Covid-19: How the lockdown affected mental health services

On July 2, Hussein Walugembe came to the end of his life’s journey. On the fateful day, the 20-year-old entered Masaka Central Police Station in Masaka City, which is 130km from Kampala City and doused himself with petrol he had carried in a small jerry can, before setting himself on fire.
Walugembe was protesting the seizure of his motorcycle, a Bajaj Boxer.

Two days earlier, a police officer had impounded Walugembe’s motorcycle for violating presidential directives barring movement of motorcycles after 5 pm. This is one of the measures instituted by the government to stop the spread of Covid-19.
Walugembe’s father, Ndawula Kalema, in an earlier interview, said his son was working and living in the police barracks as a cook.

“He did odd jobs within the barracks and also worked as a boda boda rider. He bought the motorbike about two weeks ago. He was focused and business-oriented, doing different jobs and saving money to complete the house,” he says.

Walugembe’s incident might seem isolated, but it is an indication of the increasing number of people grappling with mental health challenges as they deal with the economic upheaval caused by the lockdown that was imposed on March 18.

Mental health challenges
There is little statistical data on the national prevalence of mental ill-health in the country, but the common mental disorders are mild, such as depression, anxiety, and alcohol abuse; while severe disorders include bipolar disorders, psychosis and epilepsy.
The World Health Organisation (2006) says 7.4 per cent of Ugandans suffer from depression, anxiety, and alcohol use disorders.

However, the numbers could be higher because victims who live upcountry or in rural areas rarely seek medical help.
It is estimated that the treatment gap for mental disorders is at 85 per cent. This means 15 per cent of those with mental health disorders who need medical care do not get it. Also, many people dealing with mental challenges are not even aware of what they are experiencing.

Dr Juliet Nakku, the deputy executive director of Butabika National Referral Mental Hospital, Uganda’s only national psychiatric referral hospital, says with the advent of the coronavirus, mental awareness is generally lower than it was before.

“Many people are now having anxiety problems, stress and depression. We have seen people who have become suicidal as a result of (financial) stress. There is a lot of aggression that is being manifested in domestic violence. During the lockdown, people felt caged in, and some took it out on their spouses,” she says.

Dr Nakku adds that these mental health challenges include alcohol and substance abuse.
People, who suddenly had a lot of time on their hands because they could not go to work, resorted to alcohol and drugs.

According to Dr Nakku, the numbers of alcohol and substance abuse cases doubled in April and May compared to February.
Accessing medication, support
Grace Basaalya’s mainstay has been prescription drugs. Today, he owns a spare parts business in Kampala.

Four members of Basaalya’s family, including himself, are living with mental illness and he procures drugs for them from Butabika Hospital.
However, a new challenge presented itself mid-March when a presidential directive banned public and private transport.

“I found challenges in keeping scheduled appointments. In order to travel freely, a private vehicle needed a government sticker. I did not have a car. So, whenever my family and I needed refills, I had to request a friend to transport me to the hospital,” he says.
He adds: “I thank God that they did not deteriorate during the lockdown, although there was a challenge of finding food to eat. When you are on strong medication, all the brain needs is food. Without food, the stress you get freaks you out.”

The Mental Health Act, passed in 2018, integrates mental health services into primary healthcare.
Uganda has 13 regional referral mental health treatment units but since March, the government gazetted these units for the treatment of Covid-19 patients. Dr Hasfa Lukwata, the acting assistant commissioner for Mental Health and Control of Substance Abuse in the Ministry of Health, says turning the units into Covid-19 treatment centres was a big blow to the services offered to mental health patients.

“First of all, the kind of care we give is chronic care and for some people, treatment takes about three to four weeks, or longer. Others have to come for drug refills, so turning the units into Covid-19 treatment centres meant that people could not access them, yet there was no alternative provided. Besides, in terms of security, the units are now manned by the army,” she says.
Dr Lukwata says all the admitted patients were discharged. And, because the services were stopped, the health personnel working in the mental health units also had to go home.

“This has affected many people, because the community fears mental illness and cannot care for people who were supposed to be hospitalised. Health workers did not monitor them for three months and some went without medication,” she says.
Ms Lukia Namwanga says she struggled to get medication for her younger sister and that they missed appointments because they could not access private transportation.

“When we finally made it to the hospital, the window where we got our medicine refilled would be closed because the nurse had not come to work, probably because she had failed to get transport. That meant setting up another appointment, but since there were no assurances of transport, I was forced to use ‘Window Two’ manned by private pharmacies. The drugs they give help remove the stress, but they are not the prescribed drugs,” she says.

Of course, the long-term effect of mental health patients not accessing medication or taking wrong medicine is that the symptoms of the illness return and a patient may have to restart treatment at another level.

Post lockdown surge
Since the phased lifting of the lockdown began on June 4, Butabika Hospital has received a high number of patients.
Dr Nakku says between July12 and July 18, the hospital received about 1,050 cases needing admission, yet previously they received between 800 and 900 patients per week.
Butabika Hospital has a bed capacity of 550 while the outpatient department (OPD) registers about 350 clients daily.

“We do not know exactly what is causing the surge, but we suspect it could be due to two reasons. One is the fact that mental health services are not being accessed in other parts of the country. Secondly, it is possible that more people are breaking down because of the stress surrounding the measures introduced to combat the spread of the virus,” she says. Although the lockdown has been eased, mental health treatment units are still not accessible as they remain Covid-19 treatment centres.

“Our patients are getting care from other facilities and some of these facilities do not know how to diagnose mental illness. Someone might need a refill of their medicines but when the facility does not have the drug, patients have to buy something similar. Those who can afford, travel to Kampala for treatment,” Dr Lukwata says.

Butabika Hospital does not have a caretaker model; admitted patients who come from far off places cannot have their caretakers living with them.

The dearth of coping mechanisms
Before the outbreak of Covid-19, there were many mechanisms available to the population. However, some of these options are not there anymore.
Ms Stella Nakyanzi, a single mother-of-four, is an ardent churchgoer. Prior to the pandemic, she used to attend church three times a week but churches and other places of worship are still closed.

“On Tuesdays, we had a counseling session, where everyone who had issues in their lives could access the three pastors for personal prayers and counseling. At first, when the lockdown began, things were going well because I had the money to buy food and pay my rent,” she says.

Trouble came knocking in April when the human resource manager at Nakyanzi’s workplace called to instruct her to take indefinite unpaid leave until September.
“I panicked. I was in mental turmoil for two days before I decided to call my pastor to pray for me to retain my job. He promised to call back but he probably forgot because there must be many people calling him for prayers,” she says.

Psychological distress is a common reason for people visiting religious leaders and traditional healers.
Nakyanzi is one among the many faced with uncertainty about their present and future.
Some people cope with problems by socialising at the beach or bars and visiting friends and relatives. For the three months; March, April, and May, those options were not available to them and more human and financial resources were needed.

Dr Jean-Marie Hatungimana, a clinical psychologist working with Generation in Action – a trauma centre in Gulu District, says his research found out that one of every four people in Gulu is mentally disturbed.
Gulu District, which is 334km from Kampala, and the Acholi sub region in general, experienced 20 years of war and turmoil which ended in 2006.

“We only have 12 PhD holders in clinical psychology, but only four are working in the country. Clinical psychologists deal with human thinking and hence, treatment therapy, while psychiatrists deal with drug therapy. Unfortunately, most of the mental health units don’t have clinical psychologists, so people who just need someone to talk to so that they can feel better are just given drugs for depression without counseling.,” he says.

Dr Nakku says Butabika Hospital is well equipped and ready to handle the surge. “This is the seat for the expertise in mental healthcare. We have the space to treat people, especially those who need admission. Fortunately, the common mental disorders do not lead to admission all the time. But, our capacity may be swamped by the upcountry cases,” she says.
Uganda has a population of more than 41 million but with only 40 psychiatrists, 80 per cent of whom are based in Kampala.

Dr Lukwata says the human resource shortage in the mental health units is a problem.
“Most of those psychiatrists have retired; 14 are working in Butabika, while the rest are in private practice. It is common to find one psychiatrist manning a ward of more than 100 patients in Butabika Hospital. We have trained a number of psychiatric nurses and psychiatric clinical officers but, with the huge numbers in OPD, this human resource is not enough,” she says.

According to a 2006 WHO-AIMS Report on Mental Health Systems in Uganda, the total number of human resources working in mental health facilities is 1.13 per 100,000 persons as at 2005. Of the 225 psychiatric clinical officers, about 50 per cent are based in the central region. Of the 2117 psychiatric nurses, 40 per cent are registered nurses while the rest are certificate nurses.
Some mental health workers were taken on to continue working in the Covid-19 treatment centres.

The district local governments took others up, while a few are working on patients who still visit OPDs.
“But, it is not the same as before. We work as a team. It is not like with malaria, where the same person takes your temperature and gives you medication. With mental health, after the psychiatrist does his or her work, the psychologists and social workers must come in,” Dr Lukwata explains.

Way forward
Mental health services are allocated only one per cent of the annual budgets of the regional referral hospitals.
For instance, if a hospital receives Shs140m ($ 37,837) annually, only Shs1.4m ($378) of this goes to mental health.
But, even with the large sums of money allocated to Covid-19 (over Shs500b or $ 135m), Dr Lukwata says mental health still takes the backseat.
“When we deployed psychologists and social workers to the Covid-19 isolation units, the personal protective equipment (PPE) was not enough. Facilities had to choose who to give the available PPE and they would rather give it to a nurse than to a social worker,” she says.
With the challenges in accessing care, Dr Nakku advises the public to take care of their mental health.
“If you feel isolated, try to reconnect with other people safely. If you cannot travel, use the telephone. The Ministry of Health also has call centres with counsellors who can help,” she says.
She adds that people should have enough sleep because a well-rested brain can take on the world’s challenges much better, eat a balanced diet, and do exercises because they stimulate happy hormones that relieve stress.
However, in the East African region and on the continent, there needs to be follow up on the impact of Covid-19 on the mental health of those who have suffered from it, and on the population in general.