Monday, July 4, 2011

The last three days

On Tuesday the internet connection in the hotel goes down and the only place I can get a connection is to sit in the lobby or on the stairs to the hotel sweating profusely. We visit the psychiatric out-patients and my group see three people – one a young woman behind a veil with depression and obsessive compulsive disorder being treated with anafranil and risperidone, a second a woman with epilepsy whose main problem is the stigma of having the condition and the third an ex policeman whose main problem appears to be anxiety who is being treated with olanzapine. We go back to the University and as part of Dr. Cant’s “Amazing Exploding World” the fuse box outside the teaching room explodes and bursts into flames just before prayers. Dr. Cant is seen wrestling with a fire extinguisher (empty) whilst the locals look on sipping tea. After prayers we relocate to another room arranged like a boardroom and continue the afternoon lessons.

Wednesday brings visitors – His Excellency the Governor of the province of Gezira no less arrives to hand out a few certificates and make speeches followed by various other local dignitaries. He is an impressive man who trained as a psychologist with a PhD in brain science. The students complain that the ceremonies have taken away from teaching time which gives us an opportunity to point out the important roles doctors have in advocating for their patients at a political level. I give an impromptu lecture to the medical students in the afternoon – the main theme being that you can’t be a good doctor without knowing about psychiatry. In the evening Tom and I cross the Blue Nile to the east bank on a local boat – then come back again and have our last meal at the Istanbul.

And so to the last day – we finish with a mixture of topics – medically unexplained symptoms, bed wetting and principles of drug prescribing in mental health. Then redo the KAPS the attitude survey and course evaluation. Lots of handshakes and photos at the end then all pile into the mini bus and a mad drive back on the near death slalom course which is the three hour drive back to Khartoum. A brief stay in the Burj Al Fateh Hotel and up at 3am with neither myself or Tom having slept and to the airport – the usual border crossing hassles and then on the long flight home.

So was it worth it. The teaching was arduous – 60 hours face to face time in two weeks - and I feel I have been here for two months rather than two weeks. We know the students have doubled their knowledge of psychiatry during each week but to make this sustainable there is a need for the system to align with the goals of teaching, for example having psychiatry questions in student and post graduate exams, getting the sheiks “inside the tent” rather than outside and so on. Of course it would be better to have Sudanese psychiatrists teaching Sudanese doctors which will probably happen over time. However the ones I taught with had never done any teaching before and seemed to appreciate the support from the volunteers. Also there are only about 40 to 60 in the entire country with most leaving for higher paid jobs elsewhere – mostly Saudi Arabia and the UK. Personally although I have done a lot of teaching in the past it increased my confidence in doing teaching with short preparation time; it reminded me of the importance of lesson plans and the unimportance of PowerPoint in learning; I got some useful tips from the other volunteers; but mostly as always I admired what could be done with so little in resource poor environments.I hope to be back.

Tuesday, June 28, 2011

Today I entered “Dr. Cant's Amazing Exploding World”. It started with an explosion of yoghurt from a packaging crisis all over his greasy egg which he then proceeded to eat whist being attacked by a cockroach. Afterwards – and I quote – I feel a bit queasy now”. Then at breakfast the drink bottle he was pouring into the already dilute korkade exploded over him causing much stickiness and wetting. Finally as we were getting into the “rickshaw” to go to Istanbul (the restaurant not the well known city) he confided in me that he crashes cars....Arrived safely at Istanbul.

Apart from the introduction to this world the day went well with a session on psychosis followed by a visit to the police hospital where my group saw a man with thought disorder which provided an opportunity to demonstrate that you could do more sophisticated cognitive tests to assess different areas of the brain and to explain the difference between mania and schizophrenia. (Dr. Cant nearly arrested for taking photos of the group at the hospital...). The afternoon was spent on mood disorders with Dr. Ameira talking about bipolar disorder and myself starting on depression ending with a role play on psychoeducation to a depressed patient using DUST SHIPS. Final act of the day was MCQ’s and prize giving – Dr. Ameira clearly a closet Wills and Kate fan...

Sunday, June 26, 2011

Sunday June 26th - Day 1 Week 7

Age-standardised disability-adjusted life year...Image via Wikipedia

Age standardised DALY's from panic disorder
Brand new group - more numbers than last week. Also several house officers and more senior family doctors. Good start this morning with structuring the rest of the week and getting all the assessments done before 11. Then into the work starting off with a section on history and mental state examination with Tom revealing his hidden acting talent role playing like his life depended on it. Also got the students to do role playing in a more structured way which seemed to work. After prayers finished this off by doing some MCQ's on history and mental state exam. Tremondous prizes on offer including a Wills and Kate mug...This afternoon proceeded with anxiety and stress by Ameira and a role play of panic disorder. Whilst not in the MHGap curriculum anxiety seems to be important in primary care and probably should be included - the way it is presented in association with medically unexplained symptoms is not helpful. First mug won this pm after tie break question. Teaching team working well we now have lesson plans and clear goals about the knowledge, attitudes and skills we want the students to learn each session.
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Saturday, June 25, 2011

Break day - Friday June 24th - A plan for change?

In Khartoum wake up wandering how I am going to pay for the room but Zina to the rescue who sorts everything out. To the tremendously impressive National Musuem this morning then after a rest to the Omdurman Souk - tried to sell Sophie in exchange for camels but couldn't get a good price. Mahdi's tomb then pleasant pizza and fruit juice by the nile watching Sophie (not) feed cats.

More seriously conversation with Zina and colleague this morning about trying to sustain what we have started. Main problems identified by Zina include funding (Sudan apparently spends 3% of its spend on health care and virtually none on mental health) and strategies to get mental health care into primary care. The conversation reminded me of a research project I did 3 years ago teaching brief psychotherapy around New Zealand - the literature shows that training health professionals in new non-pharmacological interventions is not very successful with generally only about a quarter of health care workers using any new intervention after a workshop. The lessons I learned from this project that I think could apply in Sudan (and possibly elsewhere) are these:

The training

  1. Do a good initial training/workshop
  2. Follow up with "academic detailing" (supervision) of some sort - in other words after the workshop visit practitioners and talk to them about using the intervention in their practice (a Cochrane Review addresses this)

Make the system consistent with the goals of the training so everything "lines up"

For example in this case family doctors to do a psychiatric rotation (or write up a psychiatric case or some such); put psychiatric questions in their family doctor exam; explicitly put care of mental health in job descriptions; possible financial incentives etc.

Cerification - those who complete the course get accredited to do something extra that others are not allowed to do or opens other doors - for example would a "RCPsych Certificate in mental disorders in primary care (overseas)" enable family doctors to attract a different clientele in private practice?

Policy development

Then this all needs to be aligned with policy which means access to Ministers (maybe a meeting with senior figures from the College to lobby for increased attention to mental illness) and community development (includes media) so that communities press for policy change.


Until policy change leads to changes in funding priorites money will probably rely on charities/NGO to seed fund change. Could the major psychiatric colleges in the developed world raise a fund from members for mental health development - maybe a 2% annual levy on membership fees. There are probably also other charities and NGO's who would contribute if a compelling case could be made and philanthropists who may fund special (research) projects.

Technological opportunities

Technology offers two things - firstly new ways of delivering some teaching - secondly there is the opportunty for novel interventions in the developing world especially with interventions delivered by mobile phones which are ubiquitous (txt messages with health messages, reminders about medication etc). Such innovative interventions generate interesting ideas about partnerships with technology/phone companies in developing new health interventions in the developing world.

Those are my intial thoughts - any comments?

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Thursday Day 5

The chapel at the site of the old Netley Hospi...Image via Wikipedia Final day and organisation bit up in the air. "Minister" who was due to present completion certificates was due to turn up at 11 then 1 and finally at 2 which made timing of the day difficult. Also at the start of the day about a third of the students at another talk so I recapped the teaching on conversion disorders by showing the students some clips from Netley Hospital and soldiers from World War 1. Rest of the morning repeating KAP, completing attitude and evaluation forms followed by bits and pieces as the end of the course kept changing. Completion ceremony good (except for "Minister" whose phone went off during the ceremony which he answered and then wondered off without saying goodbye to the students...).

Then drive back to Khartoum where I booked into a hotel then found out I couldn't pay for it as no credit cards are taken in Sudan and ATM's only work with local accounts - bugger...

Wednesday, June 22, 2011

Wednesday Day 4

No local facilitators today so not sure how it is going to. Dr. Neima will provide some assistant but clearly she has other commitments. In the end went ok - this morning on Dementia and Delirium with an evolving case history based on a role play. I think I've now cracked how to show videos on the equipment in the teaching room. I'm still not sure how to present clinical problems to the students - doing them as role plays is a good practise of skills but immediately comes up against the language barrier.

After this Sophia on her specialities of development delay plus epilepsy (that the students seem to know quite well) and childhood disorders. I think the students get the bit about consistent parenting and behaviour modification for conduct disorders. The STAR chart also went down well.

Tomorrow not sure how many students will be there at the start as there is a conflicting talk that some of them will be going to until 10.
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Tuesday Day 3

Start off with a presentation on depression prior to the visit to the out-patient clinic. Still a problem of starting on time with students arriving between 9 and 9.30. Told at beginning of day that time to go to the out-patient clinic has changed to 10 rather 11 – just have to roll with this and not be too bothered about timetable today having to be rearranged at short notice.

Went to outpatient clinic today and the group I was with saw three cases – a 25 year old man with untreated depression currently on olanzapine. His main complaint was that he was anxious although he also had several depressive symptoms and he was clear that he had been better on amitriptyline in the past so we suggested he change back to this. The second man was an 18 year old who started to be ill 8 years ago when chopping down trees with his father and he felt that he was being attacked by insects. Since then he has been socially withdrawn and has not had any schooling. Currently he lives at home with his family and spends most of his time in his room. He was taking 100mg chlorpromazine each day plus 3mg of risperidone and was predictably overweight with extra pyramidal symptoms. He had been diagnosed as having “schizophrenic mania”. At interview he was notably withdrawn and made poor eye contact with a lack of any spontaneous movement. It was difficult to know what was going on here but we recommended that his antipsychotic medication be rationalised and that he have a trial of an antidepressant. The last patient was a middle aged man with epilepsy who was well controlled on carbamazepine and tegretol – but when he stopped his seizures came back.

Apparently lithium is not used in Sudan because of the need for monitoring so they mainly use sodium valproate.

Then back to Gizera Hospital for a presentation on suicide and self-harm – tried videos but sound quality not ok. Interesting discussion with one of the group about suicide bombers being mentally ill – very aware of not wanting to tread on any cultural toes. A recent article in Psychology Today looks at this - my simple understanding is that doing dreadful things, like murder, is rarely due to mental illness. Need TV quality sound.

After prayers lecture on bipolar disorder by Sophia. Then violence, role play of hypomanic patient by the students and quick quiz.