Out of Programme Training in Pantang Hospital, Ghana – Dr Konstantinos Tsamakis, April 2017

22 April 2017

It’s been nearly three months in Accra now. One more week to go and then back to London. Time flies!

I can’t help thinking, how can I leave Pantang? It feels like home to me now!

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 mind.

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 teaching.

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 people!

OPD waiting area

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 well. 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!

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 injections.

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 known here).

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 there.

This was quite an unusual experience for me these three months, given how friendly and hospitable Ghanaian people are.

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 training.

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 air

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, bed-bound (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 programme.

With my host family's children at home - they call me ''uncle Kostas''

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 Ghana.

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!

Medasse!

Dr Kostas Tsamakis