Written by : Dr. Duaa Alfatih Introduction: Malaria is a mosquito-borne disease caused by the protozoan parasite Plasmodium, and causes an estimated two million deaths each year world-wide (Breman, 2001), mainly due to severe complications of Plasmodium falciparum infection.In Sudan, malaria remains one of the leading public health challenges, particularly during and after the rainy season. Cerebral malaria is the most severe neurological complication of Plasmodium falciparum malaria and has few specific features, but there are differences in clinical presentation between African children and non-immune adults. Subsequent neurological impairments are also most common and severe in children (Idro et al., 2005). The Sudanese health system primarily focuses on managing the acute phase of the illness—patients often present unconscious, experiencing convulsions or other signs of cerebral involvement. Malaria affects neurocognitive functioning and severe forms of malaria are associated with greater degrees of neurologic and cognitive impairment. Previous studies have documented persistent deficits in attention and working memory in 1 in 4 school-age children 2 years after suffering CM, whereas others have documented persistent deficits in speech and language (Ssenkusu et al., 2016). In Sudan, such post-recovery complications are rarely discussed or systematically documented. This is partly due to the limited availability of mental health services, insufficient awareness among healthcare providers, and the persistent stigma surrounding psychological conditions. Consequently, many patients may recover physically but continue to suffer psychologically—without proper diagnosis, follow-up, or support. Pathophysiology of Cerebral Malaria : Despite decades of research on CM, there is still a paucity of knowledge about what actual causes CM and why certain people are more prone to developing it. Although sequestration of P. falciparum infected red blood cells (iRBCs) has been linked to pathology, it is still unclear if this is directly or solely responsible for the clinical syndrome. The pathogenesis of CM is likely a multi-factorial process, with parasite sequestration, inflammatory cytokine production and vascular leakage, eventually resulting in brain hypoxia, As a result, brain tissues cannot maintain membrane potential, which causes water inflow from extracellular to intracellular compartments, ultimately leading to cell death and tissue damage. (Luzolo and  Ngoyi, 2019; Chaudhary et al., 2022). Neuropsychological Impact of Cerebral Malaria : Cerebral malaria may lead to acute or long-term neurological deficits, even with an effective antimalarial therapy, causing reduced cerebral blood flow and other changes. Clinical features of severe malaria include cerebral malaria (CM), with impaired consciousness (including coma), prostration, and multiple convulsions. According to the time of the symptom onset, CM may be classified into two patterns of neuropsychological sequelae. The first one is immediate and characterised by coma and status epilepticus during the acute illness, resulting in focal sequelae such as hemiplegia and focal seizures, or multifocal sequelae with spastic quadriparesis, motor disorders, cognitive and behavioural impairment, blindness, speech or hearing impairment. The second pattern (post-malaria neurological syndrome) develops within months or years after CM, and behavioural deficits and/or epilepsy may occur. Malarial infection can be also associated with a wide range of neuropsychiatric symptoms. Clinically, this picture may present with disorientation, mild stupor or even psychosis. However, it rapidly progresses to seizures and coma with decerebrate posture. Occasionally, frankly psychotic behaviour can be the first manifestation of cerebral involvement during malarial infection. Paranoid psychosis, mania, hallucinations, and delusions were the commonest neuropsychiatric complications in some cases. Neuropsychiatric impairments due to CM in children include: long-term cognitive impairment, acquired language disorder, inattention, impulsiveness and hyperactivity, conduct disorders, impaired social development, Self-injurious and destructive behaviours have also been observe (Moryś et al., 2015). Gaps in Mental Health Services : Despite the increased awareness of the long-term effect of cerebral malaria on mental health, there are many challenges in Sudan and similar countries. After the patient leaves the hospital, rarely, to receive psychological follow-up and evaluation, which makes many psychological problems not notice and treatment. Mental health services are limited, especially in rural areas. Moreover, stigma around mental illness remains a major barrier, the definition of stigma proposed by Goffman posits that stigma is an attribute that devalues a person and sets them aside from others. This definition lays bare the vulnerability of individuals with a disability, especially those with mental health needs. Furthermore, it is well documented in the literature that people with a mental illness (PWMI) face stigma from multiple sources, including schools, hospitals, places of worship and sometimes even from their own families, It is clear that stigma and shame are a major stumbling block to accessing mental health services in conservative communities. Unfortunately, the stigma extends beyond the individual to their family members, exacerbating the shame they feel. In addition, the healthcare workers who are expected to support those with mental health difficulties also sometimes contribute toward the stigma and feelings of shame, leading to further discouraging patients from seeking assistance. (Booth et al., 2024). Globally, mental, neurological and substance use disorders (MNS) are a major cause of disability, accounting for more disability-adjusted life-years (DALYs) than any other type of non-communicable disease. In low- and middle-income countries (LAMICs), MNS are largely unrecognised and untreated, in part due to lack of mental health services, lack of trained personnel and lack of capacity of the primary healthcare (PHC) system to provide the care required (Ali et al., 2012). To fill these gaps, we must expand training programs for workers in health programs, introduce the mental health unit as part of the Malaria treatment protocol and an effort to educate society to reduce the stigma and encourage help-seeking behavior. Integrating Mental Health into Malaria Care : In malaria -afflicted areas, such as Sudan, the introduction of the mental health unit as part of the unit of infectious diseases is still limited despite the full knowledge of psychological effects of some diseases such as cerebral malaria. One of the most effective ways to improve outcomes for survivors of cerebral malaria is to embed mental health care within existing malaria programs. This integration means not only treating the acute infection but also preparing for the emotional and cognitive challenges that may follow. Difficulty remains the scarcity of mental-health professionals to deliver such interventions to underprivileged communities. The challenge is to adapt these interventions so that they can be delivered by ordinary health workers without previous training in mental health. Furthermore, policy makers in low-income countries need to be convinced of the public health importance of treating mental disorders so that they integrate such interventions into existing health systems (Rahman et al.,2008). Children admitted to intensive care units (ICU), such as those with severe malaria, are exposed to stressors, such as invasive procedures, respiratory insufficiency, delirium with possible psychotic experiences, different professionals providing care, and separation from families leading to mental health problems. As a result of a traumatic ICU experience, post-traumatic stress disorder (PTSD) is common in children, followed by depression after admission for a life-threatening illness. Interventions aimed at preventing these psychological reactions after discharge should address the child and caregivers’ experiences of these stressors on the ward (Bangirana et al., 2021). Finally, to find a bridge between infectious disease services and mental health care is not a luxury, it’s a necessity. Without this connection, survivors may find many psychological problems especially in countries like Sudan where both fields are under-resourced and often disconnected. Conclusion: The severe form of malaria, i.e., cerebral malaria caused by Plasmodium falciparum, is a complex neurological syndrome. Surviving persons have a risk of behavioral difficulties, cognitive disorders, and epilepsy. The adhesion and accumulation of infected RBCs, platelets, and leucocytes in the brain microvessels play an essential role in disease progression. Micro-vascular hindrance by coagulation and endothelial dysfunction contributes to neurological damage and the severity of the disease (Chaudhary et al., 2022). CM affects the CNS, and although most survivors have a full recovery, 3-31% of patients still develop neurological deficits and cognitive sequelae. The prevalence of neurological deficits is higher in children than in adults, ranging from 6% to 29% at the time of discharge. Children with CM frequently present long-term neurologic deficits, and episodes of CM imply the development of long-term sequelae in children. In children, the most common sequelae include ataxia, paralysis, paresis, cortical blindness, epilepsy, deafness, behavioral disorders, language disorders, and cognitive impairment (Song et al., 2022). In Sudan, mental health care is not routinely integrated into malaria management, leaving families without guidance or support. Most follow-up care focuses on physical recovery, overlooking the emotional and cognitive needs that can significantly affect quality of life. To change this, we must expand our definition of “recovery” to include mental well-being. This means developing community-based mental health interventions, training frontline workers to identify at-risk children, and building supportive networks for caregivers. References : Ali, S., Saeed, K., & Hughes, P. (2012). Evaluation of a mental health - training project in the Republic of the Sudan using the Mental Health Gap Action Programme curriculum. International psychiatry : bulletin of the Board of International Affairs of the Royal College of Psychiatrists, 9(2), 43–45. Bangirana, P., Birabwa, A., Nyakato, M., Nakitende, A. J., Kroupina, M., -Ssenkusu, J. M., Nakasujja, N., Musisi, S., John, C. C., & Idro, R. (2021). 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