Perceptions of depression among Somali populations in Somaliland
by Dr Djibril I.M. Handuleh, Public Health Specialist at Medecins sans Frontieres/Doctors without Borders
Mental health is one of the most neglected specialties in Somaliland. Internally recognized as part of Somalia, it has a population that is estimated to be 3.5 million. The mental health resources are among the least developed in the world. There are two psychiatrists practicing in the country with few physicians and nurses working in both primary care and public hospitals on mental health. A significant part of mental health services is delivered through traditional healers. There are no psychologists, social workers, psychiatric nurses and other allied health workers in the country. Mental health policy is in draft stage in Somaliland.
Here, I discuss the public perception of depression among the population. This is derived from eight years of practical mental health practice as a physician working in psychiatry. Mental health debate in public arena is starting in the country. This is mainly due to the increasing burden of mental health disorders among Somalis in East Africa and in the diaspora. In my practice, depression is the most common mental health disorder presented by most of my patients.
People have different understandings of how depressive illness may present. These vary from people who deny depression as a disorder or a medical condition. They point out that anyone who gets depression is cursed. Lack of religious practice is agreed among the public as depression. The second largest group believe it is either due to failed romantic relationships or failure. They dismiss depression as either medical or psychiatric condition.
The third and least numbering group consider depression as a medical condition. This group includes most of the patients who present in both general practice and mental health settings. They present with somatoform symptoms such as headaches, generalized body aches and dizziness. This can easily confuse even physicians into not taking focused psychiatric history or mental health exam.
Somalis think they are resilient society and hard to get depression due to their nomadic and harsh life conditions. Depression is not on the agenda when Somalis discuss mental health disorders, as psychotic disorder is presumed as a mental health disorder.
Women and older people may accept a diagnosis of depression while men and other more privileged community members get nervous if they meet the criteria for depression. They call it Neerfo, meaning nerve related disorder.
Based on these facts, addressing depression in Somaliland is a heavy task at hand. There is a need to train physicians on depression and its management as patients, when they are living with depression, seek medical care from general clinicians, not from mental health specialists/practitioners.
There is also a potential to increase public awareness of depression among the community via health education initiatives at population level. A good example was in Borama, which took place at schools, prisons, community neighbours and in mosques. We also trained religious imams on depression as religious interpretations are common in Somaliland.