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

Flexibility & resourcefulness

So I think I am finally starting to settle in. I have gradually slowed my pace, and modified my expectations about the realistic rate of change, and as a result I no longer feel like a slightly irate Scottish woman on a mission to assault the Pantang Medical Assistants with knowledge and better working practices. We have had 4 new MAs arrive at Pantang hospital, fresh from a new mental health teaching programme called “the Kintampo Project” - this is an excellent collaboration between UK psychiatric staff at Hampshire Partnership NHS foundation Trust and Ghanaian ministry of Health. It is a rural health college, which is training Medical Assistants in Psychiatry and Community Mental Health Officers.
Ghana

The aim is ultimately to produce a self-sustaining new generation of specialist mental health workers that can start to bridge the considerable gap between supply and demand for mental health expertise in Ghana, in particular, allowing Ghanaians in the more rural and remote areas of the country to access care. The new MAs at Pantang are coming to the end of the first 2 year run of the Kintampo programme and so far I have been hugely impressed by their knowledge and drive...

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.

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About this blog

Susie Easton

Hello, my name is Susie Easton and I am an ST6 on the UCL/Royal Free Hospital General Adult Psychiatry Rotation in North London. I have just got my CCT and when I return from Ghana, I will be moving home to Glasgow to take up my first consultant post.

When I saw the Ghana post advertised, I thought that it looked interesting, a bit scarey and an opportunity for a professional and personal adventure.

This personal blog reflects Dr Easton's own views, and not neccessarily the organisations that she is working with. However Dr Easton is indebted to the partnership between South West London and St Georges mental health Trust, the charity Challenges Worldwide and the Royal College of Psychiatrists for providing an opportunity to take part in this excellent project. She is also very grateful to Dr Peter Hughes for his regular and invaluable clinial electronic supervision, Challenges Worldwide for their excellent logistical support, and Dr Anna Dzadney the Medical Director at Pantang hospital for making her feel so welcome. And last but not least, she is indebted to the Ghanaian Medical Assistants with whom she works, for helping her learn about how mental illness in West Africa.