Mental Healthcare For Liberia

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Issa Bagayogo, a fourth-year psychiatry resident at the Icahn School of Medicine at Mount Sinai, was sitting in a borrowed office on the second floor of Beth Israel Medical Center on the lower east side of Manhattan talking into his iPhone 7-Plus.
“Did you have any interesting cases this week?” Bagayogo asked.
It was a typical question for Bagayogo, who was holding his fourth video-conferencing session with Subah, a 30-year old Liberian nurse, whose dream is to become a mental health professional in a country that has only three psychiatrists for its 4.6 million people. Only one of those is a native Liberian.
They chat like this roughly once a week, part of a pilot program from Mount Sinai that pairs residents like Bagayogo with Liberian nurses like Subah.
Bagayogo, 38, is originally from the Ivory Coast. His primary role is that of the teacher, consulting on medications and therapies, but he also acts as booster, supervisor and, not infrequently, a therapist to a nurse coping with thousands of patients who have experienced unimaginable trauma.
Bagayogo is one of nine residents participating in the program, which aims to improve mental health care in Liberia. Mount Sinai, which partnered with the Liberian Ministry of Health and the Carter Center, donated nine laptops and nine hotspots, though the internet connection is a persistent problem. The pilot program is scheduled to run through the academic year and, if successful, could scale up, said Craig Katz, clinical professor of Psychiatry and Medical Education and director of the Program in Global Mental Health at the Icahn School of Medicine.
“Mental health in Africa takes a back seat because there is so much else going on, especially in Liberia” Bagayogo said. “But, the thing is, the need is so huge because there was a devastating war, which means there is a lot of trauma that happened — broken families, so on and so forth. There is a need.”
More than 250,000 people were killed during a 14-year civil war that ended in 2003. Both sides employed child soldiers drugged with cocaine and khat.
Then, in 2014, Liberia was at the center of the Ebola epidemic. More than 10,000 people were infected with the virus and more than 4,800 died.
“A lot of the time she talks about how difficult it is to get the medication she needs, how difficult it is to get where she needs to go,” Bagayogo said of Subah. “A lot of this is me just providing support.”
Clinical supervision is only one goal, Katz said. Also important is providing these budding mental health professionals with someone they can talk to; someone who understands what it means to see patients.
“Even if we don’t provide technical support, we are preventing burnout,” he said. “Their professional isolation must be huge.”
As are the other challenges.
Bagayogo has had four years of Ph.D. training in neuroscience, two years of postdoctoral fellowship in global health, and is in his fourth year of residency training in psychiatry.
Subah completed a six-month mental health training course at The Carter Center in Monrovia, the capital, and is responsible for a large swath of territory in the northern part of the country, dealing with all manner of depression, addiction and violence.
Subah, for example, once walked into a patient’s home to find her bleeding from a self-inflicted knife wound to the stomach. The patient had sat there for days.
There is no line item in the Liberian budget for mental health, and the lone mental health hospital is inadequate for the nation’s needs, said Janice Cooper, a native Liberian and project lead for the Carter Center’s mental health initiative there. There are 80 beds, which is hardly enough, so mattresses line the floor.
“The bathrooms are truly deplorable and the one small lab rarely functions,” Cooper said.
There are regular medication shortages, explained Subah, who recited for Bagayogo the World Health Organization’s guidelines on how to approach depression when you do not have the proper resources.
When discussing her patients, Subah is systematic, as if she has memorized each protocol.
“She almost has a template that she goes through,” Bagayogo said.
When medication is short, she has two choices. She can either counsel her patients and explain that they must wait, or she can make due with what she has.
She is treating one patient with depression using Elavil, which is rarely used as a first-line treatment in the United States because of its side effects. So, she gives small doses.
“When they run out of it, they are running out of a suboptimal medication given at suboptimal doses, but [medication] is really very, very limited,” Katz said.
Katz, who first went to Liberia in 2011, said the medicine taken for granted in the United States simply does not exist in Liberia, even in the capital, let alone in the farther flung reaches of the country.

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