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.