Mental Health in Liberia - Maithri Ameresekere -The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital

With the support and mentorship of Dr. Benjamin Harris of A.M. Dogliotti Medical College at the University of Liberia, Dr. David Henderson and Dr. Christina Borba of the Chester M. Pierce M.D. Division of Global Psychiatry at Massachusetts General Hospital, and the MGH/Mclean Adult Psychiatry Residency program I have had the opportunity to come to Monrovia, Liberia as a rising PGY3. The focus of my trip is manifold and includes understanding psychiatric practice in post-conflict Liberia, teaching medical students and mental health clinicians about psychiatric diagnosis and management, providing consultation for patients at Grant Mental Health Hospital and hopefully encouraging some students to go into the fascinating and underserved field of psychiatry. I have returned to Monrovia nearly twenty years after my first visit as a child when my mother was stationed in Monrovia working for UNICEF. Returning now many years later, the country seems both familiar and unfamiliar. Now I look at the city of Monrovia with a new set of skills as a psychiatric resident. My hope is to develop a more nuanced understanding of the challenges faced by both clinicians and psychiatric patients here in Liberia. The experiences I have had so far have provided immeasurable insight into the local Liberian context and will lay the ground-work for any future research endeavors regarding mental health service provision for this population.

Liberia has suffered from violent civil conflict from 1989 to 2003 with over 250,000 people killed in two Liberian civil wars and more than one-third of the nation�s inhabitants forced to flee their homes as refugees and internally displaced persons. Although there is limited data regarding prevalence of psychiatric illness in Liberia there appears to be high rates of mental illness including depression, post-traumatic stress disorder and substance abuse. Despite the high prevalence of psychiatric illness, individuals often face multiple barriers to accessing appropriate psychiatric care including lack of human resources, minimal access to psychotropic medications, and lack of culturally appropriate interventions or treatment settings. In fact, there is only one psychiatrist to serve a population of approximately 3.5 million! Additionally, lack of perceived need for treatment, the view that mental illness is a result of personal weakness, and stigma are also significant barriers to detection and treatment of mental illness.

I have spent the majority of my time thus far at Grant Mental Health Hospital, the sole psychiatric hospital in Liberia. It has a variable census ranging from 40-70 patients and is run by psychiatric nurse specialists and mental health workers. Patients are typically brought by the police, family or community members for concerning behavior, and often after many years of wandering the streets and/or visiting traditional healers for herbal treatments. In addition to patient consultations, I am working with the medical students to provide case-based teaching and lectures on the fundamentals of psychiatric diagnosis and treatment. I have also had the good fortune to work with Dr. Benjamin Harris, the only psychiatrist in Liberia, who, in addition to the students, nurses and patients have provided an invaluable educational experience for me regarding the practice of psychiatry in Liberia. 

Dr. Harris and myself listening to case presentations 

Grant Mental Health Hospital

5th year students on their Psychiatry Rotation

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MERS-CoV cases by site of virus acquisition.

My first shot at some graphical representations of the MERS-CoV data. Much harder than for H7N9 as the data are scant. Larger versions and more detail can be found on the MERS-CoV page.

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MERS-CoV cases by sex.

MERS-CoV cases by sex.

Larger versions and more detail can be found on the MERS-CoV page.

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The H7N9 missing link: testing the wrong end?

Helen Branswell has an excellent piece detailing as yet unpublished work by the Southeast Poultry Research Laboratory in Georgia.

The researchers have found that influenza A(H7N9) virus can be detected from the nasal passages of chickens and quail - both animals implicated in transmission during the H7N9 outbreak in China. The "so what?" factor is that normally avian hosts shed influenza viruses from the gut reflecting that it is the primary site of influenza virus replication in birds.

As Helen writes, an implication is that if the thousands of birds that have been tested in China to date were only sampled at the cloaca and not from the upper respirator tract, H7N9 prevalence in these oft-blamed but seldom-positive hosts could have been grossly underestimated. However, Dr David Swayne, Director of SPRL notes that it is common practice to swab both ends of a bird when testing.

The research also plays down a major role in transmission for pigeons, ducks and geese.

The search for a definitive answer to what animal is the principal host for H7N9, goes on.

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H7N9 case dies 67-days after illness onset.

59M native of Anhui province, treated in Shanghai, died on Saturday. Case #19 on the H7N9 page Case list.

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3 deaths among existing MERS-CoV cases in KSA.

Two had underlying kidney failure. That's all we know at the moment. The WHO will fill us in later hopefully.

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Italy now hosts primary MERS-CoV cases.

Crofsblogs has been posting very informative pieces on these developments. I encourage you to keep an eye his and FluTrackers posts for the latest.

Two confirmed local cases of MERS-CoV infection, both presumed to be contracted from the imported 45M mentioned yesterday, both hospitalized in isolation in Florence (regional capital of Tuscany, population 3.8M).

Neither are severely ill. 45M's granddaughter (1.5-year old; coughing and fever, Meyer Children's Centre) was in contact on Sunday (approximately 6-day incubation) and a work mate have both tested positive.

Especially concerning in this cluster (Cluster #8) are the fact that 45M's flight from Amman Jordan stopped in Vienna and Bologna before landing in Florence. Also worrying is that the work mate and 45M's place of work...is a Hotel.

Metropol anyone?

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Possible antiviral strategy to intervene in severe MERS-CoV cases?

FluTrackers posted a link to an article that mentions the negative off-target effects of antibiotics being used in MERS-CoV cases (especially among patients with renal failure).

The story also mentions a MERS-CoV "treatment protocol" (without further clarification) involving antivirals similar to those used for Hepatitis C virus infections. I wonder if this March 2013 paper by Falzarano and colleagues in Nature could be the source of such a protocol? It involves use of interferon-a2b and ribavirin to inhibit HCoV-EMC (now the MERS-CoV) replication.

Independently, each drug was needed at relatively high concentrations in cell culture studies, but when combined, they seemed to synergize and could be used at lower concentrations.

It would be great to have more information on the Saudi Arabian treatment protocol but also to know if the Nature article's approach has been used successfully anywhere to date in treating severe acute respiratory infections (SARIs) testing positive for the MERS-CoV).

A lot of clinicians would like to know this information as soon as possible I suspect.

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H7N9 case dies 67-days after illness onset

59M native of Anhui province, treated in Shanghai, died on Saturday. Case #19 on the H7N9 page

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