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.

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.

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.

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.

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.

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.

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.

Day Four – 26 February, 2012

Bangabandhu Sheikh Mujib Medical University

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.

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….

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.
 

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.

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!