Mental health training in Somaliland - Day 37

Tuesday 29^th October

Business as usual. Today I go to the mental ward with the two mental health reps, Dr. Zainab and Dr. Abdirahman.  The students have the opportunity to meet with two patients and each rep gets the opportunity to lead a ward visit with the students. I am pleased that they have this opportunity as it is something we practiced during the TOT training that they were both part of. Again, I am thoroughly impressed by their leadership and ability to enthuse the students. I have been really impressed throughout the two week teaching at their hard work and commitment, along with their preparation for all their lectures/presentations and their knowledge.

We meet patients on the ward with diagnoses of schizophrenia and Bipolar Affective Disorder. I am always interested to find that the symptoms of schizophrenia present in just the same way and are described by people very similarly to how they are in the UK. It is also interesting for the students as sometimes believing that the theory learnt in psychiatry is true in real life is difficult.

This man presents with thought broadcasting and clear third person auditory hallucinations. It is a joy to see the patients face light up when he finally feels understood by the students asking him questions about his symptoms, and their faces light up when they are presented with the very symptoms that they have learnt about this week. One student comments that his view of mentally unwell people has been completely challenged and changed during this two week course. Before today, he had never been on a mental ward and neither had he wanted to go on one. He stated that now he is no longer scared of people with mental illness and views them just as he does any other person. It is an absolute joy to know that in only a two week teaching course this can be achieved.

On the way back from the ward, I reflect on how amazed I am at the students’ ability to study their entire medical degree in English. This is not any of their first language and I consider just how tricky it must be to not only learn  the new ‘language’ of psychiatry during this two weeks, but also to have to flit back and forth between Somali and English whilst seeing patients and then presenting their cases and doing exams. All the facilitators would agree that we have been very impressed with this group.

Good news upon our return. We find out that the mental ward has won a prize! They have been voted best ward in the hospital! Everyone is overjoyed. This is great news and is testament to just how hard working the team on the ward is. Dr. Gurguurte and Dr. Jibril grin widely, as does Faadumo and then we also find out that Suad, the chief nurse on the ward, has also won a prize, for best nurse! This is great and illustrates that the mental ward and their service are setting a precedent for standards that should be achieved on wards in the hospital. Their prize is $1500 and we all smile when we hear from both Dr. Jibril and Dr. Gurguurte what the money will be spent on. Without hesitation, both of them grin and say, ‘we can buy more medications for our patients!’

I am, again, thrilled by the enthusiasm, dedication and kindness shown by the team here who work with people with mental illness. They often work beyond their hours, and treat patients for free, as evidenced this week by Dr. Jibril consulting with numerous community patients we have seen after the students have taken their histories, for free. What a happy day! We end the evening by meeting again with all the co-facilitators and running though the plan for tomorrow OSCE examination. We have to examine 68 students, each doing two OSCE stations each and so we know we will have to run like clockwork to make it work. A big day tomorrow. 

Mental health training in Somaliland - Day 36

Saturday 26^th October

Dr. Idiris, one of our intern doctor co-facilitators, begins the re-cap this morning. We are all impressed by how he manages to control the class and with the confidence he shows when teaching. Today we have nine community patients joining us and Dr. Jibril visits the mental ward with the students. The case mix is interesting and varied, with cases of psychosis, psychosis associated with khat use, depression, learning disability, epilepsy, possible ADHD or conduct disorder in a child and a child with epilepsy, whose mother believes she has been possessed from ‘djinn from the sky.’

The beliefs and stigma associated with epilepsy are akin to those for schizophrenia or psychosis. There is huge discrimination against people who suffer with epilepsy and Dr. Jibril’s talk on organic disorders today illustrates this with cases he has seen. Epilepsy is not considered a neurological disorder for many here and so comes under the remit of psychiatry. Dr Jibril describes a case where a young boy with epilepsy was forced out of school as he kept having seizures and these resulted in incontinence. His teachers allegedly spoke of him as ‘crazy’ and asked his parents to remove him from school. We hear of many other fascinating cases from Dr Jibril. He reminds the students that not all seizures are in fact epilepsy and uses the example of a case of a young girl who presented with seizures and was treated with benzodiazepines; however, it turned out that she was in fact pregnant and had eclampsia. She died as she did not get the treatment she required due to mis-diagnosis.

It is a real joy to have Dr. Jibril here with us this year and we are so grateful to him for having organised the whole set-up of the teaching this year. His teaching is excellent and is a great person to be able to present real life examples of cases to the students. I know that I will never forget the examples he has used in his lectures. He really managed to bring alive the topic in a way that few here could. I am genuinely impressed by his knowledge, teaching skills and commitment to his career as a doctor/future psychiatrist.

Mental health training in Somaliland - Day 35

Friday 25^th October

Today is our day off - time to breathe and think a bit about how the teaching is going and whether we might change anything to improve it. One of our main challenges is the high number of students this year, which means that organizing them into groups can be tricky; however, we are all pleased with how the teaching is going so far. Today we meet and draw out a timetable for the OSCE examinations that the students will all sit next week. This is crucial, as for this to work for 68 students, our logistics will have to be impeccable!

Aidrous, a 6^th year medical student who I taught in May this year is thankfully helping us with acting and organizing the other actors, and we decide to run three separate circuits of two OSCE’s, with six markers in total. 

Mental health training in Somaliland - Day 34

Thursday 24^th October

Today’s teaching was a success. It was the first day that the medical students met with patients. Faadumo brought in 10 people with mental illness, who kindly volunteered their time to speak with the students. I, along with Zainab, the mental health rep, also took a group of students to Borama Mental ward, where they had the opportunity to take a history from a patient. This means that all the students will get both an experience of meeting with patients from the community, and also more acutely unwell patients on the in-patient ward. This for some of the students, is the first time they have met with and spoken to a person with mental illness in this context. Many are scared and wonder what it will be like.

It is a joy to witness the students talking with patients and showing respect and curiosity when taking their histories. Even more wonderful is to witness the change in the students when they return from seeing the patients. None of them now say they feel worried about meeting people with mental illness and many of them have clearly been challenging their own beliefs about mental illness whilst taking histories. Faadumo and Dr Jibril have done a fantastic job at managing to arrange this learning experience for the students, for it has taken a lot of organisation. Again today, I am thrilled to see the mental health reps presenting and Abdirahman does a great job with his presentation of mood disorders. Mustafe led the re-cap session and also did a fantastic job. I really am impressed by their teaching skills and their preparation and confidence.

As a short exercise, I ask students to write out cases of attempted suicide or suicide/self-harm they have witnessed or heard about. It is sad to find that every student has a story to tell, of a neighbour, a friend, or a relative. Many have seen neighbours who have attempted suicide. Most often, the cases the students describe are women, 69%, but it is striking that 31% of cases they report are also men. The most common method of attempted suicide or suicide is burning, though also interestingly, there are other methods used such as hanging, shooting, pesticide poisoning and also drug overdose. The students also point out how much stigma results from such acts, with those who have attempted suicide being ostracized and discriminated against. 

Mental health training in Somaliland - Day 33

Wednesday 23^rd October 

We began the psychiatry teaching in full force today, with lectures and discussions around history taking, mental state examination, suicide and risk assessment, as well as psychosis/schizophrenia. I am so impressed by the teaching skills of our co-tutors. Dr. Hodan leads our morning re-cap session and is excellent, well prepared, clear, audible, enthusiastic and informative. She began the day well and the students were clearly enthused by her teaching.

Dr. Abdirahman, one of this year’s mental health representatives gave a talk on how to take a history and perform a mental state examination and, again, had prepared well in advance. He was logical and clear in his approach and was able to answer questions from the students with no trouble at all. I was impressed by his ability to really push the students and test their learning. Dr. Zainab talked about suicide and risk assessment, a very sensitive topic in Somaliland, which she handled with ease and also with a great degree of insight, in terms of the local Somaliland context. She generated some very interesting discussion surrounding why people commit suicide or attempt suicide in Somaliland. We do a number of group exercises with the students which work well and it is great having nine of us to facilitate the group work. It means that the students have the opportunity to hear from different teachers and our co-facilitators this year include more intern doctors - Drs. Idiris, Hassan and Mustafe. 

Dr. Jibril is our lead co-facilitator this year, as an experienced previous mental health rep himself and his case histories and ability to talk about psychiatry in the Somaliland context is a great addition to the teaching. We learn from each other and for me, it makes the whole experience even more exciting, the more times I visit Somaliland, the more I learn about the culture and how psychiatry fits in within this context. We are also pleased to be joined by the Head of Medicine, who is curious to see how our teaching is organized and presented. And Faduumo and Su’ed, two mental health nurses who recently also attended the TOT training. The students enjoy the day and we end with Mandip leading discussions about psychosis and us utilizing the WHO mhGAP-IG to guide assessment and management of disorders. This is something we have used since last year and now underpins our medical student psychiatry teaching. I am reminded just what a privilege it is to be able to do this teaching, alongside my Somaliland colleagues, who have impressed me so much today. I can easily see these tutors as leaders in their chosen fields in the future.

Mental health training in Somaliland - Day 32

Tuesday 22^nd October

The first day of teaching sixty-eight fifth year medical students! We meet early to prepare the room and get ready for the students. This is an exciting, though slightly daunting, day. We are all aware just how many medical students we will have to manage during the next two weeks and though we have been planning for a long time, we hope things go smoothly. Today is about introducing the students  to psychiatry and mental illness, and setting the scene for the next two weeks. We ask the students to all write down a case of mental illness they have seen. Most of them recall cases of psychosis, which is the usual pattern and perhaps unsurprising as many of them have witnessed people with acute psychosis on the streets at some point. 


It is fascinating to hear the beliefs surrounding mental illness that the students voice. Many are scared of people they feel are ‘mad,’ others say that as children they felt that all people with psychosis were ‘killers’ and some admit that as children they would throw stones at people who were mentally unwell. They agree that many people with psychotic symptoms are thought to harbor ‘djinn’ or ‘evil eye’ and as such are ostracized from their communities, as are their families. We suggest that they keep in mind these beliefs as the two weeks progresses, and to think about whether these have changed or not during the time of teaching, and meeting people with mental illness. We take time today to talk about professionalism- as this is an important part of the teaching we offer. We also teach on communication skills, in preparation for students meeting patients and also trying to do psychiatry OSCE’s. The class is large, though we are impressed with their interaction and participation.

Mental Health Training in Somaliland - Day 31

Monday 21^st October

This morning we attended Dr. Walhad’s teaching workshop in the university faculty, and then together we prepare things for teaching tomorrow. Later in the day, we are joined by another doctor from the UK, who will co-teach during the next two weeks. As a team, we all meet together in the evening, to plan the first day tomorrow. It is great to be in a big team of teachers this time, with many of the co-tutors having just been participants on the TOT courses. I am positive about the teaching and we all look forward to it. The students have all arrived from Hargeisa and are warmly welcomed by their peers from Amoud University. For many of them, this will be the first time they have been out of Hargeisa and as well as this being a learning experience, it is also the opportunity for them to mix with their peers and make new friends and future colleagues. I am always impressed by just how much effort both students and faculty makes to welcome visitors to their town and University, and it happens in both Hargeisa and Borama. I also feel truly welcomed, though more like a familiar face when they say I am now like a ‘doctor of Borama.'

Mental health training in Somaliland - Day 30

Sunday 20^th October

This morning was spent meeting with Dr. Jibril. We discuss his upcoming residency, his career plans, the medical student teaching, a paper we will co-write about our recent TOT training and various other areas. We are met by Dr. Abdirahman Gurguurte, the other doctor who works on the mental ward here, and have a good discussion about psychopharmacology and issues surrounding poly-pharmacy. It is very interesting here that, as I found out from nurses, it is often looked down upon if a doctor should check their BNF for a drug dose before prescribing. As such, doctors may often avoid doing the check. I tell stories of the chief pharmacists in the UK always carrying around their Maudsley Guidelines or BNF and often checking them before giving advice, to try and encourage this sort of practice.

The discussion is lively, useful, and I am also taught much by these two. I hear the stories and of the work that went into ensuring the mental ward was built last year. The community initially wanted the ward to be placed a number of kilometres from the main town, though eventually there was an agreement to have it on the hospital site, much more appropriate and useful to the patients, who often need lab tests and medical care. I hear about the experience these doctors have had working in different parts of the country and the varied challenges they faced during their training and work. Most of all I am impressed by the enthusiasm, dedication and love both of these doctors show in their work with mentally ill patients and they I walk with them to teach our 6^th year medical students inspired by their commitment. We have a good afternoon practicing OSCE stations and Dr. Jibril chooses the cases this afternoon. We concentrate on documentation as a task, as this is something that can be improved in every area of medicine and having the students practicing it now is useful. 

Mental health training in Somaliland - Day 29

Saturday 19^th October

Today I meet with Dr. Jibril, Dr. Zainab, Su’ed and Faduma on the mental ward at the hospital. We do a ward round together and use it as a learning experience. Dr. Jibril presents the new admissions that he clerked two days ago and together we all discuss the management decisions. We are trying to encourage an atmosphere where discussion together among nurses and doctors is usual and where each member of the team may ask questions related to management decisions, if they are not clear or do not agree with proposed plans. Though there is often a very clear hierarchy between doctors and nurses here, I am impressed with how the team works together. Dr. Jibril consistently empowers the nurses that work alongside him and values their importance.

One of our main discussion points again today is prescribing.  I realise just what a difficult position these doctors are in; working hard on the ward without any senior supervision on the ground. Though Dr. Jibril is supervised online by a number of international doctors and makes great use of this, there is nothing like having someone there, face to face to discuss things with. I wonder how I might manage if I were in his position. I have great admiration for them all.

I also begin to understand better why patterns like polypharmacy and high dose prescribing of antipsychotics become routine here. It is easy to say that it is wrong, though considering that there is no supervision available, very few staff available to work on the ward and very high risk patients, perhaps it is understandable why this is resorted to. Patients tend to be prescribed high dose antipsychotics and even depot antipsychotics on admission to the ward, when the diagnosis may still be unclear. Our discussion is very helpful and Zainab, who will be taking over from Jibril when he leaves for his upcoming residency also finds it useful. She will also be here with only international mentorship to help guide her management of patients. Again, I see photographs of patients who are now on the ward who have been chained. During the ward round, one patient tells us a story of how he was chained by his wrists/hands when unwell and chained to a tree, very high up, for 7 days. He was taken right out to the border of Djibouti and Somaliland and left there, like this. Now, the man was calm, coherent and very pleasant and I felt so sad that he could have been treated in this way simply because he had a mental disorder. Essentially tortured, as Jibril pointed out.

There was a very interesting case presented by Jibril, a new admission to the ward. The most striking feature was his substance misuse/dependence, his extremely traumatic history and his significant risk to others. In the UK, this man simply would not be on this type of ward. He would be in secure forensic services, detained under the Mental Health Act and likely the Consultants looking after him would be answerable to the DOJ. Here there is no Mental Health Act, no forensic services, no seniors to guide management. So this patient was being managed on the ward.

I was thrilled today as I had the opportunity to visit the community mental health service. Fadumo the nurse leads and teaches ten community health workers who are trained in mental health, child and maternal health. We visit the community in which they work in Borama. Jibril tells me it is one of the largest slums in the area and houses around 37,000 families. I am lucky to be able to meet with the community health workers who do such fantastic work in this area. They are all females, and have been selected as they live within the community. They are trained for 3 months and then work closely with Fadumo. They find people with mental illness in the community and encourage them to attend appointments in the community with the doctor, or Jibril visits them in their homes with the nurses. They do a lot of psychoeducation work, which they say they feel has spread through the community. This helps to reduce stigma surrounding mental illness and therefore to lessen practices such as chaining and they report that chaining has decreased in the area they work in the time they have been there. It is interesting to hear one CHW comment on how before she began her job she too would throw stones at people with mental illness, though now loves to see people get better with treatment and really values her role and job. It is so positive to see this kind of work happening in the area. 

Mental health training in Somaliland - Day 28

Friday 18^th October

Today was officially the weekend, though we decided to meet as the mental health group, in view of a lack of time available before the 5^th year teaching next week. Myself, Dr. Jibril, Dr. Zainab, Dr. Gurguurte and Aidrous all met as a group. This was the first meeting of this kind in Borama and it was a delight to spend time with the group and discuss matters to do with mental health. The team here are very keen to be involved further and we had an interesting discussion to start with about psychopharmacology and importantly, poly-pharmacy, as it is so often used here. This proved to be useful and we agreed to continue the talk tomorrow on the mental ward, whilst looking at real patient notes. We discussed the potential plan for further integration of psychiatry into the 5^th year medical student curriculum and also discussed further potential input that could be offered, in terms of mental health. Following the meeting, I meet with Zainab, the mental health rep and we discuss and review the lectures she will present next week as part of the medical student teaching. 

Anaesthesia trainee in Zambia - A volunteer perspective.

Dr Lowri Bowen is currently in a 6 month volunteer post with the Zambian Anaesthetic Development Project (ZADP) working at University Teaching Hospital, Lusaka. She will enter her final year of anaesthetic training on her return to the UK in February.

The MMed programme has currently taken its third intake of trainees destined to complete the four year course and become Zambian trained Physician Anaesthetists, which is very exciting. The ZADP mandate has many different guises so I am frequently seen changing my hats of responsibilities! It incorporates teaching on the MMed programme as well as clinical officers (which I’ll touch on later) mixed in with trying to coordinate the department’s patient safety initiatives, resources, and equipment and governance issues.  I know this already sounds hectic – I’ll try and just give a flavor of the supervision, clinical and teaching aspects in this installment!

Monday morning. The day starts as usual with the 20 minute bicycle ride in to work alongside Dr. David Snell, the in-country lead, which is pleasant due to the temperature being cool at 7am (in contrast to the 32C in some theatres by midday). It’s a chance for some exercise and also a great time to plan the day ahead and to debrief on the way home.

I was supervising a second year trainee with a very interesting (to anaesthetists) maxillofacial case who had a HUGE swelling (most likely tumour) over his jaw extending right up to his cheekbone and slightly to the side of his eye (parotid/maxillo/temporal) area. Looked like he had mumps! Anyway he managed to open his mouth a mere 2cm and then I could see that the whole back half of the right side of his mouth was also involved so there was barely any room for doing anything there - never mind the potential bleeding risk. His jaw movements were also pretty non-existent. So goodness knows how he was eating anything solid. So, although I was the supervisor, it was time to phone a friend and off I went to find David. The three of us, Dave, the trainee and I, concocted a pretty robust plan, which included further plans B, C and D to cover all eventualities and scurried around to locate all sorts of equipment that may have been helpful. In the UK this case would have had a specialized fibreoptic guided intubation with the patient awake or a few other more complex options, which are not available to us here. So we had settled on using an inhalational induction (breathing the anaesthetic) to get him off to sleep and then placing the laryngoscope in the left side of the mouth; usually we place the blade in the right side of the mouth – but this was physically an impossibility. We had also insisted the maxillofacial surgeon to be ready for action with his knife to place a tracheostomy if all the plans failed.

Meanwhile the maxillofacial surgeon had clearly got bored of our detailed planning and decided to cut out the middle men (i.e. us) and put in a tracheostomy under local anaesthesia! So there we were - a functioning airway without the stress for us! Once he had secured the tracheostomy we could begin the anaesthetic, which was then thankfully uneventful. Once he was asleep I looked in his mouth with the laryngoscope to see what would have happened had we not placed the tracheostomy in him and actually had a pretty good view of his vocal cords - grade 2a. However, the whole planning and preparation for a difficult airway was something the trainee remarked on being a great learning experience for her (me too I thought as thinking of all eventualities out here isn’t always easy!)

I have been up and back to Ndola in the Copperbelt with another of the trainees a weekend or so ago. That was an interesting ride at night. Amazing amount of trucks and lorries. Some with and some without lights, some dangerous and some not. Some cars in ditches and some not, some pot holes and some speed bumps and some dusty off road bits but a rich pattern of life along the Great North Road. I can now easily comprehend why so many of the emergencies and resulting fatalities in UTH are road traffic accidents.

We are due to teach a Primary Trauma Course aimed at managing trauma in low resource settings – and is pertinent as it is one of the highest – if not the highest cause of deaths in Zambia. Running these courses is great as it will increase the numbers of doctors from all sorts of specialty backgrounds to be able to deal with trauma in a safe and uniform way but it also encourages Zambians to take ownership of teaching on their own courses. After a successful first course last year in Lusaka this will be the second course to be held in Zambia and will have newly trained Zambian instructors teaching on it. A particular delight to me is that one of the anaesthetic MMed trainees is one of the leads in the organization of the course. This is incredibly encouraging for the future of the course and will have further far-reaching benefits for further course developments in Zambia in the future. So as we had lots to do in Ndola and ran out of time, we came back in the dark again - via a wrong turn that almost took us to the Congo, which even I agree probably would have been dangerous!

My Monday afternoons have been devoted to teaching the MMed's alongside David. This is my favorite teaching job as it is the day where we teach our newly started ZEST sessions - Zambian Emergency Simulation Training! Zest as in lime - refreshing and new, a twist on the conventional teaching methods. The sessions are run in the nearby medical School skills lab, which has a few basic resuscitation dummies, which enable a good range of clinical scenarios to be practiced.  We usually run a few scenarios using an ipad bluetoothed to the iPhone as a remote control monitor to show observations that change according to the interventions done – so it’s as life like as possible. The origin for it came after one of the trainee’s asked if we could do a session on defibrillation (electric shock to the heart) as none of them had ever defibrillated a live patient (or dummy for that matter). This in itself is an interesting and eye-opening fact however when thought of in the context that there are no monitors or defibrillators on any wards except Intensive care (and obviously theatres) I guess most cardiac arrests are not identified as those that can be shocked or not. I do think the Vinnie Jones basic life support ‘Staying alive’ video has a role to play out here! The trainees seem to enjoy it though and are now feeling more confident to tackle any such eventuality! Anaphylaxis up next week….  

I have also got a slot teaching the clinical nurse anaesthetists every other Friday. These guys are not linked to the MMed programme and are not medical doctors. They do a basic physician helper training course and then that is topped up by a two year training in anaesthesia before potentially travelling all over Zambia to deliver anaesthesia. So far I have delivered two sessions and it has been well received and enjoyable to me. In fact I am humbled by their thirst for knowledge. I was worried in the first session as they are all required to attend teaching in their shirts and ties and wear their clinical white coats fully buttoned up. Combining this and the midday heat after a few of them have come straight from a night shift I was totally amazed that the attendance has been 100% and that only one person has exhibited heavy eyelids for a few minutes!

I have found working in Zambia fantastic so far. Yes there are frustrations but the overwhelming positivity stems from the hope for the future and the current batch of MMed trainees (as well as the small interaction I have had with the clinical officers) are certainly giving me plenty of hope for this end.  The staff at the hospital have been very accommodating and friendly, and my Nyanja is coming on leaps and bounds! It is truly a wonderful part of the world to live in and I am very grateful for the opportunity to be here and would like to thank not only the MMed trainees but also the local anaesthetic consultant faculty, the theatre and ICU staff as well as THET for allowing me to transition to life in Lusaka so smoothly. I am looking forwards to an interesting few months and hope to continue with a few further blogs of the programme in due course.

Mental health training in Somaliland - Day 27

Thursday 17^th October

The morning is spent visiting the mental health ward with Dr. Jibril. I join him for the ward round, alongside nurse Su’ed and Fatima. Fatima usually works in the community and leads the training for the ten community health workers that now exist in this area, due to the hard work the team has put in. Su’ed works primarily on the ward and so knows the patients. The patients are seen individually in their bedrooms, after the ward has been cleaned. At present there are 8 patients on the ward and five of them are new admissions!

We see three patients together. One man who was chained by his family and was experiencing psychotic symptoms at admission. He had also been chewing khat. With the right medication and discontinued khat use on the ward, his psychotic symptoms had subsided. He was now calm, able to engage in conversation and there was no aggressive behaviour shown at all. He was encouraged to come out of his room and sit in the open area of the ward to get some fresh air. We discussed the importance of psychoeducation for both the patient and his family.

Often people are chained as there is such stigma associated with mental illness and families simply do not want others to see their relatives when they are unwell. Without psychoeducation, patients simply do not take their prescribed medications, and end up relapsing, as had the next patient. We had seen him only a week or so ago, when he had consented to take part in teaching for doctors. Now he had been re-admitted and was visibly manic, disinhibited and pressured in speech. This man had also been chained up at home prior to his initial admission to the ward. Rather than being chained by his legs, his wrists had been chained together with a large rusty chain. This meant that he was totally dependent on others for his life. No matter how many times I see a person who this has happened to here, or hear another story of this type of treatment of people with mental health disorders, I am consistently shocked. I find it so saddening that people like this man can be treated in such a way. There is such a dire need for country-wide dissemination of information about mental illness and psychoeducation for both patients and their families, which the current system simply cannot support with its capacity at present.  

Following the ward round, we discuss each case and talk specifically about medication. There is a great deal of polypharmacy used to treat mental disorders, particularly psychosis, where often patients may be treated with both Chlorpromazine and Haloperidol. Dr. Jibril is currently working on an audit to analyse what is going on in this area and we discuss the importance of this monitoring to measure practice. I am very impressed with the team’s efforts on the ward. They keep an organized system of notes, with regular progress notes for each patient and are also keeping statistics of admissions and discharges, along with demographic information and information about treatment and diagnosis.

The afternoon is spent with the 6^th year medical students doing OSCE practice. We manage to get through a number of OSCE scenarios today, including mania, anxiety disorders, a couple of child psychiatry scenarios and delusional jealousy. Today I am pleased with the student’s progress. They seem to also be thinking more about OSCE technique, which is great. 

Mental health training in Somaliland - Day 26

Wednesday 16^th October

Today is the second day of the Eid public holiday celebrations. I meet Dr. Jibril at 08:00 sharp to plan a proposal for the further integration of psychiatry to the medical student curriculum. This is something that has been discussed in both Hargeisa and Borama, with senior faculty members. We decide to write a Powerpoint presentation to clarify the details in our own minds. The challenge will be who leads the students whilst they are on their clinical attachments in psychiatry and this is something we spend some time thinking together about. This will be the first time psychiatry is included on the medical student curriculum as a discrete clinical attachment and so, if it comes to fruition, it is very exciting for the Universities and also the students. 

At present, they only get the 2 week psychiatry teaching course that KTSP delivers in close collaboration with local colleagues, and it is recognized that this time period is very short. To give the students the opportunity to follow up patients for a period of a number of weeks would be a fantastic opportunity – to give them insight into the patient journey, to deepen their understanding of mental disorders and their impact upon patients, their families and the wider community, and to give them the opportunity to perhaps face their own prejudices and fears regarding mental illness. It is also a great opportunity to give medical students more time to get involved in psychiatry and perhaps it will lead to changed views about the specialty in general and a further willingness to liaise with psychiatry colleagues when they enter other specialties such as medicine and surgery. 

We email our proposal to members of faculty, the THET team, in both Somaliland and London, doctors on the ground and UK colleagues. There is the potential for this to go ahead this year, if logistically it is feasible. We look forward to their responses. We also discuss Jibril’s upcoming residency  and how we may collaborate on writing a couple of papers together. It is exciting working with Dr. Jibril; he has endless enthusiasm for psychiatry and really inspires others around him. 

Mental health training in Somaliland - Day 26

Tuesday 15^th October

Today is the Eid public holiday. The place is packed with people, families and children all wearing bright colourful clothing. The praying began early this morning and feasting follows the day of fasting yesterday. It is wonderful to see families celebrating and children running around freely. It is customary for each family to slaughter an animal, usually a sheep or a goat on this day to eat together; it is about family and inclusion.

I spend the day making amendments to a paper I have written with Dr. Peter Hughes that has now been peer reviewed and will be re-submitted, hopefully to be published.  It is based upon our work here in Somaliland and so this is an exciting thing to be doing whilst I am here in country.

I meet up with members of the faculty and Dr. Jibril later in the evening for a celebratory dinner. It’s great to hear that many members of faculty are extremely keen to continue with the TOT courses we have now piloted and in particular would like to see more of these such courses for senior members of faculty. I am delighted to hear that the Head of Medicine shall be attending the psychiatry teaching for medical students next week. It demonstrates a keen interest and a willingness to consider psychiatry in other specialties. Liaison is important here and Dr. Jibril and this doctor already act in liaison, referring each other patients that they feel may benefit from cross-specialty input. This is very positive and something that will inevitably improve the care of people with mental disorders.  Cross-specialty management may also help to break down the barriers that exist between mental health and other medical/ surgical specialties. It will also hopefully reduce the stigma associated with psychiatry and mental health in general that exists in many different places in the world, even among health professionals. 

Mental health training in Somaliland - Day 25

Monday 14^th October

The morning is spent with continuous meetings from 8 am until 12:00 midday. It is the day before the Eid celebrations and so there will be two days of holiday and we need to ensure things are going to plan for the medical student teaching that shall begin next week with 68 students! 

I first meet Jibril and we talk more about the audit he has started on the mental ward. He is looking into drug prescribing for patients admitted over a 6 month period, against the drugs suggested by the mhGAP Intervention guide, the WHO evidence-based document that aids diagnosis and management of mental disorders. This is an interesting area and we review some of his data together. It is not uncommon here for patients to be treated using multiple psychotropic medications and from his results it is clear to see that many patients have been medicated using more than one antipsychotic. With the older antipsychotic drugs being commonly used in Somaliland, the risk of polypharmacy is an increased side effect burden, increased morbidity and possibly mortality also. This is a great beginning to analyzing more closely what is happening on the ward in terms of treatment, and we think together about the reasons why this may be happening. One issue is whether the patients are receiving the correct diagnosis. Another is whether their symptoms have been documented accurately in the notes. Documentation is always an issue in audit. Another is whether patients behaviour changed during their admission, or soon after admission, thus warranting more acute treatment, which resulted in multiple drugs being used. There are many questions to ask and the positive thing is that they are being asked and considered.

The next meeting is with Zainab, the mental health representative, who is also a new intern doctor. Today is the first of our supervision sessions. We talk generally about supervision, and she brings along her ideas of what she would like to achieve through supervision. We make a plan for her to begin a portfolio, so that she can collect evidence for all the great work she will be doing. She will be taking on more of a leadership role in the near future and working part of her week on the mental ward, so she will benefit from documenting her experiences. 

Mental health training in Somaliland - Photos from TOT course.

Dr. Luren Gavaghan and Trainees

Dr. Gavaghan and Trainees

Mental health training in Somaliland - Day 21. World Mental Health Day.

Thursday 10^th October

Today is World Mental Health Day and we begin it with our fourth day of the 5 day TOT mental health skills course for doctors and nurses. I encourage the course participants to think of something they might do during the day, to commemorate the occasion. We get on with our teaching and today the participants use OSCE as a teaching technique.

Dr. Jibriil has been busy all morning arranging a celebratory meeting to commemorate World Mental Health day. At 10 am, we are joined in the classroom by many people. Dr. Walhad, the principal of the University of Amoud, Dr Ismail, the hospital Director, many of the faculty staff, public health officers and health officers of the region, religious leaders, community elders, and doctors including Dr. Jibriil and Dr. Gurguurte, who are both working extremely hard to ensure mental health services exist in Borama. Also in attendance is Fatima, who currently leads and trains 10 community mental health workers, and also all the female community health workers themselves.  

This is the first meeting of its kind in Somaliland to commemorate World Mental Health Day and I am thrilled to be a part of this. Many of the attendees make speeches and the focus is on mental health. Fatima is also invited, as am I, to speak, and later I am told that a community elder talked about the empowerment of women being a vital step forward, among other issues. This is a great thing to hear here in Somaliland. I am particularly impressed by just how much community mobilization there is in Borama. The community really do seem to have come together and mobilized in an inspiring way and from what people have translated for me from the meeting today, it is clear there is the plan among the community to continue to improve mental health services in this region. Today I really do feel privileged to be in Somaliland.  

I also hear from colleagues in London that Hargeisa has featured in a short documentary about mental health, aired on Channel 4 last night. Mariam, the nurse from the mental ward at  Hargeisa Group Hospital is shown on the programme. I telephone her after I see the footage, and tell her that she is famous worldwide! Mariam works extremely hard on the ward in Hargeisa and I am so pleased that her hard work and dedication is finally shown to the world. In her humble way, she simply says ‘Lauren, I like looking after people with mental illness.’

I finish the evening with a Skype meeting to London, where I discuss the mental health group work with the wider KTSP community/ leads. 

Mental health training in Somaliland - Day 20

Wednesday 9^th October

The morning is spent with the interns and nurse participants of the TOT training. Today we work on using group work and case discussion as a teaching technique, which the participants enjoy. We are also led by one of the participants, Layla on the mental ward. She prepares in advance for a teaching session and it is clear she has done this well. We see a young male patient whilst on the ward who has been admitted for the second time with mania. One of the participants takes a brief history and carries out a mental state examination. 

Much of today is about how the participants manage teaching in a clinical environment and demonstrate their ability to do this in the future as teachers. The afternoon is spent meeting students I taught in May this year, who are now spending the afternoons with me, revising psychiatry. We spend today working through how one might take a focused history and perform a mental state examination in an OSCE context and they practice doing a psychosis OSCE scenario. I am impressed by their level of remembered knowledge, considering they have not done any psychiatry since I was last here, they seem to have remembered many details. I will be thinking with them, as I did the students in Hargeisa, about techniques they might employ in an OSCE, as well as working on their knowledge base. I am pleased to bump into an old student of mine this evening. I find out that he did extremely well in his final medical school examinations, getting the top mark of the year, and has subsequently been attending a family medicine programme, which he is thoroughly enjoying. 

It is a joy meeting old faces that I know here and I am reminded of the work I have already done. I get some news via email regarding a paper I have written about the incorporation of the WHO’s mhGAP-IG into our medical undergraduate teaching. It has been under peer-review and I have been asked to make corrections. I hope after this it will be accepted for publication. This is exciting for me, in view of the commitment I have shown to the work done here and it would be great to see some of the work disseminated to a wider audience. 

Tomorrow is World Mental Health Day and myself and Dr. Jibriil are considering what we might do to mark the occasion. We plan to visit the mental ward and do something from there. I am happy to be in Somaliland during this time, doing what I am doing. 

MMed training in Zambia - a new arrival.

My name is Dr. Katie Williams and I am three weeks into a three month “Out of Programme Experience” (referring to my UK training programme), in Lusaka, as part of the MMed Psychiatry programme.   Back in the UK, I am based in Nottingham and I am a Specialty Registrar in General Adult Psychiatry, in my final year of training. When I heard of the exciting opportunity to spend three months working with the MMed psychiatry programme in Zambia, I thought it was too good an opportunity to miss, and so here I am!

My main base whilst I am here is Chainama, the main mental health hospital in Zambia, where the trainees gain a lot of their clinical experience.  There are clinical officers working at Chainama, who are trained for only 3 years in mental health but are not trained nurses or doctors.  They are expected to take on a lot of duties, such as deciding which patients should be admitted, clerking patients, making diagnoses and prescribing! There is a lot of difficulty recruiting doctors into psychiatry (same as in the UK), and at the moment there are only 7 doctors in the whole of Zambia doing postgraduate specialist training in psychiatry. My main role during my time in Zambia is to be involved in mentoring the first year MMed trainees in their clinical work, by providing ward and clinic-based teaching and tutorials.  

At Chainama, I am based on a male acute ward, which has about 30 patients per firm. You enter the ward through a padlocked iron gate, and unsurprisingly there is usually a gaggle of patients hovering at the same door trying to leave.  The ward reviews are slightly chaotic, as many patients wander in and out as you are trying to review somebody else, shouting, singing, praying, or becoming agitated and asking to go home.  Usually the patient you are trying to see sits there quietly, as others join him uninvited, sitting next to him on the bench, as if there is no reason they shouldn't be there.  The nursing staff try their best to encourage these patients to leave the room, however it doesn't take them long until they're back.

We have a lot of patients admitted due to alcohol problems, mostly withdrawal problems - delirium tremens, and also "alcohol induced psychosis", which I haven't previously come across in the UK.  There is a big drinking culture in Zambia, especially for those with low incomes, and the local brew is apparently very strong.  As well as the patients with mania, schizophrenia, and alcohol-related problems, we recently have had a patient admitted following a high-profile suicide attempt.  He had climbed up one of the telecommunication towers in the city centre planning to jump, and had been rescued by the fire service sparking a lot of media attention. He had stated that he was going to jump because he could not get a job and needed better housing, and the government had taken interest in this, sending victim support counsellors to Chianama to follow him up. His story was a genuinely sad one. He was a man in his 30s, the sole breadwinner, with a heavily pregnant wife and two young children already. His permanent job had ended a few months back as the company had folded and temporary jobs were getting more difficult to find. He had reported to the local government to seek advice and support, as he had no money and no food for his family. After attending again and again with no offer of a solution, he eventually started to feel hopeless about the future, hence impulsively climbing the tower with the thought of killing himself.  Since being on the ward, a social worker and clinical psychologist have visited his one-roomed family home and were appalled at the squalid and bare conditions, and the lack of food for his wife and children.  There have been some donations of baby clothes for when the new baby arrives, and the social worker is going to provide the family with some basic food, also using money from donations. There is no benefit system in Zambia, and I am told if you don't work, you don't eat. People in this situation often then rely on extended family to help them out financially; however, this man's mother had also joined them asking to be provided for by him, adding to the pressure of the situation. We are hoping that the ward social worker will be able to help with his social circumstances, which would have a significant positive effect on his mental health.

Another of the key aims of the programme currently is to support each MMed trainee to complete an audit, with the goal of directly improving patient care locally. There are different ways of doing things here, such as rapid tranquilisation, and there are some clinical areas which would greatly benefit from interventions to improve patient safety and service quality. Once these audits are completed, we hope that the trainees will present and publish their results both at a national and international level.  I am also involved in teaching medical students of the University of Zambia during their psychiatry rotation, both on the wards and in tutorials and lectures.  I understand that recruitment into psychiatry in Zambia is a challenge, similar to the problem we face in the UK, so our intention is to stimulate an interest in psychiatry at an early level, so that they may consider psychiatry as a future career. With World Mental Health Day on the 10^th October, we are arranging events for spreading awareness and education about mental health disorders, including designing informative posters, arranging a film club with a psychiatry theme, a medical student essay competition, and a carers meeting.

Finally, since arriving I have been most struck by the friendliness and politeness of the Zambian people.  Zambia itself seems to be a diverse and fascinating country, from the modern malls in Lusaka to the natural beauty of the national parks and of course the Victoria Falls, which I am looking forward to visiting at some point during my trip.  I am very grateful to all of the MMed trainees, Dr. Ravi Paul and all of the THET staff for such a warm welcome to Zambia and I am looking forward to a productive and rewarding few months ahead.

Katherine Williams with nurses and clinical officer students, Zambia.

Mental health training in Somaliland - Day 19

 Tuesday 8^th October

The second day of the TOT training goes ahead and today I am relieved to find out we have a working projector. Each day we set the students specific tasks and today they had to prepare and teach a ten minute session about psychosis/schizophrenia. This they did using Powerpoint. They are a strong group and I hope they are beginning to realise what a rich resource they can be for each other in the future. Today we also visit the mental health ward, mainly as a means of outlining how one could introduce a ward to students when teaching.  Tomorrow a participant in the group will lead us on the ward and use this visit to experience clinical teaching. 

Mental health training in Somaliland - Day 18

Monday 7^th October

We begin the second TOT training today. There are a few teething problems, such as lacking a working projector, which stalls things momentarily, though it is necessary to just keep on. It is often necessary in this kind of work to be flexible and adaptable and these are certainly the words of the day! Again, it is great to see students who are now graduated as doctors. The group seems strong, with a few a nurses too, which adds to the richness of the group. I am impressed with Dr. Jibriil’s teaching skills; he has clearly been doing much teaching here in the time since I last saw him. I am also very pleased to have Dr. Layla in the group, a member of the mental health group. Alongside her is Dr. Zainab, a new doctor who is the second mental health representative this year, and shall be taking a lead role in teaching of the 5^th year medical students in a couple of weeks. 

Mental health training in Somaliland - Day 17

Sunday 6^th October

Over the last two days I have been busy completing my online application form for jobs in the UK, for when I return. Today I travel to the west of the country with colleagues. We drive in convoy with an SPU (special protection unit or guard) travelling behind our vehicle. The movement feels nice after being relatively static in Hargeisa. The landscape changes as we drive, from arid desert to much greener lush scenery, with mountains in the distance. We arrive as the skies open and getting the ton of paperwork out of the car inside proves to be quite a challenge! I am met by the Principal of the University here, who welcomes me. I am pleased to be back here as I visited last year to undertake the 5^th year medical student teaching for the first time. Last year I was here with Dr Peter Hughes, a Consultant psychiatrist who has much experience in the field of teaching mental health in low income countries. He taught me much last year and earlier this year and I am reminded how grateful I am to him for allowing me such opportunities. This year he shall not be joining the teaching, but another doctor from the UK. This means I am leading the trip this time, which is exciting, though I quickly see just how much organization is required to enable it to happen. This year we will also have a larger group of students than ever before, 68!

I am met this evening by Dr Jibriil, a doctor who does a huge amount in terms of mental health/psychiatry work in Somaliland. It is great to see him after a year and a half and he has much to fill me in on, for he has been very busy setting up new community projects here in mental health, opening a new mental health ward in 2012 and working on a project that trains community health workers in mental health. This project has had good results in terms of patients in the community with mental health problems being recognized and referred appropriately to services. The benefits of training community health workers are huge- they are people that know their communities well, are able to communicate in simple and understandable language and gain access to communities in a way that perhaps other health professionals would not be able to. This use of human resources is also about task-sharing, in that it is not imperative for such a person to be a specialist in mental health, with the basics, these people can go out and begin to raise awareness of mental disorders within communities, which may reduce stigma and also enable people with mental disorders to access the help they need. It is a strategy that works, as shown by projects in other countries such as India and Uganda.

Dr. Jibriil and I discuss his progress also- he has been accepted to go to Ethiopia for 3 years from January 2014, to complete his psychiatry residency there. He has done much to prepare for this and is an excellent candidate. We plan for the upcoming TOT training that shall begin tomorrow, which Jibriil shall be co-leading with me on. This is a great opportunity for him to develop his own teaching skills further. 

Mental health training in Somaliland - Day 16

Thursday 3^rd October

The morning is spent seeing new patients from the community with the ward doctor on the mental ward. We see two patients together, and we are joined by a 6^th year medical student, Abdilahi, who is keen to participate in the history taking and then another 5^th year medical student who will soon be doing the 2 week psychiatry teaching.  We use the morning as an opportunity for learning and the medical students take the history, with the ward doctor Dr. Abdifatar, adding to this and formulating the management plans. The first patient is a 30 year old female, who likely has a genetic disorder, given her appearance. She has never visited a doctor, despite there having been problems with her walking, her speech, eyesight at times and more recently her behaviour, which has involved her burning and hitting herself. This is not unsurprising in Somaliland where most often the first port of call is the traditional healer or ‘Sheikh.’ She has been taken by her family to see the Sheikh a number of times and he has done many things to attempt to cure her, including slaughtering animals and praying for her.

At home now, she is often locked up if she becomes angry, and this usually leads to her burning herself. Her relative shows us burn scars on her body. It is a difficult case, though not uncommon, where there are significant problems, including social issues, with the family not feeling able to look after her anymore; however, the reality is that in-patient admission on a mental health ward is likely very inappropriate for this lady. We devise a plan for her to be checked by the medical doctors and prescribe some medication to aid her sleep, which at present is very poor. The team will continue to follow her up as an out-patient at home. The next patient is an elderly man who denies all psychiatric symptoms, though there are reports from his family (who are not present to give a history) that he has been found talking to himself. He is not psychotic when we meet him and in fact only complains of headache and pain in his arm. Often depressive illness or psychiatric illness manifests with somatic symptoms in this part of the world and so we cannot rule it out. He also looks rather flat, though we are at a disadvantage as there is no corroborative history. The team makes a plan for him to be seen to rule out organic causes for his reported symptoms, given his age and suggests he returns with a family member next time who can give some history. We are joined by Dr. Liban on the ward who gives an explanation to the medical student and the patient and they leave.

The afternoon is spent organizing all the paperwork for the 5^th year medical student teaching that will happen in October. There is a huge amount of paperwork to get ready and Samatar and Saafi in the THET team have worked hard to ensure it will all be ready on time.

One of the THET team members is leaving soon and so we all have a barbeque together at the end of the day. 

Mental health training in Somaliland - Day 15

Wednesday 2^nd 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 6^th 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. 

Mental health training in Somaliland - Day 14

Tuesday 1^st October

I meet with the Clinical Lead, Dr. Mahdi, and another international doctor who has made Somaliland his home, to discuss psychiatry on the medical student curriculum. We are thinking about how psychiatry may be incorporated as a clinical attachment in the medical student final year. At present they only get 2 weeks of formal psychiatry teaching in their penultimate year and it would be valuable for them to have a further opportunity to meet patients and discuss cases as well as this. All agree that this is important, though fitting it in to their already very busy time schedule is another thing altogether. We think up a few different options for how this might work and I present some potential learning outcomes that might form the basis of a final year medical student log-book. We agree to maintain communication about this issue and all anticipate that this could become a reality perhaps in the next year.  Supervision is highlighted as an issue, as it always is, though we are excited that there will be two doctors returning from having completed Masters in mental health in Ethiopia in a few months’ time. They will no doubt be a fantastic resource for the medical students and also young doctors.  I am pleased that psychiatry is being taken seriously, that there is a real want to include more of it for the medical students.

I spend some time re-reviewing the medication of patients I saw yesterday and making management plans with them and their relatives. I then spend some time on the mental ward and talk through the current management of a female patient with the new doctor there. We come up with a treatment plan together and I agree to return tomorrow to review a few more cases with him, using them also as a learning experience for him.

The afternoon is spent with the 6^th year students and they are excited today. They are happy and finally feel that they are really beginning to understand the art of OSCE’s for examinations. I am also pleased that they are remembering much of their psychiatric knowledge from when we taught them in May this year. They are a keen group and as always it is a pleasure to teach them and see them develop their skills. The message of our session today is ‘listen to your patient; he will give you the answers.’

I am visited in the evening by Dr. Gurgurte, who has worked very hard alongside his team to develop mental healthcare services in his part of the country. He is extremely positive about psychiatry and works tirelessly on both a mental health ward and also in the community to treat patients. He comments that he is happy to see patients, who he has treated, recover, and this propels him to continue his work. I am thrilled that he is happy working in psychiatry and, more and more here, we are seeing doctors who really do have an interest and a commitment to the specialty. Even those who do not go on to specialise in psychiatry, as very few in reality will, will be able to use their skills in mental illness wherever they are in medicine/ surgery, and so it is great to see people enthused and enjoying the subject. Unfortunately all too often there is stigma attached to psychiatry and mental illness, even amongst the profession and medical students, and it is part of our role here to also work at trying to lessen this stigma. 

Mental health training in Somaliland - Day 13

Monday 30^th September

The beginning of the morning is spent with the team in the office, organizing and trying to arrange meetings with various people this week. Part of the discussion with seniors this week will be around supervision for the final year medical students and how this might be implemented from a mental health learning standpoint. I am also trying to arrange a meeting with members of a mental health group that has been collectively set up and at present consists of doctors who have an interest in mental health and education. It is a challenge to arrange, as many of the doctors are inevitably busy and everyone is running to different schedules, though we all agree that we would like to try and meet together this week. I feel it would be valuable if this group could come together more, in order to discuss mental health and the progress they are making/activities they are involved in; they are a strong group who have already led to change and can continue to do so.

I go to the hospital where I have two patients to see. I meet them with a couple of my medical students and their relatives. The challenge of history, talking through a translator, and, as often is the case, knowing little in the way of background history or known diagnosis is something I am reminded of as soon as I see the first patient. They are complex and I am left with the impression that the first man may have a psychotic/agitated depression, which had in the past been treated with ECT, though this is no longer available in Somaliland. He has unfortunately been chained by his family for many years as he often leaves the family home and ends up on the streets chewing khat. The family are understandably worried that one day they will not be able to find him. He has clear symptoms of depression and has lost weight as he is not eating. His sleep is poor and he no longer enjoys life, saying he wants to die, though denies any intent or plans to end his life.

It appears that the second man has a psychotic illness, most likely schizophrenia, judging by the history his relative gives. He unfortunately has tardive dyskinesia, which may be due to having been prescribed typical antipsychotics over a long period of time. He is now taking Olanzapine which seems to be helping his symptoms. He has epilepsy though and his family are concerned that his seizures are not well controlled, with him continuing to experience seizures at least twice a day. This seems to be a priority rather than his psychotic symptoms.  

After taking histories from the patients, I suggest we meet again tomorrow to discuss appropriate management. I include senior Psychiatrists in the UK and email to ask their advice with regard to treatment options later in the evening. I visit the mental ward and speak to the doctor there, thinking about what might be useful to work on whilst I am here. We agree that seeing some clinical cases together, as he is new to the ward, and discussing management would be helpful and make a plan to do this.

The afternoon is spent with 6^th year medical students. Today we are discussing anxiety disorders and practicing OSCE scenarios. Unfortunately many of them are very busy on their wards and so cannot make the teaching. They are spread out around the hospital undertaking clinical placements in Paediatrics, Obstetrics and Gynaecology, Surgery and Medicine and are often caught up managing cases on the wards in the afternoons.