Utter Madness! – Mental health care in Guyana
By Crystal Conway
‘Utter Madness!’ would be a fitting description of the state of the professional scene in public mental health care.
There are only three doctors in the system to deal with the mental health care needs of the general public. At the Georgetown Public Hospital Corporation one of the lesser known but no less important wards is the Psychiatric Ward. Staffed by just three doctors, the ward caters for walk-ins as well as patients in need of continuous care.
The department’s staff is small but the work that they do is extensive. Their team consists of the three medical officers and two social workers. At the clinic, there is a permanent psychiatric nurse, two clerks and a cleaner. The small holding area of the ward is managed like any other ward at the GPHC – by the nursing hierarchy. It is staffed with a rotation of nurses and patient care assistants.
Heading up the department is Dr. Bhiro Harry, the first of the three medical officers. Dr. Harry who specialized in Psychiatry has been in the field since 1983. He is assisted by Cuban Psychiatrist, Dr. Radine Cuellar and Dr. Catherine Persaud, a young Guyanese doctor who has not yet started her specialization studies but intends to pursue Psychiatry.
In August I sat down with Doctors Harry, Cuellar and Persaud to discuss the Psychiatric Care offered by the state. One of the first points the doctors made was that they are pretty much overwhelmed with the numbers of patients that they have to see. On Mondays, Wednesdays and Thursdays the doctors hold their adult clinics where they see on average 80 to 100 patients per day. On the first and third Tuesdays of the month they hold their pediatric clinic and on the second Tuesday of each month they visit the Georgetown Prison. On the fourth Tuesday of each month the doctors will visit the regional health care center in Linden. On the third Friday of the month, they stage their monthly clinic in Parika and on the fourth Friday of the month they are at the Suddie hospital.
According to Dr. Harry, the clinics at Linden and Parika have been regular occurrences since he started at the Hospital in 1983, along with the prison visits, which though sporadic at first, have become a regular part of the Department’s routine over the last 10 years. The Suddie clinics are the latest to be added to the routine having only started in the last two years. And on non-clinic days, the doctors still take walk-ins. Because the GPHC is a referral center, non-emergency patients are usually required to seek a preliminary examination at their nearest regional health care center after which they can be referred to the GPHC.
The doctors noted that they are capable of treating ‘everything and anything’ across the mental health spectrum of neurotic and psychotic illnesses. Dr. Harry stressed however that a large part of diagnosing a person’s illness is tied to the information that they receive on each patient. There are those patients who are lucid and whose illnesses do not impair their ability to explain their symptoms. There are also complaints such as persons suffering from clinical depression. Then there are the patients who are unable to explain what happens because they are unaware of themselves when they are manifesting their symptoms. In these cases relatives and friends must assist the doctors. Then there are other matters that further complicate diagnosis. For instance, some undiagnosed and untreated chronic diseases such as diabetes can themselves cause mental manifestations. Substance abuse is another area that makes diagnosing mental cases even more tricky. Persons who use narcotics will display a range of mental aberrations that may mask underlying symptoms. Added to this prolonged substance abuse can also cause a host of problems all by itself.
Then there are the mental illnesses that are very real but not recognized for what they really are. Dr. Harry pointed out that he cannot count the number of cases where a patient is hearing voices or hallucinating and those around him insist on saying that he has been ‘cursed’ or ‘somebody do he something’ or ‘is obeah’ when in fact these are all symptoms of mental illness.
Then there are the cases where a person manifesting behaviour that is indicative of a mental illness is simply chalked up to other things like saying “Oh, he jus bad”. He recalled the case of one young man whose mother told him that he was completely normal most of the time but that there were episodes where he would become overly aggressive and start threatening everyone around him. The woman would insist that there was nothing wrong with her son, that he was just ill-behaved, until one day she let slip that they usually hear him talking and laughing by himself before the onset of these episodes. Apparently the young man had been hearing voices.
Psychiatric conditions associated with hearing voices include bipolar disorder, psychotic depression, schizoid and schizotypal personality disorders, and schizophrenia. Medical conditions affecting the central nervous system, such as brain tumors, delirium, dementia, epilepsy and other seizure disorders, and stroke, can also be associated with hearing voices.
He recounted another case that involved a young girl who was perfectly normal but over a period of months she started having serious trouble at school. Her teachers started complaining that she wasn’t paying attention and then after a while her grades started slipping. As time progressed, the reports grew worse and teachers noted that she was becoming disrespectful and rude, refusing to look at them when she was spoken to. Her mother, at her wits end, mentioned the problem to Dr. Harry who asked for the opportunity to sit with the little girl and talk to her. The little girl was later diagnosed as suffering from an Obsessive-compulsive Disorder (OCD). OCD is an anxiety disorder characterized by uncontrollable, unwanted thoughts and repetitive, ritualized behaviors a person feel compelled to perform. It just so happens that the root of the little girl’s problems at school was a clock that hung on the wall behind her. Every few minutes she would feel compelled to look back at that clock and count from one to ten. She would try to do it as fast as she could in an effort to return to the class but it was still affecting her significantly, since she could not pay attention to what was being taught in her classes, nor could she answer when called upon by a teacher since her mind was forcing her to complete the action.
This is just a brief glance into the difficulties of diagnosing a mental illness which these doctors have to deal with every day. But outside of the difficulties, all of the doctors were ardent in their belief that more people need to be educated on what being diagnosed with a mental illness means. They all spoke of the stigma attached to such a condition and noted that it could be counterproductive to the wellbeing of a patient’s recovery.
And recovery is a real possibility. The Doctors pointed out that most patients can be treated through the use of medication and regular counseling and therapy sessions. There are only a few patients in the ward’s holding area, which is a blessing in disguise, since the Department’s original home burnt down three years ago. They once had two wards with 40 beds but now after the fire, they are confined to the ground floor of the infectious diseases ward at the GPHC. The facility has a waiting area, its own small pharmacy and that’s about it. The Male Holding Area is a converted doctor’s office and the Female Holding Area is a converted Social Worker’s Office. The doctors are also forced to use a single office to see patients, which makes it difficult on all the parties involved since both the patients and doctors can literally hear each other’s conversations. Despite all the challenges, however, these three doctors are still enthusiastic about their work and approach their jobs with professionalism and large doses of good humour.
They point out, however, that there is a real need for more doctors in the system as well as better facilities to allow them to give their patients privacy and comfort. There is also a need for trained support staff such as psychiatric nurses, nursing assistants, patient care assistants and social workers with specialized training for dealing with psychiatric patients.
Besides the team at the Hospital, who not only service Georgetown but travel to several outlying areas, there is the team at the National Psychiatric Hospital in Berbice. This hospital is headed up by Dr. Mayda Grajales who has on her staff one general practitioner, Dr. Ravi Thakurdin, one social worker, one staff nurse, 10 nursing assistants, 33 nurse aides and 21 psychiatric care assistants. Together they are capable of caring for 214 psychiatric patients. Their current occupancy is 165. The purpose of the National Psychiatric Hospital is not to deal with the average patient in need of mental health care, but for those patients who need to be institutionalized; that is, 24/7 care and supervision is required for patient safety and well being to be assured. The decision to send patients to the National Psychiatric Hospital comes from the Mental Health team at GPHC, which consists of the Head of the Department, Psychiatrist, General Medical Practitioner (Psychiatry), Social Worker, Nurse and a Psychologist when available.
The National Psychiatric Hospital is known by its more popular moniker, the Berbice Mad House an impression that the Ministry of Health is trying to change. Yes, the institution does cater to mental health patients but not all of these patients are raving lunatics who need to be restrained. There are patients who actually live in self contained apartments on the grounds of the facility and are largely able to take care of themselves, but who are unable to function in the outside world because of their mental illness.
When a patient comes into the system at the GPHC, they are usually assessed, treated and released once it is possible. In some cases a person may need to be held overnight but rarely is a person held for more than 72 hours after which time the team must make a decision on whether to release that person, admit them to the NPH or in rare cases lengthen their stay at the holding area.
In a recent interview the Minister of Health, Dr. Leslie Ramsammy stated that “We are now embarking on training doctors and health workers at Regional Health Centres and Hospitals to be more alert to symptoms and be able to develop an index of suspicion. Even if they can’t definitively diagnose at health centres, then referrals can be made,” said Dr. Ramsammy. This move is expected to go a long way towards helping the doctors cope with some of the cases out there, since it gives them more information to work with.
It was also pointed out by Ramsammy that while the psychiatrist of the New Amsterdam Hospital functions at the Skeldon Hospital when there is the monthly clinic date, staff from the GPHC would serve at the other health sites. He stated, “We are hoping to soon expand more clinics to Mabaruma, Bartica and Lethem as staff increase, and also to make the clinic dates more frequent and open at other places since this issue should not be taken lightly. In fact, mental disorder is one of the leading contributors to suicide and this is prevalent in today’s society.”
In the meanwhile, we wish the teams at GPHC and the National Psychiatric Hospital well as they continue to do their best to keep the country sane.