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Liya Dibaba was five months pregnant when she was hit by severe psychosis. Her family chained her outside the house. They took her to traditional healers. Eventually, fearing for her and her baby’s safety, Dibaba and her husband made the three day journey from their rural Ethiopian home to the capital Addis Ababa. After four months in the psychiatric ward of nearby Butajira Hospital, she got better and gave birth to a healthy boy.
But since Dibaba returned home over a year ago, Abebaw Fekadu, her doctor at the hospital, says he has had no news of her. He knows she would have been unable to get the medication and care she needs locally. According to research by Fekadu and his colleagues, this is a common situation in Ethiopia, where only five to ten per cent of those with mental illness receive the help they need. 
According to a 2003 WHO report, close to 90 per cent of those in developing countries who need treatment for mental health problems receive no assistance.  Across Africa, there is only one psychiatrist for every million people.  As a result, doctors throughout the continent are realising that if they want to widen access to mental health, they can’t wait until there are more psychiatrists.
In Ethiopia, Fekadu is working on a trial in which primary healthcare facilities are put in charge of caring for people with severe but stabilised mental illnesses. The trial is comparing the care these patients get with that of patients who remain under psychiatric nurses at Butajira Hospital. If the quality of care is similar, it may be possible to refer patients like Dibaba to a local clinic for medication and follow-up treatment, even for very serious illnesses.
“When there is an effective service and people start to use it, that also has an effect on stigma. People become more accepting of people with mental illness because there is more hope.”
Abebaw Fekadu, Butajira Hospital
The project is part of a research and capacity development hub called Africa Focus on Intervention Research for Mental Health (AFFIRM). The initiative is also running in Ghana, Malawi, South Africa, Uganda and Zimbabwe, where researchers are making similar interventions.
In many parts of Africa, mental illness is often seen as the work of an evil spirit or a curse that needs to be prayed out, rather than medicated. As a result, even if modern healthcare is provided to treat mental illness, it can be hard to get people to use it.
Fekadu agrees that people are often slow to access care. But he believes this will change if more healthcare is provided for mental illness and people learn more about it. “[When] there is an effective service and people start to use it, that also has an effect on stigma,” he says. “People become more accepting of people with mental illness because there is more hope.”
One of the most far-reaching initiatives in Africa is the Programme for Improving Mental Health Care (PRIME) project, which involves Ethiopia, South Africa and Uganda, along with India and Nepal. This six-year endeavour to identify and test ways to deliver high-quality primary mental healthcare in low-resource countries began in 2011.
“If we are going to try to deliver mental health through specialists, it is just not going to work. We can deliver through non-specialists,” says PRIME’s CEO, Crick Lund. In South Africa, for example, the project is developing ways to manage depression, alcohol misuse and even schizophrenia at ordinary clinics. The researchers hope other countries will use the projects as templates for integrating mental healthcare into primary healthcare.
Recent research by WHO shows that poverty and mental health are closely linked, and solving a community’s mental health problems may also help to ease poverty. 
In Zimbabwe, a large mental health project takes place in the open air on benches outside the healthcare clinics in Mbare township in Harare. The Friendship Bench Project involves lay health workers supervised by psychologists and psychiatrists.
Over six counselling sessions, the workers focus on helping people solve personal problems. These come in many forms, but are largely related to domestic violence, HIV and unemployment. “When problems pile up, you end up losing hope completely even in the face of solutions that are staring you in the eye,” says Dixon Chibanda, the project’s principal investigator.
Once the participants — many of whom have no source of income — have completed the sessions, they can become involved in Zee BAGS, an entrepreneurial bag making scheme run by the project.
Poverty and mental health
Studies that Lund has done over the past few years have revealed a strong association between various aspects of poverty and common mental illnesses.  Lund and his colleagues’ work has uncovered a cyclical relationship between poverty and mental illness, with each causing the other. Although they found that providing someone with money didn’t always improve mental health, there is evidence that providing basic mental health interventions could improve a person’s economic situation. “It makes quite a compelling case for why we need to look at poverty and mental health together,” says Lund.
Of course, major hurdles remain to widening the availability of care for those with mental illness. Although the situation has improved — with Ethiopia, Liberia and Uganda recently formulating policies — money is often lacking to support the policies that are in place: low-income countries spend an average of 0.5 per cent of their healthcare budgets on mental health.  Lund says that, although funding for psychiatric research in low- and middle-income countries has increased over the past five years, getting governments to commit the money to roll out projects once they are developed is still a stumbling block.
Liya Dibaba’s name has been changed to protect her anonymity
 Patterns of treatment seeking behavior for mental illnesses in Southwest Ethiopia: a hospital based study (BMC Psychiatry, 2011)
 Investing in mental health (WHO, 2003)
 Peter Bartlett and others Mental health law in the community: thinking about Africa (International Journal of Mental Health Systems, September 2011)
 Breaking the vicious cycle of mental ill-health and poverty (WHO, 2008)
 Crick Lund and others Poverty and mental disorders: breaking the cycle in low-income and middle-income countries (The Lancet, 2011)
 Jodi Morris and others Global mental health resources and services: a WHO survey of 184 countries (Public Health Reviews, 2012)