Disability Rights 23: Cruel, inhuman or degrading treatment

In addition to the human rights laws in the Constitution of Uganda there are several other rights granted to persons with disabilities (PWDs). These rights are given by law in the Persons With Disabilities Act 2006 (PWDA) which is modeled on the United Nations Convention on the Rights of Persons with Disabilities (CRPD). Whether you are a PWD or not, these laws apply to you.

Section 34 of the PWDA says that PWDs should not be subjected to cruel, inhuman or degrading treatment. Also, no one is allowed to subject a PWD to a medical or scientific experiment without their free and informed consent.

PWDs are more likely to be the victims of violence than non-disabled people. And women with disabilities are much more likely to be the victims of violence than their non-disabled counterparts (see Document on Violence against Women with Disabilities). Violence against women includes the following:

• forced isolation, confinement, and being hidden in the family home 
• forced and coerced administration of psychotropic drugs or putting drugs in the food 
• forced and coerced institutionalization 
• restraint and isolation in institutions 
• creating pretextual situations to make the woman appear violent or incompetent in order to justify institutionalization and deprivation of legal capacity 
• labelling anger and self-assertion by women as behavior that is “mentally ill and dangerous” (especially if the woman has been previously institutionalized) 
• withholding medication that the person uses voluntarily, medical and mobility aids, or communication equipments 
• denial of necessities and purposeful neglect 
• threats to neglect children or pets 
• verbal abuse and ridicule 
• physical abuse or threat of it 
• being left in physical discomfort or embarrassing situations for long periods of time 
• threats of abandonment 
• violations of privacy 
• being ignored 
• financial abuse 
• restraint, strip searches, and solitary confinement that replicate the trauma of rape 
• rape by staff and other inmates/residents of institutions 
• forced abortion 
• forced sterilization

For people with mental health problems the situation is equally bleak. In a 2013 report Psychiatric hospitals in Uganda: A human rights investigation, inspectors from the Mental Disability Advocacy Center (MDAC) and Mental Health Uganda (MHU) noted in their report that Uganda has a mental health service that is under developed and under resourced. Mental health laws are outmoded and unenforceable and date back to the colonial era. There is no reference to the human rights for people in hospital with mental health problems and furthermore, there is no protection against maltreatment or abuse. These are some human rights abuses uncovered by the inspection team:

• People with mental health issues were frequently locked in dark and cold seclusion rooms, often naked, lying on the same floor where they were forced to urinate and without access to a toilet. 
• People with mental health issues were not free to leave hospital without the permission of staff, whether or not they were legally detained... The majority were forcibly brought to psychiatric hospitals in shackles or ropes, and in very few cases was there any lawful authority for such practices. 
• Compulsory and forced treatment was the norm, and the right to informed consent and refusal of treatment was completely denied. 
• The entire system was based on a highly pharmacological approach. Alternatives such as psychological or psycho-social interventions were virtually unknown and individualised care was completely absent. 
• The conditions in many hospitals were appalling, including at Butabika hospital male and female acute wards, which were seriously overcrowded. 
• The physical health care needs of the majority of inpatients were neglected. 
• Women with mental health issues were subjected to additional abuses. Women reported not being provided with sanitary pads and had to wear dirty underwear and were left without access to clean clothes or washing facilities. 
• Food was not provided by the government in hospitals, except at Butabika. This was particularly concerning as many people with mental health issues had been abandoned by their communities and families and were left destitute. 

If you are a woman with a disability and you have been the victim of abuse; or if you have a mental health problem and you have been a victim of abuse; or if you are member of the public and you have witnessed any abuse; you can report the incident to the National Council for Disability for further investigation. 

Psychiatric hospitals in Uganda: A human rights investigation.
The absence or lack of enforceable legislation is of serious concern, meaning that mental health care and abusive practices can take place without any regulation whatsoever. Uganda must now stop stalling on the passage of new, robust legislation based on and extending human rights protection to those people who use psychiatric services in the country. It should do this through the passage of legislation as soon as possible, and must ensure that people with mental health issues and their representative organisations are involved in the process.

This law is written like this in section 34 of the Persons With Disabilities Act 2006:

34. Cruel, inhuman or degrading treatment.

(1) A person or institution shall not subject a person with disability to cruel, inhuman or degrading treatment.

(2) A person or institution shall not subject a person with disability to medical or scientific experimentation without the free and informed consent of the person concerned. 

Mental Health: Stigma and Prejudice

The video below shows that mental health problems carry a great burden of stigma and prejudice. In a country like Uganda, with 1 psychiatrist for every million people the stigma and prejudice associated with mental illness are a significant problem that often forms a barrier to proper treatment.


It is thought that 90% of people do not receive the medical attention they require. Witchcraft, curses or evil spirits are often thought to be the cause of mental health problems, meaning that traditional and spiritual healers have a significant role to play in treatment.  

People with mental illness and their families often feel isolated and alone. A strong psychosocial support network of family, friends and peers is essential. Thus, creating a climate for open discussion ensures the whole family can receive the care and support they need.

People with mental health problems need compassion

Mental health was identified as the leading disease burden in the 2015 World Health Organisation budget. It is a serious problem in developing countries and is often underfunded. In Uganda only 3% of the total medical budget is allocated to mental health. The poster says:

Mental illness is one of the commonest but ignored disorders in our society. Uganda has made attempts to reverse huge statistics of mental health, but stigma and ignorance remain as hindrances’. The question on whether mental illness can be treated is routine. In this piece, we dig into efforts made to alleviate the disorder.

What is Socioeconomic Status (SES)?

Socioeconomic status (SES) is an important indicator of health and disability. In any discussion about disability it is necessary to understand this measure. This blog has already noted that persons with disabilities (PWDs) score significantly less across the board on all socioeconomic indicators (see Poverty and Disability in Uganda). The term has been used in the following posts:

• Asthma in Uganda: SES is an important factor in the development and/or exacerbation of asthma symptoms in young children. 
• Mental Health: Depression in Uganda: Risk factors for developing depression are all socioeconomic, related to deprivation (no formal education, having no employment, broken family) and poverty (low SES).
• Polio in Uganda: polio has profoundly detrimental socioeconomic consequences. 
• Spinal Cord Injury (SCI) in Uganda: SCIs are found in the most economically productive age group of 20 to 40 years and are therefore a big socioeconomic burden to the nation. 
• Visual Impairment in Uganda: River blindness is a significant socioeconomic burden that can be treated with antibiotics.

It is therefore important to understand SES. SES is an indicator used in sociology to measure an individual or a family's position in relation to others based on income, education and the work they do. SES is often summarized in 3 classes or categories (upper SES, middle SES and lower SES) Wikipedia continues the description of SES:

Low income and education have been shown to be strong predictors of a range of physical and mental health problems, including respiratory viruses, arthritis, coronary disease, and schizophrenia. These problems may be due to environmental conditions in their workplace, or, in the case of mental illnesses, may be the entire cause of that person's social predicament to begin with.
Education in higher socioeconomic families is typically stressed as much more important, both within the household as well as the local community. In poorer areas, where food and safety are priority, education can take a backseat. Youth audiences are particularly at risk for many health and social problems in the United States, such as unwanted pregnancies, drug abuse, and obesity.

Income, education and occupation are important indicators in their own right. When they are combined into SES they become a powerful tool. The following notes about each are taken from Wikipedia:

Income: Is a measure of all money earned. Low income families focus on meeting immediate needs and do not accumulate wealth that could be passed on to future generations, thus increasing inequality. Families with higher and expendable income can accumulate wealth and focus on meeting immediate needs while being able to consume and enjoy luxuries and weather crises.

Education: Research shows that lower SES students have lower and slower academic achievement as compared with students of higher SES. When teachers make judgments about students based on their class and SES, they are taking the first step in preventing students from having an equal opportunity for academic achievement. Educators need to help overcome the stigma of poverty. A student of low SES and low self-esteem should not be reinforced by educators. Teachers need to view students as individuals and not as a member of an SES group. Teachers looking at students in this manner will help them to not be prejudiced towards students of certain SES groups. Raising the level of instruction can help to create equality in student achievement. Teachers relating the content taught to students' prior knowledge and relating it to real world experiences can improve achievement. Educators also need to be open and discuss class and SES differences. It is important that all are educated, understand, and be able to speak openly about SES.

Occupation: Occupations are ranked by the Census (among other organizations) and opinion polls from the general population are surveyed. Some of the most prestigious occupations are physicians and surgeons, lawyers, chemical and biomedical engineers, university professors, and communications analysts. These jobs, considered to be grouped in the high SES classification, provide more challenging work and greater control over working conditions but require more ability. The jobs with lower rankings include food preparation workers, counter attendants, bartenders and helpers, dishwashers, janitors, maids and housekeepers, vehicle cleaners, and parking lot attendants. The jobs that are less valued also offer significantly lower wages, and often are more laborious, very hazardous, and provide less autonomy.
Occupation is the most difficult factor to measure because so many exist, and there are so many competing scales. Many scales rank occupations based on the level of skill involved, from unskilled to skilled manual labor to professional, or use a combined measure using the education level needed and income involved.

The 2003 paper Deliberate self-harm as seen in Kampala, Uganda: A case-control study shows the effects of SES. Self-Harm is described in the following way (see Self-injury (Cutting, Self-Harm or Self-Mutilation):

Self-injury, also known as self-harm, self-mutilation, or self-abuse occurs when someone intentionally and repeatedly harms herself/himself in a way that is impulsive and not intended to be lethal.
The most common methods are:

• Skin cutting (70-90%),
• Head banging or hitting (21%-44%), and
• Burning (15%-35%).

Other forms of self-injury include excessive scratching to the point of drawing blood, punching self or objects, infecting oneself, inserting objects into body openings, drinking something harmful (like bleach or detergent), and breaking bones purposefully. Most individuals who engage in non-suicidal self-injury (NSSI) hurt themselves in more than one way.

Self-harm is a diagnosed mental health disorder that carries all the usual stigma and prejudice with it. The Abstract summarizes the paper (all socio-economic references are highlighted in bold):

Objectives: A study to investigate deliberate self-harm (DSH) in an African context was undertaken in Uganda.
Methods: A case-control study in which 100 cases of DSH and 300 controls matched on age and sex were recruited from three general hospitals in Kampala and subjected to a structured interview using a modified version of the European Parasuicide Study Interview Schedule I.
Results: Among the cases, 63% were males, with a male to female ratio of 1.7:1 and a peak age range of 20–24 years. Higher educational attainment, higher socio-economic class and poor housing were significantly associated with DSH. District of current residence, district of birth, religion, ethnicity,marital status, number of children, current living arrangement, area of usual residence, employment status of respondent and partner were not significantly associated with DSH.Pesticides and medications, mainly antimalarials and diazepam, were the main methods of DSH used. The most commonly reported psychiatric disorders were adjustment disorder, acute stress reactions and depression.
Conclusion: DSH in Uganda appears to predominantly afflict the young.Disturbed interpersonal relationships, poverty and loneliness were important factors in the immediate precipitation of this behaviour. The fact that pesticide poisoning is still the predominantly used method in DSH in this area calls for a review of the legislation that controls the sale and availability of these agricultural chemicals.

The introduction to the paper describes the risk factor associated with DSH:

Deliberate self-harm (DSH), one of the major risk factors for completed suicide, has been shown in the West to be more prevalent among the young and especially young women (15–24 years) (Platt et al. 1992; Kerkhof 2000). Single and divorced people have also been found to be overrepresented among deliberate self-harm patients, as well as people of low education, the unemployed, those with a history of psychiatric treatment and those that are socio-economically deprived (Newson- Smith and Hirsch 1979; Urwin and Gibbons 1979; Platt et al. 1992; Kerkhof 2000).
Traditionally in Africa, suicidal behaviour has been viewed with intense social disapproval and regarded as a criminal act in many of the statute books on the continent. As a result, it attracted cultural sanctions (including secrecy) which made it difficult to investigate (German 1987).The situation to date does not appear to have changed very much. Looking at studies that have been undertaken on the continent on DSH, the picture that appears to be emerging is complex. Southern and Central Africa have been reported to have a picture of DSH that is similar to that reported in the West where there is an overrepresentation of the female, the young between the ages of 20 and 29 years, those with psychological problems and those with socio-economic deprivation (Gelfand 1976; Minnaar et al. 1980;Williams and Buchan 1981; Bosch 1987). Studies from this sub-region have also consistently shown a higher rate of DSH and completed suicide among the White and Indian races as compared to Black Africans (Gelfand 1976; Minnaar et al. 1980;Williams and Buchan 1981; Bosch 1987).
The picture from Eastern and Western Africa is reportedly different with, for example, a reversal of the expected female preponderance as reported in one study from Ibadan,Nigeria (Odejide et al. 1986). Other studies from both Uganda and Ethiopia reported no gender differences (Cardoza and Mugerwa 1972; Alem et al. 1999).
Most of the studies that have been undertaken on DSH in Africa are over 20 years old and are mainly of a descriptive nature with no case-control studies reported in the literature on this subject from this region. The associated factors leading up to DSH behaviour in the Ugandan context and Africa in general have also not been well elucidated.
A study was, therefore, undertaken to investigate DSH in the Ugandan context using a case-control study design with standardized psychological assessment instruments.

The results were summarized into several tables and were discussed as follows:

Looking at Tables 2 and 3, proportionally more cases had attained a higher level of education and were represented in the upper socio-economic classes of I and II than controls.However, proportionally more cases than controls were staying in single-roomed lodgings (locally called Muzigo) in deprived city slums...
Deliberate self-harm in this study was associated with a higher educational attainment and a higher socio-ecnomic status, but paradoxically also with poorer housing.Proportionally more cases than controls stayed in single-room lodgings (locally called Muzigo) which are located in slums in an environment of overcrowding with no social amenities. Mzezewa and colleagues (1999) in a study of burns patients in Zimbabwe, many of whom had suicidal intentions, noted an over representation in their sample of people living in one-roomed lodgings which were characterized by overcrowding and poor social amenities (Mzezewa et al. 1999)...

The discussion made some interesting points about the seemingly paradoxical results:

The disparity between educational attainment and socio-economic status on the one hand and the ability to access social amenities such as housing on the other could, in this environment, occur in the lives of at least two types of persons, the urban student and the unemployed graduate. Post-primary education in Uganda is privately paid for and is accessible to only a few families. In 1995,Uganda was reported to have a tertiary student to population ratio of 154/100,000, while the average for sub-Saharan Africa was 339/100,000 and that for Sweden was 2,972/100,000 (Kasozi 2002).As reported by Kasozi in Uganda, those not enrolled in any tertiary programme often came from households with a substantially lower socio-economic status, with their household expenditures averaging less than a third of those enrolled in tertiary programmes (Kasozi 2002).To obtain a good education that will increase the prospects of getting a job, most families often have to send their children to big urban centres, such as the capital city of Kampala. Those who have graduated from tertiary institutions must remain in the city in search of jobs.Both categories of persons often have to stay in the relatively cheaper city slums in order to minimize their upkeep costs....
The majority of cases had psychiatric disorders secondary to stressors in their immediate environment or internally secondary to mental illness/symptoms, with similar results having been reported elsewhere on the continent (Minnaar et al. 1980;Mengech and Dhadphale 1984). In the majority of cases, the stressor was a disturbed interpersonal relationship, loneliness,physical or mental illness.However, also in this study, as in the Tanzanian and Egyptian studies, the socio-economic factors of poverty and unemployment were significant in precipitating DSH (Okasha and Lotaif 1979; Ndosi and Waziri 1997).

The report concluded:

DSH in this study as elsewhere in the world appears to predominantly afflict the young. There was,vhowever, a preponderance of male over female cases of DSH in this study unlike in most studies carried out in the West. This may point towards the existence of culturally ordered differences between the different genders in health-seeking behaviour for DSH in the study area. That the highly toxic organophosphate poison is still the main method of DSH used in this population calls for a revisiting of the legislation that controls the sale and availability of these agricultural chemicals. There is also a need to explore means of limiting the amount of antimalarials that are available at any one moment in the households through innovative methods, such as limiting package sizes,which has been shown to have an effect (Hawton et al. 2001). The factors underlying this behaviour appear to be disturbed interpersonal relationships, socio-economic deprivation, loneliness and mental illness/symptoms.These stressors were responsible for a pattern of mental disorders characterized by more cases with adjustment disorder and acute stress reaction than is usually reported in the West, but which pattern has been reported from other parts of Africa.

In conclusion, SES is valuable tool for assessing wealth, status and educational achievement in society. That PWDs score significantly lower on all socioeconomic risk factors is significant and should not be underestimated. In the paper above it was seen that social deprivation is one of the factors that lead to DSH. From this it arises that DSH can be a prelude to suicide. DSH can then become a serious disability that is loaded with stigma and prejudice. Understanding the role of SES in DSH provides an extra dimension to the understanding of this condition.

Mental Health Peer Support in Uganda

A short documentary about the work of the East London University from the UK and Heart Sounds in Uganda establishing peer support with mental health users in Butubika, Uganda. In this model, mental health users provide support to fellow users and share common experiences. This is a common model for mental health in New Zealand. The poster says:

A short film talking hearing about mental health peer support in Uganda from those that provide it and receive it. Mike Ilamyo was commissioned to create this film for the Butabika-East London Link and Heartsounds Uganda.

Mental Health: Schizophrenia in Uganda

Schizophrenia is a mental health disorder in which the person affected has abnormal social behaviour and failure to understand what is real. Common symptoms are delusional belief, confused thinking, hearing voices, failure to engage in social situations and lack of motivation. People with schizophrenia typically have additional mental health problems such as anxiety disorder, major depressive disorders and substance use disorder. Symptoms typically come on gradually in young adulthood and last a long time. Wikipedia continues:

The causes of schizophrenia include environmental and genetic factors. Possible environmental factors include being raised in a city, cannabis use, certain infections, parental age, and poor nutrition during pregnancy. Genetic factors include a variety of common and rare genetic variants. Diagnosis is based on observed behavior and the person's reported experiences During diagnosis a person's culture must also be taken into account. As of 2013 there is no objective test. Schizophrenia does not imply a "split personality" or "multiple personality disorder"—a condition with which it has been confused with in public perception.

The 1975 survey Schizophrenia in the African countries makes the following observation about schizophrenia:

Schizophrenia in its classical form is quite rare in traditional African societies, and it appears with rapid social changes which organize societies with cultural models designed on occidental societies.

The report The Social Determinants of Schizophrenia: An African Journey in Social Epidemiology makes the following observation:

Rapid urbanization, industrialization, migration, conflict and ongoing poverty and deprivation characterize most of sub-Saharan Africa in recent decades; and it is likely that these potent risk factors for psychosis have contributed to shifts in the social epidemiology of psychosis and schizophrenia in that continent. 

This trend is reflected in the report Prevalence of delusional ideation in a district in southwestern Uganda which found that:

Higher rates of delusional ideation and higher levels of distress and preoccupation were strongly associated with urban residence.

It is interesting to conclude, the report continues, that urbanisation is significantly stressful across cultures, because these results mirror results of a study in the Netherlands.

A study Major mental disorders in Addis Ababa, Ethiopia. I. Schizophrenia, schizoaffective and cognitive disorders reports a lifetime prevalence of 0.9% for Schizophrenia and schizoaffective disorder. Applying 0.9% to the 2014 population of 34,900,000 in Uganda, there are an estimated 314,100 Ugandans with schizophrenia.

As I have shown throughout this blog, stigma and prejudice are associated with all forms of disability. Schizophrenia is no exception. This article, Stakeholder perceptions of mental health stigma and poverty in Uganda, discusses the burden of stigma for all people involved with schizophrenia. The article concludes:

According to a range of mental health stakeholders in Uganda, there is a strong interrelationship between poverty, stigma and mental illness. These findings re-affirm the need to recognize material resources as a central element in the fight against stigma of mental illness, and the importance of stigma reduction programmes in protecting the mentally ill from social isolation, particularly in conditions of poverty.

All mental health conditions besides affecting the diagnosed person have consequences for family and friends. This survey, Chronic Sorrow: Lived Experiences of Caregivers of Patients Diagnosed With Schizophrenia in Butabika Mental Hospital, Kampala, Uganda, sheds some light on the experiences of caregivers:

Our sample of 22 participants was small but representative of the feelings of caretakers for the severely mentally ill attending the national mental referral hospital. There were more females than males because the females, in this country, generally take up the role of care-giving/caretaking. It is the females who stay with the patients at home, take them to hospital and stay with them in the hospital while the men go looking for money which they provide to facilitate the care giving. This is not unusual in African communities with patrilineal kinship systems, Uganda inclusive.
Nine out of ten participants (90%) scored positive for chronic sorrow. This prevalence of chronic sorrow is similar to findings by other researchers among people experiencing different types of losses. For example among the studies that were carried out by Nursing Consortium for Research on Chronic Sorrow (NCRCS), out of 98 persons, 87 (88%) evidenced chronic sorrow (Burke, Eakes, & Hainsworth, 1999). Olwit and Jarlsberg (2014) had similar findings (88%) among the people with facial disfigurement in Uganda experienced chronic sorrow. The intense emotional experiences of chronic sorrow in this study are consistent with findings in the Western world; consisting of confusion, sadness, devastation, anger, fear and worry (Eakes, 1995). In another study, Eakes et al. (1998) found that the intensity of these feelings varied from person to person. This could be because of the mixture of the study sample, because grief-related feelings change with time, being more intense at the beginning when caretakers experience disbelief, shock, confusion and devastation but which later on abates with time. This, therefore points out the importance of health workers taking time to talk to the caregivers especially with newly diagnosed patients in hospital. This helps caretakers express their emotions/feelings and clear out any misperceptions as health-workers provide them with health education about mental illness and help them to develop positive coping strategies.

Florence Anene (left) counsels women suffering from mental illnesses

What is the experience of schizophrenia like for someone? This article, Detecting mental illness still a major hurdle in Uganda, talks about the experiences of of one woman:

In 2012, Florence Anene was just 20 years old when she got incarcerated at Bomah prison in Kitgum district after attempting to drown herself and her three children into River Ogili.
While in jail battling charges of attempted suicide, she experienced numerous epileptic attacks and psychotic incidents, which were not taken seriously.
But after six months in detention, prison authorities diagnosed Anene and found her to be suffering from severe schizophrenia; a mental illness with common symptoms like unclear perception, hallucinations, reduced social engagement and inactivity.
Thereafter, Anene was released and transferred to a World Vision mental health center in Kitgum for rehabilitation, with her three children staying at a local church for over a year.
It was discovered that Anene’s attempted suicide and murder of her children had been influenced by the loss of her husband four months before her arrest.
“After his [husband] death, I was depressed, with no job to manage the children and the needs at home,” she recalls.
Anene had met him in Mucwini sub-county during the Kony guerilla war in northern Uganda and hardly knew much about him.
“I didn’t know any of his relatives; my parents had died during the war. So, everything depended on him,” she says.
At the moment, Anene has made a full recovery and was reunited with her three children. She is now a volunteer with the Mental Health Gap Action program (mhGAP) project, a World Health Organization (WHO) initiative to scale up services for mental, neurological and substance-use disorders.
Anene specifically counsels and comforts women battling mental health illnesses. The five-year program, which is currently being piloted in the three districts of Kamuli, Jinja and Kitgum, is funded by World Vision and implemented by government.
Doctor Sheila Ndyanabangi, an official at the mental health care unit in the ministry of Health, says there are 170 mental disorder patients currently under medication, psychosocial support and reintegration in Kitgum district.
So, Anene’s touching story was just one of tales of overcoming adversity. Such initiatives where cause for celebrations as World Vision commemorated 30 years of service in Uganda; a journey that began after the 1981-1986 war that brought the current government to power.
It started with only volunteers but has now grown into a mature child-health-focused organization.

In summary schizophrenia is a mental health disorder that comes with the baggage of stigma and prejudice. It also has a profound impact on carers, often leading to depression and chronic sorrow. It is therefore important that carers be advised and offered coping strategies for their feelings about schizophrenia. Schizophrenia is a disease that affects the person diagnosed and their principle carer. As such schizophrenia carries a double burden.

For more information about schizophrenia contact the Uganda Schizophrenia Fellowship (USF) and see also World Fellowship for Schizophrenia and Allied Disorders.

Bipolar Disorder Uganda

In the past bipolar disorder (BPD), was known as manic depression. BPD is a mental health disorder characterised by periods of depression and periods of elevated mood. When the mood is elevated a person behaves or feels abnormally energetic, happy or irritable. In the elevated mood a person can often make poorly thought out choices with little regard to the consequences. Sleep is often reduced when the mood is elevated. A severe episode of elevation can result in distorted beliefs about the universe known as psychosis. Depression commonly follows a period of elevation, Wikipedia continues:

During periods of depression there may be crying, a negative outlook on life, and poor eye contact with others. The risk of suicide among those with the illness is high at greater than 6 percent over 20 years, while self-harm occurs in 30-40 percent. Other mental health issues such as anxiety disorders and substance use disorder are commonly associated.

The mechanisms of BPD are poorly understood. However with the correct medications and management strategies the person with BPD can lead a useful and productive life.

It is hard to find data on the prevalence of BPD in Uganda. A study of the Zay people Studies on Affective Disorders in Rural Ethiopia indicates that 1.8% of African people may have BPD.

A study Epidemiology and Burden of Bipolar Disorders in Africa: a Systematic Review of Available Data From Africa suggests there is a lifetime prevalence of between 0.1 and 0.6% of developing BPD based on results from Ethiopia and Nigeria. The report concludes:

Despite the heterogeneous methodologies, samples and dearth of adequate representative evidence from Africa, we have identified bipolar disorder as a major mental health issue. There still exists a dearth of evidence regarding the epidemiological, clinical, social, and economic burden of the disorder in Africa.

If the 1.8% estimate of Zay people with BPD is applied to the people of Uganda then there are an estimated 101,268 PWDs with BPD based on the 2014 calculation of of PWDs in Uganda (see Number of Persons With Disabilities (PWDs) in Uganda). However more conservative estimates of the Epidemiology and Burden of Bipolar Disorders in Africa: a Systematic Review of Available Data From Africa report indicate 0.1-0.6% of the population, 5,625 to 33,750 PWDs may be affected by BPD.
The study Prevalence and factors associated with depressive disorders in an HIV+ rural patient population in southern Uganda, besides showing a high prevalence of depression (46.4% with any depressive disorder), also shows 3.6% of people with HIV/AIDS have bipolar depression and therefore BPD. This is not surprising because BPD is associated with reckless and impulsive behaviour when the mood is elevated. This finding may be of significance for persons with disabilities (PWDs) because of the suspected high prevalence of HIV/AIDS within the community (see HIV/AIDS and Disability in Uganda).

"Lutalo" Warrior - Luganda & Uganda © 2002, 2009 by the bipolar artist John Poole

This is a report, Uganda: One Journalist's Brave Battle Against Bipolar Disorder about Angela Nsimbi who was diagnosed with BPD in 2009:

Angela Nsimbi remembers that Saturday morning in 2011 when her world temporarily stopped.
When she woke up, "something" had taken over her mind.
"I started hearing voices and I switched off. I disconnected from everybody. I did not shout at anyone. I did not breastfeed [her then four-month-old son]. I [just] stood in one position for hours," Nsimbi says. "I was sedated and I collapsed; but not immediately."
Following the collapse, she was taken to hospital and there, she spent four days, unconscious.
"I was being fed on a saline solution when I was unconscious. The doctors said if I did not start eating [after the four days of unconsciousness], they would have to put tubes through my nose so I could be fed. I got up and I remember feeling groggy," says Nsimbi, who did not want to be intubated because it makes one look rather ill.
But what was Nsimbi suffering from? Bipolar disaffective disorder.
HOW IT STARTED: In 2009, following feelings of restlessness, insomnia, paranoia and speaking rapidly, Nsimbi was diagnosed with bipolar disaffective disorder at Mulago hospital by Dr Ssegane Musisi.
"I remember having late nights. There is a time I stayed awake, in bed, till 6am. I also felt that the whole world was against me and wanted to harm me and my children. I wanted them to be around me all the time," the journalist and mother-of-five says of some of her symptoms.
She was so paranoid about her children, she says, she woke them up one day and bathed them.
"They [some] were big at that time but they allowed me. They suffered," she muses with a smile.
Following her diagnosis, her family, including her husband and sister-in-law, sought to have her admitted to Butabika national mental health referral hospital.
"The date was January 26, 2009. I remember my sister-in-law running around Butabika and me holding on to my daughter, who was then nine months old, and thinking, I am not like the people here. I do not deserve to be here," Nsimbi says.
If you have been to Butabika before, you will know that the hospital actually boasts a serenity about it, and does not necessarily have mentally-ill people running around throwing things; however, the social stigma is that once one's illness requires a stint in Butabika, then one is "too far gone for redemption".
Nsimbi could not voice her thoughts, because "when you have been declared mentally ill and you speak up, your caretakers say you are sicker".
Nsimbi, who stood under a mango tree awaiting admission, was returned home that day because being a public holiday, doctors were unavailable to admit her. Because she was not admitted, she started receiving medication as an outpatient from hospitals including Mulago and Nakasero.
Nsimbi says as a child, she did not experience symptoms that pointed to a mental illness. Since her 2009 diagnosis, she has relapsed twice, experiencing a minor episode when she was seven months pregnant with her last-born son.
STIGMA: "Auntie, nga walaba n'obulwadde [sorry about the illness you faced]," Nsimbi's nephew told her following an eight-day hospital stay.
The rest of her family was quiet and she says that silence spoke louder than any word; her husband and two sisters were supportive, however. This was not the first time Nsimbi was being treated with stigma.
"I remember in 2009, Dr Musisi was going around [Mulago psychiatric wards] with some students because I think they wanted to learn. He asked me how I was feeling and as I talked, this girl started laughing. I was actually offended and asked why she was laughing. The doctor told her if she did not stop, she would be sent away," Nsimbi says.
When she was diagnosed in 2009, she also was not told what disease ailed her.
"I think they told my husband. I remember being sedated, but I did not know what I was being treated for. I was only told when I asked the doctor, 'but what are you treating?'" Nsimbi says.
Her experience shows that sometimes, individuals with mental illness are treated like they have no ability to understand their condition; like they are too out of it to be accorded the same dignities and rights as patients without mental illness.
"At Butabika, patients are marked. They are given uniforms and their hair is cut off. I did not want to be admitted there because I did not want to be marked. The environment in which one is treated also determines treatment outcomes and I do not like the environment at Butabika," Nsimbi, who is a fashionable woman with beautiful, long hair, says.
Uganda also has old laws that encourage stigma against individuals with mental illness.
"The old laws referred to mentally-ill people as imbeciles without the right to have children," Nsimbi says.
COPING: Nsimbi is has always looked well-groomed when I have seen her at church every Sunday.
How does she, a 41-year-old mother of one secondary-school-attending child, three primary-school-going-children and a four-year-old, cope with bipolar?
"Mental illness is a stressor," Nsimbi says.
However, with her husband's and two of her sisters' support, she has been able to cope.
Interacting with other mental health patients at Heartsounds also helped Nsimbi cope. Heartsounds is a support group for individuals with mental illnesses that is led and managed by people with mental illnesses to help improve access to mental health care in Ugandan facilities.
"A patient who had seen us at hospital told my husband about Heartsounds," Nsimbi says.
Of all her sources of support, Nsimbi says that her faith in God has been her biggest strength.
"I listen to gospel music, because if you listen to other music and swear words are being used, how does that help your mental state?"
When a negative voice speaks to her, she counters it with scripture.
"If I have a thought that says I am ugly, I tell myself I am fearfully and wonderfully made," Nsimbi Says.
She lists the scriptures, "I will live to see the goodness of the Lord in the land of the living" and one which says "God has not given you a spirit of fear but that of love and a sound mind" as other scriptures that help strengthen her.
"I am a wife and mother and my children are young. I don't want another woman to raise my children," Nsimbi says of her inspiration to stay positive and be well.
She says she has told her children, particularly the eldest, that her illness is not a crisis; so, they are better able to cope. Since May 2014, she has not taken any medication and has not relapsed.
CHALLENGES: Nsimbi says she stopped taking the medicine because it had side effects such as stopping her periods and making her gain weight.
"Some people also end up getting diabetes because of the medicine," Nsimbi says.
The medicine is also expensive.
"I used to spend [Shs] 2,000 per tablet for only one type of medicine yet I had to take three types. That meant I spent [a lot of money]," Nsimbi says.
It is also difficult to access treatment, because Uganda has too few psychiatrists treating many patients. Queues to the psychiatrists are long and Nsimbi remembers feeling like she was being punished for being sick.
Stigma and unsupportive policies are the other previously-mentioned challenges, yet, Nsimbi says, mentally-ill people deserve to be treated with love because they understand what is going on and even remember things that happened when they were ill.
"[Getting better] starts from home," Nsimbi says. If a mentally-ill person is hidden away during family events and they are treated badly, their mental health deteriorates.
In true testament to not letting bipolar disorder have an upper hand, Nsimbi leads a productive life as a freelance journalist affiliated to Vision Group. She is also the national coordinator of Heartsounds Uganda and a personal shopper and housemaid procurer under her company, Abba Home.

The Basic Needs organisation describes the situation for those with mental health problems in Uganda, in their article Basic Needs, Basic Rights, Uganda:

With a population of 35 million, the country has only 30 psychiatrists, that’s less than one per million. Currently lack of access to treatment, poverty, stigma, discrimination and human rights abuses are major constraints to the rehabilitation of people with mental disorders. Studies conducted on the mental health system in Uganda suggest that a key challenge is that health workers do not want to specialise in psychiatry due to the stigma associated with mental illness.

For more information on all mental health issues contact Basic Needs, Basic Rights, Uganda. For support with mental health issues see Heartsounds on Facebook. 

Rolling back depression in Uganda

A video about the work of Dr Ethel Nakimuli Mpungu of Makarere University who was involved in Developing a culturally sensitive group support intervention for depression among HIV infected and non-infected Ugandan adults: A qualitative study. The abstract for the paper says:

Background: Depression is ranked first among neuropsychiatric diseases that contribute to the burden of disease in low- and middle-income countries. However, access to antidepressants is limited and there is a dearth of locally developed psychotherapeutic interventions targeted to treat depression.
Aim: We aimed to obtain information on the cultural understanding of depression symptoms, complications and treatment methods used in post-conflict communities in northern Uganda in order to inform the development of an indigenous group support intervention to treat depression.
Methods: Focus group discussions (FGDs) were conducted with a total of 110 men and women aged 19-68 years. FDGs took place in a private space, lasted about 2-3h and were conducted in the local language for patients and their caregivers and in English for health workers. Interview transcripts from the FGDs were reviewed for accuracy, translated into English and transcribed. QRS Nvivo 10 qualitative data analysis software was used for coding and thematic analysis.
Results: Our study revealed community misperceptions about etiology, presentation and treatment of depression. Regardless of HIV status, most FGD participants who were not health workers linked depression symptoms to HIV infection. Although there were concerns about confidentiality of issues disclosed, many FGD participants were supportive of a group support intervention, tailored to their gender and age, that would not only focus on treating depression but also provided them with skills to improve their livelihoods. Simple CBT techniques were deemed culturally appropriate and acceptable.
Limitation: Generalizability of study findings may be limited given that the sample was primarily of Luo ethnicity yet there are different ethnic populations in the region.
Conclusion: Local communities can directly inform intervention content. The participants׳ preferences confirmed the need for a gender-specific intervention for depression that extends beyond medications and empowers them emotionally, socially and economically.

Mental Health: Depression in Uganda

Wikipedia defines Major Depressive Disorder (MDD) or Depression or as it is commonly known as:

a mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities. The term "depression" is used in a number of different ways. It is often used to mean this syndrome but may refer to other mood disorders or simply to a low mood. Major depressive disorder is a disabling condition that adversely affects a person's family, work or school life, sleeping and eating habits, and general health.

It is important to understand that MDD is more than just low mood. The person diagnosed with MDD cannot just snap out of it. They may require medication or long-term therapy to come to terms with the condition.

In a 2011 study Poverty, life events and the risk for depression in Uganda, 29.3% of people interviewed were found to have MDD. The variability of MDD was strongly associated with district varying from 7.7% in Bushenyi to 49.6% in Moyo. 

Major risk factors for developing MDD in both men and women were identified as:

socioeconomic related to deprivation (no formal education, having no employment, broken family) and poverty (low socioeconomic status).

Other studies have found lower but no less alarming percentages of people affected by MDD. For instance the Assessment of depression prevalence in rural Uganda using symptom and function criteria found that 21% of respondents had depression. The prevalence of depression in two districts of Uganda reported 17.4% incidence of depression. 

In a 2013 study Prevalence and risk factors of depression in childhood and adolescence as seen in 4 districts of north-eastern Uganda the prevalence of 7.6% MDD among children and adolescents was found. Socioeconomic deprivation, experience of war trauma and orphan hood were not significantly associated with depression. However demographic factors like the quality of the child-principal care-giver relationship and the presence of psychiatric co-morbidities in the child's life were the important independent determinants of childhood depression.

Based on these figures it is possible to see that more than 1 in 5 Ugandans is affected by MDD. Moreover in a population of 5,625,000 PWDs (see my blog Number of Persons With Disabilities (PWDs) in Uganda) it is likely that many more than 1,125,000 PWDs will be affected by MDD.

A Yale Global Health Review article highlights the problems Uganda must face caring for individuals with mental health problems:

specific mental health policy does not exist and mental health is not mentioned in the general health policy. Government funding for mental health does not exist. There are a grand total of 28 mental health outpatient facilities in the entire nation. Ugandans face an alarming dearth of mental health professionals and workers: one psychiatrist for more than a million people, one mental health care nurse for every 130,000 people, one psychologist for every five million people.

There is hope, a new type of treatment has been developed:

called Group Interpersonal Therapy, or GIPT. True to its task-shifting roots, this modified form of talk therapy is facilitated by non-professionals. Unlike the aforementioned studies, GIPT was inspired by the second branch of talk therapy, interpersonal therapy. While interpersonal therapy is normally conducted one-on-one, GIPT operates in a group but focuses on improving human interaction to treat depression. In Uganda, GIPT sessions were led by locals who had undergone two weeks of training. The patients receiving GIPT drastically improved in comparison to the control group. Where the control group saw around a 40 percent reduction in depressive symptoms, the intervention group saw almost an 80 percent reduction. A New Jersey-based organization called Strong Minds implemented the GIPT intervention model from this study in other regions of Uganda. After sixteen weeks of group interpersonal therapy, Strong Minds saw incredible results: 94 to 97 percent of patients were found to be depression-free. Their mental health facilitators had been trained for just ten days in GIPT.

In Uganda Strong Minds has a team of Mental Health Facilitators that work to improve the lives of community members facing depression. The team works with individuals in the community to identify then treat depression through GIPT. Strong Minds is helping individuals to learn the skills necessary to manage and reduce their depressive symptoms, so that they can return to their productive lives.

In summary the major risk factors for developing MDD are all socioeconomic. They are:

• Low socioeconomic status
• No formal education
• No employment
• Broken family
• Poverty

It is important to understand that PWDs score significantly less across the board on all socioeconomic indicators (see Poverty and Disability in Uganda). Therefore PWDs are at greater risk than the general population of developing a MDD.

Life with dementia

A very insightful documentary examining life with dementia.

The classic signs of dementia are described. 

People with dementia can wander away from the secure environment of their home. Outside of the secure environment they are confused and vulnerable. 

The person with dementia requires time and patience from their carer. Reminders from this person's past like the songs the lady in the video sings are vital links to failing memories and very good therapy.

Above all the person with dementia needs love, kindness and reassurance to live in a confusing world....

Dementia in Uganda

The Alzheimer's Association defines dementia as

a general term for a decline in mental ability severe enough to interfere with daily life. Memory loss is an example. Alzheimer's is the most common type of dementia.
Dementia is not a specific disease. It's an overall term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. Alzheimer's disease accounts for 60 to 80 percent of cases. Vascular dementia, which occurs after a stroke, is the second most common dementia type. But there are many other conditions that can cause symptoms of dementia, including some that are reversible, such as thyroid problems and vitamin deficiencies.

There are several conditions that can cause dementia. A Case of Alzheimer’s Dementia in Uganda lists some of the most important:

Alzheimer’s disease
vascular dementias infections (commonly HIV and Syphilis) substance abuse (alcohol) trauma (road traffic accidents) nutritional deficiencies (vitamin B-12). 

A 1996 Ugandan study, Prevalence of dementia in an elderly rural population: effects of age, sex, and education, found that dementia affects 8% of the elderly population over 64 years. Dementia affects men and women equally. The numbers of those affected increases increases with age. Assuming a population of 38,000,000 of which 3.1% are 65 years or over there are 94,240 elderly people with dementia.

The story does not end there. Sub-Saharan Africa has a very high number of HIV/AIDS cases.

In 2007 Johns Hopkins published the following article, HIV Dementia Alarmingly High in Africa:

In the first study of HIV dementia on the African continent using rigorous neurological and neuropsychological tests, 31 percent of a small but presumably representative group of HIV-positive patients in Uganda were found to have HIV dementia, according to Ned Sacktor, M.D., a Johns Hopkins neurologist and senior author of a multi-institutional study that will be published Jan. 29 in Neurology...“If the rate we saw in our study translates across sub-Saharan Africa, we’re looking at more than 8,000,000 people in this region with HIV dementia,” says Sacktor.

Sacktor says an extremely high rate of HIV dementia in Africa and other poor regions of the world adds enormously to the social and economic burden of their populations and governments. Dementia not only disrupts jobs and adds to the cost of care, but also interferes with a patient’s ability to adhere to a regular course of antiretroviral medication, thus increasing the risk of drug resistance. People with dementia also are less likely to practice safe sex.

Before antiretroviral medications were available in the United States, the U.S. rate of HIV dementia was similar to what was discovered in this study in Uganda, says Sacktor. Unfortunately, he says, only 20 percent of people infected with HIV in the world are getting treatment.

“We hope studies like these will shed additional light on the devastating problem of HIV in resource-limited countries like Uganda and encourage more programs that bring much-needed medication to these poor regions of the world,” Sacktor says.

Sacktor says there’s little accurate data about HIV dementia patients in other parts of the world current estimates of the number of HIV-positive patients who have dementia range from 9 percent to 54 percent.The number of persons with HIV/AIDS related dementia surpasses the number of elderly with dementia. 

In Uganda dementia is not only a disease of old age. The high prevalence of HIV/AIDS means there is a large number of people that are suffering from the effects HIV/AIDS related dementia. A 2013 Ugandan study, Prevalence and factors associated with probable HIV dementia in an African population: A cross-sectional study of an HIV/AIDS clinic population estimates that 64.4% of HIV positive people have signs of dementia. Assuming a population of 38,000,000 and 7.3% of the population affected by HIV/AIDS there are a further 1,775,360 persons suffering from the effects of dementia.

In 2015 there were an estimated 46,800,000 people living with dementia in the world. With 1,775,360 HIV/AIDS related dementia cases Uganda has almost 4% of the worlds dementia cases.

For more information about dementia see the Facebook page of the Dementia Foundation of Uganda.

For more information about the elderly with dementia see Uganda Reach the Aged Association (URAA) on Facebook or go to the Uganda Reach the Aged Association (URAA) website.

One man's battle against PTSD

A very good introduction to post traumatic stress disorder. NTV Uganda describes the video:

Experts at the World Health Organisation say more than 200 million people globally suffer from symptoms of Post Traumatic Stress Disorder annually. The condition makes many of its sufferers experience flash backs and nightmares, while others become aggressive and withdraw from society. In this week’s Health Focus, Florence Naluyimba brings us a story of an 18-year-old man in Pader district who’s slowly recovering from the condition.

Mental Health: Post Traumatic Stress Disorder

In their paper Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective the authors give the following definition:

Post-Traumatic Stress Disorder (PTSD) is a psychiatric condition, which develops after a person experiences, witnesses, is confronted with or hears about emotionally stressful and painful experiences beyond what a human being can bear. The traumatic event may be life threatening; threatens body integrity and causes considerable fear, horror and a sense of helplessness in the affected individual (APA, 1992). Traumatic events are psychologically wounding to the individual and leave deep scars (Anonymous, 2009; and Tonks, 2007) on trauma victims; they are dehumanising, demoralising and humiliating, and may put an abrupt end to the hopes and plans of an otherwise enterprising individual, as the individual loses the sense of the future (Bardin, 2005) as one of the clinical features of post-traumatic stress disorder.

Another study notes that PTSD

is the most common mental health condition in the aftermath of traumatic stress. PTSD prevalence rates depend on cumulative trauma exposure and converge around 8% in the United States, whereas the disorder occurrence is much higher in post-conflict settings.

Statistics for PTSD for the general population are hard to find. The Victimization and PTSD in Ugandan Youth study of youths aged between 13 and 24 years in the major cities of Kampala, Mbarara, and Jinja found that there was a prevalence rate of 37.7% with PTSD. A further 28.2% of its sample had subclinical signs of PTSD. 

There is a well established link between warfare and PTSD. It is no surprise that in a report on High rates of PTSD and depression found among adults displaced by war in Uganda researchers found that three quarters of respondents, 74.3%, met PTSD criteria. A further 44.5% or almost half the respondents had depression.

Without treatment PTSD can become chronic causing severe impairment in daily functioning. There is a further higher risk of physical illness and suicide. 

The study PTSD – A Northern Uganda Clinical Perspective identified the following common symptoms:

Post-traumatic stress disorder usually presents with vegetative symptoms of depressive and anxiety disorders or alcohol use disorder symptoms. Patients may complain about poor sleep due to dreams involving the dead beckoning them unto death. Direct inquiry about probable history of exposure to a traumatic event is required as dreams about the dead may be a significant sign of depressive disorder, anxiety disorder or PTSD representing intrusive thoughts. Sometimes patients may complain about having many thoughts or thinking too much. Too many thoughts may mean being worried, and signify depressive disorder or an anxiety disorder, particularly in association with frightening dreams in which the dreamer is visited by dead relatives, is chased by enemies/armed men, or is involved in battle.

However too much thoughts may be an idiom for intrusive thoughts seen in post-traumatic stress disorder. Individuals may be described as preferring to be alone, and this description is the equivalent of loss of interest in social contact and pleasurable activities as in  depressive disorder or post-traumatic stress disorder; it is not uncommon for post-traumatic stress disorder and depression to co-exist in the same patient. Such individuals are usually intolerant to conversations that might remind them of their traumatic experiences, and may exhibit considerable levels of irritability and may therefore not wish to participate in conversations with family and friends. Individuals who prefer to be alone following exposure to traumatic events also exhibit episodes of depersonalization with aggressive outbursts. The triad of social isolation, depersonalization and aggressive outbursts is so characteristic of former rebel soldiers in northern Uganda that some communities readily recognize the psychological instability in affected individuals and often arrange a quiet room for the victims to rest before they can rejoin their peers in social activities.

In the study of PTSD – A Northern Uganda Clinical Perspective the outcome for those with PTSD in Uganda was optimistic:

... clinical experience indicates that most individuals with the disorder recover on two to six sessions of counselling. It is possible that the ubiquitous social support available to people in their communities contributes to the apparent good prognosis for victims of traumatic experiences in rural Uganda. Ovuga et al (2008) have reported that former child soldiers in northern Uganda who returned to their homes without passing through government established reception centres had lower mean scores on the Harvard Trauma questionnaire and the Hopkins Symptom Checklist for depression. Ovuga and colleagues attributed their observation on the possibility that the child soldiers who went directly to their communities had committed fewer atrocities, were more readily received and forgiven by their respective communities, and possibly experienced fewer traumatic experiences than their colleagues who returned home through the government reception facilities.

PTSD is a mental health issue that has ramifications for the whole community. Prompt identification of symptoms and treatment are of vital importance. It is not only people from war torn areas that may suffer the effects of PTSD. We should never lose sight of those that have had traumatic experiences in all walks of life.

For further information refer to Facebook - Uganda PTSD Alliance and  Twitter - Uganda PTSD Alliance.

BBC Our World - Uganda - My Mad World (2015)

Follow up on Breaking the stigma around mental illness in Uganda

In Uganda few people are willing to talk about mental illness. Those who suffer are frequently isolated, shunned by their community and rejected by their families. Our World meets a man who has broken the silence.

Breaking the stigma around mental illness in Uganda

A very good report from the BBC about the work of one man

Mental Health in Uganda

Uganda "Stop the Abuse"People with mental health issues from Uganda call for an end to abuse by police, traditional healers, in healthcare and in their families.

Mental Disabilities and Mental Health in Uganda

Everyone is equal before the law regardless of their disability. People with mental disabilities in Uganda are handicapped by outmoded and derogatory language used by the legal system, inaccessible courts and inappropriate accommodation. People with mental disabilities are often seen as subhuman and are not given their rights.

An article by MDAC the Mental Disability Advocacy Centre identifies the following problems:

• The use of outdated and discriminatory terminology such as "idiot", "persons of unsound mind" and "lunatic" in court papers and processes which entrench stigma;
• People with intellectual or psycho-social disabilities are legally denied the right to bring or defend cases and their evidence is deemed to lack credibility or refused;
• Some people with disabilities cannot navigate or understand the complex processes required to initiate or defend cases, and no support is provided to them to do so;
• Rigid application of rules of procedure in a way which is likely to deny substantive access to justice;
• Imposition of court fees discourages or prohibits people from claiming their rights through the courts;
• People with disabilities have their cases taken over by guardians ad litem or other substitute decision-makers, without the need for their consent; and
• People with disabilities are arbitrarily detained during criminal procedures, sometimes left to languish for decades in detention (See UGANDA: ACCESS TO COURTS FOR PEOPLE WITH MENTAL DISABILITIES).

"They don't consider me as a person"

Uganda is a country with a population of 35 million and only 30 psychiatrists. Lack of access to treatment, poverty, stigma, discrimination and human rights abuses are major barriers for the rehabilitation of people with mental disorders. Many workers in Uganda do not want to work in psychiatry due to the stigma associated with mental illness.

The organisation BasicNeeds has been working in Uganda for over 10 years to improve the quality of life of people living with mental illnesses. Their work involves supporting access to quality community mental health services and getting people back to productive work. They target 2 types of vulnerable groups.

The first are people who suffer from a mental disorder (schizophrenia, bipolar affective disorder, clinical depression, anxiety disorders etc) and the second, people who are likely to suffer from mental disorders as a result of the context they are living in (high risk categories include poor households, people directly affected by protracted conflict, included orphaned youth and former child soldiers, women and girls living in poverty, people with disabilities living in poverty). Significant effort has also gone into post-conflict programmes addressing psychosocial trauma and related deprivation and poverty in Northern Uganda, (see BasicNeeds: Where we work).

A summary of article 13 of the United Nations Convention on the Rights of PWDs says: "People with disabilities have the right to effective access to justice on an equal basis with others, including through the provision of appropriate accommodations."

A World Health Organisation (2001) report says that one in four people are expected to get some kind of mental health disorder in their lifetime isn't it time we removed the stigma.