Mental health care during the Ebola virus disease outbreak in Sierra Leone

Abstract Problem Reported levels of mental health and psychosocial problems rose during the 2014–2015 Ebola virus disease outbreak in Sierra Leone. Approach As part of the emergency response, existing plans to create mental health units within the existing hospital framework were brought forward. A nurse-led mental health and psychosocial support service, with an inpatient liaison service and an outpatient clinic, was set up at the largest government hospital in the country. One mental health nurse trained general nurses in psychological first aid, case identification and referral pathways. Health-care staff attended mental well-being workshops on coping with stigma and stress. Local setting Mental health service provision in Sierra Leone is poor, with one specialist psychiatric hospital to serve the population of 7 million. Relevant changes From March 2015 to February 2016, 143 patients were seen at the clinic; 20 had survived or had relatives affected by Ebola virus disease. Half the patients (71) had mild distress or depression, anxiety disorders and grief or social problems, while 30 patients presented with psychosis requiring medication. Fourteen non-specialist nurses received mental health awareness training. Over 100 physicians, nurses and auxiliary staff participated in well-being workshops. Lessons learnt A nurse-led approach within a non-specialist setting was a successful model for delivering mental health and psychosocial support services during the Ebola outbreak in Sierra Leone. Strong leadership and partnerships were essential for establishing a successful service. Lack of affordable psychotropic medications, limited human resources and weak social welfare structures remain challenges.


Introduction
The impact of complex humanitarian emergencies on the mental health and psychosocial well-being of the population is multi-layered and endures long after the emergency. 1 Studies have demonstrated that mental health and psychosocial support responses in emergency settings are often poorly coordinated, not evidence-based and not implemented within formal national frameworks. 2 Research highlights the importance of cultural understanding, training, assessment, monitoring and evaluation. 3,4 The Sphere handbook: humanitarian charter and minimum standards in humanitarian response 5

and the
Inter-Agency Standing Committee (IASC) Guidelines for mental health and psychosocial support in emergency settings provide standards on such implementation. 1 In May 2014, the first Ebola virus disease case was declared in Sierra Leone; a total of 8700 people were infected and 3600 died. Sierra Leone was declared Ebola-free in November 2015 with 5100 recorded survivors 6 and 3400 orphaned children. 7 During the outbreak, anecdotal evidence was that increased numbers of people reported mental health and psychosocial problems. 8 The outbreak affected existing health structures, halted routine activities and had a major impact on the health workforce. Mortality among health-care workers was 69% (152/219) and they were 20-30 times more likely than the general population to contract Ebola. 9 Hospital staff especially faced stigmatization, blame and social exclusion and there were high levels of absenteeism from work.

Local setting
Mental health service provision in Sierra Leone is poor. In 2009 an estimated 2058 people received some form of mental health treatment, out of about 102 000 people (3% of the 3.4 million adult population) who had a severe mental disorder. 10 There is one specialist psychiatric hospital in the country, located in the capital Freetown, to serve the population of 7 million.
During the Ebola virus outbreak, the Sierra Leone psychiatric hospital was closed to admissions to prevent disease transmission. Existing government plans to create new decentralized mental health units across the country 11 were brought forward as part of the emergency response. Mental health nurses who had received 12-18 months' mental health training in 2012-2013 from a bespoke nursing curriculum 12 were deployed to general hospitals in various districts. We describe here our experience of establishing one of the new units -a nurse-led mental health and psychosocial support service at Connaught hospital in Freetown, the largest government hospital in the country with approximately 300 beds.

Approach
King's Sierra Leone Partnership, which was already supporting the government's mental health strategic plan, assisted with the development of the unit at Connaught hospital. To equip the nurses, the World Health Organization (WHO), CBM International and local partners provided the nurses with psychological first-aid training 13 focused on supporting those affected by Ebola virus disease.
Problem Reported levels of mental health and psychosocial problems rose during the 2014-2015 Ebola virus disease outbreak in Sierra Leone. Approach As part of the emergency response, existing plans to create mental health units within the existing hospital framework were brought forward. A nurse-led mental health and psychosocial support service, with an inpatient liaison service and an outpatient clinic, was set up at the largest government hospital in the country. One mental health nurse trained general nurses in psychological first aid, case identification and referral pathways. Health-care staff attended mental well-being workshops on coping with stigma and stress. Local setting Mental health service provision in Sierra Leone is poor, with one specialist psychiatric hospital to serve the population of 7 million. Relevant changes From March 2015 to February 2016, 143 patients were seen at the clinic; 20 had survived or had relatives affected by Ebola virus disease. Half the patients (71) had mild distress or depression, anxiety disorders and grief or social problems, while 30 patients presented with psychosis requiring medication. Fourteen non-specialist nurses received mental health awareness training. Over 100 physicians, nurses and auxiliary staff participated in well-being workshops. Lessons learnt A nurse-led approach within a non-specialist setting was a successful model for delivering mental health and psychosocial support services during the Ebola outbreak in Sierra Leone. Strong leadership and partnerships were essential for establishing a successful service. Lack of affordable psychotropic medications, limited human resources and weak social welfare structures remain challenges.
Lessons from the field Mental health during Ebola outbreak, Sierra Leone Stania Kamara et al.
Meetings were held at Connaught hospital with the mental health focal person from the health ministry, the hospital management team, the mental health nurse allocated to the hospital and the King's Sierra Leone Partnership team. The agreed objective was to create an inpatient liaison service and an outpatient clinic for community access. This would be a sustainable service, integrated into the existing hospital framework and providing mental health and psychosocial support for all, including those affected by Ebola. The health ministry met the human resources costs. The hospital provided office and clinical space and funding for consumables. King's Sierra Leone Partnership provided technical expertise, staff supervision and office equipment.
The service was launched in March 2015 and was available to those living within the Freetown city area (about 1 million people) or anyone admitted to Connaught hospital. The partnership devised a standard operating procedure. Individuals of any age with a known or suspected mental health problem or psychosocial need met the referral criteria. A service level agreement with the Sierra Leone psychiatric hospital allowed transfers for inpatient care. In keeping with hospital protocol a registration fee was levied and waived if service users were unable to pay. A single mental health nurse provided the service, with prescribing of medication carried out by a linked hospital medical physician. A range of treatments were provided. Psychological interventions were the most common, comprising basic counselling and problem-solving therapy. The WHO Mental Health Gap Action Programme (mhGAP) intervention guide, 14 was the model of care used. A proforma for initial assessment of patients (including demographic information, psychiatric and risk assessment) was created. Monthly monitoring and evaluation data were collected manually from the clinic ledger and presented to the hospital and health ministry management teams.
To strengthen the skills of Connaught hospital's non-specialist nurses, mental health awareness training was provided by the mental health nurse and King's Sierra Leone Partnership volunteer. A half-day session on psychological first aid, 13 case identification and referral pathways was delivered to a group of 14 ward nurses.
Mental wellbeing workshops were held for nurses, auxiliary staff and physicians who worked at Connaught hospital, including those working within the Ebola holding unit. These workshops were created and led by the mental health nurse and comprised a series of half-day sessions, for groups of 10-15, on coping with stigma and discrimination, stress management and self-care. The mental health nurse provided one-to-one counselling to staff requiring more support. The human immunodeficiency virus (HIV) and epilepsy services at Connaught hospital were also offered halfday mental health awareness training by the mental health nurse, and referral pathways were created across the services. Partnerships were established with service user groups (e.g. the HIV peer network), national and international nongovernmental organizations (NGOs) providing livelihood support, child protection organizations and faith groups.
A King's Sierra Leone Partnership volunteer (senior mental health nurse or psychiatrist) provided regular supervision and mentoring. Weekly individual supervision of the local mental health nurse focused on clinical case review, service monitoring and continuous professional development. Monthly peer supervision including other mental health nurses in Freetown focused on clinical case review, sharing of resources (e.g. information about livelihood support programmes) and continuous professional development. The mhGAP guide was used in supervision to support case-based discussion learning and to reinforce its application within clinical practice.
Challenges facing the service were addressed during weekly mental health team meetings (attended by the mental health nurse and King's Sierra Leone Partnership volunteer). A timetable including times for home visits, clinics, inpatient work and supervision helped the mental health nurse to manage the workload.

Relevant changes
A total of 143 patients were seen within the first 12 months of the service from March 2015 to February 2016 (Table 1). Most patients (96; 67%) were referred from another department at Connaught hospital and 7 (5%) were referred from Ebola clinics; 17 (12%) were referred by themselves, or by family or other relatives.
The most common diagnostic category was mild distress or depression, anxiety disorders and grief or social problems. Thirty patients (21%) presented with psychosis requiring medication. During the Ebola outbreak, an international NGO provided some medicines (e.g. haloperidol and amitriptyline) which were allocated to those unable to pay. Some service users reported accessing alternative treatment (including traditional and faith healing) when medication was not available.
Seven of the patients (5%) had survived Ebola virus disease and 13 (9%) were relatives of the deceased or survivors. Survivors and bereaved relatives presented with normal grief or mild depressive or anxiety symptoms and often reported being stigmatized or discriminated against within their communities. Those who lost family income earners experienced financial difficulties.
Fourteen non-specialist nurses were trained in mental health awareness and provided basic support on their wards and referred patients to the service. Over 100 Connaught hospital nurses, auxiliary staff and physicians participated in mental wellbeing workshops.
Monthly updates to the hospital management encouraged service improvements. From March 2015 to February 2016, approximately 30 abandoned patients (those with no relatives to provide care or financial support) were referred to the service. Evidence of high use by abandoned patients led to a successful request for a social worker to be deployed to the hospital.

Lesson learnt
Early engagement of participants and a partnership approach with clear roles and responsibilities for all parties was key to ensuring ownership of and commitment to the service (Box 1). The health ministry and the hospital management responded positively to mental health and psychosocial support services being incorporated into a general hospital. Shared supervision was essential for maintaining clinical standards, developing competencies and providing a support network for the mental health nurses. The mental health service at the hospital is effective, integrated and has strengthened local capacity. People are now able to access affordable mental health care at a general hospital.
The service's ability to adapt and respond to changing needs ensured that support for health-care workers could be provided as the impact of the Ebola disease workload became apparent. The service provided care not only for survivors, but all those affected by the outbreak who presented with psychosocial needs.
There were challenges too. Although limited supplies of antipsychotic medications were available in local pharmacies, some patients could not afford them. The workload was high for a single nurse and the mental health nurse faced a risk of burnout and fatigue. Most referrals were from within Connaught hospital. We suspect community uptake was low because the service was new and the community had previous experience of mental health services at the hospital. Staff recruitment and training and community uptake therefore remain areas for development. Much of the focus has been on providing care for Ebola survivors, drawing attention and resources away from mental health services for the wider population.
The Ebola virus disease outbreak weakened an already fragile health system and disrupted existing plans to develop mental health services across the country. However, the emergency response provided the opportunity, resources and focus necessary to create the new units. 16 Our experience has guided the establishment of 14 other mental health units countrywide so far. The service is inclusive and accessible to the entire population. There are plans to further develop the service, with integration into primary-care structures, increased community utilization and greater staff recruitment. A service evaluation -measuring outcomes, follow-up rates, barriers to access and service coverage -is underway. We believe our approach is a suitable framework for delivering mental

Box 1. Summary of main lessons learnt
• A nurse-led approach within a non-specialist setting was a successful model for delivering mental health and psychosocial support services during the Ebola virus disease outbreak in Sierra Leone. • Strong leadership and partnerships between the health ministry and mental health nurses, nongovernmental organizations and hospital management were essential for establishing a successful service. • Lack of affordable psychotropic medications, limited human resources and weak social welfare structures remain key challenges to care delivery.
Lessons from the field

Cuidado de la salud mental durante el brote de la enfermedad del virus del Ébola en Sierra Leona
Situación Se informó de un aumento de los problemas de salud mental y de tipo psicosocial durante el brote de la enfermedad del virus del Ébola en los años 2014 y 2015 en Sierra Leona. Enfoque Como parte de la respuesta de emergencia, se presentaron los planes para crear unidades de salud mental dentro del marco hospitalario existente. Se estableció un servicio de salud mental y de apoyo psicosocial dirigido por enfermeras, con un servicio de enlace hospitalario y una clínica ambulatoria, en el hospital gubernamental más grande del país. Una enfermera de salud mental formó a enfermeras sin especialización en primeros auxilios psicológicos, identificación de casos y vías de derivación. El personal de salud asistió a talleres de bienestar mental sobre cómo lidiar con el estigma y el estrés. Marco regional La provisión de servicios de salud mental en Sierra Leona es deficiente, con un hospital psiquiátrico especializado para atender a la población de 7 millones.