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.