Eight years ago, CNN premiered ‘Locked up and forgotten’, a documentary that took us behind the gates of Mathari hospital, Kenya’s largest psychiatric facility. We were taken on a journey where we witnessed the plight of patients as they were locked down using chains, and abandoned in dark chambers after being dumped by their relatives, far away from the preying eyes within their communities. Many of these patients left to their own devices, were sexually abused by fellow inpatients, with some dying from injuries and from worsened health.
As Kenya reacted negatively to the CNN exposé showcasing the rot in the country’s mental health system, I felt enlightened about the debilitating and disabling effects on the affected individuals and their families. It was at this point that my interest in mental health was born.
It was evident that the Kenyan mental health care system and the institutional capacity was in a sorry state, incapable of providing any meaningful care. But more importantly, the documentary revealed how the society knew very little about mental illnesses, their risk factors and where to seek help for their loved ones. Instead they chose to hide them from the public because of the associated stigma and discrimination deeply entrenched in our culture towards the mentally ill or disabled. So shocking was the documentary, that it prompted a human rights audit of the mental health system in Kenya by the Kenya National Commission on Human Rights (KNCHR).
However, today the discourse on mental health is finally taking center stage across the world. For developing countries, where the core focus has been on infectious diseases, attention is now being drawn towards non-communicable diseases, and on mental health. It has perhaps dawned on us, almost too late, that ‘there is no health without mental health’.
Kenyan media is awash with stories on suicides, violence and substance abuse- outcomes that are closely correlated with poor mental health. Rarely a day goes by without hearing of a suicide case. Just last month we witnessed the story of a 14-year-old schoolgirl who committed suicide after being shamed and ridiculed by her peers and teachers for soiling her clothes with menses. The girl’s death prompted protests from parents, and the wider Kenyan population about how the teacher chose to handle the situation. What is most worrying however, is the fact that the age of suicide victims is dropping, and we are increasingly seeing younger people commit suicide following disappointment with their academic performances or bullying from their peers. What is not discussed though, is the fact that risk for suicide is enhanced by poor mental health among children and adolescents.
Suicide is an important cause of death and disability globally. According to the World Health Organization (WHO)[1], about 800,000 people die from suicide each year (that is one person every 40 seconds), majority of them aged 15-29 , in which age-group suicide is the second leading cause of death. In Kenya, WHO data estimates that 1408 people commit suicide yearly, or simply put, four deaths daily, a number that is higher than what the Kenya National Bureau of Statistics[2] reported for 2018: 421 deaths. For the seven minutes it will take you to read this article, 11 people would have committed or attempted to commit suicide around the globe.
Official numbers on suicide in Kenya may be difficult to get due to apparent under-reporting or misreporting of such deaths, in part because there are penalties in Kenyan law for attempting suicide, as well as higher levels of stigmatization. Yet, it is clear that deaths from suicide deal a devastating blow to families, friends, and communities.
Understanding the rationale behind suicide ideation and behavior
Whilst the strongest risk factor for suicide is a previous suicide attempt, a clear interplay[3] exists, albeit documented in high-income countries, between various substances (alcohol, tobacco, cannabis, illicit drugs, and non-medical use of prescription drugs) and suicide: in psychological autopsy studies[4], between 19% and 63% of all suicide cases suffered from substance use disorders, mostly from alcohol use disorders.
Still a good number of suicides happen impulsively in moments of crisis where individuals suffer breakdowns in the ability to deal with life catastrophes, such as financial crises, relationship break-up or chronic pain and illness. Suicides have also been shown to be higher among individuals experiencing conflict, disaster, violence, abuse, or loss and a sense of isolation. Discrimination and persecution breeds vulnerabilities that may predispose to suicides among refugees and migrants, orphans, and minority groups like the lesbian, gay, bisexual, transgender, intersex (LGBTI) persons, and prisoners. Negative use of social media and cyberbullying (sending or posting harmful and hurtful messages, pictures, and videos by one person or group of people) are newer and modern risk factors for suicide among younger people.
What is undeniable however is the clear link between suicide and mental disorders, particularly, depression. In 2017, a WHO report[5] ranked Kenya as the sixth African country with the highest levels of depression with at least 1.9 million diagnosed Kenyans suffering from depression.
Preventing suicide
Unfortunately, a large number of mental health problems remain undiagnosed and consequently unmanaged across Africa. Mental illness has thus been termed the continent’s “silent epidemic”. A sure way of preventing suicides is by early identification, treatment and care of people with mental and substance use disorders, or individuals in chronic pain and acute emotional distress. Among the young people (15-29) at risk of suicide, a modifiable risk factor is alcohol and drug use, which should be considered when such individuals are being treated for suicidal behavior and vice versa: suicidal behavior should be considered when young people are being treated for substance use disorders.
Access to such suicide preventive care can be enhanced by the training of non-specialized health workers in the assessment and management of suicidal behavior. The Ministry of Health in Kenya has in the past trained health care workers in primary care, emergency workers, and community health volunteers in identifying mental health problems at the community level by using pointers such as persons going through adversity, distress and substance use. People who have attempted suicide before require follow-up care and when necessary, psychological and family and community support.
Generating evidence on mental illnesses in Kenya
As we commemorate World Mental Health today, under the theme raising awareness for the scale of suicide, it is important to recognize that there exists a dearth of data on mental illnesses and their risk and protective factors in Kenya. As in many other countries in sub-Saharan Africa, Kenya has struggled to collect civil registration and vital statistics, including the cause of death data. As a result, accurate causes of death, including deaths from suicides, are not always captured in Kenya’s official statistics.
To partly address this data gap, the Kenya National Adolescent Mental Health Survey (KNAMHS)[6] will collect data across the country to quantify the burden of child and adolescent mental health conditions (general anxiety and social phobia, major depressive, attention deficit/hyperactivity, conduct and post-traumatic stress disorders) and their risk and protective factors among children aged between five and 17 years, and their parents and guardians.
In participating in the “40 seconds of action”, we join the World Federation for Mental Health, and their supporters to raise awareness of the scale of suicide around the world and the role that each of us can play to help prevent suicides.
Authors: Frederick Wekesah & Siki Kigongo
[1]https://www.who.int/news-room/fact-sheets/detail/suicide
[2] https://www.knbs.or.ke/download/economic-survey-2018/
[3] https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-018-5425-6
[4] https://doi.org/10.1080/13811110903263191
[5] https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf?sequence=1#page=19
[6] Adolescent mental health in Kenya: where is the data? https://aphrc.org/?p=10060