“I want the one that will heal me completely so it won’t come back again”: The limits of antipsychotic medication in rural Ghana

Ibrahim's story

When I first met Ibrahim, ⁴ a 34-year-old Sisala ⁵ Muslim, his ankle was chained to a heavy log, the unmistakable mark of a madman. The eldest son and a promising student, he broke down in his final year at secondary school, shortly before he was due to take his exams. He began shouting and preaching incoherently and saw visions. Following this first episode he recovered and worked for a while in the regional capital. After a couple of years he decided to try to join a friend in Europe to study construction. Unable to obtain a visa through official channels, he planned to attempt the overland route through Libya, a common ambition among educated young men in this part of Ghana. In 1996 at the age of 22 he set out on his first journey. However, the journey ended in disaster when Ibrahim was attacked and robbed in Niger, losing all the money he had accumulated for the trip. After this he became “sick in the head” (his term) and was helped by some fellow Ghanaians to return home where his family took him to the CPN clinic in Techiman. They were already familiar with the service since his uncle suffered from a similar illness. Ibrahim was treated with antipsychotics and, having recovered, in 2000 he set out for North Africa once again. This time he successfully reached Libya, where he began working on building sites. However, after around three months he again became unwell and started preaching in the streets. He was arrested and imprisoned by the police who beat him up and deported him back to Ghana.

Ibrahim has since suffered recurrent episodes of mental illness and sought treatment from two Muslim healers as well as the CPNs. According to Ibrahim, when ill, he is troubled by a foul smell like rotten eggs which invades his whole body. At night he is kept awake by visions of “big men” such as former presidents of Ghana, mmoatia (forest spirits), ⁶ angels, and White people offering him money. At the time we began to visit him, Ibrahim was agitated and irritable, speaking very loudly and rapidly. During our second visit, Ibrahim became annoyed when my assistant began to speak with his relative, shouting and pointing aggressively, and seemingly on the verge of hitting him. As we left, he slammed the taxi door hard in my face. During this period he burnt most of his possessions and destroyed parts of his house. Such behaviour prompted his family to chain him to the log and they decided to try hospital medicine once again.

Ibrahim and his family lived in a village that straddled the main transport route between two sizeable towns. A journey of around twenty minutes by public minibus brought Ibrahim’s relatives to the clinic in Techiman where they could obtain antipsychotic medication at relatively low cost. ⁷ When Ibrahim took antipsychotics they seemed to help—he became calmer, less aggressive, and less troubled by his visions. His hostility towards his mother (he had called her a witch and refused to eat in her home) also decreased. His family released him from the log and he once again joined the daily meal in the family compound. But despite these indisputable benefits, Ibrahim stopped taking the medication. He said it made him fat, lazy, drowsy, and weak. His tongue swelled and he couldn’t speak properly. Most importantly he did not have the strength or energy to return to farming. Without work and with the failures of his migration ventures, which he had hoped might make his fortune, he felt, as he put it, “useless” to himself and to his family. After the end of my fieldwork, a research colleague reported that Ibrahim had again stopped taking antipsychotic medication and become angry and hostile.

The power of medicines

On the one hand, Ibrahim and his family could be seen as beneficiaries of Ghana’s decentralised mental health policy. Relatively easy access to treatment with psychotropic drugs had resulted in exactly the kinds of effects promoted by mental health campaigners—a reduction in hostility and the substitution of the logs and shackles which are widely used by families and healers by forms of biochemical restraint (Read, Adiibokah, & Nyame, 2009). However, access to medication and repeated attempts to treat his illness through psychiatric services had achieved only partial remission. Ibrahim himself found the long-term use of antipsychotics intolerable since they interfered with his perception of well-being. As van der Geest, Whyte, and Hardon argue, in “noncompliance” patients such as Ibrahim “express their rationality vis-à-vis the doctor’s” (1996, pp. 165–166). Viewed in terms of the “social life” of medicines, antipsychotics could be said to fail in their final purpose: “The fulfilment of their life purpose lies in their effect on the well-being of the person who took them. The pharmaceutical’s efficacy is its ultimate and decisive life stage” (1996, p. 156). Moreover, judgements of efficacy are formed within historical and cultural contexts which exert considerable influence on how people weigh the value of all therapies, a process that is constantly adjusted as new forms of treatment are introduced or withdrawn. Studies of the “indigenization” of pharmaceuticals in Africa, including Ghana, reveal how biomedicine is taken up and interpreted in local terms, subjected to the same dynamics of selection and testing as other forms of treatment (Bierlich, 2000; Kamat, 2009; Kirby, 1997).

By contrast, to depict the psychiatric hospital as the “last resort” draws on a view of biomedicine as an exotic foreign import rather than, as anthropologists have long recognised, a “valuable cultural resource” (Whyte, 1992, p. 173). ⁸ Despite its epithet as aborɔfo duro (“foreign” or “White man’s medicine”) and well-founded concerns regarding the quality of hospital treatment, particularly in rural areas (Horton, 2001), in Ghana biomedicine is widely employed for a range of health complaints. As in Kintampo, district hospitals are located in every major town ⁹ and numerous pharmacists and “chemical sellers” maintain a brisk trade in a variety of pharmaceuticals. As Bierlich observed in northern Ghana, pharmaceuticals are in high demand since they are “understood to be inherently potent” (1999, p. 323). In keeping with this, the “asylum” was as commonly cited as shrines and churches as a place to treat mental illness, as one informant told us:

First they say there is some town they call “Asylum” that whoever has a serious one [patient], if he is taken there he becomes so well that if you see him you won’t think it is him. So I know that doctors can treat that illness very well.

Hospital medicine was recognised to be powerful and effective in the short term, particularly in its sedating effect on troublesome behaviour such as talking too much, wandering, sleeplessness, and aggression. This is illustrated by the case of Akua.

When we first met her in a church compound, Akua was in a distressing state: painfully thin, unwashed and barely covered by her torn and ragged clothes. She lay in the dirt, her ankles shackled, giggling and mumbling to herself. She did not sleep but stayed up all night talking. Once she had been treated with chlorpromazine by the CPN her improvement was remarkable. She began to eat and sleep and put on weight. She recommenced petty trading, setting up a stall in the church compound selling sugar, peanuts, and other foodstuffs, later selling rice in the market. As her mother told us: “Now because of the medicine she is taking the talking has stopped. She didn’t sleep, now she sleeps well.”

As Akua’s mother commented, antipsychotics were highly valued for inducing sleep since getting sufficient sleep was associated with good health and equilibrium. The sedative effect of antipsychotics fit well with the notion of madness as a “hot” condition which required “cooling,” ¹⁰ an effect also valued from the herbal medicine used at the shrine. However, despite her dramatic improvement, Akua eventually found the medication overly sedative: “I felt dizzy,” she said, “I would stand there and I couldn’t do anything without falling asleep.” Her mother told us: “Now she is only sleeping. Even when we are doing church services she doesn’t want to wake up.” Like Ibrahim, and despite a reduction in the dose, Akua eventually stopped taking the medication and relapsed.

Stopping medication is reported to be common among patients of psychiatric services throughout Ghana. The doctor at the regional psychiatric unit told us that more than half the patients admitted were former patients who had relapsed. He attributed this in part to a lack of family support and the costs of transport to hospital to collect the drugs, but also to patients “feeling fine” and so not maintaining treatment. As the CPN put it, once people enter their “lucid periods” they stop taking their medication. However, among mentally ill informants, as with Ibrahim and Akua, the most common reason for discontinuing medication was unwanted effects such as feeling “fat,” “weak,” “lazy,” and “tired.” Comfort’s complaint was typical: “When I took it the first day, I slept deeply. And all my body became very weak. So I said I won’t take it anymore.” Akua described the medicine as “too strong,” a term also used for alcohol. One father explicitly compared the effects of taking psychotropic medication on his daughter to being drunk:

When it started… I took her there [the CPN clinic] and they gave her some tablets. … but when she takes it her mouth does [sucking noise] and her saliva comes out. She wakes up and it is like she has drunk alcohol.

Ibrahim also complained of the “heaviness” of the injection he received: “When they injected me I had to sleep about two days before the power will off from my body … The injection was very heavy.”

In Ghana “strong” medicines are recognised to be therapeutically powerful, hence even painful and unpleasant effects may be taken as proof of efficacy (cf. Etkin, 1992), as with the diarrhoea and stiffness produced by the herbal medicine at the shrine. On the other hand such potency is potentially harmful, particularly if the medicine does not “mix well” with one’s blood. ¹¹ Similarly, Halliburton (2009) has reported on the perception of psychiatric treatment in southern India as fast-acting but “abrasive.” Injections of antipsychotics and diazepam administered to new admissions to the psychiatric hospitals and the resulting rapid and heavy sedation may reinforce such a view since injections are thought to be particularly powerful and effective (Bierlich, 2000). A tendency to employ high doses of tranquilising medication increases the likelihood of a negative reaction. Psychiatric nurses told me that “people there [Europe] don’t get mad like we do here” and that Ghanaian patients therefore required higher doses of antipsychotics than Europeans. ¹² Nonetheless, at least in Kintampo, antipsychotics doses were within national treatment guidelines though the combination of different antipsychotic drugs, as prescribed for some patients, may have exacerbated side effects. ¹³

Despite such unpleasant and debilitating side effects, some families encouraged the person with mental illness to continue antipsychotic treatment, having valued the results. Alice’s mother had made repeated use of Ankaful psychiatric hospital over the years and encouraged by a medical assistant from the hospital who had become a family friend, tried to persuade Alice to continue taking medication. However once Alice was home she flatly refused to take it. Alice was hostile and aggressive when unwell, insulting and sometimes physically attacking her mother. Thus it was very difficult for her mother to enforce treatment, as she explained: “If she comes home and I tell her she says: ‘What shows that I am sick?’ She doesn’t take the medicine. Then the sickness comes back.” Thus even where families were keen to try hospital medicine in the longer term, there were considerable practical difficulties in persuading a reluctant child to take it, as Yusuf’s mother complained: “When we give him medicine he doesn’t take it. So my strength is not enough that when we give him medicine I can force him to take it.” Though psychiatric nurses sometimes encourage the family to hide medicine in food, this was not always successful, particularly when a patient was refusing to eat. Though found in other low-income settings as well, this practice is also ethically controversial and can, unsurprisingly, cause resentment among those unknowingly treated (Srinivasan & Thara, 2002).

Health as strength

For many informants the most problematic effect of antipsychotics was that, like Ibrahim, they felt too weak to work well. Akosua had been taking antipsychotics for some months after suffering yet another breakdown in a long-standing mental illness. Her sister felt that medication had proved beneficial to some extent in restoring Akosua to a productive role: “She can bath. She can eat. Even meals she is able to prepare. She can see that there is dirt and she takes the broom to sweep. At first, when the sickness was there, she did not know that.” However, Akosua, who prior to her illness had sold vegetables at the market, remained too weak to do any substantial work beyond a little farming. Her sister explained: “she really likes work. Especially farm work. Yet when it comes it has now reduced her strength.” Akosua confirmed that she could no longer work hard and carry heavy loads: “As for farming, if I had the strength, I would have done some if I could. But I don’t have the strength.” She attributed this in part to the hospital medicine which, she said, made it difficult for her to wake up. Rising around 5:00 a.m. just before daybreak is usual to make the most of the cool of the morning and complete tasks such as sweeping, fetching water, and washing clothes before setting out to farm. In returning to everyday life, prolonged drowsiness and feelings of “weakness” seemed counterintuitive to notions of health. In Ghana bodily strength is synonymous with health (Aikins, 2003). The Twi wɔ ahoɔden, literally “to have strength,” carries the meaning of being healthy; nya ahoɔden, “to get strength,” means to be healed or recover. Feeling strong was necessary for many routine daily tasks such as head-loading water, chopping wood, pounding fufu (a staple food), and carrying babies, all of which require high levels of physical exertion and endurance. Farming is conducted largely without mechanisation, using hand-held hoes, and many walk long distances to the land where they work, returning with heavy loads of produce.

Kofi’s mother and sister were keen for him to take the antipsychotics which the CPN had prescribed having seen an improvement in his aggressive behaviour and social withdrawal. However, he refused to take them, preferring to visit a local church where he engaged in prayer and fasting and helped farm the pastor’s land. When we visited, we would find Kofi, dishevelled and unwashed, working on the family land around his house. He told us he did not want to take the nurse’s medicine because it made him feel sleepy and unable to work. Feeling “useless” was a common complaint, as with Ibrahim, and for patients and families returning to work was an important goal. Fatima had been given antipsychotic medication by the CPN but did not take it. Her father was troubled by her lack of productivity and continued financial dependence despite several attempts to set her up in work which he thought might be within her capacity, such as selling sachets of drinking water: “when she wakes up she doesn’t do anything. So all the problem has been put on me. So if the thing can be made stable she could go and work.” He later explained that since “Africans” have to work so hard they want medicine that makes them feel “strong,” rather than something with the opposite effect. Medicines of all kinds, including tonics, “bitters” brewed with alcohol and herbs, and other forms of herbal medicine, are used and marketed precisely for such strengthening effect.

This desire for medicines to restore the strength needed for participation in daily life was consistent with a view of illness concerned less with symptoms per se than with the impact on social functioning. As Patterson (1981, p. 27) describes, for Ghanaians: “The “sick” person was one whose health interfered with the ability to work or to fulfill social roles; obvious disease symptoms might be ignored as long as the sufferer could function.” In keeping with this, studies in Africa have suggested that mental illness may be associated less with disturbances of cognition or perception than with its impact on behaviour (Edgerton, 1966; Kabir, Iliyasu, Abubakar, & Aliyu, 2004; Murphy, 1976; Patel, 1995). Families in Kintampo seemed comparatively untroubled by the “positive” symptoms of hallucinations and delusions, compared to the impact on the person’s ability to participate in work and family life. Whilst many informants, like Ibrahim, reported seeing or hearing things which others did not, such “visions” seemed to be accepted at face value since it was not only the mentally ill who claimed to have witnessed the activities of witches or been abducted by mmoatia. ¹⁴ By contrast, the loss of the income-generating capacity of a family member and prolonged dependence on family support was keenly felt, particularly where many families were already struggling to get by. Since health is allied with strength, healing is signified by a return to productivity, as Akosua’s sister recognised. Even if the person continued to make grandiose or outrageous claims any contribution to daily chores, social relationships, and work was taken as evidence that treatment (of whatever modality) was, at least to some extent, effective. A return to social roles is thus valued above symptom control, yet such “social healing” (Mhina, 2009, p. 152) is precisely where antipsychotics may have least impact (Swartz et al., 2007).

An illness that “comes and goes”

Though antipsychotics might exert valued effects in the short term, the fact that in many cases the illness returned when the drugs were discontinued posed a further challenge to their perceived efficacy. Akosua’s sister was a nursing assistant, and therefore among those most likely to favour biomedical treatment. However, she remained frustrated that Akosua’s illness kept recurring despite the initial beneficial effect: “I brought her here [the hospital] and they gave her medicine that will let her sleep, yet when the medicine gets finished, it also returns. Sometimes when they give her medicine it goes for about two months then it returns.” As Akosua herself said: “I want the one that will heal me completely so it won’t come back again.” Studies of help-seeking for chronic conditions such as diabetes and HIV/AIDS in Ghana similarly reveal that whilst medication may alleviate symptoms, failure to eradicate the disease can prompt a search for other forms of treatment (Aikins, 2003; Awusabo-Asare & Anarfi, 1997; Mill, 2001). Ohene, a Ghanaian psychiatrist, notes that patients who attend hospital with symptoms of mental illness expect that medication will effect a “total cure” (2002, p. 47). A similar observation has been made in Nigeria, where patients were reported not only to approach the psychiatric hospital after fruitlessly trying “one traditional healer after another,” as in the “last point of call” narrative, but also the reverse: “After successful treatment in a psychiatric hospital they fail to come for follow-up and their maintenance medication […] When the patients have relapses they are taken to traditional healers, since the relapses are interpreted as a failure of modern psychiatry to procure permanent cure” (Asuni, 1979, p. 36). As one family asked when the CPN prescribed antipsychotics: “will this [medicine] be able to completely clear his mind?” Indeed the concept of complete cure is embedded in the Twi ayaresa (healing) meaning to “cut off” or “stop” pain or sickness. ¹⁵

Kwasi’s father had taken his son to hospital when he first became ill, but despite trying the hospital medicine for some time he did not see any lasting improvement: “When he took all the drugs we went back for more. Yet still, the illness was getting worse so we went to a prayer camp.” He contrasted healing, in which the illness goes completely, with a reduction in symptoms: “If a doctor gives you medicine which you take and your illness goes away but later comes back, then you are not healed. Maybe he just reduced it a bit.” Though it was recognised by healers and some carers that madness could take a long time to treat, the idea of taking medication indefinitely seemed contrary to ideas of healing. Rather there remained an expectation that if the medicine was powerful enough, at some point the illness should be cured. A recurring illness fuelled suspicions of “something behind it” such as witchcraft, demonic possession or a curse, in which case it would lie beyond the reach of the hospital doctor and his pills, however potent. A “spiritual illness,” sunsum yadeε, ¹⁶ though counterpoised to honam yadeε, “body sickness,” does not equate with a disease for which no organic cause can be found, as in the distinction in psychiatry between “organic” and “functional” mental illness, ¹⁷ it is suspected in any illness which is unusually prolonged or “keeps returning after treatment” (Konadu, 2007, p. 164). “Spiritual sickness” is defined in opposition to “hospital sickness,” precisely because chronic illness by definition cannot be cured by medical science. Mullings cites a patient at a shrine in southern Ghana: “When the trouble has a spiritual cause, you may go to hospitals but they cannot help you” (1984, p. 96).

The failure of psychiatry to achieve a permanent cure therefore confirms its spiritual nature, as one pastor explained: “when it comes like that, you will go to the doctor, the doctor will give you medicine, but it will not go. It has become spiritual sickness […] So for that, the doctor can’t cure [it].” In Tanzania, Whyte (1991) also found that, whilst psychotropic drugs were said to have “helped a bit,” only traditional healers were believed to bring about complete recovery since only they addressed spiritual causes. As Teuton, Dowrick, and Bentall argue: “the limited influence and apparent ineffectiveness of allopathic medicine in mental health provide a rationale for spiritual explanations and interventions for ‘madness’” (2007, p. 1271). Such was the case with Grace who was being treated at the shrine. Her uncle who accompanied her had been a classmate with one of Ghana’s few psychiatrists and had first taken Grace to the psychiatric hospital. However, she had developed very bad side effects when given antipsychotics. Her neck had gone stiff and her “eyes had rolled up” (suggestive of a neuroleptic-induced oculogyric crisis), and in her uncle’s view her illness had not improved, but rather deteriorated. This poor response suggested to the uncle (and even, he claimed, to his psychiatrist friend) that the illness was one which could not be treated through psychiatry but which required spiritual intervention.

Hope for a cure

Nonetheless, families were often equally disappointed in their hopes for a spiritual cure despite trying several forms of healing at significant effort and expense. When we first met him in a remote village, James was in shackles, the consequence of his father’s efforts to prevent him harassing the neighbours. Over the years, James’s father had spent a great deal treating his son at prayer camps, a shrine, and a medical doctor, but the illness always “came back as it was.” As he said, “after all that we did it was to no avail.” Whilst the promise of miraculous cures which exceed the limitations of biomedicine fuels the popularity of Pentecostal churches and the continued use of the shrines, the failure of healers of all persuasions, including medical doctors, results in a coexisting scepticism towards their healing claims. It is widely suspected that many healers exploit their customers, as one mother said: “You know herbalists, they will tell you what will get them money.”

However, this scepticism did not imply a wholesale rejection of the possibility of spiritual factors in mental illness, nor extinguish hope for a cure. Ultimately any success in healing, including biomedical treatment, was seen as due not to the superiority of the healer’s methods, but to “God’s grace” or God’s will. As one woman explained: “Unless God has ordained that he will be well, he won’t be well… even if you take him to a doctor.” Thus the choice of healing appeared to be driven less by ideological commitment or even practical considerations, than a willingness to “try it and see.” Despite the widespread and increasing use of the psychiatric hospitals and clinics, hospital medicine does not seem to be given any priority in a “hierarchy of resort” (Romanucci-Ross, 1969) when it comes to treating mental illness. Even at its most successful, rather than hospital medicine supplanting other forms of therapy, as envisioned in the modernising discourse of global mental health campaigns, it is used alongside or in turn with other forms of treatment in a pragmatic and experimental way (Pearce, 1993; Whyte, 1997). Bierlich records how in northern Ghana the sick person tries a variety of medicines, including pharmaceuticals, “to see whether they will work’ (2007, p. 97). Similarly, Kwasi’s father referred to his approach to treating his son’s long-standing mental illness, including his use of hospital medicine, as “throwing stones,” a popular idiom for “try it and see.” He explained:

The illness came a long time ago so you need to watch the medicine used to treat him for some time. Maybe from six months to one year and if the treatment is not good … or the illness cannot be cured, then you can decide to look for a different one. Even if you go to the doctor and they give you medicine, you’ll be given a lot of medicines to take. And if you finish taking them all and you don’t get better, you will be given a different one when you go back.

Such experimentation, as Kwasi’s father insisted, also required the time to watch and wait. Lengthy stays at the shrine and churches, and even at the hospital, gave families the time to judge whether or not treatment had been successful in the long term, an important consideration given the status of madness as an illness which “goes and comes back.” Thus it is only in the longue durée that the true efficacy of healing can be judged, a factor which can be overlooked among those who claim impressive effects for both biomedical treatment and traditional healing for mental illness.

The inherent pluralism of the healing landscape in Africa facilitates such experimentation in which biomedicine is but one choice amongst many (Pearce, 1993; Whyte, 1997), part of a total field, a “medical culture,” rather than compartmentalised alternative systems (Last, 1992). As West and Luedke (2006, p. 3) argue, Africans commonly “piece together disparate therapeutic resources in an attempt to meet their health needs.” Many Ghanaians took combinations of abibiduro (African medicine) and pharmaceuticals, as well as “going for prayers” at church, as one pastor put it, aduro kakra, mpaebɔ kakra—“a little medicine, a little prayer.” This was the case even for conditions such as malaria when a “natural” causation, a mosquito bite, and the effectiveness of antimalarials is widely recognised (Asante et al., 2010). In effect, this “covers all bases”: addressing spiritual factors if these are suspected; beseeching God’s grace to empower the medicine; and perhaps adding a herbal tonic to enhance bodily strength. Rather than privileging a therapeutic homogeneity, as advocated in the “evidence-based,” “standardised” treatment of biomedicine, the pluralistic healing landscape offers, as Halliburton (2004) argues, a chance that people might find a “fit” with their personality, beliefs, and preferences through strategic and piecemeal use of the various forms of healing.

Mhina (2009, p. 155) critiques the “modern hospital” in Africa, arguing that “it tends to fail those with mental illnesses, for whom appropriate treatment is seldom available.” Certainly the lack of follow-up and the difficulty in obtaining ongoing supplies of medication played an important part in patients and families discontinuing psychiatric treatment, as well as the poor conditions in the country’s overcrowded psychiatric hospitals. Yet, research in India has shown that even where psychiatric treatment is readily available, people may prefer alternative modes of treatment that may be perceived as more “pleasant” or more efficacious (Halliburton, 2009; Jain & Jadhav, 2008). Ultimately, as observed in other African societies (Feierman, 1985; Pearce, 1993; Whyte, 1997), a preference for one form of treatment over another appears to be driven not so much by beliefs about the nature of illness and its causation, as practical outcome in the long-term. As one mother who had stayed for several years with her chronically ill daughter at the shrine told us: “If she gets well here I won’t go anywhere else. You see? If you are treating an illness and she gets well you stay at that place.” Yet perceptions of efficacy, as this paper has shown, are deeply embedded within the social context of ideas of health as much as of illness (Feierman, 2000). Antipsychotics, like any other treatment, are judged on their power to end sickness, restore strength and well-being and return the person to his or her social role.

Conclusion

This study suggests that far from being ignorant of biomedical treatment for mental disorders, many Ghanaian families are aware of the availability of psychiatric treatment and try out psychotropic drugs in the search for a cure. Antipsychotics clearly provide valuable benefits for many, however Ghanaians are not alone in finding them to be less than satisfactory in the long term. Many of the concerns regarding the side effects and long-term efficacy of antipsychotics expressed by people with serious mental illness in Ghana echo those of users of mental health services in high-income countries. In these settings, the “intolerability” of antipsychotics has led to legislation and innovations in mental health services in an attempt to ensure patients continue with treatment as well as alternatives such as the “recovery approach” (Anthony, 1993) in which mental health professionals are urged to prioritise patients’ own coping strategies which may involve stopping or reducing medication.

However, in practice in both high- and low-income countries psychotropic medication continues to dominate psychiatric treatment, particularly for psychosis. The high level of supervision necessary to retain people in treatment and an enduring expectation of prolonged dependence on antipsychotics to prevent relapse has led some to suggest that psychiatric treatment may itself induce chronicity (Luhrmann, 2007). Yet despite a recognition of the need to supplement medication with interventions such as community-based rehabilitation and family support (Mari, Razzouk, Thara, Eaton, & Thornicroft, 2009; Patel et al., 2007), consideration of the limitations of psychotropic treatment can become muted in the push to scale up mental health services. In low-resource settings such as Ghana, pharmaceuticals are often synonymous with “modern” medical treatment and there are few options for psychosocial interventions within psychiatric services. However, the emphasis on social functioning in concepts of health in Ghana suggests that treatment approaches which support the resumption of a social role, however limited, may be most valued. Ghana is one of the countries to receive intensive support to scale up the provision of evidence-based psychiatric treatment under the World Health Organization Mental Health Gap Action Programme (WHO, 2008). Whilst most of the programme’s recommended treatments for psychosis refer to the use of psychotropic drugs, they also include psychoeducation, family interventions, and “interventions to enhance independent living and social skills.” ¹⁸ The impact of such interventions is most often measured through standardised measures of symptoms and disability, making it difficult to unpack the qualitative experience of subjects, and longitudinal studies are rare. Nonetheless, studies from India suggest that combining community-based rehabilitation and psychoeducation with medication may have the potential to both reduce disability and maintain patients in treatment (Chatterjee, Patel, Chatterjee, & Weiss, 2003; Chatterjee, Pillai, Jain, Cohen, & Patel, 2009; Murthy et al., 2005). As this research shows, being able to work is a principle measure of recovery, bringing the person back from a sense of “uselessness” and failure. In Ghana, the NGO BasicNeeds, with funding from the European Union, has claimed some success in providing microcredit and work placements to enable people with mental illness to engage in “sustainable livelihoods,” providing eloquent testimony to its benefits from a number of people with mental illness and their relatives (BasicNeeds, 2010). However, another community mental health project in India which included a community clinic, liaison with traditional healing centres, and vocational rehabilitation, failed to retain patients in treatment following the withdrawal of resources, despite initially impressive results (Thara, Padmavati, Aynkran, & John, 2008). This is a common problem of externally driven and funded initiatives which has also thwarted attempts to improve the community treatment of mental illness in Ghana and suggests the need to embed such initiatives within locally sustainable structures.

A larger question concerns the models on which such interventions are founded, most of which originate from high-income countries. “Evidence-based” recommendations may overlook the value of “local knowledge” (Kirmayer, 2006) which is harder to quantify and may bypass state- or NGO-funded interventions. Replicating the bureaucratic model of community mental health care of high-income countries, which draws on a pool of highly trained professionals, is not feasible nor necessarily desirable in many African settings (Alem, 2002). In the 1960s, the Nigerian psychiatrist, Lambo attempted to draw on the benefits of family and community support with his innovative “village psychiatry.” Whilst he may have been guilty of idealising “rural village life” (Bass, 1997), the idea that Africa might develop its own models of health care, rather than pale imitations of those in industrialised countries, seems to have fallen out of favour in the drive for standardisation. Research in low-income countries shows that, as in this study, families can be invaluable, not as a poor substitute for institutionalised models of care, but as active participants in maintaining the person with mental illness within his or her social milieu. Family members do most to contain and care for mental illness in daily life, and suggest the most promise for maintaining the social functioning and identity of those with mental illness. Allowing family members to stay with their sick relative in hospital is one way in which low-income countries have innovated on psychiatric treatment to the benefit of patients (Diop & Dores, 1976; Nunley, 1998; Osei, 1993).

However, the emotional, physical, and financial toll of psychosis on the family can be great, particularly in settings where there is very little state-funded welfare to compensate for financial losses and family resources are already overstretched. Families in this study expended large amounts of time and money searching for treatment and went to considerable lengths to care for a child at home and it is those with mental illness and their families, above all, who should be the focus of consultation and resources by policy makers and service providers. Psychoeducation may be helpful to gain an understanding of psychosis and biomedical treatment, although it needs to avoid a didactic approach in which the “ignorant” are educated in the “correct” medical view, in favour of an exchange of knowledge, recognising that those who live with mental illness on a daily basis are those most intimate with its individual experience. Group and peer education may be one way in which hard-pressed clinicians can maximise time as in the carers’ groups which have been formed at Accra Psychiatric Hospital and through BasicNeeds. Such education could include honest and open information on the side effects and limitations of antipsychotics as well as their benefits to enable an informed decision about whether and how to use them.

Finally, if psychiatric services are to be promoted as the best possible treatment for mental illness, then they must provide the highest standard of care which requires not just investment but ongoing training, monitoring, and accountability, not an easy task where staff are often demoralised and patient numbers overwhelming. Drugs should be administered at the lowest necessary dose and side effects monitored, not simply to improve adherence to treatment, but to minimise any adverse impact for those who take them. Meeting the complex and sometimes conflicting needs of people with severe mental illness and their families is an ethical challenge faced by all societies and has often led to abuse and neglect as much as care. Working in an era infamous for psychiatric abuses in Europe and North America, Lambo warned:

In planning and organising mental health services, psychiatry in underdeveloped countries could profit considerably from avoiding the mistakes already committed in very advanced countries of the world. When we, however, try to abstract a lesson from European and American experience we must make sure that it will apply in the contemporary African situation. (1960, p. 1703)

Context-embedded models of mental health care that draw on local resources and sociomoral frames of illness and recovery, as well as the best of biomedical treatment, may go some way towards meeting that challenge, whilst avoiding such “mistakes,” whatever the setting.