From diversity to individualized care: Africa’s contribution to psychiatry

The extent of diversity on the African con­tinent is one of the greatest potential contributions of this continent to the world, with a multiplicity of cultures and traditions, religions and other belief systems that dwarf anything found anywhere else on earth. Naturally, therefore, one would be hard‐pressed to identify a uniquely “African” viewpoint on mental health and the detection and treatment of mental illnesses.

Africans have lived with psychological distress and mental disorders for as long as humans have lived on the continent, with different cultures and traditions, including religious ones, having different explanatory models. Many African communities still utilize relatively culture‐specific models to understand the causes of mental illnesses, including demon or spirit possession, or witchcraft ¹ . Jinns (invisible spirits) in Islamic traditions, and other “evil” spirits in other communities, are considered responsible for conditions presenting with mood disturbances, anxiety, hallucinations, delusions and back pain, among other health problems ² . These diverse local conceptualizations determine and affect access to and outcomes of care for those with mental illnesses ¹ .

In our opinion, current and emerging diagnostic and treatment systems must take into consideration these existing models, and endeavour to create a bridge between them and newer ways of understanding mental conditions and health. The extension of the biopsychosocial model to include sociocultural‐spiritual components of illness and treatment ³ would encourage holistic and culturally sensitive approaches to addressing Africa’s mental health care gap.

As Stein et al ⁴ point out, classification sys­tems, at their very core, assume a universality of experience and the potential univer­sality of response to investigations and treat­ments. Novel attempts at understanding mental illness – including the Research Do­main Criteria (RDoC), the advances in neurosciences, and even personalized medicine – build upon certain “universalized” assumptions, including those on the nature of mind and the interaction between a person’s inner world and his/her environment. From a purely practical perspective, we a­gree with the implicit notion that a global model of understanding mental health and illness is desirable in the context of a rapidly globalizing world, given the ease of mobility and the resulting complex cosmopolitan cultures that sprout whenever new human communities form. We must, however, remain cognizant of the fact that, even within the most homogeneous communities, every person’s experience of the world is unique, and it may be difficult to generalize these experiences even to individuals steeped in the same culture and environment.

Diagnostic and treatment models are there­fore required to use a “global” framework of understanding mental health, but ultimately apply this to an individual’s unique experiences and background, in order to fully understand personal suffering and generate an explanatory model that makes sense to the individual and to the society from which he/she comes. To implement this approach, however, may be difficult5, 6, because many clinicians are ill equipped with the relevant social and anthropological tools, and because of the problems in creating appropriate research platforms, due to the variety of explanatory ideas.

There are inherent conceptual weakness­es in attempting to identify components of ex­planatory narratives, in much the same man­ner as it would be difficult to develop a global glossary of symptom contents for some­thing like auditory hallucinations. Treat­ing individual explanatory narratives as part of the diagnostic process as well as an integral component of treatment planning might yield better results than attempting an in‐depth understanding of the subject through quantitative research methods.

Even with culturally sensitive approaches to diagnosis and treatment, there is no level of cultural understanding that can replace the information on an individual’s own lived experience and perspectives, which vary widely even within a particular cultural context. Not everyone within a cultural or ethnic group subscribes to what is considered “traditional” to that group, and unquestioning acceptance of cultural or traditional practices in the context of individual patients runs the risk of alienating significant minorities and therefore compromising their access and response to care.

This individualized care model is already present in the management of psychological distress and behavioural problems in African communities that have different attributions for these conditions. In many cases, the practitioner collects information about the individual’s context and beliefs, and uses this information to develop an explanatory narrative for the condition and to fashion a remedy that is unique for that person even while utilizing available generic components. For instance, personalized remedies have been described in Ghana, and categorized to include banishing evil spirits, protection from relapse/further attacks, and “awakening the mind” ⁷ .

In these settings where current innovations in care are inaccessible, mainly due to the cost and investments required, attempts have been made to develop separate systems of care in the context of global mental health, including concepts of “task‐shifting” or “task‐sharing”. Unfortunately, these “contextualized” approaches have sometimes resulted in low‐income populations getting sub‐standard care, while those that can afford it – even within the same settings – are able to access high‐quality evidence‐based care. We have previously criticized these approaches, as they endorse alternative systems of care based on the assumption that poor people or societies will always remain poor and incapable of accessing care that is of high quality and evidence‐based ⁸ .

We argue that global mental health must be truly global, through the application of a global knowledge framework to understand distress and suffering, while developing solutions that take into consideration individ­ual histories, contexts and explanatory models. While an advanced knowledge of brain processes will help us in developing this global framework, an understanding of society and culture, and how individuals ­interact with and perceive their environment, will be more critical in the encounter with a given patient. The “global” in global mental health should not only be seen as addressing differences between societies, but also working with diversity within all societies.

In conclusion, we believe that a personalized diagnostic and treatment framework that is based on a core of globally applicable principles is the first step towards addressing inequities in access to care, and ensur­ing that even the most disadvantaged populations access the best available standard of care. African diversity provides the best example of how this can be approached, and the best substrate for the examination of this concept.