The psychopathology is pretty much identical, although admittedly the lag time between the appearance of symptoms and first presentation to a mental health professional is much longer here, as patients and families tend to exhaust all other potential treatment avenues before consulting a medical doctor. This usually includes some kind of “spiritual” intervention such as a residential spell at a Christian prayer camp, or the more traditional option of having rituals performed by a local fetish priest (and I promise I will return to this another time). Disorders such as mild to moderate depression and anxiety do not tend to make it as far as a psychiatrist here like in the UK, and perhaps this is because they are adequately dealt will by some other non-medical means?

Another similarity is the frequent and ubiquitous co-morbid use of cannabis in young men who present with psychotic disorders. Other forms of substance abuse do not seem to be as visible as they are in the west, but that might be just a matter of time. Furthermore, just as in the UK, the patient’s family performs an essential role in caring for and supporting the person through illness. And probably the family’s role is even more prominent and important here in many cases, as there is no social welfare system to fall back on, and community psychiatric services in Ghana are currently so spartan as to be non-existent.

It appears to be unusual for someone to live alone here, even in the capital Accra. Patients generally stay with their families and extended families. It is the family that brings the patient to clinic (and sometimes the family come to clinic without the patient), it is the family that buys their medications and administers them (sometimes by hiding the drugs in their food without their knowledge), and maybe inevitably, and certainly understandably, it the family that comes along to the hospital saying “we can’t cope any more- please admit him and give us a rest”; of course that also happens sometimes at home. However, a few days ago two brothers came into my outpatient clinic room, carrying between them their floridly manic relative, wearing only his underpants and chained at the feet and wrists with manacles. They literally dropped him at my feet. It is at times like these, well....you realise that you are not in Kansas (or Hampstead) any more, Dorothy.
 

So the differences, the differences...where do I begin? I am not even going to mention the discrepancies in financial and human resource- that is obviously a given. Clearly the biggest difference is the lack of a functioning mental health act currently in Ghana, although as I may have mentioned previously, there is a new Bill trying to be passed through parliament at this very moment. As a western psychiatrist, you perhaps become habituated to the fact that mental health act legislation, and its guiding principles, form a solid framework for much of your daily decision making. And that isn’t to mention the amount of time we spend at tribunals, writing reports, reviewing sections etc. So what is it like when that legal framework isn’t there? The other day George, one of the MAs, asked me to come to the ward with him to review a patient. In short, she was a lady who had previously been given a diagnosis of delusional disorder, but due to the sustained deterioration in her social functioning and increasingly bizarre nature of her symptoms, we both agreed that schizophrenia was a more fitting diagnosis.

Interesting, this lady had recently been admitted to a psychiatric hospital in Europe, under the mental health act, but whilst on ward leave had managed to abscond and fly back home to Ghana; her relatives had helpfully sent us some information from this hospital admission. The lady had no insight, was delusional and paranoid, and had lost a considerable amount of weight over the previous few months, with an associated significant deterioration in her self-care. She was acutely unwell, putting her health at risk,  and she was very clear that she would not cooperate with treatment voluntarily; indeed, a concerted effort to engage her therapeutically during her previous admission had failed. I was clear in my mind that we should give her a chance to have a course of treatment and I knew that this would probably involve treating her against her will. But I found it very hard to make this decision alone, even when I knew that I was using the same legal framework as in the UK in my head. It felt precarious and a much more uncomfortable decision to make solo. We ended up discussing the case at the weekly multi-disciplinary case conference, which I have managed to re-start. The central question that we asked those assembled was “under what grounds can you justify detaining and treating a patient without their explicit consent?” It took the nurses and MAs quite a bit of prompting to come round to the themes of active mental disorder and acute risk to self, others and/or health. Several people suggested that lack of insight might be reason enough. 

You can be admitted to hospital on the whim of a judge who thinks that you “might be acting a bit strangely”, and again find yourself in a different kind of prison for an indefinite period.

If your family admit you into hospital, and then decide that they can’t look after you any more, well, they just need to leave a false address and phone number, and then make themselves scarce, leaving you, the patient, with precious few options. That is, if your family can afford to bring you the long journey to hospital at all. So many times since I have been in Africa, I have reflected on the NHS and the services that we are able to provide. When I left the UK, the future of the NHS was the topic of ongoing fierce political debate and I know that this continues. It probably sounds like the most utterly clichéd and corny thing that somebody could say after working in a developing country, but maybe that is because it is true: we have literally no idea how good we have it. 

It has become increasingly apparent to me over these last 5 weeks what a difficult job the MAs do here. With only a brief additional training (at least before the Kintampo project began) they are expected to assess, diagnose and manage the full gamut of psychiatric diagnosis, from the cradle to the grave; there are no specialties such as Child Psychiatry or Psychiatry of Learning Disability or Older Adult psychiatry in Ghana… just plain old, catch-all “Psychiatry”. And in addition, the MAs are also confronted with many problems that we as psychiatrists in the UK would swiftly re-dispatch towards Neurology such as epilepsy, headaches and even stroke rehabilitation (unfortunately there are even fewer Neurologists than Psychiatrists in Ghana, I am told). And that is without mentioning the prevalence of physical morbidity - the Accra MAs were late for my tutorial last week because there had been an outbreak of Cholera on the psychiatric wards which they were trying to treat and contain.

I am not ashamed to admit that there have many times since I have been working here that I have felt far, far out of my clinical comfort zone, and this is with 5 years at medical school and 8 years of full-time psychiatric training, with all the supervision and intensive teaching that entails. Of course, the MAs are supposed to be able to access medical support and supervision to help them along, but in reality, with the work pressure that all the medical and nursing staff are under here, just in terms of volume, this is not always possible. So, like Ghanaians do with a lot of their health issues, the MAs just…manage.
 

Their obvious strengths are in their familiarity with the many nuances of West African culture, their unflappable flexibility and resourcefulness in the face daily novel clinical challenges, and their ability to assess and process a volume of patients that we as clinical staff in the UK would possibly baulk at:  would you fancy seeing over ten new patients at outpatients each day, on top of your reviews?  Me neither. They are also in a brilliant position to educate the population about the causes and treatments for mental disorder, helping Ghanaians to integrate a biopsychosocial model in with the more traditional concepts of “spiritual causes” for mental disorder. But inevitably, the necessity of speedy assessments affects the quality and depth of the history taking and mental state examination. And similarly, without an arsenal of paramedical support services on hand, such as the OTs, psychologists, CPNs and social workers that we sometimes can take for granted, the desire to be able to “offer something” quickly to the patient often plays out in the issue of a prescription. Interestingly and unexpectedly, one of my main challenges here has been to try and get the MAs to think more systematically about the possibility of NOT prescribing. Possibly this is also a cultural issue- I have noticed that Ghanaians expect to go away with a script in their hands. It is a definite contrast to the UK, where I think often the current trend is for patients to be reluctant and somewhat reticent about taking psychotropic medication (and often, quite rightly so!)

And so we continue to work together in clinics and on the wards; we see and assess the patients, we discuss the cases, I ask them questions about their reasoning around diagnostic or management decisions. Sometimes we disagree, and often I find that “what I would do if I was in the UK” is an irrelevant and pointless proposition. For example, we see a fifteen year old boy whose Father brings him in with what sounds like grand-mal seizures. In the history we find that he experienced quite significant developmental delay, not walking until the age of 2 and a half, and not speaking until the age of five and he never managed to learn to read or write, but he has never formally been diagnosed with a learning disability. He has an odd, telegraphic style of speech and it was also unclear if the seizures were new, because until recently the boy had lived with his Mother in Nigeria and there appeared to have been very little communication between the two parents. His physical and neuro exam were normal. Basically he had an undiagnosed mild-moderate learning disability of unknown aetiology and seizures that were possibly new, but not definitely. The family couldn’t afford any form of neuroimagaing, and only basic blood investigations. There is no sense in searching and searching for a possible aetiology unless there is likely to be an effective and accessible therapeutic intervention. So we started him on carbamazepine, gave his family some basic psycho education about his learning disability and his seizures and arranged to see him back for review. No neuropsychological testing, no MRI, no full organic screen, no LD support services: just… managing.

Accra psychiatric hospital was opened in 1906. It has some 700 in-patient beds wards and currently houses approximately 1200 patients. Those numbers speak for themselves. There are 5 doctors (two consultants), 5 medical assistants and a clinical psychologist. Like Pantang, the hospital is in a serious amount of debt. There has recently been a big push to try and discharge patients back into the community but unfortunately, often the community and more specifically, their families, don’t want them back. And community services for psychiatric patients in Ghana are very underdeveloped currently. So many of the discharges are simply brought back and left...or sometimes they never leave in the first place. As we are all too aware in the UK, in-patient provision is expensive, so a huge proportion of mental health funding is spent on providing bed and board for a lot of patients who would be much more appropriately housed and looked after elsewhere. But for the moment, there doesn’t seem to be an “elsewhere”.

As I walked around the hospital, it had the feel of an old asylum. I had been warned what to expect, but the wards were still quite difficult to take in. The level of overcrowding meant that sometimes patients had to sleep on mattresses on the ground, outdoors on terraces. The male “locked ward “in particular was full to the rafters (about 35 beds and 220 patients) - this seemed to be the equivalent of our forensic wards where patients were sent on “court orders”. However, as far as I could discern from the nursing staff, men arrived here regularly, but the outward traffic of discharge was much less frequent. Although there were lots of patients, there were no discernable outward signs of psychosis or aggression, just lots and lots of men, milling around looking bored.  There was also an addictions ward, where people were admitted with substance use problems, mostly “wee” (cannabis) and alcohol. However, apparently there weren’t any in-patient resources for psychological treatment of addiction (although there was an AA groups within the hospital) and it seemed as if the patients were just taken off the streets to live here instead, out of sight.

I had a chance to spend some time talking to some of the in-patient staff. As ever, I was impressed with their professionalism in the face of very difficult working conditions. They told me of the stigma that mental illness faces in Ghana, even from within its own medical profession at times. They said that often they had experienced reactions of abject horror from their friends and family when they said that they wanted to work in Mental Health, and that their still remained a great deal of superstition and fear around psychiatric illness, with even some educated Ghanaians attributing its aetiology to spirits and demons. They described the difficulties they often faced in accessing appropriate medical health care for their patients. One nurse tells me of an incident where her patient needed to be taken for a blood transfusion at a local physical healthcare facility. During the treatment, she heard a member of their staff say loudly, within earshot of the patient, that this kind of medical treatment shouldn’t be “wasted on animals”. Obviously this is not an opinion held by the majority of educated Ghanaians, but still, it is indicative of the level of prejudice that exists in some quarters.

Probably the most starkly difficult part of the hospital to take in was the Children’s ward. This comprised a large compound which housed about 30 patients with moderate to severe learning disabilities, aged between about 8 and 35. The staff told me that children with intellectual disabilities (often with concurrent physical problems) were abandoned at the gates of the hospital by their families, or sometimes found on the streets. Once here, most had no further contact with their families and remained on the ward until their lives ended. The nurses explained that having a disabled child, particularly a child with a learning disability, can be very shaming for a family, and that it is sometimes taken as a sign of some sort of malevolent influence at work.

There are 2 nurses on duty and a couple of Ghanaian volunteers who are  here three days a week to help care for the children and who also try and organise activities such as art or games. But it is very clear that relative to the individual needs of the children, the wards are critically understaffed. It is all the nurses can so to keep the children clean, fed and safe and there is precious little time left to think about their emotional or learning needs. I noticed some of the children sitting quietly rocking themselves. For the brief periods that I have been on the wards, individual children come up, grab on to you and don’t let go; I left with scratches on the back of my neck because one little girl was holding on so tightly. I try not to be the overwrought, overemotional visiting westerner, and fail. It feels like quite a lot to take in. Currently there is no available input from speech therapists, physiotherapists or child psychology.

I spoke to staff and volunteers to see if there is anything practical we could do, in conjunction with Challenges Worldwide, the charity that is supporting me in Ghana. I was thinking of trying to fundraise for some educational and art materials for the ward and I asked the staff for a list of things that  the children need: although the list did include toys and art materials, at the top were more basic requirements such as detergent, gloves, nappies and second hand clothing.  I need to have a think about how best to take this forward, and I leave feeling a bit numb.

Ambrose has recovered, so our work together can begin in earnest. We work by seeing patients in tandem: Ambrose takes the history and mental state, then I sometimes interject with some more questions/clarifications and then we do any necessary physical examination and formulate a care plan. I was heartened by Ambrose’s basic history taking and mental state examination skills. We began to work on being a bit more focused about his line of questioning, always keeping in mind what he was trying to rule out or rule in. I also began to notice the tendency here to often prescribe more than one antipsychotic at a time, with patients often receiving “booster depot injection” doses of antipsychotic at clinic if they had any psychotic symptoms, even if they were fully concordant with their oral medications and there was room to put up their oral doses. There seemed to be a perception that giving an injection as opposed to a tablet was somehow more “potent” than oral medication. We had a short discussion about this in clinic, but i think it is quite an engrained practice and I made a mental note to cover safer prescribing practice at one of our formal teaching tutorials which I will be holding on Wednesday lunchtimes.

After lunch we had to split up and see patients separately - this is obviously contrary to the spirit of the project, where everything we do should be with an MA/nurse to ensure the passing on of knowledge and sustainability once we are gone. Having said that, it is easy to say that, but less easy to stick to when the outpatient corridor is heaving with patients, some of whom have travelled hours to be there, and there are only two clinicians to get through them. In addition, seeing all the patients as teaching cases inevitably slows down the pace. I know that we will be getting more staff in a couple of weeks, and until then I will just need to try and split my time sensibly between service provision and teaching.

In my afternoon clinic, I see a man in his 50s, who is brought in by his sister. He has a long history of alcohol use, and some 4 days previously he had apparently been admitted to a medical ward with a withdrawal-related seizure. His sister brought a letter from the general hospital, addressed to psychiatry, saying that some time after admission, the man had become “aggressive, hallucinated and uncooperative with treatment” and so they had had to discharge him and could we treat his “psychiatric problem”. The most striking thing was the man had been sent home with a bag full of all the medications that his family had bought for him on admission, but had not been administered, including about 12 glass phials of IV Thiamine. The man was very ataxic, delirious and had Wernicke’s encephalopathy. I felt upset at the way the other hospital had treated (or not treated) him and I spoke to Dr Dzadney for advice; she was not at all surprised by this type of presentation and she told me that any form of mental disturbance, even if there is a clear physical cause, is felt to be the remit of psychiatry and that we should admit him for treatment, but warn his family that we could only keep him for a maximum of three weeks and that he might possibly have irreversible brain damage. We kept him for about a week and gave him IV thiamine etc and fortunately he made a full recovery.

There are some patients in the “Chronic wards”, who have been here for some forty years and they tend to have employment around the hospital site. There is an Occupational Therapy department, but it is mostly staffed by visiting volunteers at the moment, and the in-patients sometimes don’t always have much to do during the day. Having said that, lots of gardening and farming goes on all over the hospital site, courtesy of the patients. 

Despite these difficulties, all the in-patient nurses that I have met have been professional, warm and compassionate. And I was pleased to hear that a retired nurse lecturer, Michael Brenan, is coming over to Pantang with Challenges Worldwide from Scotland in a couple of weeks specifically to work with the in-patient nurses and help them with their professional development. I noticed that a lot of their time is spent completing progress reports in the notes, and less time doing one to one therapeutic work with the patients. There is a very medical model here, with a lot of emphasis on medication and less on psychosocial interventions. I also got the impression that the nurses don’t feel particularly empowered to be autonomous, but clearly they are a huge untapped resource for working more actively with the patients.

Introduction