Aline Nshuti Abatoni was first diagnosed with bipolar psychosis, often described by mental health experts as a loss of contact with reality, when she was 14.

Among a host of many other challenges, people who experience episodes of psychosis are often unable to recognize what’s real and what’s not in the world around them.

However, with the right doctors, Abatoni says that today, she is equipped with treatment and coping tools that have over the years helped her manage her condition.

Although she lives a normal life, which involved running a successful business of importing children’s clothes and toys, Abatoni says that her condition has cost her several romantic relationships, with many suitors losing interest upon her opening up.

"The moment I explain to a man that I have a mental illness, he cuts communication. After that, he will go around talking about how he could not marry a madwoman. It hurts me very deeply but I will never stop being open about my condition,” she said.

At 37, her dream to have a big white wedding and five children is fast fading. She is planning on adopting two children.

The issue of stigma around mental illness issues has been raised by different categories of people over the years.

In its 2016/2017 annual report, the National Human Rights Commission said that social stigma towards people with mental health challenges is still rampant.

The report pointed out that some members of society prefer to lock up patients, deny them food, physically abuse them and in some cases, sexually abuse them.

The report also said that the community lacks enough information about mental illness where, in many cases, even if the patient gets treatment and they move on with their lives, society continues to refer to them as ‘insane.

39-year-old Philippe Nziza has been dealing with alcoholism almost all his adult life.

He started drinking at 16 not long after he lost his only surviving parent.

By 21, he could not function without alcohol in his system.

Alcoholism is the inability to control drinking due to a physical and emotional dependence on alcohol. 

Nziza says that as he grew older, the problem became even worse. He was disowned by his family, lost his job and became the community laughingstock.

It is only when he moved to Canada that he learnt that his problem required professional medical attention.

"In Africa, if you drink a lot, you are a drunkard. Everyone writes you off as a failure. No one, including myself, thought that this was an illness. Most people don’t really know that alcoholism is a disease that requires a combination of interventions to fix,” he says.

To this day, not many people in Rwanda or African understand the link between alcoholism and mental health.

However, back in 1980, the American Psychiatric Association identified substance use disorder as a primary mental health disorder and classifies alcohol abuse as a subset of personality disorders.

While some alcoholics take the alcohol to feel good, others are addicted to drinking because the intoxication helps relieve their stress, forget their problems and in some cases, some do it to numb their emotional pain.

 Figures from the National Neuropsychiatric Hospital, Ndera, indicate that some 2,804 patients with alcohol and drug-related illnesses sought consultation in 2016, a steep rise compared to 2009 when 440 patients were recorded.

With the outbreak of the Covid-19 pandemic, socio-economic challenges are expected to push these figures even higher.

Experts weigh in

In an interview with The New Times, Justine Mukamwezi, a Clinical Psychologist doing consultancy at ‘Solid Minds’, a local clinic that provides counselling services says that lack of enough information about mental health issues within the society remains a challenge for many patients who have been diagnosed, forcing others not to seek help due to stigma.

Mukamwezi said that as a counsellor who has worked in different schools around the country, students often say that they are willing to pay to seek mental health support services elsewhere instead of utilising the free ones provided by their institutions out of fear of being labelled derogatory names like ‘mad’ that are usually given to mental health patients.

She added that for the diagnosed, the constant scrutiny within their home and workplaces is both discouraging and harmful.

"The biggest challenge is that many patients are judged through the lenses of their illness. Any slight error and everyone refers to their mental illness. It’s unfair to the patient and any other person who may be interested in seeking help,” she said.  

 She called for campaigns that will dig into normalising conversations around mental health in schools, homes and communities, saying that this will go a long way in encouraging more people to seek help.

Mukamwezi pointed out that for instance, people do not understand that having suicidal thoughts or even committing suicide or alcoholism could potentially be a mental health issue.

"Society will say, but you have everything, why would you want to kill yourself? Most of my patients who have thought or attempted suicide are rich and in happy relationships but their mental health challenges are beyond what you see on the outside,” she said.

Mukamwezi reminded of the value of providing protective factors which include being supportive and encouraging friends and family to speak out without being judged and for those who have other harmless beliefs like religion, to embrace them.  

She reminded that without protective factors, most people who have risk factors that may include underlying and sometimes undiagnosed mental health illness like depression or other past traumas like physical and emotional abuse, rape, orphaned at an early a very age can for instance easily commit suicide.

 "The fact that there are these risk factors means that someone is fragile. All it takes is being triggered when fired or their relationship breaks down. Someone without these other risk factors can manage because they have protective factors," she said. 

Start early

The Head of the Mental Health Department at CHUB Dr.  Vianney Nyirimana, said that with the correct information targeting the right people, mental health stigma and other challenges can be mitigated early enough.

Nyirimana was basing this on his research papers titled ‘Prevalence of Childhood Adversities among Inpatients with Mental Disorders at Caraes Ndera Neuropsychiatric Hospital in Rwanda’.  

He said that most Adverse Childhood Experiences (ACEs) are very common with patients with mental disorders who walk through his doors every day and as a result, 61 per cent of the ones in his research did not go beyond primary school and 42.6 per cent were unemployed.

ACEs are potentially traumatic events that occur in childhood (0-17 years). 

These events may include traumatic experiences like child abuse and neglect, growing up in dysfunctional households that are characterised by domestic violence, incarceration, parental divorce, and drug and alcohol abuse.

He called for the involvement of employers, family and friends as far back as when the child is still in the womb.

"Childhood is the foundation of adult health outcomes. If a child has insecure attachment in early development and lack of love and trust eventually as a consequence is that they will vent on other people in their adulthood. This is why it is important to tackle these issues early,” he said.

Support employees

With the outbreak of the Covi-19 pandemic, the need for a listening ear has become crucial everywhere including workplaces where most individuals spend their time.

A 2021 survey conducted by Mhub on the state of mental health at work involving 214 workers across Rwanda indicated that only about a third of respondents currently receive some form of emotional and mental health support services from their employers (36.9 per cent on average).

This is higher in NGOs (45 per cent) and lower in the public sector (26.8 per cent).

A staggering 88.8 per cent of respondents say that they wish their employer did more to support employee emotional and mental health. This desire is greatest in for-profit companies (93.6 per cent).

Mhub is a local company that provides counselling and therapy at workplaces.

The Program Manager of Mhub Rwanda, Francoise Uzamukunda, high levels of stress and anxiety among other mental health challenges can easily be dealt with if employers put in place policies and guidelines aimed at addressing these issues.

Uzamukunda explains that the employer must always check in with the employees beyond assignments and deadlines.

Additionally, it is important for the employer to create a conducive environment where employees can freely and comfortably approach their line managers to discuss anything that may be weighing them down.  

She said that this is particularly important today as the world grapples with the socio-economic impact of the Covid-19 pandemic.

"There are worries about job layoffs and this can cause lots of anxiety. Create platforms, even if they are anonymous, where positive messages are shared and where employees can freely express themselves,” she advised.

Underfunded sector

The Director of the Psychiatric Care Unit at the Rwanda Biomedical Centre, Dr Jean-Damascène Iyamuremye, told The New Times in a previous interview that there is need for more funds to be injected into this area to support treatment.

"Mental health is still underfunded yet we need to coordinate activities of treatment and prevention, fighting stigma against victims and we need to raise awareness regarding access to treatment,” he said.

Around 12 per cent of people in Sub-Saharan Africa live with a mental illness.

According to Rwanda Biomedical Centre (RBC), depression prevalence is at 11.9 per cent within the general population and as high as 35.6 per cent are genocide survivors. This means one in three genocide survivors faces trauma.

The prevalence of post-traumatic stress disorder (PTSD) stands at 3.6 per cent.