His family had accused him of being a demon, Abubakarr Jallou tells a group of patients gathered in a room at Sierra Leone’s Psychiatric Teaching hospital in the capital, Freetown. When the black magic of a local witch-doctor didn’t help, he was beaten by his brother and cast out of the house, he says. Jallou, 27, has since been diagnosed with bipolar disorder but he is not happy being here. “They sent me here, but I hate staying here. I’m not crazy.” Group counselling is now part of treatment here at the oldest psychiatric institution in sub-Saharan Africa, which has seen a dramatic transformation in the last few years away from the days when patients would be kept chained. Facilities are basic – Jallou is locked in a large room with bars on the windows with about 20 other men – but things have changed says Dr Abdul Jalloh, the hospital’s former director. “Until 2018, the hospital was like a prison. Conditions were awful. There was no running water, no electricity, no medicine and the patients were chained to the walls and beds.” Neighbours lived with screaming coming from the imposing brick building, on a hill in the east of Freetown. The Kissy Lunatic Asylum, as it was known, was there to simply stop patients hurting themselves or others. But, in a country which has historically paid little attention to mental health, the government has been raising awareness and attempting to counter stigma as part of President Julius Maada Bio’s “human capital” development agenda, which includes education reforms. The hospital is operating at full capacity, with 150 patients receiving free treatment. After patients’ chains were removed, the facility was also connected to water and power supplies. Now there is holistic care, which combines therapy and counselling with the latest medication. Yoga classes are offered and there is a basketball court. Anneiruh Braimah, chief psychiatric nurse,started working at the hospital in 1998, and says the behaviour of patients has improved dramatically since the reforms. “When people were chained they were very angry. They were throwing whole buckets of pee and poo at us. What we have noticed when we removed chains is that attacks have not increased in any way. In fact, they have decreased.” One of the biggest issues is substance abuse. Many of the teenagers at the hospital are users of tramadol – an opioid found in cough medicine. Others arrive in a state of psychosis after snorting the black residue on exhaust pipes. Ahmed Lahai, 21, was brought to the hospital in October by relatives. “My mother called all the local youth to tie me up in our house; she thought I was smoking [drugs],” he says. “But I broke down the door, which is when they said I was crazy. After that, they brought me here, where I received an injection to calm me down.” Lahai is being helped with his addiction. He doesn’t know how long he will stay at the hospital, first built by British colonialists in 1820. “The nurses are trying their best for us,” he says. “The only thing is the food – it could be more of a balanced diet than just beans and rice.” The improvements are largely funded by a US charity, Partners in Health (PIH), which helps the government with running costs. The charity has given $2.5m (£2m) towards refurbishment. There is now a full-time psychologist and a residency programme, established to train seven psychiatrists which will more than double the five that currently support Sierra Leone’s population of 8.1 million . The government is preparing to roll out basic mental healthcare across Sierra Leone’s 16 district hospitals in the coming months, which should reduce pressure on the teaching hospital. Earlier this year, Dr Carol Labor was appointed the first presidential adviser on mental health. “Reforming mental health in Sierra Leone is a big undertaking, but we are up to the task,” says Labor. “Our aim is to train 10,000 mental healthcare workers in 10 years.” A key challenge is reforming the 1902 Lunacy Ordinance – a colonial-era law that contains no mention of patients’ rights. Dr Labor says a “patient-centred bill” has been drafted, which includes protections for patient welfare. It should be passed in 2023 – giving dignity back to people with mental health problems.