(KISORO, Uganda) — Before the sun rises, psychiatric nurse Immaculate Owembabazi makes her way to a small district hospital in the rural village of Kisoro, Uganda.
Sister Immaculate, as everyone calls her, lives up to her namesake. Each morning, she greets patients in her uniform: a tailored dress, hair combed neatly into a tight bun, and a radiant smile.
Despite her cheerful demeanor, Sister Immaculate struggles with depression, the leading cause of disability worldwide, which affects one out of every six adults in the United States.
While caring for patients as a psychiatric nurse, she developed her first major depressive episode.
“I lost my husband when I was three months pregnant with my baby, [and my son] was still very young,” she said. “I was down, totally down. I feel I hated myself.”
Thirty-five percent of Ugandans are estimated to have some form of mental illness. Sister Immaculate is one of the few who received modern psychiatric treatment; 90 percent of Ugandans with mental illness never do, according to the World Health Organization.
In the United States, by contrast, 17 percent of adults have mental illness and 43 percent receive care, according to the National Institute of Mental Health.
Most Ugandans are treated by traditional healers, who often believe that mental illness is caused by a curse.
“Most of the people perceive [mental illness is] due to witchcraft. It’s due to spirits. It’s due to demons,” Sister Immaculate said.
Traditional healers may tie patients up in ropes or chains while warding off spirits with methods such as prayer, herbal remedies or blood sacrifices.
As many as 80 percent of Ugandans in psychiatric hospitals have been to traditional healers. For one, they are easier to access and culturally more accepted. After all, there are only about 30 psychiatrists in Uganda — that’s less than one psychiatrist per 1 million Ugandans.
For Ugandan health workers such as Sister Immaculate, building bridges between modern and traditional medicine is a massive undertaking.
“It’s very hard to convince somebody that this is a mental health problem that can be helped, can be managed in hospital,” she said.
That evoked memories of Sister Immaculate’s own psychiatric hospitalization nearly 10 years ago. Her husband had died, she lost her job, and she was plunged into a court battle when her in-laws sold her home.
Then, she gave birth.
Eighty-five percent of pregnant and postpartum women experience a mood disturbance, and up to 15 percent develop more severe depression and anxiety. In extreme psychological distress, some develop irrational thoughts to harm themselves or others.
In industrialized nations, many women receive help in the form of reassurance, medication and therapy.
Not so in Uganda.
“I’m looking at the world, seemingly nothing for me,” Sister Immaculate recalled. “My mind goes, ‘Kill these children. Kill yourself.'”
“I felt I would not leave them with my in-laws [or] my parents because [they] hated me,” she added. “So I felt whoever hates me will not love my children.”
Though Sister Immaculate did not harm anyone, it was only after she developed these severe symptoms that she was brought to the psychiatric hospital. She credits the four-month hospitalization for her recovery.
“Self-counseling” with psychological techniques and antidepressant treatment with Lexapro (escitalopram) and later Elavil (amitriptyline) has kept her depression at bay.
“I had never thought it would happen to me,” she said. “But sharing experiences with other people — it has kept me moving.”
Sister Immaculate also shares medical experiences with local traditional healers, trying to lead them to greater acceptance of the modern medical approach.
Seth Muhire, a Busanza-based traditional healer, stands out in Uganda. He has been practicing for nearly 40 years and collaborates with modern medical providers.
While traditional healers are secretive, Muhire told ABC News about his work in his local language.
Muhire works only with herbs gathered from the forest — and occasionally psychiatric medication. At times, he uses a padlock and loose chains to restrain patients who may run away or become violent. He said that he does not use ropes, which tend to cut through the skin and open up the possibility of infection.
Muhire learned herbal remedies from his father and grandfather. Meanwhile, he learned about the sky-blue tablets of Phenergan (promethazine), a weak antipsychotic, from modern mental health providers.
“I used to collaborate with people who had clinics, so I would learn from them and they would learn from me. In that integration, I got to learn more about using these Western medicines,” Muhire said.
When herbal remedies are not working, he sends patients to the psychiatric hospital.
Phiadorah Kampire is one example of trying both methods. She had her first psychotic episode when she heard the deep voice of an old man calling out to her, but no one was there.
A university student majoring in tourism and hotel management at the time, Kampire believed that her schoolmates bewitched her, but her family took her to a psychiatric hospital. She was diagnosed with schizophrenia in 2008 and put on Haldol (haloperidol) — but at 2500 Ugandan shillings ($0.70 per month), she lapsed in her treatment.
Since then, she occasionally seeks treatment from traditional healers as well.
“During the time I am sick, I have no insight of anything. I don’t even see the good of being on treatment during the time. I’m in attack,” Kampire said. “I think I will never be well.”
Each psychotic episode is longer, more intense and leads to further isolation. She left the university, cannot maintain a job because of her paranoia and was ostracized by her family.
When asked if she saw any hope in her situation, Kampire reached out for a single, immaculate blade of grass before fanning her fingers outwards and sweeping them across her view of the countryside. She said she can see meaning in the long grasses that sway on the steep hill across from her.
“I put myself in a simple kind of living,” she said. “Working at my pace, at my own rate, and in peace. Peace of mind, peace of heart, hoping to achieve heaven.”
Christy Duan is a psychiatry resident physician at Zucker Hillside Hospital in New York and a resident at the ABC News Medical Unit.
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