In the streets of Addis Ababa, amidst the cacophony of daily life, there exists a poignant and often overlooked reality: the mentally challenged individuals who roam these streets. Their presence is an indelible part of the urban landscape, impossible to ignore yet frequently overlooked. At every corner, in every market, and along every main thoroughfare, they manifest. Club-wielding figures wander, drifters expose themselves, scavengers scour, loners mutter, gazes turn vacant, and preachers rant on every corner- —each a testament to the city’s silent epidemic. This scene is not unique to Addis Ababa but is mirrored in cities across Ethiopia.
At the heart of this crisis stands Amanuel Hospital, the nation’s only dedicated mental health institution. Here, men and women clad in identical checkered cotton pajamas navigate the narrow gate, populate the buildings, and linger in the courtyards. They are patients enduring their treatment journey. Men and women are housed separately, with the men occupying more spacious courtyards to prevent violence that confinement can provoke.
In the men’s ward courtyard, young men pace—some in solitary contemplation, others in groups, occasionally with a companion. They all share a common thread: they are on psychoactive drugs tailored to their needs.
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“We have reached our in-patient capacity,” Kibrom Haile(MD), Medical Director of Amanuel Mental Hospital, told The Reporter Magazine. “We cannot admit even one more patient under the current circumstances.”
Kibrom admits the state of mental illness in Ethiopia remains largely unstudied. “We lack a nationally representative study,” he says.
Yet, the recognized triggers of widespread mental illness—armed conflict, gender-based violence, poverty, unemployment, drought, inflation, and the burdens of life—persist with increasing severity. These are the stressors of both individual and public psyche.
An article in BMC Medicine, a UK-based online journal, titled “Burden of Mental Disorders and Unmet Needs among Street Homeless People in Addis Ababa, Ethiopia,” assessed 217 homeless adults.
It found that 90 percent had experienced some form of mental or alcohol use disorder. Most of these individuals had numerous unmet needs, with 30 percent living with a physical disability (visual, sensory, and/or impaired mobility).
Astonishingly, only 10 percent of those with psychosis had received treatment for their illness, and most had lived on the streets for over two years.
A Glaring Service Gap
Located in one of Addis Ababa’s busiest neighborhoods, Amanuel Hospital houses hundreds of patients suffering from the most severe mental health conditions. Until recently, it was the only mental health institution in the country, with a few other institutions, like Gondar and Jimma Universities’ Hospitals, beginning to offer some support.
The hospital has its roots in violence. Initially a general hospital, it was converted into a mental health facility after the massacre of over 30,000 civilians by Italian occupying forces in February 1937. The aftermath of this atrocity left a lingering mental health crisis that the hospital was established to address.
Decades later, mental illness in Ethiopia remains a profound issue.
Available data, though scarce, and daily observations reveal a shocking gap in mental health services. “The country’s mental health service gap stands at 90 percent,” Kibrom reveals.
In other words, only one in every ten Ethiopians in need of mental health services receives it.
According to the World Health Organization (WHO), “One in eight people in the world live with a mental disorder,” defining mental disorders as involving “significant disturbances in thinking, emotional regulation, or behavior.”
Most people lack access to effective care for mental health issues, ranging from mild symptoms to severe conditions categorized under psychosis. These include anxiety disorders, bipolar disorder, post-traumatic stress disorder (PTSD), schizophrenia, eating disorders, and neurodevelopmental disorders, according to the WHO.
The mental health crisis is made worse by the reluctance of individuals to seek mental health services for themselves or their loved ones. Kibrom says people do not seek mental health services for themselves and loved ones, but if and when they do, they cannot get the service nearby where they live.
“It is very challenging for Ethiopian families to bring those suffering from mental illness all the way to Addis Ababa for modern diagnosis, say from Jimma or Assosa,” he explains. As a result, most Ethiopian mental patients languish at home, on the streets, far from modern mental health service establishments.
Kibrom reveals the immense pressure faced by AmanuelHospital: “Our capacity is very limited, and we are giving the service under much stress.” He claims that up to 500 people appear at the hospital for diagnosis every day. “With only eight psychiatrists on staff, each must diagnose as many as 30 patients daily.”
“It is very difficult for a single psychiatrist to diagnose as many as that in view of the uniqueness that verbal communication with the mentally challenged presents,” he adds.
Most patients have passed the stage where ‘talk-therapy’ is viable; thus, the administration of psychoactive drugs becomes the primary treatment option, according to the Director. However, there are also patients who attend “group-talk” therapy, particularly those being treated for mental illness caused by addiction and substance abuse.
Too visible to ignore
The state of mental illness in the country is an undeniable reality, glaringly evident yet long ignored. The streets of Addis Ababa, a melting pot of ethnicities, vividly illustrate this issue. Step outside Amanuel Mental Hospital, and one encounters countless mentally challenged individuals.
This situation is true of all cities and urban settlements in Ethiopia—a country that assigns one psychiatrist for every 1.2 million people. The existing mental health institutions cannot meet the demand for services, and the populace often views mental health services as a last resort.
Local studies examining the state of mental illness from sociological perspectives indicate that traditional beliefs and practices heavily influence perceived causes and preferred interventions for mental illness. Many studies agree that these traditional views grossly simplify mental illness, often labeling it as “madness.”
One study, titled “Perceived Causes of Severe Mental Disturbance and Preferred Interventions,” identifies causes of mental illness as inherited traits, alcohol and khat (a stimulant), biological and psychological factors such as loss and worry, exposure to blood and muddied/dirty water, exposure to wind during childbirth, evil spirits/bewitchment, evil eyes, and supernatural influences.
These studies highlight that local communities are more inclined to seek counsel from wise men, spiritual healers, or employ other traditional means to treat and heal mental illnesses rather than seeking modern treatment services.
“[Modern] psychiatric diagnosis and treatment should devolve to the grassroots communities,” says Kibrom. “The problem of mental illness as encountered in Ethiopia today cannot be tackled by expanding facilities likeAmanuel Hospital. Establishing even ten or so more such hospitals may not effectively tackle the problem.”
He believes that mental illness treatment and diagnosis should be integrated into primary health care being rendered across the country via health centers, stations, and posts.
“So our recommendation is to bring psychiatric servicescloser to communities, and there have been activities by the government towards that goal by trying to avail one psychiatrist per health station at district levels,” he notes.
However, until these recommendations are fully implemented, Ethiopian city streets, homes, charitable institutions, and churches continue to house people suffering from mental illnesses. The persistent armed conflicts, violence, poverty, insecurity, and warfareonly exacerbate mental health issues.
The invisible scars of conflict: Mental health in war-affected areas
Studies conducted in camps for internally displaced people (IDPs) in northern Ethiopia confirm that war and armed conflict significantly contribute to mental illnesses.
A study, titled “Prevalence of Depression and Associated Factors Among Community-Hosted Internally Displaced People of Tigray During War,” revealed that “the prevalence of PTSD among the respondents was 67.5percent,” with causes including witnessing property destruction, multiple displacements, forced unemployment, and witnessing distressing situations.
Another study also sheds light on the situation at an IDP camp in Dembia, Gondar zone of Amhara regional state, involving 406 IDP’s. “The prevalence of depression among internally displaced people was 81.2 percent, with more than 60 percent categorized as moderate and severe depression,” it states.
A March 2022 study published in The Lancet further underscores the severe impact of conflict on mental health in Ethiopia.
Abel Fekadu, a Public Health and Social Epidemiologist and Biostatistician, highlights a critical issue in his recent journal article: “Mental health problems are major indirect consequences of armed conflicts and can have short-term and long-term effects on the well-being of individuals living in war-affected areas.”
His analysis, using a WHO-approved formula to assess age-standardized and co-morbid mental illness in conflict settings, paints a stark picture of the mental health crisis in Ethiopia’s war-affected regions of Afar and Amhara.
Abel’s findings are alarming: “…there are a minimum of 28,560 individuals with more severe forms of mental health disorders that require immediate intervention, of whom 12,566 are children and 14,566 are women.” The destruction of over 1,500 health facilities and the displacement of around 10,000 health workers have rendered treatment for these individuals impossible.
“Given the large population in need of mental health interventions in northern Ethiopia, there is an urgent need to use affordable, attainable, and effective multisectoral collaborative care models in addition to interventions via awareness raising, psychoeducation, skills training, rehabilitation, and psychological treatments,” the study advocates.
It underscores that mass killings, injuries, and gender-based violence—often underreported due to social stigma and inadequate mental health services—exacerbate the mental health crisis in these regions, impacting not only the survivors but also their families and communities.
These findings starkly illustrate how armed conflict heightens susceptibility to mental illness. However, they also highlight the complexity of the issue, making it challenging to generalize about the nationwide state of mental health in Ethiopia. The country’s vastness and the multitude of contributing factors complicate efforts to gain a comprehensive understanding.
Despite these challenges, ignoring the grim realities of mental illness in Ethiopia is not an option. The daily lives of many Ethiopians are a testament to the pervasive impact of mental health issues.
Kibrom calls for international and local support to train psychiatric physicians and nurses. Such training would enable the hospital to extend its reach to affected communities. He emphasizes the need for improved physical infrastructure at the hospital, including wider and better building spaces.
The World Health Organization (WHO) also advocates for the engagement of community leaders, such as religious figures, elders, and public personalities, as well as the use of cultural institutions.
Collaborative care models, community engagement, and improved infrastructure are critical steps toward addressing this crisis.These measures can significantly enhance the effectiveness of mental health interventions, ensuring they reach a broader population.
