Mad, bad or sad?

Weather - Maximum temperature 44 degrees Celsius

- Weekly rainfall a few drops

Highlight of the week

Mating lions within stroking distance.

Lowlight of the week

The Valley stays hot and dry. South African chardonnay notwithstanding.

June 2019

The focus that day should have been on gender equality. Project Luangwa were launching colourful, reusable, sanitary pads to give girls and women freedom throughout their reproductive years. Project Luangwa empowers the people of South Luangwa to break down the barriers of inequality. Dancing and theatre showcased their ideas and their ethos that day. But the focus soon shifted. Instead, Saul made himself the centre of attention. Vocal and obnoxious. Saul heckled and seemed to rail against equality.

Valley doctor, Dr Ian Cross intervened. He tried a few gentle words to encourage Saul to move on. Experience told Ian that Saul was hypomanic. Village attitude to emotional ill health is often very laissez faire. Saul’s potential audience at Project Luangwa failed to respond to his provocations. They might have been angry and frustrated with Saul’s bit of drama eclipsing the main event, but silent tolerance worked wonders that day. Saul soon lost interest and wandered off.

A few days later, Saul finally triggered a reaction. Saul had smashed up his family home and had pulled a door off its hinges. His family could take no more. His own mother, Grace, incensed by the havoc wreaked by her son, garnered superhuman strength and chained him to that door.

Everyone in the village had said that Saul was mad. Saul had little insight. It wasn’t until he had torn the door off its hinges that Saul realised that no one else in the village thought he was sane. The door and chains limited Saul’s activities. Despite the criminal damage that Saul had committed, to avoid the uncompromising involvement of the police, Grace and Project Luangwa contacted Dr Ian to try the softly, softly approach. Dr Ian already had the respect of the community in Kakumbi. He worked a variety of magic on Saul. The chains came off. Mood stabilising medication ironed out Saul’s highs and lows. Saul was one of the first patients whose medicines were paid for by the new psychiatry fund. To this day Saul’s bipolar disorder remains in remission thanks to the funds that Dr Ian continues to raise.

Back in present day Zambia psychiatric conditions continue to be misunderstood. Laughter is a common defence: He’s mad. An abdication of responsibility, born from impotence. We have no staff specifically trained to recognise or support patients with mental health problems. The Zambian ministry of health does not provide medications that might help with emotional health issues. Perhaps we have another chicken and egg situation here? In the early 1990s Zanzibar clinics repeatedly only saw patients on four days in a month. Medical supplies were often exhausted by irrational prescribing practices. When the medicines ran out, the patients knew not to come. In the 2020s our Kakumbi clinic provides no medicines for mental health issues, so mental health issues stay away in their droves.

Patients have had little reason to think that clinicians at Kakumbi can help with their emotional health. Families likewise seek solace elsewhere. The church, traditional healers, the bottle. These patients have been labelled as mad, bad or something in between. King Canute sits on his watery throne and expects the tide of emotional health problems to recede. Denial is not working.

Dr Ian Cross came up with a way of offering the Valley some hope. Evidence based and alcohol free. Generous donors have facilitated access to medicines to replace chains and uncertain traditional techniques with science. The nervous laughter used by locals to ease their own guilt can now be replaced with practical action. Families and friends are starting to bring their wards to the Valley doctor. Keith currently holds the supply of psychiatric medications. Thirty-two years of experience as a doctor. Keith holds four medications that work for emotional health conditions.

At our first outreach clinic in the community, we met Thomas. Thomas is 25 years old. We were setting up to get the children weighed and vaccinated. Have you brought my injection? I need it now. Thomas was a little distressed. He hadn’t had his usual injection for several weeks. The staff told us: He’s a bit loopy. Keith peeled off and found a quiet area to talk to Thomas. We asked the staff if they knew what injection he needed. They suggested we pretend to give him an injection: Just stick a needle in his leg and tell him we have given him his medicine. Not our style I am afraid! Keith realised that Thomas had some learning difficulties and asked one of the villagers to find his mother and his health record book.

Thomas, his mother Ednas and Thomas’ health book unlocked the past. Antipsychotic medication had been started for angry outbursts several years earlier. But there was no history of psychosis. Thomas had learning difficulties. At times Thomas found it hard to express himself. During those times he would get angry and occasionally violent. The family had asked for help to stop the angry outbursts and Thomas had been given injections. The outbursts stopped, so everyone decided to continue the injections. Keith loves a bit of de-prescribing, so he asked Thomas and Ednas if they were interested in trying something safer.

Anger is a poor orphan in the UK. No one seems to want to look after people with anger issues unless they have learning disability. Fortunately, there are excellent services for learning disabled people in the UK. Everyone else with anger issues throughout England gets GP care. Consequently, Keith has some experience in this field and knows what is in the tool kit to deal with anger. He has never previously used an antipsychotic in the absence of psychosis. He was not keen to use a powerful, potential life limiting drug on Thomas when it might be possible to help Thomas and Ednas understand his feelings and reactions. Would you like to know more about why you get angry and how to control your anger? Keith asked. Both Thomas and Ednas nodded.

Keith arranged for a patient information leaflet to be translated into Nyanja. He dropped the leaflet off for Thomas and Ednas the following week. Although Thomas does not read, he listened intently as Ednas read out the Nyanja explanations. Off medication Thomas has more energy to work in the fields. He still gets frustrated at times when he can’t get his point across, but his family and friends understand his frustration better and help him to take his anger out through digging or building. He tells his mum when the anger bubbles up and Ednas distracts him by reminding him that he now has more energy without the injections. We still see Thomas at the tree clinic from time to time. Thomas has never asked for medication since that day.

Intermission: Our story this week has more legs. Stretch yours and come back to part two later:

Keith had a brilliant mentor when he worked as a GP trainee in a psychiatry post. Jim Birch helped Keith to understand that the key to providing effective psychiatric care was in getting the talk right. The drugs were only a back-up plan. But Jim admitted that the drugs do work too, especially when you don’t have the time to deliver best talking therapy. Understanding a patient’s beliefs, fears and expectations allows us to figure out what measures can be therapeutic. But you can’t understand a patient until they trust you.

We arrived at clinic one Monday morning and had barely got out of the car when Sara appeared. Where have you been doctors? I have been waiting for you. I need to see you. You need to see me now. She spoke fluent, fast English. Pressured energetic speech. We had never met Sara before. She appeared supremely confident. Keith guessed, incorrectly, that she was a senior administrator from the District Health office. We assured her we would see her as soon as we could. She followed us into the clinic. She interrupted our greetings to the clinic staff. She would not give us a minute’s peace. The staff told us: Don’t mind Sara, she is mad. Keith’s first Zambian bona fide psychiatry patient had arrived.

Keith found an empty room to see Sara. But Sara was unable to sit still for more than a few seconds. Keith’s first question: What would you like to talk about today, Sara? led nowhere fast. Sara jumped from issue to issue without provocation. Keith tried another tack: What were you hoping that I might do to help you today, Sara? This was greeted with suspicion: “Has my brother put you up to this?” Keith had been looking after Sara’s brother Claude for several weeks by then. Claude had just recovered from a nasty bout of COVID related myocarditis. Claude now had health anxiety and a sister on the edge of madness. Keith had dutifully suggested that Claude might bring Sara to see him. Perhaps I can help? Keith had ventured.

Sara seemed paranoid and agitated on that first meeting. One of our nurses popped into Keith’s room to ask a question. Sara slipped silently out and promptly disappeared. This wasn’t going to be easy.

But Keith is a persistent chap. He spoke to staff to find out more about Sara. He discovered that Sara had a part time job with a local organisation providing support in the community. Keith probed to find out whom Sara might trust most. He wanted to gain Sara’s trust so that he could share options to help Sara feel better. The organisation was a good initial lead, but it was Sara’s sister Lena who became the lynch pin. A WhatsApp message to Lena invited her to bring Sara back to see Keith.

Take two. Sara returned to our Kakumbi clinic with her sister Lena. Lena knew exactly how to calm Sara’s paranoia and agitation for just long enough for Keith to gain her trust. Sara wanted something to help her to sleep. As I mentioned earlier, we are not overwhelmed with a choice of management options at Kakumbi. Haloperidol however, seemed to fit the bill. A cautious low dose to start with, just at night. With a warning to look out for tight muscles. Dystonic reactions occasionally occur with antipsychotics. Tight muscles, particularly affecting the jaw or neck, are unpleasant unwanted side effects of this group of medicines. Drowsiness and an enhanced appetite are more predictable things to be expected. Sara particularly liked the sound of the drowsiness. During her illness she had become worryingly thin. A better appetite appealed too. A two for one deal.

Gradually over time, Keith gained Sara’s trust. They focused on Sara’s health needs. Her sleep and her appetite returned. Sara flirted a couple of times with Keith. Offering to become his wife. Keith raised his voice so that he could be heard through the paper-thin consulting room walls. I’m sure that my wife would be delighted about that. He replied, making sure that I could hear his comments next door. He also made a mental note that Sara’s hypomania was not yet fully under control. Excess sexual appetite and over confidence are part and parcel of hypomania. As her hypomania and agitation settled Sara stopped fighting with her brother Claude. Another two for one deal. Claude no longer needs Keith’s services.

Sara’s bipolar disease is now better understood by Sara, her family, and her work colleagues. The near loss of her brother, Claude, to COVID myocarditis and her new part-time job had pushed Sara into a state of agitation and hypomania. Understanding her illness, getting better sleep, better nutrition and a more predictable daily routine have all played their parts. Keith sees Sara less often now. They adjust her medication together to control her tendency to agitation. The plan is to slowly wean down and to stop the haloperidol. A mood stabiliser is likely to be a useful option for the medium to long term. Again, our choices are limited here. The psych fund can offer carbamazepine. Carbamazepine has a good safety record and can be very effective as a mood stabiliser. Preventing the high highs and the low lows. Dr Ian Cross’ psych fund really has made a difference here in the Valley.

On our first day working here in the Valley, our car was flagged down by an anxious woman keen to collect repeat prescriptions. Maude wanted haloperidol and carbamazepine for two family members. She had no medical records to hand and neither did we. COVID had created a skeleton service for psychiatric patients. Medication had been issued without clinical review. The assumption had been that if these patients were out of sight they were doing fine. In fact, they were just out of mind. We dispensed a small stock of medications and insisted that we needed to see Maude’s wards as soon as possible.

We have had a steady stream of relatives attending the clinic requesting psychiatry medications. Keith has declined to issue medications on a reflex. He wants to know the stories behind the prescriptions. The personal narratives. He wants to involve the patient. There are pros and cons of being on medication. He wants to be able to chart, together with the patient and their relatives, what the best dose of medicine might be to manage their condition whilst minimising side effects.

Many patients with emotional health issues had been started on medication following a long expired psychotic episode. Others had previously had significant outbursts, often related to mood disturbance or anger. Families sometimes feared that they might be violent again. Monthly drug collections became the norm for this group of psychiatric patients. Months became years. The system of Valley doctors swapping every 3 to 4 months added to a lack of continuity in care provision. Repeat prescribing systems can be useful for stable patients but they tend to discourage clinical review. Many of this group of patients have not had a face-to-face review for quite some time.

We want to avoid a One flew over the cuckoo’s nest situation here. Antipsychotics are useful but powerful medications. Our role is not to zonk out these patients. We need to be empowering patients and families to get them functioning again. Because we are offering a two for one deal during our placement, we have been able organise regular face to face reviews for these vulnerable patients. Two doctors for the price of one.

Prescribing and deprescribing are Ying and Yang. Back in the UK Keith spent more time stopping medications than starting them. Psychiatric medications are now ironically the most likely medications to be provided long term in the Valley. For the psychiatry fund to continue to be a power for good: the Yang of prescribing effective medications needs to be balanced with the Ying of stopping medicines, or reducing the dose, when they are no longer needed. Nurse Ratched has no control of the drug cart here.

Chained down

Sorry I will be late for work today - elephant in the garden

Are you done yet?

On the prowl