Teaching psychiatry and establishing psychosocial services – lessons from Afghanistan

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Abstract

We describe the extremely limited psychiatric resources of war-torn countries like Afghanistan. In such countries, we suggest to apply experience from training medical students in industrialized countries to teach a very basic and simplified understanding of psychiatric classifications and core diagnostic symptoms to medical students (who will later serve in various medical disciplines in regional and district hospitals) and to medical staff including nurses and psychosocial counsellors working in health posts and district hospitals. We describe such a brief but clinically relevant list of symptoms and classifications based on experiences with medical student and practitioner training.

Introduction

Countries suffering from long term civil war, such as Afghanistan, are characterized by high rates of traumatization [14]. Quite often, such prolonged conflicts also impair the education of medical students, particularly in topics that –in spite of evidence to the country– are widely not recognized as urgent or life saving such as mental health.

In spite of a population in which more than 50% have been reported to suffer from symptoms of posttraumatic stress disorder and other symptoms of affective disorders [9], Kabul, a city with more than 5 Million inhabitants, hosts only two public psychiatric inpatient services besides newly developed addiction centers. Such sparse medical resources for the treatment of mental disorders are rather normal in large parts of the world: the average number of psychiatrists in high income countries is 200 times greater than that in low income countries [11].

In the academic teaching hospital of Kabul's Medical Faculty, training of medical students in psychiatry and psychotherapy is limited to a two week internship during the last year of medical education. Psychiatric services including outpatient facilities are extremely rare both in Kabul and the countryside. Doctors dealing with mental disorders often tend to prescribe neuroleptics, antidepressant medication and antiepileptic medication at the same time in varying doses, and there are hardly any organized meetings to ensure quality control of medical care for the mentally ill [6].

Lack of treatment resources for mental disorders contributes to the persistence of widespread psychosocial problems in Afghanistan: subjects suffering from posttraumatic stress disorder and other affective disorders often also display further problems such as high rates of opiate abuse and dependence and high frequencies of impulsive violence, particularly in domestic contexts [5,10,15]. Therefore, there is a spiralling continuation of violence within families and thus within society.

Here we report our experiences with establishing basic mental health care by training psychosocial counsellors (often with medical background such as nurses) and by establishing a road map for psychiatric care within the Afghan Medical System, report on teaching efforts within the Mental Health Hospital, a psychiatric clinic owned by the Ministry of Public Health, and the Ali Abad Teaching Hospital of Kabul's Medical Faculty. We focus on aspects of mental health care and training that can easily be generalized and applied to other countries and contexts, in which medical infrastructure is impaired by long lasting civil and military conflicts.

Section snippets

Psychosocial care as a necessary foundation for psychiatric medical care

The very low number of doctors focusing on mental health care in Kabul (about 30 medical doctors mainly trained in internal medicine with varying degrees of exposure to psychiatric patients) compared to the number of inhabitants of Kabul (about 5 million) shows that even with the highest efforts, training of medical specialists for mental health care cannot match the need for psychosocial care in a highly traumatized and large population. Therefore, medical care should only be secondary to

Training of psychosocial counsellors

Besides basic knowledge in the classification of mental disorders (which is required e.g. to decide when referral is necessary), it is of main importance for psychosocial counsellors to be able to understand and interpret social conflicts from different perspectives and the meaning of the symptom in the given cultural context. The key to successful treatment is to help the patient feel again that she/he can actively influence their lives again. Furthermore, counsellors need to have the skills

Learning a Basic Medical Approach to Psychopathology

An alternative approach to identifying psychopathology is based on university experience in the training of medical students around the world. This training also does not focus on clear identification of single disorders in ever more complex classification systems. Rather, medical student education focuses on distinguishing between six types of psychiatric disorders: Acute and chronic exogenous psychoses (e. g. delirium and dementia as examples of cognitive disorders with a “brain organic”

Training of psychiatric specialists

Our experience in Kabul revealed that even doctors trained in internal medicine and specializing on mental disorders within mental health hospital require training in basic neurological examination skills. Clinical examination, a mainstay of neurological diagnosis until recently, when brain imaging became available is a must in countries with limited medical resources such as Afghanistan. Of extreme importance is also the distinction between epilepsy and dissociative states. Therefore, the

Summary and outlook

In countries which limited financial resources such as Afghanistan, a vast majority of patients with psychiatric disorders profit from psychosocial intervention and will never see a doctor trained in psychiatry. In such settings, limitation of unnecessary medication and polypharmacy in order to prevent iatrogenic harm appears to be as important as basic training in helpful medical interventions. With respect to psychosocial training, intervention skills alone are not enough in order to prevent

Conflict of interest statement

None.

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