The morbidity management program (MMP), is an aspect of the global program to eliminate LF (GPELF). Although it aims to address the chronic manifestations of LF, it is currently not sensitised to any of the psychological consequences of the disease. Medical officers and field workers participating on the MMP, only focus on patients’ physical management, and admit to never exploring psychological issues. One MMP worker discloses ‘Actually, we didn’t think about that, the psychological part ...If we can do something more that [will be] better’.
The World Health Organisation (WHO) has classically defined health as:
‘A complete state of physical, mental and social wellbeing and not merely the absence of disease or infirmity’
Through physical disability and social stigmatisation, patients with Lymphatic Filariasis (LF) are vulnerable to poor mental states, and subjected to lives lacking all these defining aspects of health. Recent research in Galle, Sri Lanka has established that nothing is being done to identify and address such issues, whilst a solution is within reach.
Moreover, the patients themselves do not present their psychological problems to health services. Socio-cultural characteristics such as shame, pride, or stigma, create a reluctance to access help. No psychiatrist or psychologist in the region has ever consulted a patient with problems associated with the disease. Interestingly this was not only in the case of LF, but extended across most other diseases, suggesting that the concept of formal psychological healthcare is alien to the population.
Example Patient Case: Paul is a 55 year old illiterate male with severe bilateral lymphoedema; he developed the symptoms of LF as a teenager, never married, and lives with his sisters’ family in the Matara district of Sri Lanka. He is quiet, subdued and teary eyed, and suspected to be clinically depressed. His family members complained to the researchers about the smell of his legs as he does not take care of his condition, and they asked for help.
Although Paul is a more severe case, he exemplifies the complex interrelationship between poor physical and mental health. There is a ‘treatment gap’ as such people are in need of psychological services but do not access them. This is a gap which the Sri Lankan researchers hope to help close. Although their findings are context specific, they suggest some useful strategies to encourage more holistic MMPs in other areas of the world.
What can be done for patients, to bridge the gap between services designed to address the physical problems of patients with existing disease, and the psychological or psychiatric services?Mobilisation of non-formal resources such as family will be essential to help recognise and refer patients in need of therapy.
To overcome the shortages of human resources, mental health specialists could be redefined by shifting therapeutic tasks to the MMPs’ medical officers and field workers. They could be trained to assess patients’ mental health and consult them, and only refer patients on to psychologists or psychiatrists as a final option of care, known as a ‘stepped care’ format.
Key community players such as religious leaders or ‘Gramaselanevaldi’ (respected members within the district) can be educated to help address misconceptions surrounding LF, it’s manifestations, and management.
Finally, sensitisation to mental health is paramount; sensitisation of policy makers; sensitisation of health service providers; sensitisation of communities; and sensitisation of the patients themselves. Initiatives will not achieve a maximal impact unless there is an appreciation of the connection between the neglected tropical diseases and poor mental health.
Feasible solutions could be implemented across other countries and address other NTDs where there is a mental health component - the co morbidity between neglected infections and mental health is a new dimension in addressing the challenge of mental health and neglected diseases in the poorest parts of the world.
We ought to open peoples’ minds to finally close the gaps.Lizzie Litt is a 5th year medical student from the University of Liverpool in the UK. She completed an MSc in Humanitarian Studies last year at the Liverpool School of Tropical Medicine for which she undertook this research with LF patients in Sri Lanka, with the Department of Parasitology, University of Ruhuna, Galle. This research was funded by GlaxoSmithKline. Lizzie would also like to credit the following people: David Molyneux (LSTM), Mirani Weerasooriya, Channa Yahthugoda and Chandie Senadheera (University of Ruhuna, Sri Lanka)
A standard preventative treatment for LF is a combination of the drugs Albendazole and Ivermectin. Ivermectin also treats river blindness, so treatment campaigns often address both diseases simultaneously. For GHFN stories about river blindness, go to http://www.ghfn.org/1-topics-general-pages/river-blindness.