It’s been nearly three months in
Accra now. One more week to go and then back to London. Time
help thinking, how can I leave Pantang? It feels like home to
I still recall the first day when I entered the hospital main
administration front door asking to speak to Dr Gyimah, who I had
been told was expecting me. I was full of excitement, but also a
bit nervous: will I be able to help in a meaningful way? Will
my work schedule be effective? How do they work here? Do they
really only have Chlorpromazine and Amitriptyline? What are
the wards like? How will they treat me?
These, and numerous other questions were crossing my
Fast forward three months later, I now feel full of new
experiences and a strong feeling of reward!
Outside Pantang Hospital
It took a week or so to get familiar with the working
environment in the beginning. Since there has been no SpR here
since 2014, I had to make certain arrangements and schedules from
scratch. Thankfully, the old reports from previous SpRs (which I
got thanks to Dr Hughes and Amy from Challenges Worldwide) proved
to be quite helpful.
But things worked out fine!
I met with the lovely and always smiley Dr Osei, the head of Ghana
Mental Health Authority, who has also been the local lead in
this programme for years. I was touched when I heard about
the arduous efforts MH professionals have been making here
for decades, in order for MH to be taken more seriously by
the governments in Ghana. This culminated in the passing of the
Ghanaian Mental Health Act two years ago; It is still not fully
implemented, but it’s a big first step.
With Dr Osei, Head of Ghana Mental Health authority
and Dr Baning, Pantang hospital Director
The team at Pantang welcomed me and made me feel at home very
soon. I confirmed my work plan with the hospital Director Dr Baning
and the Specialist psychiatrist Dr Gyimah and got to work
straightaway. Within the first few days I did my first presentation
to the hospital medical staff ,during their weekly academic
The main goal of this programme is to support MH nurse
prescribers known as Clinical Psychiatric Officers (CPOs). CPOs are
MH nurses by background, who have had an additional 3 years
training in Psychiatry. They are able to practice fairly
independently, reviewing patients on their own and prescribing
medication. The reason the programme focuses on CPOs is because
they review a big portion of psychiatric patients in the clinics.
Psychiatric doctors are still scarce in Ghana: there are between
16-20 qualified psychiatrists in the country’s three
psychiatric hospitals – Ghana has a population of about 28 million
||With my CPOs
Soon, with the help of Philip, the calm and efficient training
coordinator, I gathered my CPO teaching ‘’group’’ which
consists of 7 people: Aaron, Chei, Benjamin, Ambrose, Anthony,
Humphrey and Emmanuel. The arrangements go like this: during the
weekdays I sit in with them in their outpatient clinics; once they
review the patient, they discuss with me about the presentation and
management. In addition, every Wednesday afternoon we have our
weekly teaching presentation at the conference room. There, I
present a different topic each time (eg psychosis,
communication/clinical interview skills, mood disorders, dementias,
etc), which we then discuss analytically. The presentations are
quite interactive and include material from MH GAP, the WHO manual
on delivering mental health in primary care. Our teaching is also
attended by trainee CPOs and sometimes psychiatric trainees as
In the beginning, I was curious to see how well my teaching
sessions will be attended, as from previous reports it seems
that attendance had been an issue in the past. However, my group
has shown enthusiasm and commitment and the attendance has been
100% during most sessions. Benjamin went as far as to continue
showing up to the teaching sessions while being on annual leave -
and based far way from hospital!
Full conference room -
teaching in session
As time passed, my role was ‘’expanded’’. Every now and
again psychiatric colleagues would ask me to review complex
patients with them in the wards or the clinics and share my opinion
with them. Esther, our lovely nurse training coordinator, kindly
asked me to organise teachings for the all the MH nurses in Pantang
(around 150-200 of them), which we did once a month. On Fridays, I
also arranged to visit Accra Psychiatric hospital and teach CPOs
over there as well.
In addition, I led an Audit project on prescribing
antipsychotics in the outpatient department. On completing this, I
run two Focus Groups to try and understand what the current
rationale for combining antipsychotics is. We are now developing a
local protocol on principles in prescribing Long Acting
During my work at the outpatient clinics and the wards, I
started to realise how significant role the spiritual
and religious element play when it comes to psychiatric
care here. You simply cannot treat patients, if you
don’t take people’s beliefs (about bad spirits, bad energy,
witchcraft) into consideration and work alongside them.
The perception of depression is different in Ghana than in UK.
Most patients seem to be unfamiliar with the fact that depression
is a disorder of mental health. They can answer questions about
being ''happy'' or ''sad'' , but being 'sad' is not the reason why
they come to the outpatient department. The usual presentation is
of fatigue and insomnia, and vague somatic symptoms. Patients do
not spontaneously mention suicidal thoughts. They have to be teased
out and on a few occasions I was surprised to find patients
experiencing worrying suicidal ideation, since they had already
reassured me they had no concerns. Accidental (due to lack of
awareness) or deliberate (due to stigma) minimising of symptoms is
frequent. Relatives of patients seem uncomfortable when
questions about suicide are asked. Their stress reaction can be to
laugh, which in the beginning was very confusing and unnerving for
me. I now realise that this is a way to react to stress, rather
than lack of care. Suicide is little spoken about. Yet, in the last
few weeks in Ghana there were three suicides of young girls that
have been all over the news. I cannot stop talking about risk
assessment in my lectures.
I was able to see first hand the numerous challenges that my
colleagues face here: for example, how difficult it is to maintain
engagement with patients, since awareness of mental illness is
quite poor and patients just stop attending (‘’default’’ as it’s
Also, how (the lack of) money plays a major role when deciding a
treatment plan. Patients cannot afford lab tests, and sometimes can
only afford the cheapest medication options- Sodium Valproate is
too expensive for most.
Risk Assessment teaching
Stigma plays a big role and people don't want to be labelled as
suffering with depression or any mental illness. As one local
friend put it: ‘there is only one mental illness in Ghana and that
is "madness’’. On many occasions, people with MH problems are
considered ‘’mad’’, regardless of diagnosis. These patients usually
end up getting marginalized with reduced opportunities of
getting a job or getting married. Depressed people, tend to be seen
as ''weak'', unable to enjoy life or do everyday things because
they don't try enough. Society thinks they should just get
themselves back together, or should pray more.
Before considering psychiatric services, families tend to take
unwell patients to pastors or ‘’prayer camps’’, where pastors pray
for them in order to get better. This happens not only because of
the high religiosity of the Ghanaian society, but also because this
is much more socially acceptable - and less
stigmatizing. Prayer camps have a somewhat bad reputation of
maltreating psychiatric patients. I tried to visit a prayer camp
outside Accra myself, and was surprised to be refused access to the
premises in which psychiatric patients reside. We were given
quite a few excuses (including that the pastor is too tired to show
us around), but clearly we did not feel too welcome
This was quite an unusual experience for me these three months,
given how friendly and hospitable Ghanaian people are.
|Teaching the CPO group
|| At the
Another challenging issue is the grey areas around ‘voluntary’’
admission of patients who wish to leave hospital; MHA is still
doing baby steps here.
Furthermore, during our teaching, nurses voiced many concerns
about managing patient aggression, and the fact they
sometimes feel unsafe and lacking skills to deal with violent
patient behaviour. After liaising with the senior hospital
management, we agreed that this is something we need to take
decisive action on and try and improve. Therefore, with the
valuable help of Ray -a Ghanaian friend who worked as a MH nurse in
UK and now relocated to Ghana- we arranged a full’s day
training session on breakaway and safe restraint of patients.
It went very well and people who attended reported feeling valued.
I think It was one of the most rewarding experiences
I had here. Subsequently, the hospital director approved
the arrangement of a two-day training in breakaway/restraint for
all nursing staff, and the plan is to maintain this as annual
Great! And this is exactly the spirit of this
programme: to bring on sustainable change.
And there was more good news and progress. One of the wards was
beautifully renovated (we had a nice opening party covered by the
press) and is ready to accommodate patients. The Mental Health
Authority has approved the creation of new training posts in
Psychiatry, and as a result there will be more (so needed)
psychiatrists in the next few years. Pantang hospital now has
two residents (equivalent to trainees in UK) in their first year of
training. In addition, importance is given to research: I attended
a meeting with the lead psychiatrists in Accra, where
research projects are being discussed and allocated to Specialist
Psychiatrists. This is a prerequisite to complete their fellowship
and become Consultants.
And yes, Olanzapine and Risperidone and Sertraline have strongly
entered the market and they are all used as first line treatments!
So what have I learned in my three months here?
From a practical point of view, I feel I have expanded both my
clinical knowledge and my leadership skills. For example, I
regularly came across psychopathology not so frequently seen
in my everyday practice in UK, such as catatonia, conversion
disorders, and even a case of full blown NMS.
Doing an audit in the open
In addition, I learned to value more, certain things
(procedures, infrastructure, training ) I have been taking for
granted back home - I will possibly complain less about NHS
when I get back.
But most important of all, I feel that the whole experience has
helped me further develop my ability to respect and embrace
diversity and cultural differences; not to rush to make assumptions
until I know the underlying context and challenges. I faced ethical
dilemmas and questions with no easy answers: how do we deal with an
aggressive and unwell patient in OPD who refuses admission (who
police are not bothered about, and the Mental Health Act cannot be
implemented in time)? What do we do with a demented, bedbound (with
infected bedsores) patient who does not need to be in a MH
facility, but has no relatives, no funds and the medical hospitals
won’t touch him? And the money used for his care could be used to
pay for the required admission of other patients?
I saw first hand how important it is to work collaboratively
with local staff and with respect to their systems and culture. My
approach to the nurses, doctors and non medical staff at Pantang
(they call me ‘’Dr Kostas’’) was this of a guest colleague and a
friend, rather than an ‘’expert from UK’’. This helped me to build
really strong relationships with them, which I hope will last for
years to come.
I have had an amazing experience here. I felt we achieved good
things and hopefully made a difference even if it’s a small one.
Ghanaian people are friendly, hospitable, positive and they are
eager to learn and improve. I liked their culture , their relaxed
approach to life, the sun, the songs and the beautiful nature.
I urge my UK colleagues to consider applying for this
With my host family's children at home - they call me
Finally, I would like to thank all people who helped make this
placement a unique experience: First, I would like to thank my
Clinical Supervisor, my TPDs, the Medical Director and
Clinical Director at ELFT who gave me the opportunity to take time
for this OOP. I would like to also thank the Royal College of
Psychiatrists - and specifically Dr Hughes - for supporting
me though all this time , and for our supervision whilst in
Furthermore, I could not have arranged any of this without the
help of Challenges Worldwide: Amy and her tireless responses to my
numerous emails and question, and Kelly and Simon who made all the
arrangements for my lovely stay here .
Also, I want to send a big thanks to staff at Pantang who made
me feel so welcome- I hope you remember me; I know you will
be in my heart!
In addition, I would like to thank Bernard, Wendy and their
three lovely little children for hosting me at their home - I lived
like a true Ghanaian for three months!
And last, but certainly not least, a big thanks to my brother
for practically helping me to pursue this programme when funding
issues arose, to my family for their encouragement, and my
girlfriend for being so supportive and loving!
Authored by Dr Kostas Tsamakis