Profile of suicide in rural Cameroon: are health systems doing enough?
Abstract
enObjectives
To describe the characteristics of suicide and assess the capacity of health services at the district level in Cameroon to deliver quality mental health care.
Methods
The study covered the period between 1999 and 2008 and was carried out in Guidiguis health district which had a population of 145 700 inhabitants in 2008. Data collection was based on psychological autopsy methods. To collect data, we used documentary review of medical archives, semi-structured interviews of relatives of suicide completers, a focus group discussion of health committee members and a survey to consulting nurses working at the primary health care level.
Results
Forty-seven suicides were recorded from 1999 to 2008: 37 (78.7%) males and 10 (21.3%) females, yielding rates of reported suicides that ranged from 0.89 to 6.54 per 100 000 inhabitants. The most frequently used suicide method was the ingestion of toxic agricultural chemicals (in 76.6% of cases). According to the relatives, the suicides were due to an ongoing chronic illness (31.9%), sexual and marital conflicts (25.5%), witchcraft (14.9%), financial problems (8.5%) or unknown cause (25.5%). In 25 (53.2%) cases, suicide victims exhibited symptoms suggestive of a mental disorder but only six of the suicide committers who presented behavioural symptoms sought health care. Only two of the 15 consulting nurses were able to cite at least three symptoms of depression and were aware that depression can lead to suicide. All of the nurses acknowledged that they had never received any specific training or supervision in mental health care.
Conclusions
Suicides are not a rare event in rural settings in Cameroon. The health district capacity to provide quality mental care is almost insignificant. The integration of minimal mental health care services at the community and primary health care levels should be considered a priority in sub-Saharan Africa.
Abstract
frObjectifs
Décrire les caractéristiques des suicides et évaluer la capacité des services de santé à l’échelle du district, au Cameroun pour fournir des soins de santé mentale de qualité.
Méthodes
L’étude a porté sur la période comprise entre 1999 et 2008, et a été menée dans le district de santé de Guidiguis qui avait une population de 145.700 habitants en 2008. La collecte des données a été basée sur des méthodes d'autopsie psychologique. Pour recueillir les données, nous avons utilisé la revue documentaire des archives médicales, des entretiens semi-structurés avec les parents des victimes de suicide, une discussion focalisée de groupe avec des membres du comité de santé et une enquête auprès des infirmier(e)s de consultation travaillant au niveau des soins de santé primaires.
Résultats
Quarante-sept suicides ont été enregistrés de 1999 à 2008: 37 (78,7%) hommes et 10 (21,3%) femmes, révélant un taux de suicides variant de 0,89 à 6,54 pour 100.000 habitants. La méthode de suicide la plus fréquemment utilisée était l'ingestion de produits chimiques agricoles toxiques (dans 76,6% des cas). Selon les parents, les suicides sont dus à une maladie chronique (31,9%), à des conflits sexuels et conjugaux (25,5%), à la sorcellerie (14,9%), à des problèmes financiers (8,5%) ou à une cause inconnue (25,5%). Dans 25 (53,2%) cas, les victimes de suicide présentaient des symptômes évocateurs d'un trouble mental, mais seules six d'entre eux présentant des symptômes comportementaux ont recherchés des soins de santé. Seuls 2 des 15 infirmier(e)s de consultation étaient capables de citer au moins trois symptômes de dépression et étaient conscients que la dépression pouvait mener au suicide. Tous les infirmier(e)s ont reconnu qu'ils n'avaient jamais reçu de formation ou de supervision spécifique dans les soins de santé mentale.
Conclusions
Les suicides ne sont pas un événement rare en milieu rural au Cameroun. La capacité du district de santé à fournir des soins de santé mentale de qualité est presque insignifiante. L'intégration de services de soins minimaux de santé mentale au niveau communautaire et des soins de santé primaire devrait être considérée comme une priorité en Afrique subsaharienne.
Abstract
esObjetivos
Describir las características del suicidio y evaluar la capacidad de los sistemas sanitarios distritales en Camerún a la hora de entregar servicios de calidad en salud mental.
Métodos
El estudio cubrió el periodo entre 1999 y 2008. Se llevó a cabo en el distrito sanitario de Guidiguis, con una población de 145,700 habitantes en el 2008. La recolección de datos se basó en métodos de autopsia psicológica. Se utilizó una revisión documental de archivos médicos, entrevistas semi-estructuradas de parientes de los suicidas, grupos de discusión focalizada de miembros del comité de salud y una encuesta a las enfermeras de atención primaria.
Resultados
Se registraron cuarenta y siete suicidios entre 1999 y 2008: 37 (78.7%) hombres y 10 (31.3%) mujeres, con una tasa de suicidios reportados de entre 0.89 a 6.54 por 100,000 habitantes. El método de suicidio más común era la ingestión de agroquímicos tóxicos (en 76.6% de los casos). Según los parientes, los suicidios eran debidos a sufrir una enfermedad crónica (31.9%), conflictos sexuales y maritales (25.5%), brujería (14.9%), problemas financieros (8.5%), o causas desconocidas (25.5%). En 25 (53.2%) de los casos, los suicidas tenían síntomas sugestivos de alguna enfermedad mental, pero solo seis de los suicidas que presentaban los síntomas buscaron ayuda. Solo 2 de las 15 enfermeras consultadas pudieron citar al menos 3 síntomas de depresión y eran conscientes de que la depresión puede conllevar a un suicidio. Todas las enfermeras reconocieron que nunca habían recibido un entrenamiento especial o supervisión en cuidados relacionados con la salud mental.
Conclusiones
Los suicidios no son un evento raro en emplazamientos rurales del Camerún. La capacidad sanitaria del distrito para proveer cuidados de calidad en salud mental es prácticamente insignificante. La integración de servicios mínimos de salud mental a nivel comunitario y de atención primaria debería considerarse como una prioridad en África subsahariana.
Introduction
In 2004, self-inflicted injuries were the eighth leading cause of morbidity for 15–44-year-olds worldwide. In 2008, approximately 1 million suicides were registered worldwide; of these, only 50 000 were reported in Africa owing to rudimentary reporting systems among other concerns (WHO 2008a). The Mental Health Gap Action Programme (WHO 2008b) has identified suicide as one of eight global priority mental, neurological and substance use disorders. It also highlighted suicide as the third most common cause of death among 15–34-year-olds. Suicide represents 1.4% of all disability-adjusted life years worldwide.
Suicide is a complex public health problem that has huge psychosocial and financial impacts on families and communities (WHO 2000, 2004; National Conference of State Legislatures 2005). There are few studies that examine suicide in Africa (Reza et al. 2001; Ajdacic-Gross et al. 2008), and the ones that exist were mostly conducted in urban areas (Dong & Simon 2001; Reza et al. 2001; Gunnell & Eddleston 2003; Vijayakumar et al. 2004). In Addis Abeba, Ethiopia, the average suicide rate was estimated at 7.8 suicides per 100 000 inhabitants over a 15-year period (Abdullahi Bekry 1999). In general, policy makers in developing countries hardly prioritise mental health issues (Gureje & Alem 2000; Richard & Sherer 2002), despite their frequency. The lifetime prevalence of mental disorders was recently 12.1% in Nigeria (Gureje et al. 2006) and has been as high as 30% in South Africa (Stein et al. 2008). The Mental Health Gap Action Programme (WHO 2008b) highlighted the huge gap in mental health services and proposed a package of interventions to help prevent and manage mental disorders. Effective measures to prevent suicide include reducing access to suicide ‘methods’ and improving access to health care. However, the demographic characteristics of people who commit suicide and the methods of suicide are context-dependent, and access to health services varies worldwide (WHO 2000). Therefore, more robust information about suicide in a particular population can support the design of better suicide prevention strategies and programmes (Reza et al. 2001; Richard & Sherer 2002; Ajdacic-Gross et al. 2008). In Cameroon, there have been no studies about suicides or about the capacity of the district health services to adequately address mental disorders.
This study aimed to examine the suicides reported in Guidiguis Health District (HD) and concurrently assess the capacity of district health services to adequately manage mental health problems in general, and to prevent suicide in particular.
Methods
Mental health programme
The Mental Health and Human Behaviour Programme is one of 28 vertical programmes designed in Cameroon's 2001–2010 Health Sector Strategic Plan. This programme aims to provide mental health services to 80% of HDs in Cameroon and prevent 10% of behavioural problems in communities (MINSANTE 2002).
Guidiguis health district
This study was conducted in the Guidiguis HD, a rural district in the Far-North Region of Cameroon with an estimated population of 145 700 inhabitants in 2008. Guidiguis HD has a district hospital and 15 health centres (HCs). The population also seeks health care from traditional and spiritual healers. The majority of the population is involved in subsistence farming; the only cash crop cultivated in this Sahelian area is cotton.
Suicide
In this study, a suicide is defined as death resulting from injury, poisoning or suffocation for which there is either explicit or implicit evidence that the injury was self-inflicted and that the person intended to kill himself or herself (WHO 2004).
In the HD, the death of an individual due to accident, suicide, homicide or any unnatural cause should be immediately reported to law enforcement officials, who then consult a medical professional. An autopsy is performed, and the doctor files a written report for the district hospital's archives. However, the use of health services is uncommon, and most people die at home. Therefore, some cases of suicide that also had clinical manifestations could have been classified as natural deaths by relatives and thus gone unreported. Family members of a person who has committed suicide are expected to perform expensive ‘traditional ritual cleansings’ and are summoned by law enforcement officials for inquiries. All of these factors could contribute to underreporting of suicides by relatives.
Data collection
Data collection was based on psychological autopsy methods (Jacobs & Klein-Benheim 1995; Inserm 2004). Completed suicides from 1999 to 2008 in Guidiguis HD were included in the study. We collected data from four different sources: a review of autopsy reports, semi-structured interviews, a focus group discussion (FGD) and a survey of nurse practitioners. The date of death, demographic characteristics of the deceased and method of suicide were obtained from the reports. Using a semi-structured interview guide, we interviewed 47 first-degree relatives who lived with a person who had committed suicide. A brief inquiry was made in each household to identify the most suitable person for the interview. Some clarifications were made by other family members. The themes that were investigated were the precipitating factors leading to the suicide, the symptoms that were presented by the person who committed suicide and the method used. The semi-structured interviews were recorded after verbal consent was obtained from the interviewees. In addition, we conducted a FGD with 15 health committee members (termed participants in this study) from each of 15 health areas to assess the public opinion of suicide. These health committee members were leaders of their respective health area committees. The interviews and FGD were conducted in French or the local language. A questionnaire was administered to 15 consulting nurses working in the HCs to assess their knowledge regarding the manifestations and complications of depression and its correlation with suicide.
Results
Demographic characteristics
A total of 47 suicides were registered. Of these, 37 (78.7%) were committed by men and 10 (21.3%) by women, with a ratio of 3.7 male deaths to each female death (Table 1). However, the male-to-female ratio of suicides was 1:1 between the ages of 10 and 19 years. The largest proportion of suicides in women (40%) occurred in this age group. Two to nine suicides were registered each year, yielding rates of reported suicides from 0.89 (in 1999) to 6.54 (in 2006) per 100 000 inhabitants (Figure 1).
| Age | Number of cases (%) | Total (%) | |
|---|---|---|---|
| Males | Females | ||
| 10–19 | 4 (10.8) | 4 (40.0) | 8 (17.0) |
| 20–29 | 9 (24.3.0) | 2 (20.0) | 11 (23.4) |
| 30–39 | 6 (16.2) | 1 (10.0) | 7 (14.9) |
| 40–49 | 8 (21.6) | 1 (10.0) | 9 (19.1) |
| 50–59 | 5 (13.5) | 1 (10.0) | 6 (12.8) |
| 60–69 | 3 (8.1) | 1 (10.0) | 4 (8.5) |
| 70–79 | 2 (5.4) | 0 (0) | 2 (4.3) |
| Total | 37 (100) | 10 (100) | 47 (100) |
Suicide methods
Ingesting toxic agricultural chemicals was the most common method (n = 36; 76.6%), followed by hanging (n = 8; 17%) and ingesting non-agricultural toxic chemicals (n = 3; 6.4%) (Table 2). The women who committed suicide all used poisonous agricultural chemicals.
| Suicide method | Number of cases (%) | Total (%) | |
|---|---|---|---|
| Males | Females | ||
| Ingesting toxic agricultural chemicals | 27 (73.0) | 9 (90.0) | 36 (76.6) |
| Hanging | 7 (18.9) | 1 (10.0) | 8 (17.0) |
| Ingesting non-agricultural toxic chemicals | 3 (8.1) | 0 (0) | 3 (6.4) |
| Total | 37 (100) | 10 (100) | 47 (100) |
The first-degree relatives of all people who ingested toxic agricultural chemicals said that these were remnants from chemicals that had been procured from the local cotton company for use on the cotton farms. However, the relatives acknowledged that this company provides farmers with a quantity of chemical that is proportional to the size of the farm to avoid chemical leftovers. During the FGD, it was noted that despite these measures, farmers manage to take home extra chemicals to treat other crops, such as beans, or to kill termites that destroy the straw roofs of their homes. When asked whether the use of pesticide is critical to farming, one participant said, ‘Cotton is a heritage. If we are stopped from using this product, it means we will also stop cultivating cotton, as our harvest will be insignificant’. Another participant said, ‘Many people use the pesticide to commit suicide because they know it is very poisonous and a surest means to die. You die quickly without suffering compared to other methods such as hanging where one suffers before death’.
Precipitating factors leading to suicide and the reporting of suicide
From the interviewees’ responses, suicides were categorised into groups according to precipitating factors. Fifteen suicides (31.9%) were preceded by chronic illnesses, 12 (25.5%) involved sexual or marital conflicts, 7 (14.9%) were associated with witchcraft, 4 (8.5%) were related to financial issues and 12 (25.5%) had unclear precipitating factors (Table 3).
| General causes (%) | Specific causes | Total (%) |
|---|---|---|
| Witchcraft issues 7 (14.9) | Accused of witchcraft | 5 (10.6) |
| Bewitched by a sorcerer | 2 (4.3) | |
| Sexual and marital issues 12 (25.5) | Accused of adultery | 2 (4.3) |
| Unwanted pregnancy | 1 (2.1) | |
| Spouse refused sexual intercourse | 2 (4.3) | |
| Attempted to kill his wife and did not succeed | 2 (4.3) | |
| Compelled to reimburse the dowry of divorced daughter | 2 (4.3) | |
| Compelled by the parents to return to husband for fear of reimbursing the dowry | 2 (4.3) | |
| Frustration after the husband took a second wife | 1 (2.1) | |
| Financial issues 4 (8.5) | Squandered school fees | 1 (2.1) |
| Accused of theft | 1 (2.1) | |
| Farmland seized | 1 (2.1) | |
| Frustration after misplacing a friend's money | 1 (2.1) | |
| Known illness 15 (31.9) | Stress of living with a chronic disease | 2 (4.3) |
| No breast milk to feed a newborn baby | 1 (4.3) | |
| Mental disorders | 5 (10.6) | |
| Alcoholism | 4 (8.5) | |
| Multiple deaths in the family | 3 (6.4) | |
| Unknown causes 12 (25.5) | Unidentified specific causes | 12 (25.5) |
When asked why men alone commit suicide because of witchcraft, one participant said, ‘This type of witchcraft, locally called “sarr”, is only done by men to kill people so as to become wealthy. Individuals accused of witchcraft are stigmatised to an extent they cannot bear and they commit suicide’. Also, when asked about suicide among men, one participant said, ‘Men have more financial means to buy drinks and become alcoholic than women’.
The husbands of women who committed suicide said that they were unaware of any precipitating factors during interviews. However, during the FGD, many participants suggested that many young married women commit suicide as ‘a result of domestic violence by men’. One participant argued, ‘As the bride price is locally paid with 12 cows, poor parents frequently force their daughters to get married so that they receive this bride price’. Another participant added, ‘Men after paying the bride price consider the wife as their property bought with cows’. Therefore, in cases of abuse, ‘These “bought wives” have no right to return to their parents’ home; otherwise, their parents would have to reimburse the bride price’.
Participants also described situations in which some families could not afford to reimburse the bride price. For example, one participant said, ‘Maltreated women who run to their parents for safety are even chased back by their parents to the wicked husband's house since they have already consumed the bride price’. One participant remarked, ‘a helpless woman with an “omnipotent” husband commits suicide because she has no structure where she could be understood’. Another participant said, ‘A wife frustrated by the husband's behaviour returned to her parents and committed suicide’. All participants agreed ‘Some marital problems are unbearable by women, but they have little or no decision voice on family matters’.
The relatives of suicide victims all agreed that they knew that it is an obligation to report suicides to the local authorities. One participant argued, ‘By notifying, inquiries are done to attest that it was really a suicide, and this avoids further administrative and judiciary problems’. However, during the FGD, participants unanimously recognised that some suicide deaths are not reported to avoid expensive traditional cleansing rituals and family stigmatisation.
Psychiatric and physical symptoms prior to suicide
According to information gathered from interviews, 25 (53.2%) suicide victims exhibited symptoms suggestive of a mental disorder, 2 (4.3%) had physical symptoms and 20 (42.5%) had no noticeable symptoms prior to the suicide (Table 4). All relatives of the 25 suicide victims with psychiatric symptoms mentioned that they had observed some abnormal behaviour before the suicide, but did not realise that such behaviour might lead to suicide. The exhibited symptoms included loneliness or social withdrawal, hallucinations, delirium, epileptic crises, continuous crying, agitation, nervousness, insomnia, attempted suicide, increased alcohol intake, talking about willingness to die, continuous singing and refusal to go to the market. Physical symptoms included chronic chest and lower abdominal pains.
| Symptoms observed prior to suicide | Number of respondents (%) | Number who sought modern health care (%) | ||
|---|---|---|---|---|
| Males | Females | Total | ||
| Psychiatric symptoms | 21 (56.8) | 4 (40.0) | 25 (53.2) | 5 |
| Physical symptoms | 1 (2.7) | 1 (10.0) | 2 (4.3) | 1 |
| No symptoms noticed | 15 (40.5) | 5 (50.0) | 20 (42.5) | 0 |
| Total | 37 (100) | 10 (100) | 47 (100) | 6 (12.7) |
Six (24%) of the 25 suicide victims with psychiatric symptoms sought medical treatment in a health facility of the HD. The relatives of these six individuals mentioned that the consultants did not inform them that the patients’ symptoms were related to mental illness or that the patients needed mental health care. Furthermore, no specific counselling was provided to the patients.
The capacity of the district health system to deliver mental health care
Fifteen consulting nurses were interviewed using a structured questionnaire. Only 2 (13%) nurses were able to name at least three signs or symptoms of depression and were aware that suicide is a possible complication of depression. The remaining 13 (87%) had no knowledge of the signs and symptoms of depression and were unaware that it can lead to suicide. All interviewed nurses acknowledged that they had never received any specific training or supervision in mental health care. In addition, we noticed that there were no specific medications or guidelines for the management of mental health disorders within primary healthcare (PHC) facilities.
The district hospital had two medical doctors trained in general medicine. The extent of their mental health experience had been provided during their undergraduate medical training, and they had never been supervised regarding mental health care. In the entire Far North region, which had a population of more than 3 million inhabitants in 2010, there is not a single medical doctor trained in psychiatry. Cases of severe mental illness at the Guidiguis district hospital are referred to the specialised psychiatric hospital in Yaounde, the capital, which is more than 900 km from Guidiguis. Specialists in the capital do not provide any feedback or follow-up to medical doctors at the Guidiguis district hospital.
Discussion
Some of the first-degree relatives who were interviewed in our study might not have recalled all of the precipitating factors leading to the suicide. The suicides might have been considered natural deaths by the relatives because of the stigma of suicide in the community. Furthermore, as in many other HDs in Cameroon, registries are not well maintained or updated in Guidiguis HD. These factors may have resulted in gross underreporting of suicides.
Nevertheless, this study provides a useful overview of suicide characteristics and of the capacity of Cameroon's HDs to address mental health problems. Men commit suicide more often than women. Toxic agricultural chemicals are the means most often used by suicide completers. Relatives noted clinical manifestations prior to suicide in 27 cases (53.5%), mainly related to mental disorders. The capacity of the district health services to adequately manage mental health problems remains poor.
The rate of reported suicides ranged from 0.89 (in 1999) to 6.54 (in 2006) per 100 000 inhabitants in our study. The rising number of law enforcement officials within the health district and the improved hospital reporting system might explain the progressive increase of reporting of suicides after 2003. In Ethiopia, the crude suicide rate ranged from 3.24 to 11.64 per 100 000 inhabitants per year between 1981 and 1996 (Abdullahi Bekry 1999). In 2010, standardised suicide rates in India were higher: 26.3 suicides per 100 000 inhabitants for men and and 17.5 for women (Patel et al. 2012).
Hanging and strangulation were the most commonly used methods of suicide (70%) in urban Ethiopia (Abdullahi Bekry 1999). In developing countries, poisoning is the most commonly used means for people to end their life in rural areas (Gunnell & Eddleston 2003). Therefore, access to toxic products should be restricted, as research findings indicate that suicide can be prevented if access to lethal means is restricted or denied (WHO 2000; Brigham 2003; Dzamalala et al. 2005). Conversely, agricultural products also improve crop production and conservation. Therefore, the use of agricultural chemicals should also be monitored, and if possible, cotton farms should be directly treated by the staff of the cotton company, or by trained agents rather than farmers.
Some methods of suicide frequently used in other settings, such as gun deaths or drowning, were not registered in our study. Cases of drowning have been registered in Guidiguis HD during the rainy season, but cannot necessarily be considered suicide as many rivers do not have bridges, especially in rural areas.
In our study, more men than women committed suicide. This tendency was also described in urban Ethiopia, where there was a 5.19:1 male-to-female ratio of completed suicides (Abdullahi Bekry 1999). There was a limited capacity to prevent and manage mental health disorders in the HD. At the community level, relatives mentioned mental disorders as precipitating factors in only a few cases (10.6%). Relatives might have not related these symptoms to mental disorders that require health care. Jacobs and Klein-Benheim 1995) noted that informants are often ignorant of or might downplay psychiatric symptomatology, which contributes to a low proportion of people with mental disorders seeking health care. Indeed, only 24% of the people who had some precipitating factors prior to committing suicide sought treatment in healthcare facilities. This tendency not to seek treatment may also be related to barriers to access to modern health facilities (WHO & WONCA 2008). In any case, nobody who accessed health facilities received adequate care. Indeed, if some precipitating factors (e.g. alcoholism) had been addressed earlier and well, some suicides might have been prevented. Research has indicated that brief counselling by PHC workers can reduce alcohol consumption in men with alcohol-use disorders (Patel et al. 2007). Vijayakumar et al. (2004) have argued that suicide attempts in developing countries are often successful because of limited access to medical facilities in general, and to mental health services in particular.
To improve mental health care in Africa, the member states of the WHO African Region adopted resolutions in 1988 and 1990 (AFR/RC39/R1 and AFR/RC40/R9, respectively) calling on each member state to formulate mental health policies, programmes and action plans and to deliver mental health services at PHC facilities (Desjarlais et al. 1995; WHO 2001).
Many studies have revealed that depressive disorders are quite common in Africa (Nwosu & Odesanmi 2001; Vijayakumar et al. 2004; Petersen et al. 2009). In one study, suicide attempts were more common during the month prior to the diagnosis and treatment of depression (Simon & Savarino 2007). Unfortunately, Cameroon has insufficient mental health professionals and services: in 2008, there were only 0.33 mental health professionals per 100 000 inhabitants (WHO 2008b), and very few hospitals have psychiatric services. Mental health specialists are concentrated in major cities. Moreover, there are no in-service training and supervision of PHC workers regarding mental health care, and consulting nurses have hardly any basic knowledge of depression, which is the most common risk factor for completed suicide (WHO 2000). All of these factors lead to limited ability of district health services to manage mental disorders, which in turn leads to missed opportunities to prevent suicides, especially in rural communities.
Psychological and pharmacological therapies are effective in preventing suicide in developed countries (Reza et al. 2001; Khan 2005). Meanwhile, the rates of suicide and other mental, neurological and substance abuse disorders are increasing in developing countries, but barriers to accessing treatment persist (Dzamalala et al. 2005). This situation was also described in Sembabule HD of Uganda, where 20–30% of the population was suffering from mental disorders, but only 2.3% sought care at a healthcare facility (WHO & WONCA 2008).
There is currently a great shortage of mental healthcare professionals in low-income countries in general, and in sub-Saharan Africa in particular. The scarcity of trained mental health specialists and the extent of the problem justify the integration of mental healthcare activities into front-line PHC services (Okasha 2002). The multipurpose health workforce desperately needs to be enabled to deliver, at minimum, basic mental health care (Bruckner et al. 2011). The case of Tanzania is illustrative: 2 weeks after PHC workers completed training in mental health care and the rate of proper identification of mental disorders by PHC workers increased from <1% to 25% (Ventevogel 2006). However, this integration should not be limited to modern health systems, as many people in rural areas seek health care primarily from traditional or spiritual healers. Community organisations and cultural associations should also be partners in the process of raising awareness and advocating for mental health care.
Optimal integration will require clear policies, and a political will to provide the necessary resources. The model of integration could be defined along the six components described by Gask and Khanna (2011): community mental health teams, the presence of mental health professionals within the PHC system, a consultation–liaison system, collaborative care, stepped care and matched care. Finally, integration should be based on the 10 non-negotiable principles for integrating mental healthcare activities into the PHC system (Box 1), which were developed by WHO & WONCA (2008). More importantly, integration should not be considered an end goal, but a process that requires continuous improvement to achieve a better interface. Indeed, the endeavour is not to integrate entire mental healthcare programmes per se, but rather to integrate (some of) the constitutive activities of such programmes. That decision will necessarily depend on context.
Box 1. Ten principles for integrating mental health into primary health care
- Policy and plans need to incorporate primary care for mental health.
- Advocacy is required to shift attitudes and behaviour.
- Adequate training of primary care workers is required.
- Primary care tasks must be limited and doable.
- Specialist mental health professionals and facilities must be available to support primary care.
- Patients must have access to essential psychotropic medications in primary care.
- Integration is a process, not an event.
- A mental health service coordinator is crucial.
- Collaboration with other government non-health sectors, non-governmental organisations, village and community health workers and volunteers is required.
- Financial and human resources are needed.
Source: WHO & WONCA (2008).
In conclusion, suicide is an underreported, under-recognised and poorly managed public health problem in Cameroon, certainly in remote rural areas. Most people who committed suicide exhibited symptoms prior to their deaths; if their symptoms had been identified and properly treated, these deaths may have been avoided. This study points to the lack of adequate quality mental health care at the district level in Cameroon, which results from a lack of integrated mental healthcare activities within the PHC system. Physical and mental health problems are closely interconnected: it is therefore justified and efficient to foster an integrated approach to manage both physical and mental problems. Such an approach may help to reduce stigma and treatment delays, as well as to improve health outcomes, social integration and rehabilitation. All of these benefits may lead to more effective suicide prevention (WHO 2007) and enhance the credibility of Cameroon's healthcare delivery system.
