Dreams do come true: How an mhGAP exchange project inspired a medical student to pursue a career in psychiatry

Dr Syed Bushra Imtiyaz is a post-graduate student in Psychiatry at the Institute of Mental Health and Neurosciences (IMHANS) Kashmir, and a participant of the mhGAP psychiatry exchange programme.

I’ve always believed that  mental  illnesses are often more distressing and debilitating than physical illnesses, not only to the patient but to their families and friends as well. However, people are always more accepting of a physical malfunction than a mental one; A physician consultation and a psychiatric consultation is never the same deal, ever!

I think mental illnesses are often underestimated in terms of their seriousness. So when I first came across the advertisement notice of the mhGAP psychiatry exchange programme, I knew in a heartbeat that it was something I would never  want to miss out on, and immediately signed up for it. After the selection process I was paired with Dr Joanna Cox, who was back at that time in her final year, just like me.

We then registered with Medicine Africa, a Kings College London co-ordinated interactive website, through which we scheduled our sessions and held discussions on various mhGAP modules using the WHO formulated mhGAP interactive guide.

My first session was kind of memorable. It was my birthday and it was snowing in Kashmir. I was struggling with internet speed and it took us a while to figure out how Medicine Africa worked, still thank Joanna for all the patience she showed that day! With inputs from Dr Hussain and Dr Keynejad, we were finally able to begin our first session.

Our first discussion was on depression. We began by discussing the definition, signs and symptoms and types of depression, and then went on to discuss awareness regarding depression as an illness in our respective cultures. We also discussed how the mhGAP master plan could be used to deliver mental health services by non-specialists at a grass-root level. We found it practical, on-point and easy to comprehend. As the discussion went on we became increasingly interested in knowing how the psychiatric practices differ in our respective countries. How stigma attached with mental illnesses can affect the outcome of mental health. We also discussed the effect of conflict on mental health in Kashmir and the possible ways in which some of the negative effects could be effectively dealt with.

When the first session was over, I was already looking forward to the next!  And so it began. A series of about ten more sessions followed, one every 2-3 weeks, each of about 1 hour duration. Before starting a new session, we would receive instruction on the topic to be discussed. Then we would log into our Medicine Africa accounts and fix a date and time for our session. Following the same pattern of discussion as we did for depression, in the remaining sessions we discussed:

• Psychosis
• Bipolar Affective Disorder
• Epilepsy / seizure disorder
• Behavioural disorder
• Alcohol use and alcohol use disorders
• Substance use and substance use disorders
• Dementia
• Self-harm/suicide
• Other emotional and medically unexplained  complaints
• Advanced psychosocial interventions.

We would begin by discussing theoretical aspects and then delve into the practical aspects. Our favourite part was doing the UK vs Kashmir comparison – presentation, cultural views, stigma and management approaches including on the lines of the mhGAP master plan. I was impressed to find out about the community and home treatment teams in the UK while Joanna was amazed to learn about the role of faith-healing as a form of informal psychotherapy.

Those six months passed quicker than I had expected and before we knew it, it was time for the last session. However, Joanna and I decided to stay in touch and exchange views/ideas via social media, and we continue to do so to date. It’s always a pleasure interacting with her.

Once the sessions were over, we filled in the post partnership surveys and questionnaires, received our valuable completion certificates and then we all got busy with our exams. To be honest, I was a little sad that it was over, but there was one thing that I was more sure of than ever before: that I wanted to pursue a career in psychiatry.

It’s not every day that one gets to be really lucky. I had to pinch myself twice when Dr Hussain told us that we were going to be a part of the Medical Observership programme, to be held in the UK, thanks to his incessant efforts and huge support from Lincolnshire Partnership NHS Foundation Trust, especially Dr Sue Elcock, Medical Director of the Trust, who approved the proposal on behalf of the Trust and Dr Raheel Aziz, Consultant Psychiatrist and Incharge Undergraduate Programme, for formulating the Observership programme.

In those two weeks in May, we experienced both the outpatient setting at Grantham and the inpatient setting at Lincoln.

During week 1 at Grantham, we rotated  through the various subspecialties of psychiatry, shadowing expert consultants, including:

• Child and Adolescent Mental Health  (CAMHS) with Dr Nazir  and  Dr Thompson
• General Adult Psychiatry with Dr Aziz
• Community Mental Health with Dr Hussain
• Geriatric Psychiatry (Manthorpe House) with Dr Al-Kaisey
• Drug and Alcohol Rehabilitation (DART) with Dr Wright

For me it was absolutely amazing to experience first-hand what I had discussed with my partner online. I was especially impressed by the organization of the mental health services in the UK and the efficient delivery of the services by the various specialist teams.

I visited care homes for the elderly and learned about the various facilities and services offered. The concept of care homes is not well established in Kashmir. Strong family support still exists and the elderly are generally cared for in their own homes by their own families. This attitude is partly shaped by religious beliefs.

I was also lucky enough to get an opportunity to see a patient in the community with the community mental health team led by Dr Hussain, and then was able to see the same patient again in the in-patient department where she was admitted informally following an assessment under the Mental Health Act. This gave me a fair understanding of the approach to the management of a patient in the community as well as in the hospital, as well as application of the mental health act.

During week 2, we rotated through the following wards/units:

• Connolley and charlesworth wards (Female and Male closed wards respectively) with Dr Al-Kubaisey and Dr Rajkumar
• Francis Willis Forensic Unit with Dr Monti
• Discovery House (Rehabilitation center)
• Electroshock Therapy (ECT) unit

We attended ward rounds, learned about managing patients in in-patient settings and observed how patient records were meticulously maintained electronically, something which is yet to be introduced in Kashmir. Also, the concept of rehabilitation centers/half-way homes is not well established in Kashmir while in the UK it is pretty impressive.

Near the end of our observership, we gave a presentation on our experience with the UK mental health services and compared it with the system in Kashmir, highlighting advantages and disadvantages of both. Following the presentation, we were awarded with certificate of completion of the project by Dr Sue Elcock.

Outside of our observership schedule, we grabbed every opportunity to travel in and around Lincolnshire, visited places of historic importance like the world famous Woolsthorpe Manor, home of Sir Isaac Newton. 

We also visited Birmingham, where I was able to catch up with Joanna. She was as excited to hear about my observership experience as I was to tell her about it.

As I bade her goodbye and prepared to fly out of the UK, I wondered whether it was the end to a beautiful time or the beginning of a new chapter. I landed back home and in a couple of days resumed my internship in the hospital and started preparing for the MD entrance exam. A few months later I took the exam and secretly prayed to get selected for training in Psychiatry. The day the results were out was perhaps the day I realized that dreams do come true. I got selected for MD Psychiatry and presently I’m in my first year of training at the Institute of Mental Health and Neurosciences (IMHANS), Kashmir, under the able guidance of Dr. Mohammad Maqbool Dar, Head of the department, Dr. Arshad Hussain, Dr. Zaid Wani and Dr. Yasir Hassan. With their kind support, and invaluable guidance from Dr Sayed Aqeel Hussain, I was selected for a fellowship programme to attend a conference at the Postgraduate Institute of Medical Education & Research, Chandigarh, India, where I presented a poster on my experience of the delivery of mental health services in the 21^st century NHS, UK, and Kashmir- a conflict area with limited resources.

Special Thanks to Professor Ajit Avasthi, Head of the Department of Psychiatry, Post Graduate Institute of Medical Education And Research, Chandigarh, for organizing the GERON 2017 Conference and considering me for the Fellowship programme.