Africa turns to telemedicine to close mental health gap

Abstract

Prior to the COVID-19 pandemic, mental health in Africa was a major concern with the continent underperforming on several key mental health metrics, including the numbers of hospital beds for patients with mental illness and coverage of outpatient facilities being lower than the global average. Crick Lund, Professor at the Alan J Flisher Centre for Public Mental Health (University of Cape Town, South Africa) notes that due to the numerous challenges that African countries are dealing with, including poverty, infant and maternal mortality, and infectious diseases, the importance of mental health had been overlooked. He adds that the state of mental health in Africa has also been compounded by factors including low awareness of mental health conditions, stigma, and the perception of mental health illnesses as untreatable. These issues not only affect the mental wellness of Africans, but also the practice of mental healthcare. Africa also has a mental healthcare expertise problem; most countries with the fewest mental health professionals per 100 000 population are in Africa. Olatunde Ayinde, a Nigerian psychiatrist, tells The Lancet Digital Health that few doctors are choosing to specialise in psychiatry because of stigma associated with the specialty. “Not only are clients stigmatised, even we who are psychiatrists are also stigmatised. There is that differential preference of medical graduates for specialties other than psychiatry,” Ayinde says. On Oct 10, Africa joined the rest of the world in celebrating World Mental Health Day. As well as bringing attention to the state of mental wellness across the continent, this year it also drew attention to the impact of the COVID-19 pandemic. Aside from exacerbating mental illnesses among patients with a history of mental health conditions, the socioeconomic impacts of COVID-19 can also precipitate mental illnesses in individuals without any previous history. Unlike economies that were able to provide social safety nets for citizens during and beyond lockdown, Africans in most countries had to deal with the effects of the pandemic with little or no social support, putting them at risk of conditions including anxiety and depression. In May, 2020, the Africa Centres for Disease Control and Prevention issued guidance for mental health and psychosocial support during the COVID-19 pandemic. Similar to WHO guidance, it provides practical steps to reduce stress, anxiety, stigma, and psychological disorders associated with COVID-19 and improve overall mental health and wellbeing. But despite such guidance, the COVID-19 response measures introduced by many African countries largely excluded mental health provisions, even though need for them soon emerged. Mental health specialist Victor Ugo leads the team at Mentally Aware Nigeria Initiative (MANI). He argues that the lockdown measures triggered mental illnesses, and exacerbated already existing mental health conditions. “One of the key things we know that doesn't help with mental health problems is isolation. We now have people who are more lonely, jobless, and now have more reasons to be hopeless. They struggle to keep food on the table. So we're seeing increasing levels of stressors. Those also apply with those that have mental health conditions.” The surge in mental health stressors, Ugo says, culminated in an increased demand for mental health services which could not be met as many hospitals were only attending to COVID-19 cases and very severe emergency cases; other patients, including patients with mental illnesses, were asked to go back home. With hospitals now reopening and patients returning to clinics, a backlog has been created. Moreover, with COVID-19 measures requiring social distancing, appointment times are now being spaced out, and in the few hospitals with psychiatrists, patients may not get an in-person mental health therapy session appointment until 2021. Several countries in Africa, including Nigeria, Ghana, South Africa, and Kenya, already have a telecommunications density exceeding 100%, and according to the Global System for Mobile Communications (GSMA), mobile telephone connections in sub-Saharan Africa are expected to increase from 816 million in 2019 to 1·05 billion in 2025. The Mobile Economy 2020 report further predicted that smartphone connections in sub-Saharan Africa will nearly double by 2025. Realising that more Africans will continue to have mobile devices with which they can be potentially reached with information, African disease control agencies and partners began to roll out technology-based services to aid efforts, particularly addressing COVID-19 misinformation and providing information on local testing centres. Technology-based services are also aiding efforts to clear the mental health backlog. Prior to the COVID-19 pandemic, patients seeking mental health consultations were required to visit the hospital and be booked for an appointment if necessary. But COVID-19 has forced a reawakening. Even though in-person consultations are still happening, attention has shifted to expanding access using telehealth methods as it is now easier and quicker to book a virtual session than pursue the conventional approach. Across Africa, mental health tech startups including Wazi in Kenya, PsyndUp in Nigeria, MindIT in Ghana, and the MEGA project in South Africa and Zambia are joining local and national associations of psychiatrists who are providing free virtual online mental health consultations, to provide easier and quicker access to mental health services. Although the pandemic has driven more attention to telemedicine, not only for mental health but also for other aspects of healthcare, Ayinde argues that this paradigm shift predated COVID-19. “Before the pandemic, many places were already putting in place virtual consultations for and beyond mental health,” he says, describing telemedicine for mental healthcare as an emerging platform for general healthcare delivery that is allowing him to deliver counselling services to patients in any part of the world in real time. “Even though the human touch is missing, patients are still able to get the service which is still better than nothing.” He adds that the approach enables African countries to increase access to mental healthcare while maximising the scant mental health resources. “In a situation where mental health resources are scarce and people are widely dispersed across the regions, online is a useful platform.” Ugo, on the other hand, argues that online counselling is as effective as in-person one-on-one counselling. “We have to start thinking about how to ensure that services become available to people, we have to think about telehealth services. They are well advanced. It's not a case of one replacing the other; I will say it's about combining different approaches.” Since the pandemic forced organisations like Ugo's to suspend in-person activities, they have moved more of their operations online, and this approach is emerging as a great opportunity for the organisation to expand to more locations at reduced cost. “If we want to reach as many people as possible in Nigeria, we are not going to have offices in every state. Most of our volunteers are healthcare professionals who have their own jobs and we don't want to take people away from their jobs. They don't have to leave their comfort zones and their office space to counsel people physically. But it comes down to people's preferences,” Ugo says. Ayinde notes that online mental health consultations have gone from an ambitious idea to “the new normal” while Ugo adds that MANI had to acquire more capacity—technology and personnel—for it to be able to handle the additional number of users of its online platform. Hauwa Ojeifo, founder of mental health-focused platform She Writes Woman, said traffic to its associated helpline has increased by over 60% since the pandemic began to hit African countries and 80% of inquiries were on how to cope with uncertainty, fear, and anxiety. Since the outset of the pandemic, telehealth service providers have rapidly scaled offerings and are seeing 50 to 175 times the patients via telehealth than they did before the pandemic. Africans are opening up to telemedicine for mental health and are joining the rest of the world in using social messaging tools such as WhatsApp to provide telemedicine services. Habiba Amin, a Mental Health Practitioner working in emergency COVID-19 response in Nairobi, Kenya, revealed that online platforms are also being deployed to help citizens through daily strains, such as isolation, unemployment, and a disrupted social life, that were brought about by the pandemic. In Ghana, misinformation regarding COVID-19 was a stressor for anxiety, fear, and confusion among citizens, which was why Atsu Latey and his team at MindIT Ghana created the Telegram chatbot to address this issue. MANI is pushing the limits of virtual interaction to ensure Nigerians in need of its services continue to stay socially connected and engaged, even though they cannot physically meet in groups. “We set up programmes on our social media pages that encourage people to participate—something like a community. You join a bookclub for example, movie night, something to keep people occupied and to provide an outlet for the struggles and difficulties they are facing,” Ugo said. In their review of Kenya's mental health response to COVID-19, Florence Jaguga and Edith Kwobah, psychiatrists at Kenya's Moi Teaching and Referral Hospital, recommended that the country's 24h COVID-19 call centre should be expanded to incorporate delivery of brief psychological interventions to the general public. However, although African psychiatrists welcome the concept of leveraging web-based tools for counselling and therapy sessions to maximise the few mental health professionals on the continent and to expand access to professional care, concerns now exist regarding the standardisation of online mental health practices. In South Africa, the mHealth policy that was introduced in 2015 provided no guidance on the use of telemedicine for the delivery of mental healthcare. The implication of this, according to Andrew Wooyoung Kim, human biologist and medical anthropologist at Northwestern University (IL, USA), is that there is no standard of service delivery for telemedicine platforms in mental health care, and a lack of clarity regarding liability—largely leaving the regulation of the services to their providers. Despite the numerous bottlenecks facing telemedicine for mental health in Africa, Ugo feels the pandemic has drawn attention to a threat to mental wellbeing that can only be properly controlled by ensuring access to services, and online platforms are emerging to fill the wide gap—both in the short term and long term. “Most importantly for us, we want to make sure people have someone to talk to. With COVID-19 exacerbating mental health, we need to start integrating mental health into the conversation right from the start [because] in crisis situations, people are more likely to develop mental health problems.” © 2020 Abugrafie/Shutterstock.com 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.