Accra — Doris Appiah, 57, has bipolar disorder. In her early twenties, she was sent to an overcrowded psychiatric hospital followed by a "prayer camp" to be treated. She stayed there for five years, at times tied to a wall or forced to fast. Her story is mirrored by thousands of mentally ill people across Ghana, according to a 2 October Human Rights Watch (HRW) report entitled Like a Death Sentence.
The government is trying to update the country's mental health care laws, starting with the passing of the 2012 Mental Health Act. The act is supposed to improve access to mental health services and prevent abuse. But HRW says the law does not go far enough as it only addresses the formal health sector rather than community-based mental healthcare needs.
Patients with mental health problems are often kept against their will in overcrowded and unsanitary psychiatric institutions.
Ghana has only three public psychiatric hospitals (all of them in the south), 12 practising psychiatrists, and 600 psychiatric nurses. In one ward of Accra Psychiatric Hospital in the capital, there are just 26 functional beds for 205 in-patients, according to HRW. Nurses, lacking cleaning equipment, "instructed patients to clean the wards and toilets, including removing other patients' faeces without gloves", said the researchers.
Without enough staff to properly restrain aggressive patients, staff routinely turn to violence, patients told HRW. Patients reported physical abuse in the form of beatings, forced seclusion and involuntary electro-shock therapy.
One 25-year-old pregnant woman told a group of HRW researchers who visited three institutions and eight prayer camps earlier this year, that while kept in a seclusion room for 12 hours she was beaten by nurses.
Health Ministry spokesman Daniel Osman said he acknowledges that Ghana's psychiatric hospitals are overcrowded, understaffed, and difficult to access for many people in need, but said progress was being made. "We are making an effort to decentralize [the system] so every regional hospital has a psychiatric unit," he told IRIN.
The World Health Organization has estimated some 2.8 million people have mental disabilities in Ghana, 650,000 of them severe. The most common problems are schizophrenia, bipolar disorder and major depression, Akwasi Osei, director of Accra Psychiatric Hospital, told HRW. Less common, but prevalent, are drug-related psychosis and epilepsy.
Families send their relatives to such institutions when a mental health crisis becomes acute and often because they feel they have few alternatives: There is little-to-no community care for mental illness in Ghana.
"It is so stigmatizing even to be seen entering the gate of a psychiatric hospital. People will brand you," said Medi Ssengooba, a disability rights research fellow with HRW in New York. "If services were provided in the community, people would go in and seek them freely," he said, acknowledging it would take time for attitudes to change.
Mental disability in Ghana is widely considered to be caused by evil spirits or demons. When "orthodox" psychiatric treatment does not work, some resort to prayer camps which enact so-called spiritual healing.
Bondage and fasting
In reality, many residents of prayer camps face severe abuse. Aggressive residents are chained up, according to Ssengooba. "Almost everyone we met... was chained to trees or to walls," including children as young as nine.
Residents are regularly denied food and drink for a three-day period or required to fast 12 hours a day for up to 40 days, as this is thought to rid the body of evil spirits. "I'm really, really hungry and they won't feed me. I don't understand... Why can I not eat? They give me porridge at night, but that's not enough food," a woman identified as Afia at Mount Horeb Prayer camp in Ghana's Eastern region told researchers.
Doris Appiah spent 19 years in prayer camps and psychiatric hospitals before being discharged in 1989. "They kept moving me because they were not seeing results, and they were not seeing results because the right thing was not being done," she told IRIN.
"You think you are human, but people no longer think you are human," she added.
Residents of both hospitals and prayer camps are often kept against their will": Prayer camp leaders say they must wait for messages from God before releasing residents, said Ssengooba.
The Ministry of Health's Osman said the government had little oversight of prayer camps, as they are run by churches.
The situation is improving slowly. Thanks to the disabilities act, people can now challenge their detention in institutions. Access to appropriate medication has also improved over the past 30 years, and several advocacy organizations now lobby to improve the quality of services for the mentally ill.
Appiah has learned to manage her illness with the right medicine and the help of international NGO Basic Needs. She now works as the treasurer of the Mental Health Society of Ghana.
But parts of the act still transgress the 2006 Convention on the Rights of Persons with Disabilities (which Ghana has ratified), as it still enables forced admission and treatment in psychiatric hospitals. And there is not enough emphasis on community-based care (providing the mentally ill with housing and health care, for instance) or on monitoring the quality of hospital care, warns HRW.
If quality monitoring worked, some institutions would be forced to cease taking on patients altogether. "If you don't have the means to house them [mentally ill patients], or to feed them - if the only means you have to constrain an aggressive person is to chain them, that person should not be a service provider," Ssengooba told IRIN.
This report does not necessarily reflect the views of the United Nations