Friday, 4 October 2013

Mental health training in Somaliland - Day 15

Wednesday 2nd October

Today I visit the mental ward first thing. The ward is extremely busy as today is a follow-up day for community patients. There will be approximately 40 patients that have to be reviewed by the doctors and nurses on the ward. This means that the whole team is busy. Everyone has a role, from making little paper slips for patients to take away, with their next appointment date written down for them, to finding patient notes amongst files in the ward office, to sitting down with patients and speaking with them and their relatives. I speak to both Mustafe and Dr. Abdifatar on the ward and we agree that it might be better if I came back tomorrow to see the in-patients. I spend some time on the ward interacting with patients, some of whom I have met before and so they recognize me. I meet with the manager of GRT, the organization that has done much to improve things on the ward over a number of years. 

Two years ago, all patients on the ward were chained up and their living quarters was a block that contained nothing more than tiny cells. Now no patients are chained and they all have a separate room to sleep in, with beds and mattresses. The deputy manager from GRT spends some time with me today, taking me through the history of the ward and it is clear just how much they have done. Implementing change takes time, as does changing attitudes and even small things, like moving the place of eating from bedrooms to the open communal area, mean a real difference for patients, in terms of the cleanliness of the ward. They seem to have an organized system for documenting new admission case histories, a place to keep files of notes and a system for monitoring statistics, including, number of admissions, number of discharges, gender, age of patients, what their diagnosis is. All this is excellent to see, as it will help inform change later on.

Epidemiological data is scarce in Somaliland and it is great to see the ward staff diligently collecting this each day. They have also implemented a programme of activities for patients and have social workers who are on the ward to fulfill this. There is even football scheduled for the male patients and I am impressed seeing female patients taking part in sewing in a separate room with sewing machines in. There is a separate small room with a simple examination couch inside, where patients may have physical examinations carried out in privacy. It is clear to see that the nurses and doctors here work hard taking care of the patients and they tell me of their joy at seeing community patients recover and respond to medication they prescribe. By counseling patients and their families at follow-up appointments, not only are they able to tell them about their disorder and inform them of what they should expect from medication, in terms of side effects and beneficial effects, but they also get the opportunity to inform people about mental illness. Many people here believe that mentally unwell people are somehow cursed with ‘Djinn’ or evil spirits. As such people are usually taken first to a traditional healer, rather than the doctor, which means patients may have been unwell for a long time before they ever receive medical treatment.

Informing people about mental illness and the possible causes is vital here as this propels the spread of this information amongst their communities. Unfortunately, people are often chained for many years as their relatives have little knowledge about mental illness, no access to medication and beliefs about what the cause of their illness is. This can lead to devastating consequences for patients, who, with a diagnosis of schizophrenia, may well have responded to antipsychotic medication. Last year, I met a man who had been chained for in excess of 20 years, as his family simply had no knowledge about mental illness, he was violent due to his psychosis and they felt they had no other choice. They did not want him to escape and hurt anyone or himself. He was kept like this until he was eventually found by Dr. Jibriil, a doctor in Borama, who diagnosed him with schizophrenia. He was treated with antipsychotic medication and his psychotic symptoms improved. Unfortunately he developed PTSD symptoms as a result of his experiences and had difficulty communicating with people, having essentially been confined to a cage for such a long time. Another man on the ward developed severe leg contractures, so that now he cannot walk, as a result of having been chained for many years. Outcomes like this are tragic, as they might have been avoided if their disorder had been appropriately treated. Therefore, having the opportunity to raise awareness about mental illness is a key part of the ward staff’s job.

As I leave the hospital to go back to the office, I witness the aftermath of a car accident, with people being brought into the hospital on the backs of trucks. RTA’s are common here and, owing to the severity of the mens’ head injuries, it is likely that these people may not survive. It is a reminder to me of just how fragile life is and how lucky we are in other countries to have a very organized system for dealing with such emergencies.

The afternoon is spent with the 6th year medical students. Today we practice OSCE scenarios of childhood mental disorders including ADHD, which may well be, from people’s reports, common here. In Somaliland there is no child psychiatry at all and so it is difficult to know which disorders exist in the community. We concentrate on how to explain the illness to a relative and take a history. We also practice an OSCE station of an elderly male with memory problems and possible delirium. I stress that organic disorders must be ruled out first, as often in Somaliland physical illness, particularly infections, complicate the clinical picture.


The evening is spent meeting with members of the Mental Health Group, a group we have formed collectively as doctors, which includes previous mental health representatives and others with an interest in psychiatry/mental health. This is exciting as it is the first ‘formal’ meeting of its kind. The idea is to share ideas, to think together about how mental health may be developed further in Somaliland, to think about the medical student curriculum and also post-graduate learning. I am joined by Dr. Liban and Dr. Ayaanle, two Somaliland doctors who are currently undertaking a Masters in Mental Health in Ethiopia. They will soon return to Somaliland and will no doubt become leaders in the field of mental health in Hargeisa and beyond. Dr. Layla also joins the meeting, a previous mental health rep, as does Dr. Mariam who has recently assisted in the TOT mental health skills training course in Hargeisa for new intern doctors. One of the new reps for this year, Dr. Abdirahman also participates in the meeting. Dr. Adam, Dr. Gudon and Dr. Abdirazak have given their apologies as they are unable to make the meeting. Dr. Jibriil, another member, is in Borama, as is Dr Gurgurte. It is a very positive meeting, with many ideas coming from all members. We talk about both the bigger picture of mental health in Somaliland and also more specifically about undergraduate training and the possibility of these doctors taking on a more supervisory role within mental health education. The first agreement is that the group will aim to meet regularly to discuss such matters and share knowledge. It is so encouraging to see this group of professionals keen and interested in bettering mental health in Somaliland and I hope the meetings continue.