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

The Gambia

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May 2012 Posts

22/05/2012 15:41:47

Tanka Tanka

Inpatient setting

I have recently spent much of my time working in the inpatient setting, which is a separate 60-place psychiatric hospital about half an hour outside Banjul, down a 1km dirt track from the highway. It’s a bustling and vibrant place, with large grounds for the patients to use including a vegetable garden that they work on themselves as part of their occupational therapy. It’s always full or over capacity, and the turnover of admissions is quite high – every day is different and challenging, caring for a very diverse patient group in limited circumstances.

The in-patient service has been restricted for the last month by inconsistent supplies of medication.  Any one preparation of a drug may run out: usually there is at least one antipsychotic for use, but the patients will experience the medication being changed from one drug to another. The antipsychotics used here are oral haloperidol and chlorpromazine, and fluphenazine depot. The only antidepressant available is amitriptyline, and for sedation there is IM haloperidol, IM diazepam, but no oral benzodiazepines at all. There is also carbamazepine. This week the hospital finally ran out of all antipsychotics. The families of some patients are able to take prescriptions to local pharmacies and bring back the medication for them, but for most this is not financially possible. We’re told by central pharmacy this situation will be resolved in the next few days, but for now the hospital can only take emergency admissions (which is most of them!), and we have tried to discharge as many people as is safe, with prescriptions for those who can afford to buy their treatment in local pharmacies to carry on treatment at home. I have found the decisions about whether to discharge people for this reason difficult, but I’ve had to ask myself what the point of admitting people is if we cannot treat? So the decision has been based on risk assessment for each person and how well the family could manage and support them at home.

 

"People seem to be less averse to injections here than at home; I think they expect injections from doctors and that is part of the road to recovery."

There are so many challenges here to what I have come to expect, based on how we work at home. The inconsistency of antipsychotics, of necessity at the very least, leads to skewed prescribing practice, as we are always aware of the low supplies, and prescribing rationale is based on practical issues. Depots are used very often as the supply is usually more reliable, as they only need to be available once per month for each patient, and they are always available at one time in a month. This way the patient has the most reliable treatment without missing doses and the best chance of achieving a steady state of medication. People seem to be less averse to injections here than at home; I think they expect injections from doctors and that is part of the road to recovery. Side effects are obviously a constant battle and source of distress, but thankfully during my time here so far the supply of trihexyphenidyl has not faltered!

Tanka Tanka Hospital

"The extended families are very involved in the care of their relatives here.."

The matron of Tanka Tanka Hospital is keen to share our practice from the UK; so we’re working together to develop some staff training, starting with the management of agitated and challenging patients. There is a seclusion room in the unit which was closed last year after it became clear it was not being used safely.

This makes the management of some patients very difficult, and appropriate means of rapid tranquilisation is not always available. The staff do an impressive job of keeping the calm and managing the risk with these limited facilities, but the outcome is not always favourable, and the potential for assaults and distressing situations is often borne out. Having limited means to manage patients’ distress can make me feel very impotent. It makes me wonder about how much we tend to use our other skills to calm patients and make them feel safe, and how much we rely on medication. The training is designed to empower the staff, who are not all trained nurses or mental health nurses. It also improves risk management, safety for patients and staff, and reduces incidents. The matron and I are planning to go through de-escalation techniques, physical techniques, rapid tranquilisation and safe use of seclusion. We are designing a protocol for secluding patients, and paperwork for record keeping and monitoring.

A study at Tanka Tanka last year showed that as many as 50% of people admitted abscond from the unit, and the largest group are those admitted with psychosis associated with substance abuse. I have found that those who abscond are often brought back by family members the next day, or come back again in some weeks, but many are not seen again for some time. The extended families are very involved in the care of their relatives here, compared to what I have experienced at home. I don’t think I have often seen families bringing back patients who have absconded at home, perhaps this is because our services take responsibility for us, and here without social or outreach services, families naturally take up the burden themselves and are much more assertive.

In high risk situations the police can be involved, but there is no obligation for them to bring back absconders, unless of course there is a public disturbance. This leads me on to mental health legislation; there is a Mental Health Act 1917, amended 1967. There is provision to detain patients for a renewable 6 month period. The police may use an “emergency certificate” which is similar to a Section 136 to most intents and purposes, although rather more simply described. The CMHT in The Gambia run busy open access outpatient clinics in Banjul every day, but are not able to provide home visits or outreach services. There just isn’t the funding for a vehicle, the fuel, or indeed enough staff. I have found that working without being able to rely on an outreach service is very different, and indeed more is expected from the families here to fill this gap. Working in this way with people who strive to offer the patients full care in such constrained conditions, has given me a keen awareness of the sophistication and development of our mental health system in the UK. Things we take for granted, like having another professional to refer to who will step in and offer follow up care, would indeed be a luxury here, although very much needed.


An update on my last entry: the young woman I suspected has lupus; I introduced her to the visiting dermatologist from Dakar who agreed it was likely lupus, and did her best to arrange for her bloods to be sent to Dakar for immunology. Unfortunately the best laid plans were thwarted and her bloods did not get there, so we settled for a clinical diagnosis, with a high ESR and low CRP, and treated her for lupus. She went back to the provinces in April, and plans to come back for review after 3 months. So far I’ve not heard how she is.
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About this blog

Dr Imogen Kretzschmar

 

Dr Imogen Kretzschmar is a CT2 in psychiatry at South West London and St Georges Mental Health Trust, and is spending 6 months in The Gambia in West Africa on Out of Programme Experience.