A total of 359 articles were identified through the literature search. These articles were evaluated and 127 publications that met the inclusion criteria were selected for further analyses (Fig. 1). Initially, the publications were grouped into themes based on their research foci. The following are the number of studies per research focus: epilepsy and seizures (9 studies), depression and suicide (14 studies), neurological disorders (6 studies), neurocognitive impairments in non-nervous system disorders (20 studies), nervous system effects of substance misuse (7 articles), and mental health among women (18 articles). Others included: the national mental health system (16 studies), support and help-seeking for mental health patients (6 studies), psychopharmacology and pharmacogenetics (3 studies), community studies such as those that investigated the relation between poverty and mental health (11 articles), as well as clinical surveys and case reports (13 articles). The percentage distribution of the number of articles for each research focus is provided in Table 1. These articles were further evaluated based on the (i) specific focus of the research reported (ii) number of articles reported under a particular research area, expressed as a percentage of the total number of articles evaluated, and (iii) annual publication trends and the institutional affliliations of Ghanaian authors (Table 1 and Fig. 2). We identified that about 60 % of the articles evaluated were published within the last seven years (Fig. 2). In the rest of this article, we will discuss in detail the epidemiology of neurological and neuropsychiatric disorders as reported from Ghana, the neuroscience-related research directions in the country, as well as the established legal and healthcare frameworks regulating neuropsychiatric service delivery. We will also discuss the existing neuroscience research capacity in the country, areas where improvement is needed and what might be required to deliver this improvement.
Epidemiology of neurological and neuropsychiatric diseases
Initial studies, conducted over five decades ago, predicted future increases in the burden of psychiatric disorders in Ghana due to anticipated impacts of industrialisation and acculturation (Field 1958). However, it remains largely unknown whether these predictions have been achieved or not. This is because recent epidemiological studies have focused mainly on small sections of the population and have relied almost exclusively on clinical surveys (Read and Doku 2012). While the review of hospital records provides important information about disease epidemiology, hospital cases alone may not be reliable indicators of disease prevalence, especially in African settings where (i) many people have difficulties accessing healthcare (ii) the under-resourced and over-stretched nature of healthcare facilities means that not all patients can be adequately attended to (iii) record keeping in health facilities is sometimes poor, and (iv) appreciable portions of the population depend on herbal and traditional medicine for their healthcare needs (Ferri et al. 2004; Nguta et al. 2015; Roberts et al. 2014; van Andel et al. 2012). Larger-scale and more diverse epidemiological studies combining data from multiple sources are therefore required. This would help to inform new decisions in health policy, preventive healthcare, evidence-based medical practice as well as better-targeted biomedical research aimed at identifying disease risk factors and potential therapeutic targets and agents (Quansah and Karikari 2015).
One of the major studies identified in terms of disease epidemiology was a retrospective study conducted into the prevalence of psychiatric disorders among adolescents attending a psychiatric out-patient clinic in Accra from 1987 to 1994 (Turkson 1996). Out of the 454 adolescents (239 females) whose records were reviewed, 269 patients (59.3 %) were reportedly diagnosed with psychiatric illnesses. Out of these 269 patients, 88 were diagnosed with functional psychoses (including depression and psychoneurotic disorders), 55 were diagnosed with personality disorders, 27 were diagnosed with organic psychoses and 36 were suffering from other kinds of psychiatric disorders (Turkson 1996).
A frequently-used means to assess disease occurrence and people’s perceptions about diseases is self-reported community surveys (Hunt and Bhopal 2004). Community-based studies reporting on the prevalence of psychiatric disorders and related diseases have been conducted in Ghana, although the use of standardised epidemiological methods have been lacking in some of these investigations (Ferri et al. 2004; Field 1958). By using a self-reported questionnaire and mental state examinations, Osei (2003) interviewed 194 study participants in Kumasi, the capital of the Ashanti region. It was identified that five women who participated in the study were suffering from schizophrenia, five men were suffering from somatisation and 38 others (including 33 women) were living with depressive illness. A psychiatric illness prevalence rate of 27.51 % was reported from this study. More of such community-based surveys conducted on larger scales are urgently needed to help in the estimation of disease prevalence. This is particularly necessary due to the fact that many Ghanaians seek healing from neurological and psychiatric conditions from spiritual centres, meaning that such people would be missed in clinical record surveys (Turkson 2000).
The focus of research on neurological and neuropsychiatric diseases in Ghana
Research on neurological diseases in Ghana is limited. The available studies in this area reported on PD (three studies), economic impacts of dementia and a clinical report on a schizophrenic patient (one study each). Only one study focused on the genetic aspect of a disease. In that study, 54 patients suffering from PD and 46 matched controls were screened for the presence of the G2019S pathogenic mutation in the leucine-rich repeat kinase 2 (LRRK2) gene, which has been associated with familial PD (Cilia et al. 2012). However, this mutation was not found in the genome of both the patients and controls, suggesting that the genetic basis of familial PD among Ghanaians might differ from people elsewhere (Cilia et al. 2012). This finding corroborated earlier reports from Nigeria and South Africa that showed that the LRRK2-G2019S pathogenic mutation was missing among study subjects (Bardien et al. 2010; Okubadejo et al. 2008). These results support the growing body of evidence suggesting that the genetic basis of specific neurological diseases is population-specific, justifying the need for further studies into how these diseases progress among African populations (Karikari and Aleksic 2015; Quansah and Karikari 2015). Given that modern humans were believed to have originated from Africa, increasing the involvement of African populations in disease-focused genetic and genomic studies might provide novel information that would shape the future of neurological research and healthcare on the continent (Karikari and Aleksic 2015).
Another disease that has received research attention in Ghana is epilepsy. In 1995, it was reported that convulsive disorder accounted for 3 % of outpatient visits to the pediatric department of Ghana’s biggest tertiary hospital, Korle Bu teaching hospital, over a decade (Commey 1995). 51.5 % of these patients were enrolled in the hospital’s pediatric neurodevelopmental clinic (Commey 1995). In examining data on active convulsive epilepsy from five African countries including Ghana, Kariuki et al. (2014) identified some important features (seizure types, neurologic deficits, encephalopathy) and co-morbidities (malnutrition, cognitive impairment). Based on the findings, it was proposed that these features should be integrated into the management of epilepsy. Even though epilepsy is one of the most-studied neuropsychiatric disorders in Ghana, the available investigations were mostly clinical reports; non-hospital-based estimations of disease prevalence, potential causes and public perceptions about the disease were lacking. One of the largest community surveys on epilepsy was conducted by Nyame and Biritwum (1997). Upon interviewing 380 participants in Accra, the researchers reported that while almost all the people sampled could accurately describe an epileptic person, 172 (45.3 %) of them did not know the cause of epilepsy and 37.6 % did not know how it could be treated (Nyame and Biritwum 1997). It was further reported that out of the 358 responses about the causes of epilepsy, 114 (31.8 %) respondents believed that epilepsy was an inherited disease while 100 (27.9 %) believed that it had spiritual causes.
Furthermore, efforts have been directed at estimating the prevalence of depression among Ghanaians, particularly among women. In a cross-sectional analysis using data from a national representative survey conducted in 2009–2010 (involving 9,524 participants), the Kessler Psychological Distress scale was used to measure psychological distress (Sipsma et al. 2013). An overall psychological distress rate of 18.7 % was reported among the participants, with 11.7 and 7.0 % reporting either moderate or severe psychological distress respectively. Moreover, it has recently been reported that out of 270 university students (138 females) interviewed using the Center for Epidemiological Studies Short Depression Scale (CES-D10), overall prevalence of depression among university students in Ghana was estimated to be 39.2 %, with 31.1 and 8.1 % having either mild or severe depressive symptoms respectively (Oppong Asante and Andoh-Arthur 2015). Given the cross-sectional nature of most of these studies, increased numbers of participants may be required in order to make future findings more representative.
Substance misuse is another area that has been given research attention. Studies here have been focused principally on the neuropsychiatric effects of tobacco and alcohol use. With regard to this, Yawson et al. (2013) estimated the prevalence of daily tobacco smoking among adults in Ghana to be 7.6 %. This data was generated from 4305 study subjects aged 50 years and above.
Other publications were focused on mental health among women. These studies reported specifically on antenatal depression, antepartum depression, anxiety disorders and depression among infertile women (Table 1). In addition, a few other publications reported on the following: the relation between poverty and mental health, psychopharmacology, the use of herbal medicine in treating neuropsychiatric conditions, and help-seeking and support system for patients (Table 1).
Overall, it is worth noting that no research work has been conducted on diseases such as Alzheimer’s disease, fronto-temporal dementia, bipolar disorders, Huntington’s disease, dyskinesia as well as neurodevelopmental disorders such as autism and attention deficit hyperactivity disorder. Hence, the prevalence, causes (both genetic and sporadic) and patient care platforms for these disorders in Ghana have not been evaluated. Moreover, reports on the genetic, genomic and molecular underpinnings of common neurological diseases and neurological aspects of other diseases were lacking. A plausible explanation would be that the scientific capacity for experimental neuroscience and neurology research in Ghana is low (Karikari and Quansah 2015). This viewpoint is supported by findings of the Thomson Reuter’s Global Research Report in 2010. While Ghana was the sixth best-ranked country in central Africa in terms of annual number of publications (in this report, African countries were broadly categorised into north, south and central Africa), the country was not part of the top five African countries in the neuroscience and behaviour field (Adams et al. 2010).
Appropriate mechanisms should therefore be developed to improve neuroscience research (particularly bench-science, clinical and computational aspects) in the country (Karikari and Quansah 2015).
Publication trends and institutions conducting neuroscience-related research in Ghana
The average number of publications on neuroscience-related research from Ghana between 1995 and 2008 was about six per year. However, a change in this trend was later observed as over 60 % of the articles were published in the last seven years (2009–2015), with about 20 articles published in 2013 alone (Fig. 2). This represents a recent improvement in neuroscience-related research output in Ghana. Most of the studies were either clinical case reports or community-based studies, with only a few (4.7 %; Table 1) examining neurological and neurodegenerative disorders. In addition, about 15.7 % (Table 1) of the studies investigated the neurocognitive impairments associated with non-nervous system diseases, giving an indication that scientists in Ghana have been applying neuroscience concepts to address pressing health concerns in diseases such as HIV/AIDS, breast cancer and malaria. With most of the publications being hospital-based reviews, majority of the authors were affiliated with the two leading hospitals in Ghana, that is, the Korle-Bu teaching hospital (KBTH) and the Komfo Anokye teaching hospital (KATH; Table 1). Many other authors were affliliated with the University of Ghana Medical School, which is associated with KBTH. The remaining authors were affiliated with universities such as the Kwame Nkrumah University of Science and Technology, the University of Development Studies, the University of Cape Coast and the University of Education (Table 1). The Kintampo Health Research Center and Noguchi Memorial Institute for Medical Research were also identified as the major research centers contributing to neuroscience-related research in Ghana (Table 1).
Ghana’s mental health system and the mental health law
There are currently three psychiatric hospitals in Ghana; these are the Accra, Pantang and Ankaful psychiatric hospitals (Roberts et al. 2014). These hospitals have a total of about 1322 beds, although only one has a children’s ward consisting of 15 beds (Roberts et al. 2014). In 2011, in-patient admissions in the three hospitals totalled 7993; 32 % of these patients were females while 68 % were males (Roberts et al. 2014). The major diagnoses leading to in-patient admissions included schizophrenia (32 %), substance misuse (26 %), mood disorders (19 %), and neurotic/stress-related disorders (1 %) (Roberts et al. 2014). Disorders such as epilepsy accounted for 6 % of all in-patient admissions. The combined human resource capacity of these hospitals is 1887, including 8 psychiatrists (Roberts et al. 2014). This brings the psychiatrist- to- population ratio to 0.07 per 100,000 persons. There are also 31 non-psychiatrist medical doctors, 21 social workers, 4 occupational therapists, 19 psychologists, 1,256 nurses and 546 other workers (including health assistants and other auxilliary staff) (Roberts et al. 2014). These data suggest that the psychologist- to- population ratio in Ghana is 0.08:100,000 and the psychiatric nurse- to- population ratio is 5.19:100,000 (Roberts et al. 2014). With regards to treatment, only 19 % of patients in the psychiatric hospitals are reported to receive one or more psychosocial interventions, and all the hospitals had at least one psychotropic drug in each therapeutic class (antidepressant, anti-psychotic, mood stabiliser, antiepileptic and anxiolytic drugs) available in their facilities throughout the year (Roberts et al. 2014). However, the hospitals sometimes run out of drugs such as olazipine (an antipsychotic medication), compelling patients to be put on other drugs (Roberts et al. 2014).
The foregoing overview of Ghana’s mental health delivery system shows that there is an urgent need to train more healthcare professionals to support efficient psychiatric care delivery. The low availability of pharmaceutical supplies is also an important concern that needs to be addressed. At the end of the year 2011, the total government spending on mental health delivery was about 1.4 % of the total national health budget (Roberts et al. 2014; World Health Organization 2011). Figures from the Ministry of Health indicate that the mental health sector was allocated a budget of 4,516,163 Ghana cedis (excluding staff salaries) (Roberts et al. 2014). However, a total amont of 5,656,974 Ghana cedis was spent on the delivery of mental health services, showing that the initially-approved funding was less than what was actually needed (Roberts et al. 2014). Most of this amount was spent on operational expenses at the psychiatric hospitals, meaning that costs incurred in the delivery of psychiatric care in other health facilities were not considered here (Roberts et al. 2014; World Health Organization 2011). Also, no mental disorder is covered by social insurance schemes and there are no social benefits for patients, leaving the financial burden solely to patients, families and carers (World Health Organization 2011). In addition to public funding, some international development partners and non-profit organisations have contributed to mental health delivery in Ghana. The contributions of these agencies have usually been made through the donation of essential drugs (Roberts et al. 2014).
In March 2012, the Parliament of Ghana successfully passed the Mental Health Act into law (Act 846 of 2012) (Doku et al. 2012). The aim was to increase the quality of mental healthcare through improved protection of the rights of patients and clinicians (Doku et al. 2012). However, three years after the passage of this law, there are still challenges and weaknesses in the implementation of policy and legislative frameworks. Among these challenges are (i) insufficient government funding towards the efficient delivery of mental health services (ii) little use of the legal provisions to effectively regulate the detention and handling of patients in health facilities and spiritual healing centres (iii) lack of regulation regarding the practice of psychiatry by traditional and spiritual healers, and (iv) insufficient use of clinical guidelines even where they exist (Doku et al. 2012; Roberts et al. 2014). Moreover, several challenges also exist in terms of mental health service delivery, recordkeeping and records monitoring and evaluation (Roberts et al. 2014; World Health Organization 2011). Mental health information systems are not regularly updated. Similarly, mental health data are not consistently aggregated to provide national reports on the burden of mental health (Roberts et al. 2014).
The mental health policy was formulated and implemented by the Ministry of Health and the Ghana Health Service respectively (World Health Organization 2011). The existing mental health policy was revised in 1996 and refined in 2012 but it still does not address the integration of mental health into primary health care (World Health Organization 2011). However, the policy includes the following components: protection of human rights of patients, human resources, involvement of users and families, advocacy and promotion, equity of access to mental health services across different groups, financing, monitoring system, quality improvement and a list of essential medicines (including anxiolytics, antipsychotics, antidepressants, antiepileptic drugs and mood stabilisers) (Roberts et al. 2014; World Health Organization 2011). The so-called 2007–2011 Mental Health Strategy ensured the revision of the mental health plan and contained a budget, specific goals and timeframes (Roberts et al. 2014). However, due to lack of funds many of the goals have been unattained. Additionally, the country has no emergency or disaster preparedness plan for mental health (Roberts et al. 2014).
Neuroscience research capacity: challenges and prospects
The foregoing discussion is a clear indication that, while major achievements have been recorded, research in neuroscience in Ghana needs to improve both in diversity and quantity. Particularly, information is lacking on the (i) epidemiology of many mental and neurological disorders (ii) effectiveness of psychotropic treatments (iii) genetic, genomic and molecular bases of neurological and neuropsychiatric disorders (iv) social, economic and healthcare implications of these diseases, and (v) effectiveness of therapeutic approaches and patient care platforms currently used. In this section, we will highlight some of the challenges that have contributed to the low neuroscience capacity in Ghana. We will also provide some suggestions and discuss current approaches aimed towards building capacity for neuroscience research in Ghana.
Inadequate expert scientists
Neuroscience is a rapidly evolving field, with implications for social development and economic growth through its applications in areas such as education, business management, sociology, economics, criminal justice, psychology and advertising (Karikari et al. 2015a; Yusuf et al. 2014). Investment in neuroscience education and research is therefore likely to make enormous contributions to building better societies through improved understanding of how the brain works and the application of this knowledge to improve service delivery (Karikari et al. 2015a; Yusuf et al. 2014). However, neuroscience attracts relatively low interests from Ghanaian students and scientists, leading to a disparity in research output between Ghana and other countries (Karikari et al. 2015a, b). This apparent lack of interest is mostly due to challenges such as the lack of research funding, inadequate research infrastructure as well as the lack of degree programmes to prepare students for careers in neuroscience (Karikari et al. 2015a, b). Difficulties in accessing well-resourced neuroscience research facilities in the country may also contribute to the low availability of molecular and genetic studies into neurological and neuropsychiatric diseases. Additionally, the dearth of resident neuroscientists plays a major role in the absence of neuroscience degree programmes in the country, due to the unavailability of experts required to provide world-class student training in this area (Karikari et al. 2015a, b). In order to attract more researchers and students into neuroscience in Ghana, the development of strategies aimed at addressing the infrastructural, training and funding issues will be essential (Karikari 2015a; Karikari et al. 2015a). Ongoing and suggested attempts to address these challenges have been discussed in the sections below.
Neuroscience research infrastructure and training programmes
Although there are dozens of registered higher education institutions in Ghana, there is no degree programme in neuroscience offered in the country at the moment (Karikari et al. 2015a, b; Karikari and Quansah 2015). This negatively affects the supply of scientists and clinicians with appropriate training in neuroscience to help improve biomedical research and healthcare delivery in the country (Karikari et al. 2015a; Karikari and Aleksic 2015). In order to provide well-resourced facilities for neuroscience research in Ghana, the KBTH in partnership with the Korle Bu Neuroscience Foundation (KBNF; a registered charity dedicated to supporting neurological healthcare, education and research) are working towards the establishment of a proposed Korle Bu Neuroscience Center of Excellence (KBNCE) (Cain 2011). Under KBNCE, a collaborative neuroscience graduate programme has been proposed to provide local opportunities for Ghanaian students to study neuroscience (Cain 2011). This programme, which would be offered at the University of Ghana, is aimed at supporting the future sustainability of the research component of the KBNCE through the development of basic and clinical neuroscience research capacity in the country (Cain 2011). The introduction of interdisciplinary graduate programmes of this nature would greatly benefit the country, by enhancing collaborative research especially those requiring neuroscience expertise (Karikari et al. 2015a, b). Due to the challenging nature of neuroscience education, particularly in resource-limited environments, institutional partnerships between neuroscience and computer science departments would support student training in the use of Internet- and computer-based tools in exploring neuroscience concepts and techniques (Karikari 2015b, c). Aside from degree programmes, practising scientists and clinicians wanting to deepen their neuroscience knowledge in order to advance their research and teaching activities may find the short-term training programmes offered for African scientists useful. Notable examples of these programmes include the following: (i) training programmes in neurogenetics, insect neuroscience, genomics data analysis and open labware provided by the science-based non-profit Teaching and Research in Natural Sciences for Development in Africa (TReND; http://trendinafrica.org) (ii) other neuroscience-focused workshops organised under the sponsorship of the International Brain Research Organization (IBRO) and other organisations to provide practical training in specific neuroscience research areas to African scientists, and (iii) IBRO-funded teaching tools workshops aimed at training faculty members in the best methodology for the effective teaching of neuroscience in Africa (Baden et al. 2015; Juliano 2012; Karikari 2015a; Karikari et al. 2015a; Karikari and Aleksic 2015; Yusuf et al. 2014).
The ability of scientists to undertake high-impact research in neuroscience in Ghana is often hindered by the low availability of appropriate technology, modern equipment and local content in the scientific literature (Awenva et al. 2010; Karikari et al. 2015a). Addressing these challenges would contribute immensely to bridging the existing scientific productivity gap between Ghana and other countries (Awenva et al. 2010). Higher education institutions in Ghana could benefit from training and research equipment donation programmes offered by organisations such as Seeding Labs (http://seedinglabs.org), Adequation (http://adequationgermany.embl.de/), TReND (www.TReNDinAfrica.org) and KBNF (http://kbnf.org/). These organisations support African hospitals, research centres and universities with functional medical and research equipment. Details about how these initiatives work have been provided elsewhere (Karikari et al. 2015a; Yusuf et al. 2014).
Ghanaian scientists could also benefit from travel fellowships and short courses offered or supported by international organisations such as IBRO, the Society for Neuroscience (SfN), the National Academy of Sciences (USA), the United Nations Educational, Scientific, and Cultural Organization (UNESCO), Guarantors of Brain and The World Academy of Sciences to help scientists in developing countries to obtain state-of-the-art neuroscience training. Some of these workshops have been aimed at building scientific capacity in Ghanaian universities, helping to improve teaching and learning of neuroscience. For example, IBRO’s fourth teaching tools workshop, funded by IBRO with support from UNESCO, SfN and NAS was held at the University of Cape Coast Medical School in Cape Coast, Ghana, in September 2011 (Juliano 2012). At this programme, participants selected from all over Africa were trained in how best to teach neuroscience concepts using simple-but-effective approaches (Juliano 2012). In addition, The International Parkinson and Movement Disorder Society and the World Federation of Neurology recently teamed up to organise short training courses for non-neurology specialist physicians in Ghana and elsewhere in West Africa (Cilia 2013). The purpose of this initiative was to help improve the quality of clinical neurology in the sub-continent, by ensuring that more non-specialists are trained to become more competent in diagnosing and treating neurology cases (Cilia 2013). More of such programmes are needed to help improve the capacity of both scientists and clinicians in Ghana in neuroscience.
Neuroscience research funding
With the existing challenges involved in accessing government funding for research, conducting cutting-edge research to help tackle local health needs is difficult in Ghana (Karikari 2015a). The country lacks established mechanisms to competitively fund research, innovation and technological development (UNCTAD 2011). Notably, the financial contribution of the Government towards basic research is low; for example, only about 0.3 % of the country’s gross domestic product is allocated to basic research (UNCTAD 2011). However, only about 10 % of this fund is used to support actual reseach costs, since about 90 % is spent on staff remuneration and other operational costs (UNCTAD 2011). In addition, there is no government-led competitive research funding programme in Ghana, meaning that scientists often rely on funding from international agencies for their research (Karikari 2015a). However, the research priorities attached to these international funding calls may not be necessarily aligned with the research priorities of Ghana (Karikari 2015a; UNCTAD 2011). Also, the highly-competitive nature of international funding programmes makes it difficult for early-career scientists and senior scientists with low publication records to obtain funding. Concerning funding improvements, the African Union, about a decade ago, challenged all member states to spend 1 % of their gross domestic product on local research and development (Irikefe et al. 2011). However, Ghana has not been able to reach this research funding target (Irikefe et al. 2011; UNCTAD 2011). To ensure that more Ghanaian scientists conduct research that is in line with national research priorities, more funding support from the Government, industries, charity organisations and philanthropists will be necessary (Karikari 2015a; Karikari et al. 2015a; Karikari and Aleksic 2015; Quansah and Karikari 2015; UNCTAD 2011). Increasing financial investment would not only help to ensure the long-term sustenance of neuroscience research in Ghana, but would also help to improve local neurological healthcare. Mechanisms should also be put in place to ensure that governmental funding allocated to higher education institutions are spent specifically on the indicated assignments.