Cultural response to mental illness in Senegal: Reflections through patient companions—Part II....

~ Pergamon 0277-9536(95)00108-5 Soc. Sci. Med. Vol. 42. No. 3, pp. 325-338, 1996

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C U L T U R A L RESPONSE TO M E N T A L ILLNESS IN SENEGAL: REFLECTIONS T H R O U G H PATIENT

C O M P A N I O N S - - P A R T I. METHODS AND DESCRIPTIVE DATA

ROBERT R. FRANKLIN, t DOUDOU SARR,: MOMAR GUEYE, 30MA R SYLLA 3 and RENI~ COLLIGNON 4

~Tulane University School of Public Health and Tropical Medicine, 1430 Tulane Avenue, New Orleans, LA 71)112, U.S.A., 2H6pital Psychiatrique de Thiaroye, S~nfgal, 3Centre Hospitalier Universitaire de

Fann, Dakar, Senegal and ~Centre National de la Recherche Scientifique, Paris, France

ANtraet--Patient records from the Thiaroye mental hospital in Senegal were analyzed to see if the patterns of persons accompanying patients to the hospital could help portray the community's response to mental illness. A systematic sample of 935 records of initial out-patient visits were examined. Patterns of patient companionship were found to strongly correlate with specific patient sociodemographic and clinical characteristics. Interpretation of these findings helped to clarify both prevailing attitudes toward the mentally ill and the social response and management of mental illness. This article presents the study setting, methods, patient sociodemographic and clinical characteristics, and characteristics of patient companions. The second article in this series examines the statistical associations of companion number, gender and kinship relationship with patient sociodemographic and clinical characteristics.

Key words psychiatry, medical records, Africa, Senegal, culture, companions, health seeking behavior, social psychiatry

I N T R O D U C T I O N

Mental illness in Senegal is popularly believed to be caused by one of four invisible agents: witchcraft, sorcery, attacks by ancestral spirits, or attacks by genies [1-3]. Witches (dYmm in Wolof, the predominant local language) are thought to physically re- semble ordinary people but to have certain innate and compelling supernatural powers that make them attack others and devour certain internal organs. The attack is believed to take place on a psychic rather than physical level, thus leaving the victim's external appearance unchanged. Nonetheless such attacks are believed to cause a variety of morbidities including madness and eventually death [4]. Victims are thought to usually develop an abrupt and massive anguish with fear of imminent death, and frequently also exhibit pressured speech during which they may identify and accuse their attacker. While the belief in witchcraft may seem incredible from a modern per- spective, its importance to Senegalese society should not be underestimated. It is one of the more frequently cited causes for mental illness by patients on psychiatric wards.

Consistent with Evans-Pritchard's description of the Azande, sorcery, or magic, in Senegal (termed liggeey in Wolof, or maraboutage in local French) is believed to be different from witchcraft [5]. It is thought to be produced by ordinary human beings who have learned to cast spells by undergoing long

apprenticeships under magicians or through developing their own contacts in the spirit world. The services of these sorcerers are available for hire. Therefore whereas witchcraft is believed to take place directly between the witch and the victim, magic requires the interaction of three persons, the instigator who wants the magic performed, the magician whose services are for hire, and the victim.

There are various types of magicians throughout Senegal ranging from unorthodox quasi-Islamic leaders (marabouts in the non-orthodox sense of the word) who create magic using verses of the Koran, to more humble healers in rural areas who use plants and roots in addition to spirit helpers. Psychiatric patients often suspect the cause of their illness to be magic spells initiated by rivals in conflicts involving love, money, or professional activities.

Belief in magic is quite widespread in Senegal [6]. It is difficult to find anyone, even among the most highly educated groups, who does not partake in at least some magical practices. However most people admit only to defensive practices such as wearing charms (grigris) which deflect the spells back upon the sender, or taking baths with special powders to enhance one's luck on special occasions.

Belief in ancestral spirits (rab in Wolof, pangol in Serer) and performance of periodic rites honoring them are still important aspects of life in the more traditional and rural parts of Senegal [7, 8]. Since such beliefs are prohibited by Islam, the more

SSM 42/3~ 325

326 Robert R. Franklin et al.

strongly Islamic ethnic groups (especially Tukulor) and much of the male population in general appear to attribute mental illness to ancestral spirits less often than do others.

Ancestral spirits are believed to live invisibly in communities close to the area they inhabited while alive. Some are thought to monitor the activities of their descendants and to take offense at immoral behavior or failure to observe the customary rituals and offerings. Others are thought to spontaneously develop affection for certain living individuals and want to form close relationships with them. Since communications between the visible and invisible worlds are difficult, ancestral spirits are thought to produce madness in humans in attempt to have their presence recognized and ultimately have their wishes granted.

The existence of genies (jinn~) is accepted by all ethnic groups in Senegal and also by Islam. Accord- ing to local Islamic belief genies were created by God at the same moment as were humans, and have the potential for doing either good or evil, but with a propensity toward evil. They are believed to prefer living with their genie families in rural areas, often inhabiting particular trees or rock formations. While they are usually invisible, they sometimes can be seen, and because of their capricious and violent disposi- tions often produce madness in individuals who accidentally stumble upon them. Therefore madness of sudden onset, occurring during a walk through an unfamiliar countryside is usually believed to be caused by genies.

All four of these alleged causes of mental illness act invisibly through mysterious means. While in English one has a tendency to encompass all four forces within the term, 'invisible world', or 'spirit world', no such terms exist in Wolof or in the other local languages in Senegal. The closest term in Wolof is waxtu rab which literally means 'the hours that belong to the spirits'. This difference in terminology reveals a fundamental conceptual difference between the more modern societies and Senegal. For Ameri- cans and Europeans, the spirit world is most easily envisioned as separate and far removed from the human world. However for most Senegalese the two worlds are one and the same, and must be shared by both visible and invisible beings. There are, however, certain periods of day when the world is the proper domain of each. Just after noon, twilight, just after midnight and to a lesser extent at dawn, the world is reserved for the spirits. Humans must stay at home during these times or if not, expose themselves to possible aggression from the spiritual forces at large.

*The use here of the term companion should not be confused with the practice of having a relative or close friend stay with a patient during hospitalization. However this latter practice (which also frequently employs the term companion or accompagnant in French), is widely practiced in Senegal as well as many parts of sub-Saharan Africa (see Gbikpi [14]).

Following the onset of madness in an individual the first therapeutic step in Senegal is to identify which forces in the spirit world are responsible. A diviner is contacted whose skills and contacts with spirit colleagues permit him special knowledge of the spirit world. He identifies the forces causing the illness and also tries to determine the specific social dilemma or conflict which has ultimately led to the attack. Once the diagnosis has been established there are a variety of traditional healers to choose from, each specialized in treating illnesses due to specific causes. If after beginning a traditional treatment a cure is not soon forthcoming, this entire process is repeated, often using increasingly more distant, more famous, and more expensive healers.

Modern psychiatric care is the most culturally unfamiliar and hence intimidating therapeutic op- tion. It usually follows numerous unsuccessful visits to a variety of healers. Since the etiology of mental illness is viewed as originating in the social and spirit worlds, there is little faith that the drugs of modern medicine will ultimately resolve the problem. The resort to modern psychiatric care therefore often represents a quite extreme and desperate final measure which is taken following the exhaustion of traditional therapeutic networks and frequently also the exhaustion of the family's financial resources as well [9].

Throughout the entire therapeutic process the family plays a very important and central role. Con- cerned family members may assemble to decide how to deal with the problem. Similar to what Janzen describes among the Bakongo in Zaire, a sort of 'lay therapy managing group' may emerge and make logistic and financial decisions regarding the diagnosis and treatment of the illness throughout its course [10, 11]. During this process the patient assumes an entirely passive role and is held blameless by the community for his condition since it is believed to be caused by social and spiritual forces beyond his control [12]. The patient's family members fear the illness as if it were their problem and responsibility, fully believing that the forces responsible for the illness have a major potential to impact on their lives too [13, 3].

In Senegal the concept of family is largely based on lineage (i.e. a line of relatives that traces descent through parents, grandparents, etc. of only one sex). While most of Senegalese are predominantly patrilineal, there are ethnic groups in which matrilineality may also play an important role (e.g. Serer). There- fore, the families are quite extensive and include a much greater number and variety of relatives than found in most European or American families. Hence the constellation of family members involved in managing patient care can be quite variable. Since the resort to modern psychiatric care is usually considered an extreme measure, those persons accompanying patients to the mental hospital (henceforth called patient companions*) assume a particularly

Cultural response to mental illness in Senegal--Part I 327

important role. They are by definition those family members (1) particularly concerned with the patient's illness, and also (2) invested by the family with the responsibility to act on the patient's and family's best behalves both financially and logistically.

One method to better understand the social response to mental illness in Senegal is to study the characteristics of these patient companions and the correlations between their presence and certain sociodemographic and clinical characteristics of the patients. The current study examines the companions accompanying patients during their initial outpatient visit to the national mental hospital in Senegal, Thiaroye Psychiatric Hospital. It is based on medical records generated over a four-year period that include the number, gender and specific kinship relationship of all companions accompanying patients during their initial out-patient interviews.

The study results are presented in a series of two articles. This article, the first in the series, describes the study setting, methods, patient sociodemographic and clinical characteristics, followed by a description of the number, gender and specific kinship relationship of the patient companions. These data are interpreted in light of other socio-cultural data from Senegal as well as comparative statistics from other Sub-Saharan African countries and from the United States. The second article in the series explores the statistical associations between the number, gender, and specific kinship relationship of companions to the sociodemographic and clinical characteristics of the patients.

STUDY SETTING

Senegal is located at the western most point of sub-Saharan Africa (see Fig. 1). It has a population

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THE GAMBIA

ATLANTIC OCEAN

of about seven million people of which over one-fifth live in the region which includes the capital city, Dakar. The economy is essentially based on agricul- ture, however fishing and mining are also important. Senegal's political history has been typified by contin- ual political stability and democratic government since independence in 1960, an unusual record in comparison to most of Africa. Formerly the capital of the French West African colonial empire, the country has maintained strong ties to France. The official language is French, the local currency is supported by the Bank of France, and the government administration has been modeled after that of France.

Despite its stability, Senegal suffers from many of the same problems as other African countries: low per capita GNP ($630); low literacy rate (37% men, 19% women); high population growth rate (2.8%); and insufficient food production aggravated by poor soil conditions and limited rainfall. National statistics reflect the seriousness of the public health problems: the life expectancy is 48 years; the infant mortality rate is over 100 infant deaths per 1000 live births, the crude birth rate is 45 and contraceptive prevalence is only 12%. The physician to population ratio which is about 1 : 1"7,000 nationwide, is less than 1:100,000 in many regions, and the hospital bed per population ratio is less than 1:1200 nationally [15J8].

Modern psychiatric care is of fairly recent origin in Senegal. The ward at the University Teaching Hospi- tal (Farm) opened in 1956 followed by the opening of the Thiaroye Psychiatric Hospital in 1961. Under the direction of Professor Henri Collomb some of Africa's most creative psychiatric efforts took place in Senegal in the 1960's and 1970's. Families were intimately involved in patient care, patients activities were encouraged in many spheres including arts and

MAURITANIA

r SAINT LOUIS . F F " \ . . . . . -k, .,.....~ . .~

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MALl

ziGu~.-----c.o, '~ • ,o,oA ~.

GUINEA BISSAU GUINEA

Fig. 1. Map of Senegal.


crafts, collaborations were developed with traditional healers, and psychiatric villages were opened in rural areas. With subsequent changes and funding cuts, many of these activities were eliminated, but there remains in each psychiatric service an orientation towards family involvement (e.g. each patient is required to have an accompagnant stay with him full time in the hospital) and an openness to traditional medicine (e.g. no attempts are made to discourage patients from using traditional medical therapies while hospitalized).

There are currently twelve Senegalese psychiatrists practicing in the country. Nearly all of them work at the University Psychiatric Service or National Mental Hospital. There is also a psychiatric residency program, in operation since 1970, which produces between three and six psychiatrists per year, about half of whom are Senegalese and remain in Senegal.

Senegal has three psychiatric services, all of which are located in the region of Dakar: (1) Fann, the University Psychiatric Service, which contains 60 patient beds (and 60 companion beds) and which employs the great majority of psychiatric personnel, (2) a small psychiatric ward at a hospital adminis- tered by the French military (H6pital Principal), and (3) the Thiaroye Psychiatric Hospital where the present study was conducted. Thiaroye Hospital was originally created as an asylum to handle the overflow and more severe, chronic cases from the University Hospital [19]. Subsequently its role expanded to be much like that of the University Psychiatric Service. There are currently about 50 active patient beds (and 50 companion beds) and it is staffed by one to two psychiatrists, a psychiatric resident, and a limited numbers of nurses and social workers. Modern psychiatric care in the other regions of the country is limited to occasional rural practicums by psychiatric residents and three small psychiatric villages which are staffed by nurses or aids with little or no psychiatric training or supervision.

METHODS

The population from which the sample was drawn consisted of patients consulting for the first time at Thiaroye Hospital as outpatients during the period December 1984 through December 1988. Only those patients seen by one of the authors (D.S.) in his capacity as staff psychiatrist and Medical Director of Thiaroye were included in the study. It was decided to limit the study to patients seen by him in order to maximize standardization and reliability of the data collected. Patients were brought to him in rotation with the other one to two psychiatrists on duty with no system of priority or other apparent source of selection bias. A 50% systematic sample of medical records written during these visits was selected for the study sample. Record loss was estimated at less than 1%.

Variables systematically recorded on the medical records that were analyzed in this study included: name, date of consultation, age, sex, profession, permanent residence, marital status, number of children, presence or absence of nine specific signs and symptoms (delusions, auditory hallucinations, visual hallucinations, agitation, psychomotor retardation/catatonia, pressured speech, mutism, insomnia, and loss of appetite), time interval between first psychiatric signs or symptoms and date of consultation, preliminary disgnosis, and the number, gender and kinship relationships of all persons accompanying the patient during the visit to the hospital.

For purposes of data analysis date of consultation was categorized in several ways: by year, by season (rainy, harvest, or dry), by month, and by week (first, second, third, or fourth and later of each month). Permanent residence was categorized in two ways: by administrative region of the country and by urban (30,000 or more inhabitants) vs rural. Distance from permanent residence of the patient to the hospital was added as a variable. It was calculated based on distance from the city nearest the permanent residence to Thiaroye Hospital using a map of Senegal.

Age was collected in years. Subsequent analyses showed mild value heaping for ages that were mul- tiples of five and ten years beginning at 20 years of age and becoming severe at 50 years of age. Age was regrouped in ten year categories for further analyses. Ethnic group was not collected on the medical records at the time of patient visit. However it was approximated retrospectively based solely on known associations of names with major ethnic groups. Profession was determined at time of interview based on the patient's previous training and experience whether or not the patient was currently employed.

Inquiries were made concerning the presence or absence of auditory or visual hallucinations and also difficulties relating to eating or sleeping. Patients were also examined for signs of agitation, delusions, pressured speech, mutism and psychomotor retardation/catatonia. If these signs were not present at the time of the examination the companions were systematically questioned concerning their possible earlier appearance. If there were strong positive his- tories of such behavior, the signs were recorded as positive. The time interval between the onset of first psychiatric signs or symptoms and first modern psychiatric visit was recorded whether or not that visit was made to Thiaroye Hospital.

Principle preliminary diagnosis was recorded at time of patient visit. In some cases (only possible for patients hospitalized or seen for follow-up visits) this diagnosis was subsequently modified. Diagnoses were regrouped for data analysis in two ways: (1) into one of the following broad diagnostic categories: non- organic psychoses, affective disorders, epilepsy, neuroses and related diagnoses, substance abuse, and other (including non-psychiatric medical problems, mental retardation, and dementia), and (2)

Cultural response to mental illness in Senegal--Part 1 329

psychotic (including organic psychoses, temporary psychotic states and chronic non-organic psychoses) vs non-psychotic.

Information was systematically recorded concerning each of the patient 's companions (the persons accompanying him during his initial out-patient visit to the hospital). The information collected included gender and specific kinship or non-kinship relationship to the patient. These data were analyzed by: number of companions present, their sex, and their specific kinship relationship to patient (e.g. maternal uncle). Due to the use of a multiple response data collection format for the companion variables, it was possible to study whether certain characteristics were present lbr ~any' vs "all" of the companions (e.g. "Were all of the patient's companions male?'" vs "Were any of the patient 's companions male?").

Medical records for each patient were originally handwritten on one or more 5" x 8" cards. All data were subsequently transcribed to numeric form on coding sheets by D.S. (who had originally recorded all of the data) and then keyed in for computer analysis. Data processing was accomplished using SPSS/PC + V3.1 software. All comparison of proportions were tested fOE statistical significance using the raw Z: statistic or Fisher's exact test. Due to the large number of these analyses, only the P-values are reported in the text. Multivariable associations were analyzed using multiple logistic regression analysis. The backward elimination method was employed using independent variables found to be significant in the contingency tables.

When interpreting results of record studies from mental health facilities, it is important to bear in mind that the data always reflect the influence of two separate but interacting lbrces in the population: (1) the [¥equency (i.e. incidence and prevalence) of mental diseases, and (2) the utilization rates of the facility by the affected population. In studies of this type it is not possible to know the exact role played by each of these forces in any particular instance. Also since the data includes only patients presenting at Thiaroye Hospital, no information is available on how these patients differ from those using only traditional healers and medicine, or how the decisions to use modern medical treatment were made. Unfortunately, there are no data from epidemiologic field studies of these factors yet available, ttowever, based on available ethnographic data from Senegal, certain assumptions can be made that will assist us in interpretation of the results.

While the major objective of this article is to study the companions accompanying patients during their initial visits to Thiaroye Psychiatric Hospital, an examination of the sociodemographic and clinical characteristics of the patients themselves is useful in order to better understand the clinical setting. There- fore these descriptions will be presented first along with comparative statistics from other sub-Saharan African countries and from the United States and

interpretations in light of certain socio-cultural data from Senegal.

RESULTS; AND INTERPRETATION

Sociodemographic characteristics of patie ts--Results

The study sample included 935 patients. Approxi- mately two-thirds (63.5%) of the patients were male and one-third female (see Table 1). The ages ranged from 4 to 84 years with a mean of 28 years. Almost half (46.6%) of the patients were between the ages of 20 and 29 years and over 80% were between the ages of 10 and 39 years.

The distribution of patients by age differed by sex (see Fig. 2). Over half of the males were in their third decade of life (52.6%) compared to approximately one-third (36.3%) of the females (P < 0.0001). Over a quarter of the females (25.7%) were less than 20 years of age compared to one-sixth (16.5%) of the males (P < 0.0001).

In comparison with the recently released 10% sample of the 1988 Senegalese national census, it is clear that lhese age and sex distributions are not at all representative of the general population [18]. As in most developing countries, the census showed the majority (57.7%) of Senegalese to be less than 20 years of age and only 15.8% between the ages of 20 and 29 years. Similarly the sex distribution of the sample differed markedly from that found in the census in which the sex distribution was approximately equal both globally (48.7% male: 51.3% female) and when stratified by age for all but the oldest age groups.

The distribution of marital status by sex is given in Table 2. ]-'he majority of the study population was single (57.7%), while 25.3% were in monogamous marriages, and 9.5% in polygamous marriages. At first glance the differences in marital status between the sexes is striking. The percentage of males that were single (73.4%) was found to be over twice that for females (33.6%) (P <0.0001). However, after stratifying by age and comparing the study sample to the Senegalese national census, the only significant differences in marital status by gender were that the study sample had: (1) a higher percentage of single males for the age groups 20-29 (84.0% vs 70.3%) and 30-39 (45.9% vs 20.1%) (P < 0.0001), (2) a consistently lower percentage of women in polygamous marriages in each age group (P <0.01) (however,

Table 1. Distribution of patients by gender and age group, N = 928 Age Males Females Total Cumulative group 'f °0 N % N % % 0-9 3 2.2 7 2.1 20 2,2 2.2

10 19 84 14.3 80 23.6 164 17.7 19.9 20 29 30 52.6 123 36.3 433 466 66.5 30-39 125 21.2 50 14.7 175 189 85.4 40-49 23 3.9 33 9.7 56 6.0 91.4 50-59 14 2.4 26 7.7 40 4.3 95.7 60+ 20 3.4 20 5.9 40 4.3 100.0 Total 589 63.5 339 36.5 928 100.0


P E R C E N T A G E OF PATIENTS 6 0 r

5 0

4 0

3 0

2 0

10

0 0 - 9 10 - 19 2 0 - 29 ' 3 0 - 39 4 0 - 49 60 AND ABOVE

AGE GROUP IN YEARS

F E M A L E S

Fig. 2. Distribution of patients by gender and age group.

sample sizes were too small for statistical significance in age groups 40 years and above); and (3) a tendency (not statistically significant) toward more females in monogamous marriages. About two-thirds of the patient population had one or more children.

Regarding ethnicity, 83.7% of the patients were from one of three ethnic groups: (Wolof (45.1%), Tukulor/Peul (24.4%) or Serer (14.2%). No other ethnic group accounted for more than 6% of the sample. This distribution by ethnic group closely resembled that found in the Senegalese national c e n s u s .

The distribution of patients by profession and sex is given in Table 3. Over 40% of the men were unemployed, approximately one quarter were blue collar workers, and another quarter farmers, fisherman, or herders. For women the percentage unemployed was nearly four-fifths (P < 0.0001) and of those working the great majority were farmers.

Both the capital city, Dakar, and Thiaroye, the community in which the hospital is situated, are located in the region of Dakar. Over half (58.2%) of the sample lived in the region of Dakar compared to 21.6% of the national census (P < 0.0001). The only geographically contiguous region to Dakar, Thi4s (see Fig. 1), accounted for 15.9% of the sample, and no other region accounted for more than 6% of the study sample. The percentage of patients from urban areas in the sample (71.9%) was much higher than that found in the national census (39.4%) (P <0.0001). This was also true when considering only regions outside of Dakar.

The distance traveled by patients from their residences to Thiaroye hospital for consultation varied from 0 (residents of Thiaroye) to 698 km with a mean of 81 and a median of 18 km. These figures excluded the four patients with permanent residences in other countries. The percentage of patients in the study sample decreased with increasing distance from the hospital. Only about a quarter (26.5%) came from

farther than 100 km, and less than 10% from farther than 200 km.

In terpretation

Males consulted at Thiaroye nearly twice as frequently as females. Both past and recent studies of sub-Saharan African psychiatric in-patients and (although less numerous) out-patients consistently show a predominance of males, usually representing about two-thirds of all patients (range: 56-77%) [20 31]. Comparison of figures from the United States are quite different. Based on a national survey of all types of organized mental health settings, admission rates to organized out-patient mental health programs are approximately equal for men and women (52.5% vs 47.5%). Based on data from the National Health Survey, visits to office-based psychiatrists show a predominance of women over men (59.4% vs 40.6%). However, men predominate over women in admission rates for hospitalized patients to organized mental health programs by about 15% (57.3% vs 42.7%) [32, 33].

The predominance of men as psychiatric patients in Africa could theoretically be due to either increased frequency of mental diseases among males or increased utilization of psychiatric services by males. While the relative influence of each cannot be pre- cisely determined with these data, the major influence

Table 2. Distribution of patients by marital status and sex, N = 748

Marital Males Females Total Cumulative status N % N % N % %

Single 333 73.4 99 33.6 432 57.7 57.7 Monogamous

marriage 79 17.4 I10 37.3 189 25.3 83.0 Polygamous

marriage 21 4.6 50 17.0 71 9.5 92.5 Widowed 15 3.3 26 8.8 41 5.5 98.0 Divorced 6 1.3 9 3.3 15 2.0 100.0 Total 454 60.7 294 39.3 748 100.0

Cultural response to mental illness in Senegal--Part 1

Table 3. Distribution of patients by profession and sex, N = 716 Males Females Total

PI ofession ~¢" % % N % °4 %

Unemployed No profession 145 33.0 Student 34 7.8

Salaried worker Blue collar

worker 109 24.9 Other 24 5.5

N on-salaried Farmer, herder

or fisherman 103 23.5 Other 23 5.3

Total 438 100.0

40.8 78.8 55.5 206 74. I

13 4.7 30.4 3.3 19.8

6 2.2 3 I.I

28.8 17.9 24.7

46 16.5 4 1.4

100.0 278 100.0 100.0 100.0

331

in Senegal is probably a higher utilization rate by males. Men in Senegal are more educated, more literate, and more fluent in French than women, thus favoring their interface with the modern medical system. Their social roles also allow them to travel more readily and emphasize the importance of them staying healthy since they are usually the primary financial support for the family. In addition, the importance of Senegalese women in the daily social support of the family cannot be underestimated. Their duties are sufficiently all encompassing that they rarely leave the homestead except in the case of dire emergency.

Data from other sub-Saharan African studies consistently shows a predominance of young adults among psychiatric patients. Most studies report about 40% (range 37-47%) of all patients to be between the ages of 20 and 30 years and mean ages of patients to be in the low 30's [20, 22-24, 26, 28, 29, 31, 34-36].

By regrouping the Thiaroye data on age it was possible to compare them with United States figures. The proportion of Thiaroye patients less than 25 years of age (42.2%) was higher than that for both American psychiatric in-patients (20.6%) and out- patients seeing private psychiatrists (14.2%), but approximately the same as United States out-patients in organized mental health programs (39.9%) [32, 331.

Part of the explanation for the younger ages of patients at Thiaroye may be explained by the major changes and consequent levels of stress associated with passing from childhood to adulthood in Senegal. While the importance of individuality and the associated burden of responsibility during childhood is probably greater in the U.S. than in Senegal, the change in these factors when passing from childhood into adulthood is clearly more abrupt and probably more traumatic in Senegal. The high relative proportions of males aged 20-29 in the sample (over half) may reflect the emotional stresses inherent at this stage of life involving attempts at securing em- ployment in the face of high national unemployment rates and financial constraints prohibiting marriage.

The relative increase in proportion of women aged 10-19 compared to men may reflect the stresses

inherent in adolescence for women and the conflicts with their families regarding their behavior (especially sexual). The earlier marriage age for women in Senegal and the associated stresses of becoming mothers, housewives and usually geographically relo- cating to the residences of their husband's parents (i.e. patrilocality) must also play a role. The decreased percentage of women patients in the sample in polygamous marriages as compared to the national census probably reflects the decreased utilization of modern psychiatric care by more traditional women. Since polygamy is notorious for producing conflict and stress lbr the women involved, one might expect to have a higher percentage of women in polygamous marriages if hospital utilization rates were comparable.

The finding of an inverse relationship between distance of residence from Thiaroye Hospital and percentage of patients in the sample has also been found consistently in studies in the U.S. and Europe [37]. In Senegal it probably reflects a combination of financial constraints, social obligations, and hesi- tancy to use modern medical care to treat problems viewed as non-medical in origin particularly by the more distant, rural and traditional inhabitants.

It was surprising that the ethnic distribution of patients was nearly identical to that found in the population census, particularly in light of the cultural diversity of ethnic groups and their varied geographic distribution. However, earlier studies at the Univer- sity Hospital psychiatric service in Senegal also showed ethnic distributions of patients similar to that of the general population [20, 24]. These data increase our confidence in the ethnic group data which were approximated retrospectively rather than determined at the time of patient visit (see Methods).

A comparison can also be made between the patient characteristics of Thiaroye Psychiatric Hospi- tal and the other major psychiatric service in Senegal, Fann, at the University Hospital using the study of Ndiaye [20]. The two populations were found to be quite similar and to differ by less than 5% for gender (male: Thiaroye 63.5% vs Fann 67.5%), age (ages 20-29: 46.6% vs 47.2%), marital status (single: 57.7% vs 60.4%), and ethnic group (Wolof: 45.1% vs 49.5%). The two populations, however, did differ


Table 4. Distribution of patients by broad diagnostic categories, N = 930

Diagnostic categories N % %

Non-organic psychoses 35.8 Schizophrenia

or schizophreniform 279 30.0 Miscellaneous 54 5.8

Epilepsy 150 16.1 Substance abuse 13.8

With psychosis 97 10.5 Without psychosis 28 3.0 Chronic alcoholism 3 0.3

Neuroses and related disorders 108 11.6

Affective disorders 7.6 Depression 63 6.7 Mania 8 0.9

Other and medical problems 15.1 Dementia 16 1.7 Mental retardation 24 2.6 Non-psychiatric

medical problems 100 10.8 Total 930 100.0

more by geographic residence (Dakar Region: 58.2% vs 67.7%; Thies Region: 15.9% vs 9.2%) which is consistent with their geographic locations [20].

Clinical characteristics of patients--Results

Preliminary diagnoses were regrouped into six broad categories for analysis (see Table 4). Non- organic psychoses accounted for over one-third of all diagnoses, and of those, schizophrenia or schizophreniform disorders formed the great majority. The next most frequent diagnoses were epilepsy (16.1%) followed by substance abuse (13.8%) of which the portion due to chronic alcoholism was negligible. Neuroses and related disorders, and non- psychotic affective disorders formed only 11.6% and 7.6% respectively. While mental retardation and dementia were rarely present, non-psychiatric medical problems were frequently seen (10.8%).

Nearly half (48.7%) of the patients coming for consultation were psychotic. Patients were also categorized by the presence or absence of nine specific signs and symptoms (see Table 5). Noteworthy were the high frequency of severe signs and symptoms. Delusions were present in just over half of the patients (51.5%), and auditory and visual hallucinations in 29.4% and 22.5% respectively.

The time interval between onset of first psychiatric signs or symptoms and consultation at Thiaroye Hospital (or other modern psychiatric facility) is

Table 5. Frequency of specific signs and symptoms

Sign or symptom present N % Total

Insomnia 513 63.8 804 Delusions 461 51.5 895 Decreased appetite 264 39.6 667 Auditory hallucinations 224 29.4 762 Agitation 242 26.4 915 Visual hallucinations 168 22.5 747 Pressured speech 156 17.1 913 Psychomotor retardation,/

catatonia 64 7.0 914 Mutism 50 5.5 916

Table 6. Interval between onset of first psychiatric signs or symptoms and first consultation at a modern psychi-

atric facility, N = 772

Cumulative Interval N % %

Less than I month 162 21.0 21.0 1 5 months 173 22.4 43.4 611 months 64 8.3 51.7 I 4yr 228 29.5 81.2 5 9 yr 75 9.7 90.9

l0 18yr 70 9. I 100.0 Total 772 100.0

shown in Table 6. The time interval ranged from consultation the same day that signs or symptoms first appeared to consultation 25 years later. The mean time was 2.6 years and the median time was 9 months. Almost half (48.3%) of the patients waited a year or longer before seeking modern psychiatric care, and nearly one out of five (18.8%) waited 5 years or longer. The rate of hospitalization following consultation was 18.8% for the study sample.

Patients were also analyzed by the number of severe signs and symptoms which they demonstrated among the following seven: visual hallucinations, auditory hallucinations, delusions, agitation, pressured speech, mutism, and psychomotor retardation/catatonia. The number of these symptoms ranged from zero to six with a median value of one; about 30% of the patients had three or more.

Interpretation

In view of the fact that this patient population was being seen for initial interviews, the proportion of patients with severe clinical conditions is impressive. Approximately half were psychotic and over a third had non-organic psychoses. While there are few comparativc studies in sub-Saharan Africa of initial out-patient visits to psychiatric facilities, most also tend to find over half the patients to be psychotic [20, 21, 27, 31,38, 39].

While there are some important differences between the strongly French influenced nosographic scheme used in Senegal and the United States' DSM- HI-R, it is still possible to compare certain broad categories of disease between the countries. The distribution of diagnoses in the study sample was different in several ways from that found in the United States. While affective disorders are a major component of American private psychiatric practice (35.5%), hospitalized psychiatric care (30.8%), and to a lesser extent organized psychiatric out-patient programs (14.4%), they were conspicuously less numerous in the study population (7.6%) [32, 33]. Low proportions of patients with affective disorders have also been reported in most sub-Saharan African studies whether of out-patients or in-patients: out- patients range--Nigeria (7%, 16%), Senegal (14%); in-patients--Nigeria (3%, 6%, 16%), Swaziland (8%), South Africa (16%), Nigeria (16%) [20,25,27,30, 31,40-42]. However there are also exceptions: Nigeria (33%), Mall (42%) [28, 29].


Jegede from Nigeria has reviewed the low percentages of depressed patients in most African studies and feels that they underestimate the true prevalence of the disease partly due to missed diagnoses due to the frequent somatic nature of symptoms [43]. Both Prince and Binitie in reviewing the literature show much higher rates of depression beginning after 1957, around the time of independence for most African countries. They suggest the possibility of bias for earlier years due to prevailing colonial attitudes along with different symptomatology and different social response, and but also the possibility of true increases in the rates of affective disorders in the population for more recent years [44,45]. In Senegal depressed patients pose fewer problems for the family than do agitated and aggressive ones and thus are more easily accepted and integrated into the home despite their condition. Therefore, the smaller numbers of depressed patients at Thiaroyc hospital may represent a selection bias against use of modern psychiatric care for these patients.

Due to the strong Islamic influence in Senegal and the consequent prohibition against alcohol, alcohol related problems were rarely seen at Thiaroye and are rarely seen in the society in general. In comparison alcohol related diagnoses in the United States represent important percentages of both in-patient and out-patient mental health programs (14.8% and 9.5% respectively) [32, 33].

Other psychoactive substances abuse is just emerg- ing as a major problem in Senegal [46]. The drugs most commonly involved are Cannabis satit'a (locally called ycamba), to a much lesser extent certain pre- scription drugs (especially valium and barbiturates), and some naturally growing hallucinogenic plants. Heroin and cocaine use is still rare. However 13.5% of the Thiaroye consultations had diagnoses of non- alcoholic substance abuse diagnoses which is more than the percentages seen in in-patient and out- patient mental health programs in the United States (6.6% and 3.1% respectively) [32, 33]. Part of the explanation for these differences may lie in the fact that while Senegalese consider most psychiatric problems to be best handled by traditional medicine, they consider drug problems to be of modern origin and thus best treated by modern medicine. Therefore there is probably a selection bias in the data in favor of patients with substance abuse over other diagnoses. Another factor is that there are no specialized agencies to deal with drug abuse problems in Senegal as there are in the U.S., thus increasing the proportion of drug abuse cases that seek psychiatric care in comparison with the U.S.

Together, non-psychiatric medical problems and epilepsy were the primary diagnosis for over one- quarter (26.9%) of the patients. While in the United States neither of these diagnoses are regularly treated in psychiatric institutions, in Senegal the shortage of modern medical care forces physicians to retain their more general medical skills in addition to their psy-

chiatric ones. Interestingly on further analysis it was found that the percentage of patients with non-psychiatric medical problems did not vary much for those residing in the Dakar region in which the hospital is located vs in the other regions (11.7% vs 8.4%).

A further comparison can now be made between the diagnoses of patients seen at the Thiaroye Psychi- atric Hospital and at Fann. In the study by Ndiaye at Fann, there were no patients with primary non- psychiatric medical diagnoses vs 10.8% at Thiaroye. Also the percentage of patients at Farm with a primary diagnosis of epilepsy was smaller (6.0% vs 16.0%). Both these findings are consistent with the greater availability of other medical specialties at Fann, a university medical center. Percentages of most other clinical diagnoses were relatively similar between the two institutions: substance abuse (Thiaroye 13.8% vs Fann 15.5%), affective disorders (7.6% vs 11.2%), dementia and mental retardation (4.2% vs 3./)%), and neuroses and related disorders (11.6% vs 4.2%). Because of the different diagnostic categories used in Ndiaye's study it is not possible to compare 1he percentages of schizophrenia and other non-organic psychoses. Overall, however, the clinical pictures are generally similar among the two institutions [20].

Popular opinion in Senegal draws no tirm distinc- tion between epilepsy and psychiatric illnesses. Both are seen as causing uncontrolled behavior. Epilepsy is popularly believed to be caused by the same forces m the spirit world that cause other psychiatric disorders. It may be that Senegalese are more committed to seeking traditional medical cures for epilepsy than for psychiatric illnesses. The percentage of patients wait- ing 5 years or longer among epileptics was 41.9% vs 14.2% for all other diagnoses (P < 0.0001). Unfortu- nately, epilepsy is also popularly considered to be communicable through contact with the saliva or other bodily fluids. This misconception relegates most epileptics lo a very lonely life in which they usually eat alone, sleep apart from others, and have little opportunily to marrv.

In countries such as Senegal with limited availability of psychiatric care, psychiatric patients with primary diagnoses of neuroses and related problems are much less frequently seen than in American out-patient psychiatric practices. Due to the patient load, shortage of psychiatrists, and the population's lack of familiarity with modern psychiatric care, extended psychotherapy is rarely undertaken.

Perhaps the most remarkable clinical finding in view of the severity of the diseases encountered is the long time interval for most patients between first psychiatric signs or symptoms and presentation at Thiaroye. These intervals certainly emphasize the importance of traditional medicine for the population. Most patients see a variety of traditional healers prior to trying modern psychiatric care. The authors have recently finished collecting data in a


Table 7. Distribution of patients by number of companions, N =910

Cumulative Number of companions N % %

None 34 3.7 3.7 One 428 47.1 50.8 Two 307 33.7 84.5 Three 108 11.9 96.4 Four 31 3.4 99.8 Five 2 0.2 100.0 Total 910 100.0

Table 9. Number of companions per patient by gender of companions, N = 818

Number of companions

Male companions Female companions N % N %

None 175 21.4 511 62.5 One 410 50.1 271 33. I Two 179 21.9 32 3.9 Three 46 5.6 4 0.5 Four 8 1.0 0 0 Total 818 t 00.0 818 100.0

field study which should clarify this process. Data collectors were sent to the homes of psychotic patients to elicit complete information concerning all traditional healers seen both prior to and after presentation for modern psychiatric care.

It is noteworthy to again compare Thiaroye and Fann for time intervals between disease onset and consultation for patients. Recalculating the Ndiaye's Fann data to eliminate missing values, it is found that the two distributions are quite similar with none of the categories varying by more than 5%: less than 1 month (Thiaroye 21.0% vs Fann 25.8%), 1-11 months (30.7% vs 34.0%), 1-4 years (29.5% vs 24.3%), 5-9 years (9.7% vs 7.2%), and 10 years or more (9.1% vs 8.6%) (P <0.05). These data are again consistent with the use of Thiaroye as a general mental health care facility rather like Fann rather that predominantly as an asylum.

Characteristics of companions--Results

Out of the total of 935 patient records, 910 (97.3 %) had information recorded concerning the companions accompanying them on their initial out-patient visit to Thiaroye Psychiatric Hospital. The number of companions ranged from zero to five (see Table 7). Only 34 (3.7%) of the 910 patients were not accompanied by someone. Approximately half (47.0%) of the patients had one companion, and approximately a third had two companions. Only 3.6% had four or more companions. There were a total of 1500 companions for the 910 patients.

The gender of the companions is shown in a variety of ways in Table 8 for those patients in which companion gender was known. The great majority of patients had at least one male companion (78.6%) and this percentage was over twice the percentage of patients with at least one female companion (37.5%) (P < 0.0001). Although not shown in this table, the distribution of all companions by gender (73.0% male vs 27.0% female) (P < 0.0001) was also largely

Table 8. Distribution of patients by gender of their companions

Number and percentage of patients with companions, N = 818

Gender of companions N %

At least one male 643 78.6 Only male 477 58.3 At least one female 307 37.5 Only female 141 17.2 Both male & female 166 20.3

predominated by males. The percentage of patients with exclusively male companions was over three times as high as those with exclusively female companions (58.3% vs 17.2%) (P < 0.0001). The percentage of patients with companions of both genders was approximately equal to the percentage with only female companions (20.3% vs 17.2%).

Of patients with two or more companions, a female companion was present in about half (48.8%) of the cases. The relationship between number of companions and companion gender is shown in Table 9. While over a quarter (28.5%) of the patients had two or more male companions, patients rarely had two or more female companions present (4.5%) (P < 0.0001).

Those relationships of companions that were present with a frequency of at least 2% are shown in Table 10. The first and second numeric columns of this table represent the number and percentage of patients with at least one companion of the indicated relationship (i.e. percentages arc calculated using the total number of patients, 910, in the denominator). The third and fourth numeric columns show the number and percentage of all companions which were in this relationship to a patient (i.e. percentages were calculated using the total number of companions, 1500, in the denominator).

The most frequent relatives to accompany patients to the hospital were father or mother, each being present about one-fifth of the time. The next most frequent categories were maternal uncle (i.e. mother's brother--14.9%), older brother (with both parents

Table 10. Distribution of patients by relationship of companions. Total number of patients = 910; total number of companions = 1500

Patients Companions Relationship of companions N % N %

Father 185 20.3 185 12.3 Mother 174 19.1 174 11.6 Uncle (maternal) 136 14.9 148 9.9 Older brother (same parents) 129 14.2 141 9.4 Male cousin (maternal) 105 11.5 111 7.4 Husband 65 7. I 65 4.3 Uncle (paternal) 53 5.8 58 3.9 Male friend or neighbor 52 5.7 58 3.9 Older sister (same parents) 51 5.6 52 3.5 Younger brother (same parents) 35 3.8 35 2.3 Son 33 3.6 35 2.3 Male cousin (paternal) 30 3.3 32 2.1 Brother-in-law 29 3.2 30 2.0 Nephew 28 3. I 28 1.9 Aunt (maternal) 23 2.5 24 1.6 Police, Fire, other official 21 2.3 22 1.5 Daughter 20 2.2 21 1.4 Grandfather (paternal) 18 2.0 19 1.3

Cultural response to mental illness in Senegal--Part I 335

identical to the patient's parents--14.2%), and male maternal cousin (i.e. mother's sibling's son--11.5%). All other kinship relationships were present about 7% of the time or less. It is interesting to note that numeric columns 1 and 3 differed by 5% or more only for uncles (maternal and paternal), older brothers (same parents), male cousins (maternal), and male friends or neighbors, indicating that only these relatives had any tendency to accompany patients in multiple numbers.

This table further underlines the predominance of male companions. Other than the category of mother, the most frequent female relative, older sister (with both parents same as patient's), was present only 5.6% of the time. Of the eighteen categories with a frequency of 2%, only four of them were female.

Relatives formed the great majority (87.2%) of companions. Consanguine (i.e. blood) relatives were much more frequently represented (78.3%) than affines (i.e. spouses and in-laws) (8.9) (P = 0.0001), and nuclear relatives (i.e. parents, siblings, children) accounted for about half (55.4%) of the consanguine relatives. When companions were studied by whether they were matrilineally vs patrilineally related to the patient, it was found that matrilineal and patrilineal relatives were present with about equal frequency (53.6% and 48.4% respectively).*

Approximately half of the affines were husbands. If the patient was female and married, husbands were present 40.6°/'o of the time. However, if the patient was male and married, wives were present only 9.0% of the time (P < 0.0001). Despite the fact that there were 50 female patients in polygamous marriages, there was not a single instance of a co-wife being present as a companion.

Friends and neighbors of either sex were present as companions only 6.3% of the time and represented only 4.2% of all companions. Male friends or neighbors were more often present than females (5.7% vs 0.6% respectively). It is interesting to note that government employees designated to deal with emergencies (e.g. police, fire department, etc.) were companions for only 2.3% of the patients and represented only 1.5% of the total number of companions. Of the patients accompanied by government officials, 65% were psychotic and 15% had non- psychiatric medical problems.

Of the patients who had companions that were relatives. 10.1% did not fall into one of the coded relationship categories. These accounted for 7.1% of the total number of companions. Examples of such

*It was not possible to determine the lineage for a small percentage of companions since not enough information was collected. For example even though a companion was recorded as a male maternal cousin, he would be part of the matrilineage only if he were the patient's mother's sister's son but not if he were the patient's mother's brother's son. Therefore the total number of companions who were identified as members of patients' matrilineage or patrilineages is slightly underestimated.

companions included: friends of relatives, colleagues from work, more distant relatives, religious leaders, and health personnel.

Interpretation

The characteristics of the persons accompanying patients to Thiaroye Psychiatric Hospital help to bring to light many of the underlying values and principles which govern the response to mental illness in Senegalese society. Since the data just presented are descriptive, the interpretations to follow will be general in nature, stressing their correspondence to known ethnographic information from Senegal. The second article in this series will more rigorously examine factors predicting type of patient companions by looking at statistical associations among socio-demographic and clinical characteristics of paeients and their companions.

Social isolation is almost unknown in Senegal. Consequently it was not surprising that few of the patients coming to Thiaroye were not accompanied by anyone, and half by two or more companions. The great majority of these companions were relatives.

In Senegal the solidarity of the family is considered higher priority than in most modern industrialized socieites which tend to stress individualism. It is therefore not surprising that the appearance of mental illness is treated as a family emergency. Family members come together to reorganize and redis- tribute social responsibilities that can no longer be carried out by the affected member. Important financial, logistical and therapeutic decisions are made for the individual as they become necessary. Since many of these decisions must be made at the time of psychiatric consultation, often far from the patient's home, the ~persons accompanying the patient to the hospital art," invested with the power to make them.

The role of companion appears to be predominantly a male duty. Nearly 80% of patients had at least one male companion vs only about a third with a female companion, and over half of the patients with a female companion also had a male companion. The presence of more than one female companion was very rare, but over a quarter of patients had two or more male companions.

It is not surprising to find that in a patient population as clinically severe as those seen at Thiaroye (e.g. half psychotic) that frequently two or more companions were present, and usually males. In Senegal males play the more active role in decision making because of their dominant role in family finances, greater degree of education, and hence greater case of interface with the modern medical care system. In addition, severely compromised mental patients may necessitate physical restraint requiring the physical strength of males.

The data on the specific relationships (kinship or other) of companions to patients bring to light several fundamental principles of Senegalese culture: (1) if available, ~-elatives nearly always took responsibility


for a family member's welfare; (2) consanguine relatives took such responsibility much more frequently than affines; (3) among consanguine relatives, nuclear ones were involved about half the time; and (4) matrilineal relatives took such responsibility at least as often as patrilineal ones.

Only rarely was there not a family member present as a patient's companion. Whereas in more urban, industrialized societies relationships with friends or neighbors might take precedence in times of stress, in the study sample they represented only 4% of total companions. Similarly, law enforcement and emergency personnel designated to promote safety and welfare and who play a major role in dealing with mental patients in emergency situations in the United States were present less than 3% of the time in the study sample.

Among family members, consanguine relatives were much more often present than affines. While relationships with in-laws often involve conflict in Senegal as they do in the United States, it is surprising that spouses did not play a more active role. Less than half of the husbands, and less than 10% of the wives accompanied their spouses to the hospital. Certainly, part of the explanation lies in the important role of the women in the household and of men in interfacing with the modern medical care system. Moreover, it has been frequently observed by the hospital staff that following the initial consultation if husbands are hospitalized, wives come to stay with them in the hospital much more often than do husbands if the wives are hospitalized.

However, part of the explanation also lies the principles of family alliance and bride wealth. Mar- riage in Senegal, as in much of sub-Saharan Africa, still often retains the property of being an alliance between families. There are exogamy rules for marriages and some marriages are still arranged by the families without the future spouses even having met each other. In some ways marriage can be viewed as a contrast between two distinct consanguine groups (lineages). Since the principle of patrilocality (i.e. the wife when married goes to live with the husband among his relatives) is observed by most ethnic groups in Senegal, part of the contract involves one group (the wife's family) loaning one of its members (the wife) to the other group (the husband's family) in return for certain goods and services (i.e. the principle of bride wealth) [47]. Implicit in the arrangement is that the wife will be providing the husband's family with certain services (e.g. child bearing, child raising, housekeeping, assistance with food production, etc.). However, when mental illness prohibits a wife from carrying out these duties, the contract in a sense is no longer valid and the wife's family must take responsibility for her until she can again function well enough for the contract to be operational. In the case of a mentally ill husband, his family must take responsibility, but since he is already living among them, this

often requires fewer overall changes in the family structure.

Among consanguine relatives the study data show that: (1) nuclear relatives were present about half the time, and (2) matrilineal companions were present as often as patrilineal ones. The first concept seems quite logical for most societies, including the United States. Clearly, the nuclear family unit is the closest emotion- ally and the most interdependent economically. The parent-child bond is an extremely intense one and it is not surprising that parents are the most frequent companions for their children. While there are often siblings present in a family who are children of co-spouses (i.e. half-siblings), they were rarely present as patient companions, probably reflecting their relative emotional distance compared to siblings of the same two parents and the inherent rivalries in these relationships. The absence of a single co-wife as a patient companion certainly reflects the common rivalry among co-wives. It is often observed clinically that women of polygamous marriages frequently interpret their illnesses to be caused by magic instigated by their co-wives.

The presence of matrilineal relatives with a fie- quency relative to patrilineal ones might at first appear to be a surprising finding for Senegal. The predominant Islamic influence stresses the importance of paternal kinship relationships and most Sene- galese are members of ethnic groups that determine descent predominantly based on patrilineal rathcr than matrilineal principles, However, two additional principles must be kept in mind. First, it is important to realize that many of the ethnic groups in Senegal have been evolving from matrilineal to patrilineal over the past several centuries coincident with the expansion of Islam. While the Wolof, for example, are predominantly patrilineal they still retain strong matrilineal features. Of the three major ethnic groups in Senegal (1) the Wolof employ 9 double descent kinship system, in which patrilineal elements predominate over matrilineal ones, (2) the Scrcr also havc a double descent kinship system, but the matrilineal elements dominate, and (3) the Tukulor and Fulbe are patrilineal [48].

The second principle is that there is a tendency for the mother and her relatives to play a much more important role during times of illness and stress than the father and his relatives. Since the mentally ill in Senegal's society assume a role that is passive, blameless and therefore childlike in character, this might be viewed as a sort of regression to an earlier develop- mental state in which maternal relatives were more important. Furthermore, while the patient's role is blameless, the patient's mother's role is certainly not. She is always held responsible by society for the behavior of her children [48]. As expressed by a popular Wolof proverb "Bu doom baa.rk, doomi nepp la; bu doom bonO, ndey am la" (When a child succeeds, he's everyone's; when a child turns bad, he's his mother's). Even if the patient is an adult, his


mother and her relatives are still held responsible for his behavior, including that exhibited when he is

mentally ill.

SUMMARY AND CONCLUSIONS

Sociodemographic and clinical characteristics of the patients

This psychiatric patient population was similar to those reported in other studies from sub-Saharan Africa in several respects. Males outnumbered females by a ratio of two to one. This difference probably reflects differential utilization rates rather than differences in frequency of disease in the population. It is undoubtedly influenced by certain cultural values such as the importance of women staying with their families whenever possible, and priority for modern medical care given to males. Young adults represented the greatest proport ion of patients and children were rarely present. The predominance of single male patients aged 20 29 years may reflect the stresses inherent in this demographic group associated with entering adulthood faced with limited financial opportunities and limited possibilities for early marriage. The predominance of married female patients at slightly younger ages may reflect the stresses in that group associated with adolescence, early marriage, child bearing and separation from their original families.

Patients resided more often in the region which includes the hospital or in other urban areas than the Senegalese population in general. However the ethnic distribution of patients closely resembled that of the country as a whole.

Clinically, approximately half the patients were psychotic and schizophrenia and schizophreniform disorders were the most common diagnoses (30.0%). The predominant diagnostic categories differed con- siderably from those seen in psychiatric care in the United States. Similar to many other studies in sub-Saharan Africa, affective disorders were rarely seen (7.6%), and over a quarter of the diagnoses were epilepsy or other non-psychiatric medical problems. Neuroses and related, less severe problems represented only' 11.6% of the cases. These patterns of diagnoses probably reflect differential utilization rates rather than disease prevalence. Such factors as the predominant use of traditional healers, the lack of psychiatric care in much of the country, and an increased family acceptance and willingness to care for the mentally ill at home undoubtedly were important.

The time intervals between first signs and symptoms of psychiatric illness and presentation for psychiatric care were quite long. Nearly half the patients waited a year and nearly one-fifth waited five years before coming to the hospital. These extended intervals undoubtedly reflect the importance of traditional medicine for the great majority of the population when seeking treatment for mental illness.

Characteristics of patient companions

Nearly all patients were accompanied to their first

psychiatric out-patient visit by someone and half had two or more companions. Male companions were present in the great majority of cases (78.6%) compared to female companions in only a minority (37.5%). These data probably reflect cultural values such as the importance of women staying at home to maintain the family and the greater preparedness and social acceptance of males to travel, interface with modern medicine and handle aggressive behavior.

The data on the specific relationships of companions to patients followed four major principles: (1) relatives nearly always took responsibility for a family member's welfare; (2) consanguine relatives took such responsibility much more frequently than affines: (3) among consanguine relatives, nuclear ones were involved about half the time; and (4) matrilineal relatives took such responsibility as often as patrilineal ones did.

Some of these principles are easily understood in terms of traditional values in the United States and elsewhere, such as dependence upon family members during crisis, and the often delicate nature of re- lations with in-laws. However, others stem from principles of social organization very basic to Senegal such as the concepts of family alliance and bride wealth as part of marriage, the preservation of matrilineal elcments in most ethnic groups despite predominantly patrilineal orientations, the importance of maternal family during times of illness, and the social accountability placed on maternal relatives for behavioral deviance in children.

Acknowledgements This research was supported in part by USAID grant nos 685-0242-G-SS-9351-00 and 698-0463-G- SS-9024-00.

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Cultural response to mental illness in Senegal: Reflections through patient companions—Part II....

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