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.

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.