The RCPsych Article of the Month for May is from BJPsych International and is entitled ‘Mental Health in Malawi’ by Philippa Lilford.

Prior to starting my training in psychiatry, I visited Malawi to volunteer in mental health for three months. Malawi is one of the poorest countries in the world and when I was volunteering there, had only two qualified psychiatrists; neither Malawian. I was very nervous about the challenge that lay ahead and, on my journey, reading that the treatment gap in low- and middle-income countries (LMIC) is as high as 85%, braced myself to feel frustration and devastation at the scale of the problem.

While I did not want to paint an overly optimistic picture of a country in poverty with woefully under-resourced mental health services, what I tried to communicate in this reflective essay were some personal experiences which explain why my impressions of mental health in Malawi did not chime with my expectations. I saw countless numbers of patients in clinic and detained only one under the Mental Health Act, who I talk about in this essay. The social structure in Malawi with a family member being ‘allocated’ to a patient in times of need, is a remarkably positive resource for recovery. I saw a young lady who was catatonic and whose Aunt cared for all her needs. In the assessment room she did not speak or react and she was carried into the room by her Aunt. I saw her nearly every week for two months and by the time I left she was smiling, responding, dressed in a beautiful chitenje and working as a hairdresser. Seeing low cost psychological and pharmacological interventions work this well in clinic was very uplifting. Of course, the majority of people with mental health needs in Malawi do not have access to these interventions. This led me to think about the role of traditional healers in mental health in low-income countries.

In this essay I describe a case of a young woman with post-partum psychosis who approached the clinic two years after developing symptoms and having been seen by a traditional healer during this time. Her psychotic symptoms responding quickly to a low dose of an anti-psychotic medication initiated in clinic. Care pathways for psychosis in low-income countries remain an interest of mine and I have recently completed a systematic review in the area. The majority of people in LMICs access care for mental illnesses through traditional healers which has led to a question about whether traditional healers and biomedical care could become more joined up. This would not be simple given the different epistemological and sometimes opposing ethical views held by both fields. The complexity of the pluralistic care pathways in LMICs is an area I am fascinated by and which needs much more research. Perhaps I’ll make it back to Malawi one day to continue this venture.

Why I chose this article
In this issue, we have chosen as our article of the month an account by a specialist registrar of her visit to Malawi’s psychiatric services, made before she commenced psychiatric training. She was inspired to go by the 2007 Lancet series on Global Mental Health. This brief description of her experiences there (part of our Global Echoes series) illustrates with strong emotional resonance the challenges faced in guiding good psychiatric practice within a country that lacks so many basic resources. Her account reflects on the substantial support patients receive there, from both staff and family members, as well as the optimism engendered by her experiences.

David Skuse, Editor-in-Chief, BJPsych International

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