoeye categorized them as Predisposing factors, Precipitating factors and the Perpetuating factors.

“The Predisposing factors are factors operating in the early life of the individual that tend to make the individual vulnerable to the development of a major mental disorder. For example, during pregnancy a mother may fall ill, suffer from malnutrition or the child might suffer some injury or infectious at childbirth. Also, early in life, the person may have suffered from a major illness like severe infections either due to virus or bacteria infection. These could be a major access to the brain. Aside those, other Psychological factors can also lead to Schizophrenia, such as someone not having any Parental attachment or closeness early in life. Schizophrenia can also be transferred from Parents to Offspring, that is to say that it is also hereditary.

When you talk about the Precipitating factors, these are factors operating in the life of individual around the time that the illness started and thus appeared to have caused it or precipitated it, making the person mentally vulnerable. This varies from Physical condition to social situations.

Finally, we also have the Perpetuating factors. These are factors that help to maintain the illness that will not allow the person fully recover even after treatment. For example, where you have a family that is too emotionally over-involved with the individual. Or those families that run critical comment that discourages the person suffering from Schizophrenia from taking medication. Also, when educated individuals find out the extent of the illness, they feel demoralized and become socially withdrawn. As a result, the illness perpetuates further.”

Signs and Symptoms…
“The major signs and symptoms of this illness vary. But the major one is that the individual will start experiencing auditory hallucination, hearing voices of unseen people either discussing him or her in a third-person among themselves or commanding the person on what to do.

They may have strong paranoid delusions. For example, they may believe the family member is responsible for their problem or believe they own the whole world and become so grandeur. Apart from that, they may also execute some bizarre behavior. Sometimes, these believe may be so bizarre that it will be difficult to comprehend. They experience a situation where their thought is being spoken aloud to them, thus causing them to believe that their thoughts, actions or plans are being made known to everybody without them informing anybody. These are the major symptoms associated with these individuals.

Treatment and medication…
"The illness can be successfully treated and managed…but most of these medications are very expensive. Some of the poor patients face the challenge of sustaining the medication and rehabilitation process. Some of them are very poor and there is a limit to which the government can subsidize these drugs. There is no Social Security System to cover them. I don’t think they are included in the National Health Insurance Scheme. Some of these conditions require a long-term treatment, which is quite expensive so their families are left to do all the running around to raise fund."

Psychotic conditions and Religion:
“When we look at the issue of religion, we must take it from the general cultural perspective. As a result of our cultural background and beliefs, it is discovered that a lot of people may not believe that the illness needs treatment. So they go to all sorts of unorthodox places like “Babalawo”, spiritual homes, Churches etc., because they believe that the illness is Spiritual, their approach to treatment is spiritual. This sometimes also contributes to the delay in treatment. But in some of these Churches, whose leaders are educated, the moment they recognize the symptom, they pray for the person and ask him/her to go for medical attention.” Owoeye said.

Meanwhile, to further expatiate on the discourse, Dr. Richard Ademola Adebayo said “We try to be holistic in our approach because we cannot isolate our believe from how we see things. Thus, we do what is called evidence base medicine. That is, medicine is not just what you practice; there must be an evidence for it.

From the cultural or religious point of view, I’m a Christian and I believe that everything that is not good is not of God. Because the Bible says that God’s thought towards us are thoughts of good and not of evil, to give us an expected end. So it means that anything that is not in line with that is not of God.

Also, knowledge comes from God. Science is not an anti-god device, science is knowledge from God but it is the wrong application that is not desirable. So if you believe science comes from God and through science we have been able to proffer solutions to problem then it will be very wrong to say in a myopic way that mental disorder is from a particular cause.

From the science point of view, the current thinking is that mental disorder can be seen from a biological and social perspective. This means that mental disorder can be genetic i.e. hereditary or socially incurred. From the cultural point of view, they see it as a curse running in that family but in reality it is the genes. Just as Down syndrome can be genetic, so also can Psychiatric disorder be inherited from the genes of parents. Other biological conditions that can manifest into mental disorder later in life include childhood infections, road traffic accident that affects the brain, the medication a pregnant woman uses that may affects the child, drug or substance use, hypertension etc.

While Psychological factors that may cause mental disorder include unemployment, broken relationship, abandonment etc., the Sociological factors include, overcrowding, traffic jam, even the economic meltdown is enough to cause mental disorder… That someone in a family has a mental disorder caused by domestic accident doesn’t mean his or her children will inherit it.”

From your experience as Psychiatrists, what are some of the social –cultural beliefs limiting the treatment of mental disorder in our society?
Dr Ademola said “People tend to read meanings to the condition of someone suffering a mental disorder and such person is often stigmatized and ostracized. Even after the person is treated or the situation is managed, the person might still be avoided by others. Unlike developed countries, in this part of the world we are still holding on tenaciously to our cultural belief. Sometimes Schizophrenic people are called witches who want to confess their evil deeds. For example, a young patient once went to a grave and said she was responsible for the death of the person. Meanwhile, the dead had long been buried before the patient was born. If not for that the people would have thought she was a witch. As part of the cultural believes, people with mental disorder are taken to various places- herbalist homes, Churches etc. Some of them are dehumanized, chained, beaten and stigmatized etc in the process of finding solutions to what they deem is spiritual. It is called pathway to care.

On this pathway to care…
“ This (Federal Neuro-Psychiatric Hospital) is one of the largest Psychiatric Hospital in West African. Because of the stigma associated with mental disorder, people don’t usually think of this place. Pathway to care refers to the passage or process of seeking help before the person is brought to the Hospital. Because of our cultural belief, people connote causes of mental disorder as religious and call it demonic attack or spiritual curses. So the first place they go to are religious or traditional places. They shop around for solution in these places thus causing delay in medical treatment. The patient passes through all sorts of things. Some of them are deprived of food, made to undergo vigil and even sexually abused before they are eventually brought to Hospital for treatment. But with enlightenment now, a lot of people come to the hospital directly, to avoid unnecessary delay in treatment, which might lead to prolong recovery.

How can we eradicate such misconceptions?
“That is why we are telling our people that the only thing that is permanent in life is change. We need to change from our perspective of being myopic. We shouldn’t just think that anyone that is having a particular problem must be addressed from the religious point of view. We thank God that a lot of patients have come to this place and they have recovered. The medication and mode of treatment we use is universal. Without anyone stigmatizing them, these people return home to live normally and fulfill their destiny.”

Advice for religious leaders:
“They should not see Psychiatric conditions as being caused by demons because there are others causes. Even if they are caused by demons, they can still benefit from our treatment. Let them do the praying aspect but they must send the patients to us on time. While the patient is in Hospital, they can come here and pray with them. God is not limited by any barrier or distance. We don’t discourage our patients from going to churches. Unfortunately, we have some Pastors who will tell patients not to take treatment. They tell them to exercise their faith. But the same Bible tells us that faith without work is dead. The work aspect is for patient to take treatment, listen to doctors etc. We are not working against Pastors or religious leaders; we should have a meeting point. Ultimately, God is the healer and not man.”

Some other challenges most Psychiatrists face in curbing the trend…
Dr. Owoeye: The major challenge we face right now is the lack of adequate infrastructure to manage the people. Our Psychiatric facilities are not adequate. We do not have rehabilitation home for them, Vocational center is not adequate and in the area of personnel, we do not have enough of the personnel to take care of the patients. The few we have need training and re-training. All these need government intervention. There are some of these patients who cannot live in the community; there is need for accommodation for such people. If we have such, those people you see living under the bridge or walking naked along the road won’t be there. They are Schizophrenics, the Epiphrenic type, which are those ones that hoard rubbish. So the challenges we face are in the area of infrastructure, personnel and facilities/equipment.

The challenges listed above are more of government’s responsibilities. Is there anything the public can do to support?
“Yes. The Non-Governmental Organizations can help by establishing these foster homes…They can encourage community participation in the management of these patients in their rehabilitation back into the community. In some of the Psychiatric Hospitals where they lack one or two things, they can come up with a Structure to help the Psychiatric home; individuals can also do that to help.”

Some basic things people need to do to remain mentally healthy:
“First, do not go beyond limit- don’t bite more than you can chew. Also, you must abstain from drugs and alcohol. Also, you must have an easygoing attitude and be able to tolerate others to avoid bitterness and grudges. ...learn how to be content with whatever God has given... Don’t say because somebody is riding a Jet then you must ride a Jet overnight. Most importantly, you must try to avoid stressful situations. Although this may not be possible because you need some degree of stress to make it in life but one must try as much as possible to avoid unnecessary stress. By so doing, you can remain mentally healthy and live a fulfilling life.

Stay mentally healthy! And support those going through any form of mental illness by directing them to the right pathway to care!