Photos: Swahili building techniques, Central square in Lubutu1 September 2009
Unmentionables
There are many bad contagious diseases floating around here. The three most common things I see each day are also the three biggest killers: malaria, diarrhea, and pneumonia. I've got the protocols for these three diseases memorized. The threshold for treatment of these conditions is very low. If patients come into an MSF clinic with one day of diarrhea and aren't clinically dehydrated, we still prescribe rehydration salts. We make them a follow-up appointment in 1-2 days. If they look even minimally dehydrated (dry mouth, sunken eyes) they drink rehydration solution in the clinic. They wait around several hours to make sure things don't worsen. Diarrhea kills people here so the threshold for diagnosis and treatment is low.
In contrast, mental illness is hardly recognized and rarely treated. Since my arrival, I've seen major depression, panic attacks, post-traumatic stress disorder, adjustment disorder with depressed mood, and psychosis. I fear I'm the only one paying attention.
Early this afternoon I was at Kalibatete seeing patients with the Consultants. It's always fun because the four of them share interesting patients. If one room has an unusual case or physical finding, we all go see it. I am constantly moving from one exam room to another to help out and learn. So when I got a call to come to the end room, I wasn't surprised. I was surprised at the tone of panic in the Consultant's voice.
Flopping (literally) on the exam table was a young woman. Was this a seizure? It didn't look right. I examined her and realized this crise (pronounced "kreez") was a conversion reaction. Subconsciously, she had turned anxiety or stress into a physical manifestation. Fifteen seconds later, every person who works at Kalibatete was in the exam room with me. Four Consultants, two pharmacists, the security guard, the cleaning lady, two people who register patients, two people who take vital signs, and the guy who does crowd control. That's fourteen people and me watching a fake seizure in a room about 6 by 8 feet. Two hundred curious onlookers were trying to peek in. Yikes.
I explained that this was not a crise epileptique but a crise anxietique. The family of this poor young woman were dragged in and quizzed. This 17 year old was pregnant. Her partner was in Kisangani, 4 hours away. He was unfaithful. She had been seen in the Centre de Santé that morning for a sexually transmitted disease. It was Ramadan and she hadn't eaten since sunrise. So guess what the crowd decided was the origin of her crise anxietique? Yep, they decided it was because she was hungry.
The Consultants are receptive to the concept of mental illness. It simply does not occur to them as a diagnostic possibility. Even if they think about it, they discount its importance. A patient at Mungele with major depression was initially counselled that he'd stop crying and start sleeping again if he didn't work so hard. Many people in Western developed countries have experience (personal, family, or friends) with mental illness. We know the disability brought by depression or anxiety. It can kill. That personal experience with mental illness is lacking here.
Without diagnosis, medical treatment for mood and anxiety problems is not possible. Fluoxetine (the generic of Prozac) is available, but has rarely been prescribed in the three years this hospital has been open. Why? Clearly most importantly is underdiagnosis/misdiagnosis and unfamiliarity.
A second big problem is the way people are prescribed medicines. In our Centres de Santé patients are given a prescription for 5-7 days, no matter how long their anticipated treatment. At their initial appointment, if they have an infection that requires 4 weeks of antibiotics, they get a prescription for 7 days. After that time they come back to the Centre de Santé and wait in line for another 4 to 6 hours. Then they get another 7 days of therapy. Why? My predecessors were worried that if people were given too many pills, they would sell them. People who are depressed or anxious need medicine for 6 to 12 months, if not forever. If you're feeling depressed or anxious enough to need medicine, are you going to put up with waiting for hours once per week? I doubt it.
So now that I planted the concept of mental illness in the minds of the Consultants I tackled some of these prescribing habits. Now when we see a therapeutic response we give people 2 weeks of therapy. Not a major victory but a start. But we still had another problem. Patient who take antidepressants need to take the medicine for up to 6 weeks before they see a therapeutic effect. Unfortunately, the side effects sometimes don't wait that long; patients temporarily feel worse before they feel better. To the Consultants, the concept of taking a medicine that might temporarily make you feel worse was met with a mixture of disbelief and "even if that's true, why would anyone take the stuff?"
We Westerners also deny and discount the importance of mental illness. I've had many patients with conversion reactions or pseudoseizures whose family deny the possibility of a psychiatric problem. They ask for a second opinion. When they don't like that answer, they ask for a third opinion. When that's unsatisfactory, it's off to Mayo Clinic where they are sure they'll get a "real" diagnosis.
People with mental illness also pay more for their care than those with "real" sickness. If they see a doctor for hypertension or heart disease, they likely owe a low co-payment. Go to a psychiatrist (who is an MD) and they probably pay the same amount. But if they need psychotherapy, the co-payment is significantly higher. After all, the therapist isn't really doing anything, at least in the mind of the insurance company.
Is there a solution here in Lubutu? I don't know. When I do my one on one teaching, I try to discuss mental illness at least once per day. I've started some formal lecture presentations and will add Mood and Anxiety Disorders to the list of upcoming topics. Yes, I know that depression isn't as likely to kill you as malaria. I can't change the culture here. But perhaps I can help a few people with mental illness get it diagnosed and treated in this corner of Congo
Unmentionables
There are many bad contagious diseases floating around here. The three most common things I see each day are also the three biggest killers: malaria, diarrhea, and pneumonia. I've got the protocols for these three diseases memorized. The threshold for treatment of these conditions is very low. If patients come into an MSF clinic with one day of diarrhea and aren't clinically dehydrated, we still prescribe rehydration salts. We make them a follow-up appointment in 1-2 days. If they look even minimally dehydrated (dry mouth, sunken eyes) they drink rehydration solution in the clinic. They wait around several hours to make sure things don't worsen. Diarrhea kills people here so the threshold for diagnosis and treatment is low.
In contrast, mental illness is hardly recognized and rarely treated. Since my arrival, I've seen major depression, panic attacks, post-traumatic stress disorder, adjustment disorder with depressed mood, and psychosis. I fear I'm the only one paying attention.
Early this afternoon I was at Kalibatete seeing patients with the Consultants. It's always fun because the four of them share interesting patients. If one room has an unusual case or physical finding, we all go see it. I am constantly moving from one exam room to another to help out and learn. So when I got a call to come to the end room, I wasn't surprised. I was surprised at the tone of panic in the Consultant's voice.
Flopping (literally) on the exam table was a young woman. Was this a seizure? It didn't look right. I examined her and realized this crise (pronounced "kreez") was a conversion reaction. Subconsciously, she had turned anxiety or stress into a physical manifestation. Fifteen seconds later, every person who works at Kalibatete was in the exam room with me. Four Consultants, two pharmacists, the security guard, the cleaning lady, two people who register patients, two people who take vital signs, and the guy who does crowd control. That's fourteen people and me watching a fake seizure in a room about 6 by 8 feet. Two hundred curious onlookers were trying to peek in. Yikes.
I explained that this was not a crise epileptique but a crise anxietique. The family of this poor young woman were dragged in and quizzed. This 17 year old was pregnant. Her partner was in Kisangani, 4 hours away. He was unfaithful. She had been seen in the Centre de Santé that morning for a sexually transmitted disease. It was Ramadan and she hadn't eaten since sunrise. So guess what the crowd decided was the origin of her crise anxietique? Yep, they decided it was because she was hungry.
The Consultants are receptive to the concept of mental illness. It simply does not occur to them as a diagnostic possibility. Even if they think about it, they discount its importance. A patient at Mungele with major depression was initially counselled that he'd stop crying and start sleeping again if he didn't work so hard. Many people in Western developed countries have experience (personal, family, or friends) with mental illness. We know the disability brought by depression or anxiety. It can kill. That personal experience with mental illness is lacking here.
Without diagnosis, medical treatment for mood and anxiety problems is not possible. Fluoxetine (the generic of Prozac) is available, but has rarely been prescribed in the three years this hospital has been open. Why? Clearly most importantly is underdiagnosis/misdiagnosis and unfamiliarity.
A second big problem is the way people are prescribed medicines. In our Centres de Santé patients are given a prescription for 5-7 days, no matter how long their anticipated treatment. At their initial appointment, if they have an infection that requires 4 weeks of antibiotics, they get a prescription for 7 days. After that time they come back to the Centre de Santé and wait in line for another 4 to 6 hours. Then they get another 7 days of therapy. Why? My predecessors were worried that if people were given too many pills, they would sell them. People who are depressed or anxious need medicine for 6 to 12 months, if not forever. If you're feeling depressed or anxious enough to need medicine, are you going to put up with waiting for hours once per week? I doubt it.
So now that I planted the concept of mental illness in the minds of the Consultants I tackled some of these prescribing habits. Now when we see a therapeutic response we give people 2 weeks of therapy. Not a major victory but a start. But we still had another problem. Patient who take antidepressants need to take the medicine for up to 6 weeks before they see a therapeutic effect. Unfortunately, the side effects sometimes don't wait that long; patients temporarily feel worse before they feel better. To the Consultants, the concept of taking a medicine that might temporarily make you feel worse was met with a mixture of disbelief and "even if that's true, why would anyone take the stuff?"
We Westerners also deny and discount the importance of mental illness. I've had many patients with conversion reactions or pseudoseizures whose family deny the possibility of a psychiatric problem. They ask for a second opinion. When they don't like that answer, they ask for a third opinion. When that's unsatisfactory, it's off to Mayo Clinic where they are sure they'll get a "real" diagnosis.
People with mental illness also pay more for their care than those with "real" sickness. If they see a doctor for hypertension or heart disease, they likely owe a low co-payment. Go to a psychiatrist (who is an MD) and they probably pay the same amount. But if they need psychotherapy, the co-payment is significantly higher. After all, the therapist isn't really doing anything, at least in the mind of the insurance company.
Is there a solution here in Lubutu? I don't know. When I do my one on one teaching, I try to discuss mental illness at least once per day. I've started some formal lecture presentations and will add Mood and Anxiety Disorders to the list of upcoming topics. Yes, I know that depression isn't as likely to kill you as malaria. I can't change the culture here. But perhaps I can help a few people with mental illness get it diagnosed and treated in this corner of Congo
Thanks for your e-mail, Doug. We continue to follow your bulletins with great interest.
ReplyDeleteJust off to Romania for a fortnight. One weather channel predicts wall to wall thunderstorms but another is more optimistic!
Regards fom us both
Margaret and David
Hi, Doug, if you need some help with this, you can count on me. Hugs, Camila cdonnola@ig.com.br
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