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.'