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The Royal College of Psychiatrists Improving the lives of people with mental illness

Bangladesh

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25/04/2012 09:43:12

The visit to Pabna

Pabna Hospital
The major focus of this week was a visit to Pabna hospital, only 200km from Dhaka, but a hair-raising 8 hour journey on the bus.  Pabna is the largest mental health hospital in Bangladesh and has been open since the 1950s.  I had heard numerous rumours about Pabna, mainly circulated by persons that hadn’t been, so I did not know quite what to expect.  The Chairperson of the BSMMU, Professor Mullick, had worked there previously and recommended that I visit.

The hospital is centred in around 120 acres of land, just outside the town of Pabna, and the initial approach, I guess is not too dissimilar to some of the older larger mental health hospitals in the UK, reminding me a little of Middlewood in Sheffield. The staff had arranged for me to give a presentation on both psychiatry in the United Kingdom and transcultural psychiatry (delayed a little by a power cut!) which started the day.

I guess I was pleasantly surprised by the setting. Lots of green space, a theatre hall, a mosque, a garden area – much more tranquil than the hospitals in Dhaka. The staff were keen to point out the positives of the unit in terms of being an ideal environment for recovery. I understand several weeks before I arrived, the unit had been portrayed in a negative light on national television, with a documentary piece talking about locked wards and old-fashioned treatments – the staff were clearly unhappy with what they considered to be an unfair representation.

I understand that there are 18 wards, around 2/3 male with one substance misuse wards – I was able to see 6 of the wards – with a total of around 490 patients.  The majority of patients’ care is funded by the government, with a smaller separate paying unit.  Yes, the wards that I saw were locked – the staff informed me that the wards are generally locked in the mornings, with activities and more freedom in the afternoon.  The staff said that the wards were locked for the safety of the patients – there were clearly a large number of very ill individuals with a variety of illnesses, and a variety of ages.  The average stay is around six weeks, although some patients have been here for much longer.  Often the difficulty is finding suitable onwards care if families have disowned individuals.

Pabna Hospital
The staff informed me that they utilise the government formulary (that I had previously seen in the National Institute in Dhaka) which has a reasonable selection of psycho-tropics from different groups.  The staff I spoke to seemed very enthusiastic, but were a little upset that more doctors are not interested in working there – there are only 4 psychiatrists and a few other non-specialist doctors covering both the hospital, with a huge outpatient clinic, also.  Few of the senior psychiatrists wish to leave Dhaka (I understand mainly due to family and private work commitments).  On a positive note, I met my first mental health social worker since coming to Bangladesh, and I understand that there are three individuals who use an Occupational Therapy model, as well as one psychologist.  Interestingly, I was informed that sometimes the patients take part in psychodrama in the theatre.

This part of the Royal College Link was more for my own experience. There were clearly a lot of positives about the environment, the setting, the enthusiasm, knowledge and skill of the staff. The wards are locked, and I did see several patients who had bindings on. (admittedly these patients did appear very agitated). Visiting the unit, I could understand this in the context of not enough staff to effectively manage and treat the patients in a more open ward environment. There may be potential for future doctors under the Royal College volunteer programme to do some more work at Pabna hospital - the team informed me that I was the first British psychiatrist to visit the unit in many years and were supportive of the idea of a possible future link.

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10/04/2012 10:29:35

Half-way point

A quick trip out of Dhaka

The volunteer link is nearing the half-way point, with a huge amount left to achieve over the next few weeks. I have been working on an interesting project looking at establishing an early intervention service in psychosis at the BSMMU. Essentially the task is to ascertain whether it is feasible to set up such a service without any further resources (feels like in the UK…), and to establish whether there is an evidence base for such a service in a low income country (I am yet to find such information…)


As I have spoken about previously, there are no mental health workers in the community here. Despite this, however, the team at the BSMMU believe that an early intervention service could be replicated, with biological interventions provided by a specialist clinic, psychological interventions, i.e. CBT and family therapy, provided by the psychology department, and social interventions provided by the extended family network that pretty much each patient seems to have – i.e. in-house occupational therapy and rehab training for families.

There is clearly a potential demand – a range of individuals with psychosis present to the outpatients department– the challenge is, however, that often they present later on in the time-course of illness, and it is actually the traditional and spiritual healers who are providing early intervention services currently.

I continue to work along-side the junior doctors at the BSMMU and every day am seeing large numbers of interesting patients, including many conversion cases, which are difficult to treat, as again individuals present at a later stage, via the alternative healers, and then usually via large numbers of private clinics, all of which perform a multitude of physical investigations first (often repeated several times) which seems to reinforce the belief system of many of the patients. (Including one who said he had spent £5000 on investigations, a huge amount of money here). Also, although there is no direct evidence base to support it, I am beginning to believe that there are larger numbers of individuals presenting to the services who could potentially be diagnosed with personality disorders but are not, maybe due to the necessary speed at which patients are seen in the department. A last observation is the continuing input from the drug companies – no different form the UK several years ago, but noticeable, nevertheless.

Mental health has been well-represented in the media over the past few weeks – Bangladesh lost to Pakistan in the Asia cricket cup, and the local media linked the result to seven suicides. The papers seem to have a weekly suicide report. This has previously been criticised for being sensationalist, rather than providing useful information on how to access help.

Medical Conference - Dhaka style

Perhaps surprisingly, I am not encountering much suicidal ideation or behaviour here (compared to the UK) which is slightly at odds with the media reports – local attempts have been made to raise awareness, with suicide being the major topic of a day seminar by the Association of Therapeutic Counsellors here in Dhaka – a very good day topped by a cultural evening in which all of the doctors took part.

Ending on a positive note, the staff tell me that times might be starting to change a little in terms of recognition of mental health - the daughter of the prime minister is a psychologist, and mental health has been discussed at several political meetings (which is new here). I understand that the department is due to move into larger premises in a year or two, also, with more space.

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04/04/2012 08:22:26

Knuckling down to some work

The multidisciplinary team in action
The placement is progressing quickly - It is about time to talk about some of the expected outputs from the RCPsych link. The first part that I have been working on with Professor Mullick is a research project to culturally validate life stressor rating scales for both adolescents and adults in Bangladesh. This has been identified as a local priority area – stigma surrounding mental health is huge here, but people do seem to understand the role of life stressors, and placing mental illness in this context can help individuals understand.
There is a huge respect for qualifications in Bangladesh, and perhaps more importance is placed on these than outright experience – because of my Msc in Transcultural psychiatry I have been judged the right person to write the research protocols for the adolescent and adult rating scale validations - which I have just sent to local research and ethics for approval. To summarise, the research will be of mixed methodology and comprise of focus groups and a survey phase. The current life stressor scale commonly used was designed in the states in the 1960s and has less relevance to Bangladesh today. A large number of potential life stressors need to be added that are culturally appropriate here - eve teasing, dowry stress, effect of siblings getting married, to name a few. The research will continue after I have left, but it is hoped that a validated rating scale will be produced by the end of the year which can be utilised in Bangladesh and possibly in areas of the UK with larger Bangladesh communities The curriculum for the mental health trainees in Bangladesh is a mix of that in the United Kingdom, the States, and Canada, and is being re-written at the moment. A lot of the buzz words familiar to those trained in the UK are becoming topical here – competency based learning is in the process of being introduced, with a slight shift from purely relying on knowledge. I have been working with the curriculum designers here to improve the curriculum a little (although it is already very comprehensive) and will be working on an OSCE programme for the trainees over the next few weeks. The other project just starting is working with the doctors here to establish whether an early intervention service would be feasible. There clearly isn’t any more budget, and there isn’t any community psychiatry, so the work centres around whether such a service could be re-created at outpatients to cover pharmacological and psychological interventions, and by the use of the family to provide some of the social interventions. Patients here usually have the benefit of a stronger family network than compared to the west. Watch this space.
The alternative to the cycle rickshaw
Aside from the above, I have been giving weekly talks at the journal club, up to now on transcultural psychiatry, the royal college scheme and early intervention in psychosis, and am hosting more informal teaching sessions each week for the trainees on a variety of practical-experience-based topics, including treating early onset psychosis and presenting a lecture (trying to think about what I was taught on training the trainers….)

I spend a large proportion of the week working directly with the junior doctors seeing patients on the ward, and at outpatients, which I am finding the most rewarding, including a very interesting steroid induced psychosis case on the medical ward, which we had to assess in the corridor surrounded by about twenty people holding their drip bags above their heads as the ward was being fumigated for bed bugs. I have a few interesting visits lined up for the next few weeks – I shall be going to Patna, the “tertiary” referral centre I guess, which is the largest inpatient unit in Bangladesh and is around five hours away. I don’t want to end on a negative point, but have heard a few “rumours” about conditions there, and, I guess, want to make up my own opinion. Afterwards I will be going along with the WHO to one rural Upazilla health centres to look at the work they are doing educating primary care staff in mental health.


If you would like to post a response to Adrian's blog, please email your message to the Website Manager, who will be pleased to upload it to website.
14/03/2012 11:42:22

1 psychiatrist per million

BSMMU medical staff
Time to report back after a somewhat busy first week. Work here begins at between eight and half past, and after a quick cycle- ride (I have bought a bicycle, much to the amusement of the local doctors, and have become quite adept at constant bell-ringing whilst cycling) and ascent of eleven flights of stairs (also amusing to the local doctors, but better than waiting twenty minutes for the BSMMU lift) I arrive at work.

 

The day generally starts with junior doctor reviews of the inpatients, followed by a split into ward round or outpatient reviews. After this follows the special clinics, such as psychotherapy or child and adolescent, then teaching for the junior doctors and more patient reviews. The junior then tend to spend the latter part of the afternoon pursuing research interests. The RCPsych volunteer scheme talks about the bilateral exchange of knowledge, skills and experience – I am certainly receiving my own share of all three. During the first clinic I saw more patients with conversion disorder than I have seen in total in my previous training. Clearly one of the most common conditions here, it is skilfully diagnosed and managed by doctors of all grades. The outpatients is extremely busy. Around 30 patients are seen by each doctor over a three to four hour clinic. Most are new patients, and severity and diagnosis varies greatly.

 



My new bicycle
My initial thought was that the doctors diagnose and treat with medications too soon… but that is from a western perspective. Given the vast pressure of patient numbers, and the likelihood of a lack of follow-up, or “watchful waiting” doctors have to treat here, and patients expect medication. Inpatients is much calmer than the clinics, and patients receive a comprehensive clerking (with a proforma that is better than any I have seen in the UK) and a strong academic focus to investigations and management. There is a broad range of patients in terms of diagnosis, and turnover is swift. To provide a flavour, I have seen a 16 year old girl with treatment resistant bipolar, conversion disorder ranging from seizures, to paralysis to head-aches and head tremor, liaison patients including acute lupus psychosis and yet again more conversion disorder. Relatives stay with the inpatients, providing much needed support (and staffing) on the ward. The confidentiality issue struck me initially, in that the next patient in the queue (and their family) at outpatients gather round whilst the doctor is seeing the preceding patient. Also, at ward round, the doctors are usually joined by an interested group of patients and relatives. This is in part due to space constraints at the BSMMU (psychiatry is due to move to a larger ward in the next few years) but is also, not dissimilar to the situation that occurs in Bangladesh anywhere – the bank, the train station, buying cha (tea), and although bizarre to myself, is not seen as strange here. A counter argument that has been explained to me by the doctors is that the support generated by such a crowd is actually beneficial in patient recovery – perhaps an interesting qualitative research project?
BSMMU Department of Psychiatry
I have found it difficult as an overseas doctor to understand the vast variance in services between different parts of the country. I spoke last time about the private and public split. I do not want to sound critical of any part of mental healthcare in Bangladesh, it is what it is, with huge financial and logistical constraints. The reality is that there are around 150 psychiatrists in Bangladesh, and with a population of around 150 million - 1 per million people. The BSMMU is producing psychiatrists every year, all of whom have been through a very rigorous education programme, and the total number of psychiatrists is growing slightly. However, this is countered by a “brain drain” of trained psychiatrists to other countries (I guess including the UK) Because of the financial and logistical restraints, huge parts of the country are without any psychiatric input at all. I have seen several people at outpatients who have travelled up to eight hours to get there, not ideal if you are being monitored for clozapine/lithium, etc!


That brings me to the question of what is my role in the link is. It is tempting to decamp into the rural areas where there is no psychiatry and see patients to prevent them having to travel so far. The reality is, however, that any similar attempts would only be temporary. There is already a WHO programme training community workers in mental health to improve capacity. The BSMMU is a fantastic place to start due to its key role in training the doctors of the future. Identified aims of the volunteer scheme link include 1) a collaborative research project to culturally validate rating scales 2) An update of the curriculum using my experience of training through the royal college version 3) Teaching sessions in transcultural psychiatry, early intervention and crisis intervention, 4) The establishment of a mock OSCE for the junior doctors (who have just started OSCES and quite nervous having never been through this type of examination)
Aside from work – over the last week I have been improving my cultural competence through attending a local wedding and going to the Bangladesh Premier League Cricket final – weddings and cricket being two of Bangladesh’s favourite pass-times.
Local wedding
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28/02/2012 09:39:35

BSMMU

Day Four – 26 February, 2012

Bangabandhu Sheikh Mujib Medical University

Streets of Dhaka
The official start to the working week at the Bangabandhu Sheikh Mujib Medical University (BSMMU) is eight thirty in the morning on Sunday - the traffic outside where I am staying is already at a complete gridlock and I am at risk of being late on my first full day.  Taking a cycle rickshaw seems to be the only option to navigate the traffic and my driver takes great pride in navigating towards the BSMMU on time.
Dhaka is reported to have 250,000 cycle rickshaws, which is not hard to believe when attempting to cross the cycle rickshaw lane. On first impressions one can feel uneasy considering the low pay, long hours and difficult conditions the drivers have to endure. The counter-argument is that the rickshaws are a major employer and drivers’ pay compares well to jobs of a similar skill level. In a city where noise and traffic pollution rate amongst its greatest difficulties, the quietness of the cycle rickshaws (well, aside from the constant tingling of cycle bells) and their green nature do appeal to the environmentally minded amongst us. The BSMMU certainly is a huge hospital. It comprises of four blocks, each up to 17 stories high, with a range of inpatient and outpatient facilities for the majority of medical specialities. The department of psychiatry is on floor 11 of block C. The BSMMU is the primary medical university in Dhaka for postgraduate teaching and qualifications, including training for both MD and MPhil in psychiatry, and the links it has across the country mean it is a great starting point for setting up a Royal College Volunteer Scheme link.
Professor M Mullick is the man in charge of the psychiatry department, the lead contact for the link, and I am sure will be mentioned again in the blog. The doctors at the BSMMU have a wider range of clinical interests than I initially expected. The first doctor I speak to properly is Dr Ahsan, who tells me about his desire one day to gain experience at the Porterbrook psychosexual clinic in Sheffield. (without knowing where I am based!) There is definitely a strong interest in collaborative working. I think the next three months are going to become very busy. When we did the previous scoping work looking at mental health services in Bangladesh, the need to start by establishing similarities between health systems, rather than differences, became apparent. The BSMMU provides inpatient (both paying and non-paying) and outpatient services.
Streets of Dhaka
Patients are recommended to attend outpatients by a community doctor or can self-refer – the model is generally recognisable with the UK. There is, however, no real community psychiatry, and more limited availability of psychotherapy - the BSMMU does have a psychology arm, however. There are several other government hospitals in Dhaka, as well as a variety of private inpatient and outpatient services, accessible to those with greater finances. There is a specialist child and adolescent service at the BSMMU, although other specialities are less developed. Of course, "Dhaka is Dhaka" as I have heard several residents say, and the availability and set-up of services varies greatly across the country- I hope to be able to explore rural psychiatry later in the placement. Briefly back to the link….As this is a new link, the early priority is establishing clear and achievable aims and objectives….More on this next entry….
23/02/2012 09:40:39

Port Dhaka

Day One – 23 February, 2012

I shall begin by providing an introduction to Bangladesh and its capital, Dhaka.  I am lucky enough to have visited Bangladesh two years ago, with colleague Dr Ashique Selim, when scoping for partners for the RCPsych link.  Despite this previous trip, nothing quite prepares you for the colour, noise (and traffic) that hits you after landing – certainly a dramatic wake-up call following an overnight flight.  Dhaka is a vibrant, energetic and rapidly expanding city, currently home to around 12.5 million of Bangladesh’s 160 million population.  With an area the size of England and Wales, makes Bangladesh the fourth most populated country (after the city states of Monaco, Singapore and Malta), and is set to rise to 180 million by 2015.  The rapid expansion, of course, leads to challenges in areas such as future health-care and social provision. Another major topic of conversation when discussing Bangladesh is water.  The geography is dictated by the great Himalayan rivers that pass through Bangladesh – the Brahmaputra and Ganges, the delta of which forms the majority of the coast-line.

Port in the Old Town, Dhaka

Bangladesh has both a rich cultural history, and a turbulent political history.   The majority of the population is Muslim, with smaller pockets of Hinduism, Buddhism and Christianity.  In Dhaka itself, the influence of the various cultures and religions is perhaps best physically demonstrated within the old town.  Ancient Mughal forts and mosques lie along-side Buddhist and Hindu temples.  More recent history is dominated by Bangladesh Independence in 1971 following the Liberation War and despite many political twistings and turnings over the past 40 years, Bangladesh is undergoing a period of relative stability, under the Prime Minister, Sheikh Hasina government.

The Bangabandhu Sheik Mujib Medical University (BSMMU) is a major Government training institute for post-graduate doctors specialising in mental health. It is located within central Dhaka and my placement there commences tomorrow. In the next entry I shall describe the BSMMU in more detail as well as look at the provision of mental health care in Dhaka and Bangladesh as a whole.
22/02/2012 10:15:38

Flying out to Dhaka

RCPsych Volunteer Scheme Link with the Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.

Welcome to my blog. 

Over the next few months I hope to provide an insight into the Royal College of Psychiatrists Volunteer Scheme link with the Bangabandhu Sheikh Mujib Medical University in Dhaka.  I will be the first volunteer to take part in the scheme and will be flying out to Dhaka on 21 February 2012 for three months.  The blog aims to cover the background to the link, experiences along the way, and hopefully act as a catalyst for those interested in the volunteer scheme and who may possibly take part in the Bangladesh link in the future. 

The first official blog entry will follow shortly!

 

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About this blog

Dr Adrian Phillipson

 

 

 

 

 

 

Dr Adrian Phillipson is an ST5 in general adult psychiatry, based in South Yorkshire.  He is currently part way through a year out from his training rotation, utilising the time to pursue research and travel interests.  Adrian is the first psychiatrist to take part in a new Royal College of Psychiatrists Volunteer Scheme Link with the Bangabandhu Sheikh Mujib Medical University in Dhaka, Bangladesh.  He hopes that this blog will provide good insight into the link, and will encourage others thinking of taking part in the volunteer scheme.

Adrian’s attraction to transcultural psychiatry stemmed from a chance encounter with a local practitioner in Malawi in 2003, where he witnessed a traditional healing ceremony for psychosis.  He has further developed his interest through completing a masters degree in Transcultural Mental Health Care at Queen Mary, University of London, as well as through further overseas exposure.   In 2010 Adrian made an initial scoping visit to Bangladesh to look at mental health services and help establish a sustainable link.  A report from this project can be found here.