We describe the key findings under two main sections, context and mental health and the themes within each.
Context
Exploring the context is important to understand the perception and behaviour relevant to mental health of people and different stakeholders. This understanding could help to design an appropriate programme for mental health (11).
Historical context
The informal discussions showed that Somalia had undergone a transition from a traditional Somali pastoral and nomadic life to a settler life. At one time, 75% of the Somali population were nomadic travelling for months and sleeping as soon as it became dark. Then, many started settling. The ongoing urbanization and the need of settlers for meat and milk and the nomads for essential commodities brought the two groups closer. The nomads started to graze their camels closer to settler areas and often established villages nearby. The settler life was easier than the nomadic life and gradually more nomads opted for it.
Men’s position
In Somalia, culturally, men are viewed as strong and protectors. Many respondents thought that the use of mindfulness does not work in Somalia as people might consider it a weak approach.
“Somali culture is little bit harsh. Because of the normally nomadic culture, it’s very tough. If they see you, you are not (strong), if you look weak, and they call it if you have hard time. So, every one of us try to hide what feeling reality and show quite fix. That’s our culture. It’s very tough culture”. (FGD-5.1 10:43 − 11:05min).
Informal support system and sin tax
A strong informal support system existed in the community either through clans or relations which stemmed from the nomadic background. Many participants agreed with the need for family members and their close relatives as noted by a counsellor.
“…. People, they have all the structures. We can focus on protective factors. Somali people are very social, so social connection, social network. We can also strengthen social network”. (FGD-3.1 -22:55 − 23:10min)
The one residential facility for mental health in Puntland was established by a collective effort of a religious leader, clan leader, volunteers and donations from patients who were treated there.
However, a new way of generating funds for mental health care has emerged, a so-called sin tax. This is a tax on khat (chewing plant used as stimulant) of US$ 0.05 for each kilogram imported. The Somaliland administration raised US$ 2 000 000 in 2022 from this tax and donated the entire amount to the Department of Mental Health of the Somaliland Ministry of Health to support care for people with mental health conditions.
Armed conflict, natural disaster and khat use
All but one of the 17 regions in Somalia was facing some type of emergency at the time of the study, either armed conflict, natural disasters, clan issues or a high prevalence of khat chewing. During June–October 2023, 255 explosions from improvised explosive devices were reported claiming 692 lives and five suicide bombings occurred killing more than 100 people (19). These perpetual security incidents are one of the main contributing factors to the worsening mental health situation in the country. A senior public health official substantiated this.
“Tribalism, terrorism [Interviewer: Tribalism?] yeah, clan. They undermine each other, they kill each other, they humiliate each other. Somali contexts are tough. You name.” (IDI-1-5:50 − 6:10 min)
The situation in relation to emergencies is different across different regions of Somalia. This was reflected in the key informant interview with a psychologist working in mental health in Somalia.
“Every area is different, what they are facing from which. For now, you are in Garowe. So, people are more stable there. They have food security, so they don’t have that problem, maybe if they have (problem in) education. What increases the level of mental health diseases; conflict, unemployment, lack of education, lack of work and everything. But we cannot generalize. … If you look to Mogadishu, all people are suffering from trauma because we have mass casualties, every now and then there is explosions happen, there is, we are living in a stressful situation. In other areas, they have, maybe drought or other emergencies there; they are facing different forms. (KII-1 25:44 − 28:10mins)
However, the situation often changes and sometimes abruptly. For example, during a field visit while in Garowe, a political conflict turned violent and reportedly claimed 27 lives. Additionally, 73 patients were admitted to Garowe General Hospital with injuries because of a gunfight at Las Anod, the administrative capital of Sool which is a contested area between Somaliland and Puntland. The director of the hospital claimed that 68% (50/73) of the injured were not mentally stable. We also observed the worried faces of women waiting outside the hospital for family members injured by the armed violence.
The law on gun possession is not the same across the regions; A gun license is not necessary in some places. One of the respondents recalled an incident where a small boy hid himself when he heard a gunshot. When asked why he was hiding, the mother said his father had been killed by a gunshot. The child was a typical case of post-traumatic stress disorder (PTSD). This incident shows how armed conflict is taking a toll on the mental health of Somali people, especially on the children and the young people. The situation continues to be further complicated because of environmental and climatic factors such as droughts and excessive rainfall because of El Nino, which are also affecting the mental health of the people.
One of the most important risks for mental health illness in the country is the use of khat. Evidence shows that khat use is associated with mental health illness (20, 21). The proportion of people chewing khat in Somalia varies across different region, with the highest use in Somaliland with around 60% of males and 5% of females chewing khat. The government allows the import of khat from Ethiopia and Kenya as it earns large tax revenues. One key informant mentioned a hospital in Mogadishu which has a department for mental health with 100 beds. She said, “… 94% of those beds, we can say are occupied by those with substance abuse problem.”
Mental health
Neglect of mental health
“The concept of mental health is very new” commented a key informant who is a psychiatrist. Mental health is not given adequate attention in the medical education system in Somalia and few medical schools provide opportunities for mental health internships for junior doctors, as explained by a key informant.
“While most are not, most of them, they don’t do any practicum, they don’t do clerkship or internship. They only do the theoretical part” (KII-3-39 :23–39:38mins)
This is also reflected in an interview with a psychologist and focal person for mental health at the federal government level.
“...a basically neglected area and for the last, we can say, for the last 20–30 years it is a neglected area and because of that there is not much of infrastructure regarding the mental health at country level with lots of the emergencies now going on, a bit increase and the, and the discrimination in society related to mental diseases. Common mental causes in other facilities are psychosis and neurological problems but majority of that facilities, 90% are dealing with mental health problem of people who are dealing with substance use. And there is no awareness in the community about that problem.” (KII-1-1:48-~3:0 min)
Another problem related to poor mental health is the use of steroids by women to lighten their skin colour; weight gain is a side-effect of these drugs. In informal discussions with a female psychiatrist and doctors, they noted that around 30% of women in Somalia use steroids for cosmetic reasons. This may explain why some women are suffering from depression and psychosis as studies have found a positive association between these disorders and the use of steroids (22).
Perceived magnitude of mental illness
No quantitative estimates are available of how many people are suffering from mental health conditions across Somalia. Mental health conditions can be seen as an iceberg; the actual prevalence is likely much higher than recorded. A counsellor in private practice in Somalia mentioned the main conditions affecting health-care seekers.
“Most of the time, people who come to our office are mainly, we are dealing with depression, anxiety, and some, most of the cases as you know, most of population in Somalia, they experience trauma.” (FGD-3.2–00:54:01:45mins)
Another respondent, a male psychologist, also mentioned symptoms of trauma such as withdrawal, isolation, avoidance, lack of trust and anger, and drug addiction as a coping mechanism.
Somali people, especially teenagers and young people, want to leave Somalia to escape the trauma. Failing to leave Somalia or thinking about how to leave often resulted in mental illness. These young people are known as buufi, that is people to whom nothing else matters except leaving Somalia and the precarious situation there (23), as noted by a nurse manager.
, “Many people now are complaining to stay in Somalia. They want to go abroad. Going abroad is a part of mental problems” (IDI-2-11:35 − 11:41).
The burden of mental illness could be higher in Mogadishu than in the north of the country (Puntland and Somaliland) because armed conflicts are more prevalent in the south. A respondent, a doctor in a private hospital, talked about Galkayo, the third largest city and the capital of Mudug region, where armed conflict has been ongoing for the past 10 years,“If ten patients come to you, 8 or 7 of them complaining mental health problem. But in Garowe, it is stable (in terms of armed conflict)”. However, during our study, Garowe also faced armed conflict. One of the key informants gave his view on the perceived prevalence of mental health conditions.
“I will, I will say with (substance) use increasing, maybe 40% like that. But I am not sure. [Interviewer: 40% in Mogadishu?] Yeah. But I am not calculating, right? Because, in Somaliland, they don’t have conflict, they have excessive khat chewing.” (KII-1-28:05–28:28min)
We asked our respondents about the perceived prevalence of mental health conditions in the community. According to their perception, the prevalence varies between less than 5% and 50% with a median of 10% (Table 2). Two suicide incidents were also reported at the study sites before the study and at least one of these incidents was attributed to mental illness.
Table 2
Perceived prevalence of mental health conditions according to respondents of focus group discussions in Somalia
Perceived prevalence of mental health conditions, % | No. | % (n = 41) |
1–5 | 12 | 29 |
6–10 | 11 | 27 |
11–20 | 6 | 15 |
21–50 | 12 | 29 |
Perception of mental health conditions
People in general are not aware of mental health problems, nor do they know where to seek help. Our informal discussion revealed that around 95% of those needing care were not receiving proper treatment.
“Another problem we have that, community do not understand what the mental health problem and or disease. So, they go for traditional healers, which also play a big role in the community, and we are trying to assess …the rehabilitation centre. If we can also train them (staff and traditional healers), will be fantastic, so that they can refer the mental patients.” (KII-1-4:29 − 5:11min)
People often equate mental illness with madness. Only severe mental health disorders with serious behavioural abnormalities are considered as such and are called wali. Walis are misunderstood in society and are not generally given care or medicines. Children throw stones at them and yell “wad waalan tahay” meant “You are mad; you!”.
The poor perception of mental health prevails even among health care providers. Case vignettes of schizophrenia, depression, anxiety and ADHD (translated into Somali) were read to the health workers. They did not consider ADHD, depression, or anxiety as diseases, nor did they consider any treatment was necessary for these conditions. No psychotropic drugs were available in most of the PHC centres. Some centres did not collect information on mental health conditions for the health information system, while in others, the appropriate row in the health information form was labelled “zero” meaning no patients with mental health conditions were reported at those facilities. This suggests that the attending physicians did not have the ability to diagnose mental health conditions.
People in general, including 75–100% of our participants, believed in black magic, that is that jinn and evil spirits can cause mental illness. This includes even support staff of an international organization working in Somalia in the health sector. Their logic is that when an otherwise physically fit person develops a mental illness, that must be jinn as the person did not have any problem (physical) before.
Mental health care
Mental health services are largely absent in the health care delivery system of the country except in few places mostly in the north. There is a shortage of qualified mental health personnel in the country. This may result from a lack of emphasis on mental health conditions in the medical curriculum, lack of training opportunities in mental health and, more importantly, the apparent belief among the community as well as policymakers and health care professionals that there is no much need for mental health care. The private clinics mostly did not have any mental health care facility nor were they interested in providing such care to health-care seekers. When patients with mental health conditions came to public hospitals, the attending health care provider usually told them that the hospital “We have nothing for you. Look for another place.” There are around six psychiatrists and 25 psychologists throughout Somalia. Even many regional public hospitals do not have a psychiatrist because they cannot afford to hire one. There are no beds or wards for treating patients with acute mental illness either, as explained by the director of a regional hospital.
“We don’t have psychiatrist here …, Last year we have psychiatrist, IOM (International Organization of Migration) was supporting us. After that the project was finished and he left. …[Interviewer: How do you manage your patient now?] We have doctor, who is a neurosurgeon... They are so aggressive, they are fighting, so we cannot keep in the hospital. … [Interviewer: you send them?] We refer to that facility” (ID-2-0:14 − 2:29min).
Later we visited the facility and found no psychiatrist and no regular staff for mental health care. It was just an isolation centre for those with mental health conditions who cannot be managed at home, where the rights of the patients were ignored.
The country does not have any mental health act. Under a new initiative, the Government was developing a new mental health policy and strategy for 2019–2022 needed review and updating. While armed conflict continued, the Somali population also faced climatic shocks such as drought and flash floods. However, mental health is yet to get attention from the humanitarian organizations in Somalia. One of the key informants echoed this.
“We have lot of problem with increase in emergencies in the country. We do not have lot of focused mental health activities within the humanitarian settings. Now we have all these responses to emergency drought but with shelter and food, but no one is looking to mental health and psychosocial support aspect to the humanitarian response, which is also increasing creating lot of problem for us.” (KII-1-6:50 − 7:20min)
“The health worker even, instead of the community, the health workers even don’t know how to deal with mental, what mental illness. We have insufficient data. We don’t have unified HMIS system for mental health and also now we are facing lot of problem with the difficulty of referral pathway for clients or patients with MNS conditions.” (KII-1-7:20 − 8:40 mins)
Technically, many doctors who were aware of mental health conditions did not even assess the mental status of the patients. Treatments were given based on clinical diagnosis but no patient was seen to have been diagnosed with a mental illness. The doctors were seen to change the diagnosis to a mental illness when medicines prescribed for the initial diagnosis failed to provide any improvement. The views of the director of a regional hospital substantiate this observation.
“We are all doctors. We don’t focus (on) the patient for mental (health problem). We just focus with the patient; what happened, are you seek, there are anything you eat, we do thing (diagnose this way). After we finish 7 days or 6 days, he will come back and say I will not take this medicine, I don’t need it. That’s the way we understand he is mental problem. (ID-223:30 − 23:53min)
We observed neurosurgeons working as neurologists and psychiatrists and treating mentally ill patients. One such neurosurgeon confirmed that, “yes, most of my clients, yeah, most of my patients are with mental health (problems)”.
Only wali were considered as having mental health disorders. When a wali or drug user cannot be managed at home and cannot be helped by an Aas-shefa (traditional healer), the person would be taken to a regional hospital, doctor (usually was a neurologist or neurosurgeon) or a rehabilitation centre for treatment. The rehabilitation centres also often do not have any psychiatrists. They restrain (sometimes with chains) and isolate patients to protect the family and friends and prevent the patient from taking drugs, committing suicide or self-harming. A focal point for mental health of a state Ministry of Health explained.
“There is a lot of places, whether it is private, or partially public, people are being, they are looked after, you know feed them, they have somewhere to sleep but no treatment.” (KII-2-2:18 − 2:33 min)
During our study, one patient was seen chained at a health centre (Fig. 1). The family members informed that the key to the lock was lost and as such the patient was not freed.
Figure 1. Patient chained at the ankle in a health centre
However, there were some facilities providing good-quality mental health care. We had a discussion with two young diaspora psychologists who were operating such a private counselling centre. The number of such facilities, however, is not enough to meet the need and some of these facilities were struggling to keep open as the demand for good-quality mental health care among those seeking such care was low. Some diaspora doctors reportedly helped provide mental health care through tele-psychiatry and some regularly visited one centre every 3–4 months to provide mental health care.
Care-seeking behaviour
Understanding care-seeking behaviour is important to develop a service delivery model. We found that most people, even educated ones, visit traditional healers (called as a sheikh) or Aas-shefa when they get sick. This is because they trust ulema (religious scholars). These traditional healers also charge less and use prayer and recitation from the Koran, which are culturally preferred for many Somali people. This is also true for mental health patients.
“They have physical complaints or acted abnormally to themselves, people take them to traditional healers (who often treat) by (recitation of) the Quran, sheikh and those, those people, they took them. We have traditional healers in Somalia, they are playing a big role. They have lots of mental patients. They call them, ‘no’, they have jinn or sixir (black magic). …They don’t refer, because they also don’t have training what is mental health disease”. (KII-1-45:33–46:59)
Care for mentally ill people, as revealed during our discussion, also depended on the knowledge of mental health issues and the economic status of the family. Wealthy people usually kept the mental health status of their family members secret and looked for treatment elsewhere. These people go abroad to, for example, Ethiopia, Kenya or India to seek treatment for their family member. The poorer section of society tended not to seek care for their mentally ill family member, presumably due to lack of knowledge or awareness. People were also observed to be reluctant to seek care for mental illness because of stigma. Sometimes, people try to buy over-the-counter medicines before seeking care from a service provider.
Cost of mental health care
Care-seeking behaviour was a complex issue with many factors playing a role. One important factor was cost, which affected the choice of care provider. Some people hold negative views about conventional medical practitioners as they are perceived as giving unnecessary tests and medicine for financial benefit.
“You pay five dollars to Qur’anic healer; you get next seven days free. But if you go to the doctor, you pay the first 10 dollars for doctor’s card (prescriptions), then it will take more than 100 dollars in one hour. You pay in the laboratory, ultrasound. They will charge you even if you don’t need ultrasound, they put your money to ultrasound”. (FGD-6-18:21 − 18:46min)
The local residential facilities which admit mostly substance use patients and people with severe mental disorders vary in their charges.
“Most of facilities for mental health, (treat) by admission, monthly for around 100–150 (US) dollar per patient but that always can be changeable because some of them do not take that much.” (KII-1-41:41–42:05min)
Psychologists in Somalia were understood to charge around US$ 25–40 per psychotherapy session. The cost of psychotherapy was a deterrent to uptake as it usually takes several sessions for complete remedy. However, people in general are not familiar with this type of treatment.
“Basically, they charge 25 per session. People don’t understand what psychotherapy and counselling is. The community even don’t understand. If you don’t give them medication, they don’t believe there is help with only talking”. (KII-1-36:37–37:02min)
Referral to mental health care
Understanding how people access mental health care is important to develop an appropriate programme. There were no referral guidelines, nor was there any law for referral of patients with mental health illness. Furthermore, anyone can call themselves a doctor and treat patients. Even the psychologists prescribed medicines and used the title of “medical doctor” in front of their names. The lack of psychiatrists in Somalia played a role in the poor referral practice for patients with mental illness.
“They (general practitioners) are not referring to the psychiatrist, they refer it to neurology. There is lack of psychiatrists at country level, so who is near to them is the neurologist, so they refer to neurology doctors. So, most neurology doctors in the country, they work as psychiatrist. You cannot say every doctor will do it" (KII-1-42:39–43:37min)
A female psychiatrist in a private hospital did not see a single patient while she was there. This was partly because patients with a mental health illness that is not very severe often prefer to be labelled as nerva (a local term for symptoms of mostly anxiety or depression) and see a neurologist. Unless the neurologist refers them, they would prefer not to see a psychiatrist for counselling. Even when referred, these patients may not seek care from a psychiatrist because of the stigma surrounding mental illness. This phenomenon was observed even in the largest public hospital in the country in Mogadishu.
“That issue was even in our largest, our referral hospital. They started (a) psychiatry clinic, and no one usually go to psychiatry clinic, instead they go to neurologist. Even the psychiatrist went to neurologist, and they ask them why do you have these patients? Please refer, even you are not get paid. Your center is big, it is not private, you are not getting something, anything, it is, except workload. …Still they kept doing”. (KII-3-48:52 − 49:26 min)
The same key informant said that in Somalia, neurologists were delivering services before psychiatrists. So, people think that they are the qualified ones for the treatment of mental health conditions. He also recalled that he used to work with a neurologist, who only used to refer the difficult cases.
However, such referral existed for care-seeking in some places such as between one Aas-shefa and another; a physician and an Aas-shefa; a private counselling service and a neurologist who manages mental health patients; a neurologist and a counselling provider; a neurologist and a psychiatrist in complicated cases; and a physician and a psychiatrist or neurologist. Rarely, young patients contacted mental health care providers through the internet and received online services.
Stigma and discrimination
How the individual, family and community perceive a disease and whether it is stigmatized have important implications for programme development and use (24, 25). The word “mental” was highly stigmatized in Somalia even among health care providers. People usually do not go to a psychiatrist because of stigma. One of the key informants, a psychiatrist, shared his experience.
“Initially, he was talking about psychiatry, no one showed up (at) the (psychiatry) clinic. Then … they started saying that they do neuropsychiatry, … because our mhGAP treats people, you know. Whenever they started treating epilepsy… then patients who had somatic part of depression (showed up) …. Then the clinic become busier, because patients (with) somatic (complaints) who had either anxiety or depression showed up.” (KII-3-47:45–48:38min).
Stigma was also found in doctors. Very few doctors were willing to have a career in psychiatry because of stigma. A focal point for mental health at a state ministry of health explained.
“We have (a) lot of doctors. Even with the University they don’t have mental health doctors…. We keep advocating (to open a department for mental health) for them. But people (doctor), they don’t want it because there is lot of stigma. Even if you work with mental health people, they will stigmatize you. They will think, you know, you have an issue as well.” (KII-2-14:17 − 14:40mins)
Stigma about mental health often affects every aspect of patients’ lives until they die. During one in-depth interview, a lady who had established a mental health centre in 2005, said that sometimes she had picked up patients from the road without knowing who they were. To illustrate how stigma can be detrimental to peoples’ lives, she recalled that during the COVID-19 pandemic she had contacted the families of patients who died of COVID-19 in her health centre. The relatives of seven people came and buried the body. However, six people remained unidentified and were buried with the permission of local government.
Stigma also appeared to be a barrier in the integration of mental health and psychosocial support within PHC services. A senior official working for a state ministry of health mentioned that when they were integrating mental health in PHC services, which were providing services for maternal and child health, the staff working in these facilities resisted saying-, “No, no, mad man can kill the (a) woman.”.
Tools
We did not come across any activity or tool to raise awareness, reduce stigma, promote mental health conditions as a disease, improve selfcare and seeking appropriate care. We felt the need of such a tool that can be used by community people, community health workers, traditional healers, community leaders including cultural or religious leaders and schoolteacher, which would help them to understand when anyone’s mental health condition can be considered as abnormal and as a disease and like other disease it can also be treated at PHC.