Commentary from Yousuf Ali Rahimi, MD
MRCPsych
Imagine London with only one poorly
functioning, 60 bed mental health hospital with half a dozen senior
psychiatrists and a dozen junior trainee psychiatrists. The
patients would be not only from London, but referred from all over
the UK.
Demanding
Imagine yourself in a busy outpatient clinic,
assessing a 12 year old child who has been caught just before
blowing himself up in a crowded market and you are asked by the
court whether he had mens rea.
With only a medical school degree to your
name, and no formal post-graduate psychiatric training (but maybe
with a few years in the psychiatric hospital), no forensic nor
child and adolescent psychiatry training, you are expected to asses
him and provide a court report while a crowd of around sixty
patients with their relatives are waiting outside to be seen. This
all has to be done in a very short time, as the customary attitude
to work in your country dictates a working day of only about three
or four hours in the morning. On top of this you have a ward round
to do. You are expected to meet the needs of all the inpatients,
finish your jobs for the day by about noon, then go to your private
clinic where you will see another fifty to sixty paying
patients.
Would a British FY1 or FY2 or CT1-3 accept
this job and the responsibility of it all? For a psychiatrist
working in Kabul, this is to be expected as the pattern of normal
clinical practice – and there is no alternative.
Facts and figures
Kabul, Afghanistan’s capital, with its rapidly
growing population of around 5 million people, has witnessed four
decades of unrest, mass migration and civil war, and as a result is
now the fifteenth least developed country in the world, according
to the Human Development Index. The average life expectancy is 43.8
years, and, according to UNICEF, it is the most dangerous place in
the world for a child to be born.
Even before the arrival of Taliban in 1996,
symptoms that met the criteria for major depression were prevalent
amongst 97% of women who lived in Kabul and refugee camps in
Pakistan. Post-traumatic stress disorder was recorded at 42%, and
86% of these women had significant anxiety symptoms (Rasekh Z,
Bauer H, Manos M, Iacopino V, JAMA, 1998; 280(5):449-455).
During the Taliban era, major depression was
reported 73-78% among women exposed to Taliban policies compared to
28% for women living in a non-Taliban controlled areas. (Amowitz
LL,
Heisler
M,
Iacopino
V. Physicians
for Human Rights, Boston, Massachusetts, J Women’s Health (Larchmt), Jul-Aug; 12(6):577-87;
2003).
Following the fall of Taliban, in a national
multistage, cluster, population-based mental health survey of 799
adult household members (699 nondisabled and 100 disabled
respondents) aged 15 years or older conducted from July to
September 2002, Barbara Lopez Cardozo and colleagues reported:
symptoms of depression 67.7% (95% CI 54.6%-80.7%) and 71.7% (95%
CI, 65.0%-78.4%), symptoms of anxiety 72.2% (95% CI,
63.8%-80.7%) and 84.6% (95% CI, 74.1%-95.0%) for nondisabled and
disabled respondents, respectively.
The prevalence of symptoms of PTSD was similar
for both groups (nondisabled, 42.1%; 95% CI, 34.2%-50.1%; and
disabled, 42.2%; 95% CI, 29.2%-55.2%). Women had significantly
poorer mental health status than men did. (Lopez, et all,
Mental Health, Social Functioning, and Disability in Postwar
Afghanistan, JAMA. 2004; 292(5):575-584.
In another post-Taliban study in the Nangarhar
province of Afghanistan, Scholte and colleagues reported:
- 38.5% having symptoms of depression,
- 51.8% with anxiety,
- 20.4% with PTSD.
Symptoms were more prevalent in women than in
men (depression: OR, 7.3 [95% CI, 5.4-9.8]; anxiety: OR, 12.8 [95%
CI, 9.0-18.1]; PTSD: OR, 5.8 [95% CI, 3.8-8.9]). Higher rates of
symptoms were associated with higher numbers of traumas
experienced. (Scholte W. et al, JAMA, Aug. 4, 2004, Vol. 292,
No.5).
Two years ago it was estimated that more than
8% of the population between 15 and 64 years (approximately 940,000
people) in Afghanistan use illicit drugs, twice the global average
(UN Office on Drugs and Crime (UNODC): Drug Use in Afghanistan:
2009 Survey, pp. 3-4). This figure might now be much higher, as the
physical existence of a large population of addicts living under
the bridges in Kabul currently is something that was unheard of few
years ago.
Services
 Mental Health services are provided by the Ministry of
Health who run one psychiatric hospital in Kabul with only 60 beds
allocated to people with mental disorders, and 40 beds for drug
addicts.
This is not to suggest that there is a huge
demand for beds, with overflowing wards: on the contrary, bed
occupancy rates are usually low (less than 60% in the 2011). This
is due to a combination of various factors, such as poor facilities
and security, a stigma against mental health, staff attitudes and
particularly unhelpful policies (patients are not admitted
unless a relative can stay with them at all times). The average
duration of inpatient stay is 8.4 days, with a range from one to
fifty one days (unpublished audit, Rahimi et al). Perhaps of
interest to westerners is that all mental health clinicians have to
wear white gowns in the hospital, and in the out patient
clinics.
In 2011, the European Union funded a project
implemented by International Medical Corps to improve mental health
services in Kabul Mental Health Hospital. A college member, Dr
Yousuf Ali Rahimi from Oxford, joined a small team in Kabul,
including a mental health nurse from UK, to train clinicians in
this hospital. The team designed a training programme which
included:
- core training in psychiatry,
- experiential group psychotherapy,
- group and individual clinical
supervision,
- the use of a training portfolio.
Much time has been spent in designing the
format of patient records, various assessment and referral forms,
and offering technical help and support to the medical records
office and the pharmacy. A crucial part of their time has been
spent in the development of an outpatient and inpatient service
culture, where patient confidentiality and good record keeping have
been at the heart of their efforts. It has also involved developing
a new of way working, so that patients seen are assessed in a
private area. This is in the outpatient clinics and inpatient
areas, and includes the multidisciplinary ward rounds, and in group
and individual psychotherapy sessions.
Another College member, Dr Rex Haigh, also
joined Dr Rahimi in Kabul to design a psychotherapy training
programme for Afghanistan. He studied the current situation and
practice in Afghanistan and what the needs are for the future of
mental health in Afghanistan. Based on his experience in service
development and designing training programmes, and after
discussions with Afghan professionals, he developed a psychotherapy
training curriculum and programme for Afghanistan that is
“biopsychosocial, culturally congruent, and inexpensive”, being
based on principles of group psychotherapy and an EU-defined
‘greencare’ philosophy. Details of this are in the following
section.
Dr Haigh and Dr Rahimi met with our President,
Professor Sue Bailey, and Chris Naughton, the College’s
International Liaison Manager, on 21 December 2011 to discuss how
the College can further support the development of the psychiatry
profession, training programmes and mental health services in
Afghanistan. You will hear more about this development in the next
bulletin of our e-news.
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