Organization of mental health services
The Division of Mental Health & Substance use Management Unit at the Ministry of Health is the mental health authority to which the county department of health reports. The Head of Mental Health & Substance use Management Unit heads the department. Mental health services are organized in terms of service areas namely Kilifi county and Malindi sub-county.
Mental health outpatient facilities
There are three outpatient mental health facilities available in the County; two facilities are run by the County government and there is one private facility which is run by a non-governmental organization. Additionally, there is an epilepsy research clinic run by the Neuroscience Department of the KEMRI-Wellcome Trust, which provides follow-up care for study participants with epilepsy. There is no facility allocated for children and adolescents. These facilities together treat about 180 psychiatric patients per 100,000 populations (95% CI 155–208), based on the number of outpatient visits only. Of all users treated in the mental health outpatient facilities during the 2 months’ prospective surveillance, 58.1% (95% CI 51.7–64.4%) are females and 41.9% (95% CI 35.6–48.3%) are males. There was no statistically significant difference in the frequency of mental disorders among males and females (p = 0.129), although the small sample size and convenience sampling prompts caution. Fifteen point eight percent (95% CI 11.5–21.0%) of all contacts are with patients 20 years or younger, 25.6% (95% CI 13.0–42.1%) of whom were children (<14 years).
Mental health problems treated in the health facilities were classified into either of the following priority psychiatric illnesses: depression, psychosis/schizophrenia, bipolar disorder, epilepsy, developmental disorders, behavioural/emotional disorders, dementia, alcohol and drug use disorders, self-harm/suicide, and other significant emotional or medically unexplained complaints. The users treated in outpatient facilities were commonly diagnosed with psychosis/schizophrenia and related disorders [47.1% (95% CI 40.7, 53.6)] and epilepsy [14.1% (95% CI 9.9, 19.1)] (Table
1).
Table 1
Spectrum of illnesses in an outpatient facility in Kilifi County over a 2-month period
Anxiety | 1 | 0.4 | 0.0–2.3 |
Attention deficit hyperactivity disorder | 2 | 0.8 | 0.1–3.0 |
Autism | 1 | 0.4 | 0.0–2.3 |
Bipolar disorder | 20 | 8.3 | 5.1–12.5 |
Depression | 10 | 4.1 | 2.0–7.5 |
Epilepsy | 8 | 3.3 | 1.4–6.4 |
Other seizure disorders | 34 | 14.1 | 9.9–19.1 |
Post-traumatic stress disorder | 1 | 0.4 | 0.0–2.3 |
Psychosis | 31 | 12.8 | 8.9–17.7 |
Schizoaffective disorder | 15 | 6.2 | 3.5–10.0 |
Schizophrenia | 114 | 47.1 | 40.7–53.6 |
Somatic symptom disorder | 2 | 0.8 | 0.1–3.0 |
Suicidal ideation | 1 | 0.4 | 0.0–2.3 |
Other significant emotional or medically unexplained complaints | 2 | 0.8 | 0.1–3.0 |
Data on suicide in the KHDSS was available between the years 2008–2016. One hundred and four people committed suicide between the years 2008 and 2016 with 6 committing suicide in the year 2014, the year for which outpatient estimates for other mental conditions have been provided above. The six persons were between the ages of 19 and 66 years with 5 (83.3%) being males. There were no suicide reports among children (<14 years) with only 7 (6.7%) out of the 104 people who committed suicide being under 20 years. This data only included reports which were marked as “intentional self-harm” and so does not include relatively common category of “indeterminate cases” some of which may include suicides. The total number of people who committed suicide in the whole county is unknown, since KHDSS only represents a part of the county. The average number of contacts (an interaction e.g. an intake interview, a treatment session, a follow-up visit involving a user and a staff member on an outpatient basis) per user is unknown.
There is no active community follow-up care for people with mental illnesses, some people report back to the clinics when their psychiatric conditions have deteriorated. In terms of the available treatment, some (21–50%) of the outpatient facilities offer unstructured psychosocial treatments. Sixty-seven percent of mental health outpatient facilities have at least one psychotropic medicine of each therapeutic class (anti-psychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic medicines) available in the facility or a near-by pharmacy all year round. There are no day treatment facilities, forensic facilities, community residential facilities, or mental hospitals available in the County.
Human rights and equity
The status of voluntary/involuntary admission to general hospitals, which serve as admission facilities for mental health patients, is in general not taken into account. However, it is estimated that the majority of admissions are involuntary. The proportion of patients who were restrained or secluded at least once within the last year in all facilities is unknown. Most violent patients visiting psychiatric outpatient units are chained by caregivers, but it is difficult to precisely know for how long this happens before hospitalisation. However, reports from our community fieldworkers suggest that the patients are isolated and tethered at home for sustained periods.
There are no beds allocated for psychiatry within the County, not even in Kilifi County Hospital, the only referral hospital in the region. This greatly limits access to care as admission is dependent upon availability of beds in the general hospital. There is equity of access to mental health services for other minority users (e.g., linguistic, ethnic, religious minorities) within the County.