CORRESPONDENCE.

Sir: On 30 May 2012, I received a call from a psychologist living in the Emilia region of Italy, after two major earthquakes that month. My colleague had gone here to put together a group of experts on emergencies, who met near a school; the roof of the building had caved in and the health workers were on the lawn nearby to provide help.

My house, too, had swung frightfully – I live on the eighth floor; cracks had appeared on the walls, but it had held. ‘Let’s go into the belly of the dragon’, I told myself. Of this I was sure: I definitely preferred to be of some help than stay at home, waiting for the next shake. But as I was putting together an emergency bag, I wondered about what tools I could bring within myself, and whether I would be able to exploit my professional skills and experience in such an exceptional situation.

I have been working for three years within a collaborative project addressing the mental health of political refugees and torture victims. Under the supervision of Marco Mazzetti, we studied how to deal with torture, war and violence (Mazzetti, 2010), as we felt that our standard training in psychiatry was insufficient in this regard. The earthquake, I told myself, may be a little like that: like a dragon, an external enemy, violent and unpredictable. In those few hours, before I reached the meeting point, my experience with refugees allowed me to pack my bags more appropriately.

In people affected by torture, as well as by earthquakes, an external action produces objective psychological reactions than cannot be interpreted in terms of individual, intrapsychic conflict. This external action undermines one’s own foundations of being: victims no longer feel at home with their own thoughts. What is left is a human being bared of complexity and affectivity, at the mercy of ancient traumas awaken by the shock. Their experience, as I collected it in small-talk on the grass around the ruins, was that of being attacked, violently attacked in their physical and psychic identity.

So I worked to return to people their integrity and sense of self-determination, to differentiate the parts within them that had become powerless from those that were still functioning, to let them expel the invading and destructive presence of the earthquake, as if it were a torturer. I had to act quickly, to ‘go into the belly of the dragon’, right inside, to stop the colonising process of fear within the territories of free self-determination. By picturing the earthquake as a torturer, I found the right attitude to get in touch with both the injured and the resilient portions of self of those who needed my help. Just as with torture, we can speak of the earthquake as a living scar of something that is no longer here.

That journey, those 40 kilometres, were like a round trip through a time portal into another dimension, one which felt even more real than reality itself.

Sir: Since moving from London to take up my first substantive consultant position in one of the Channel Islands, I have been reflecting on the challenges and opportunities that working in such a setting provides. Guernsey is a small island about 55 km (35 miles) from the Normandy coast, which is legally and financially independent from the UK and the European Union but is a British Crown Protectorate. Its total area is 65 km2 and its population 62 000.

Working within a small service in a discrete, largely coastal community has allowed me to see and manage a far wider range of psychiatric and addictive conditions than I would working in inner-city psychiatry and to work more closely with multidisciplinary colleagues. Often we hear early on about a patient’s relapse, which allows for early intervention. However, a community grapevine poses challenges for clinical confidentiality and may also entrench stigmatised attitudes to mental illness and addiction. Working as a consultant with a specialist interest in drugs and alcohol, I was interested to find there is little heroin available on the island, largely due to a highly effective border agency, and that, as a result, people dependent on drugs tend to misuse mostly prescription medication (either diverted or imported). A 2011 audit revealed that 96% of Guernsey drugs clients in treatment reported misuse of prescription-only medication (POM), compared with about 16% in the UK. Compared with inner-city heroin users, it can be clinically challenging, for example, to estimate total opiate intake when patients report use of up to five or six types of opiate over 2–3 days, depending on availability. There was a surge in the use of ‘legal highs’ (emerging drugs of concern, or EDOC), with an increase in admissions for drug-induced psychosis, until these were made illegal in 2008. Because these substances come in an ever-changing variety of chemical formulations, it is challenging to keep abreast of their neuropsychiatric manifestations, and to test for their use in routine drug screening. For the first time in Guernsey, a joint strategic needs assessment is being undertaken with expert UK partners, which will allow for an independent review of current drug treatment services and service gaps.

These challenges represent opportunities for a creative psychiatrist. There is immense potential for both service development and research within a stable, relatively homogeneous population, often with multiple family generations available. Discrete populations may offer improved follow-up and novel research approaches. One example is the piloting of a primary care psychological service embedded within general practice, which appears to have reduced inappropriate referrals to secondary care and has possibly reduced high levels of antidepressant and benzodiazepine prescribing.

To address the risks of professional isolation, Guernsey is working actively to build clinical, academic and professional relationships with National Health Service trusts in the south of England. On a personal level, I have been privileged to join a peer group for the purposes of continuing professional development, based in Bristol. In addition to ensuring that I keep my skills and knowledge up to date, the group provides a useful reflective and comparative space. Guernsey is refreshing its local psychiatric academic programme and I would welcome contact from potential guest speakers or partners worldwide.

Sir: The third meeting of the Young Psychiatrists (YPs) Network of the European Federation of Psychiatric Trainees (EFPT), ‘Stigma from the YPs’ perspective: hopes and challenges’, took place in Minsk at the end of September 2012. It gathered 74 early-career psychiatrists from 21 countries, ranging from Portugal and the UK in the west to Armenia and India in the east. The meeting was set to tackle one of the most challenging problems of modern healthcare – the stigma attached to psychiatry, its patients and professionals. The programme included not only lectures by senior psychiatrists but also workshops, run mainly by young specialists themselves. They provided a forum for discussions about stigma and other relevant topics. A much-appreciated part of the programme in previous meetings was the discussion of ‘tricky cases’. This session allowed participants to compare diagnostic and treatment approaches between countries and to gain valuable insight from world-renowned experts. Another attractive feature of the programme was the opportunity to deliver a presentation on any interesting topic during the participant-generated session called Barcamp. Patients contributed to the conference with an exhibition of paintings and a musical concert which took place during a study visit to the local hospital.

The YPs Network started in 2010 in Vilnius with its first meeting supported by the Swedish Eastern Europe Committee (SEEC). The second meeting took place in Riga in 2011 with the support of the World Psychiatric Association and the SEEC. In 2012 the meeting was arranged in cooperation with the EFPT in line with its goals of improving psychiatric training in Europe (Kuzman et al, 2012) and was supported by the Ministry of Health of the Republic of Belarus, the Belarusian Medical Academy of Postgraduate Education (BelMAPGE) and the Belarusian Psychiatric Association (BPA).

Every year this unique event attracts more attendants. The main aims of the meetings are to exchange experience of practising psychiatry in different parts of Europe, to allow early-career doctors to develop an international peer-support network, and to inspire collaboration and the development of joint projects (Bendix et al, 2011).

At the end of the conference anonymous evaluation surveys were distributed and 52 were returned. The meeting was evaluated positively by all. Large majorities of the respondents anticipated future positive influence of the meeting on their professional (81%) and personal (88%) career.

Participants and organisers wish to continue with future meetings and are happy to welcome other early-career psychiatrists to the Network, who can join at any time. Stronger cooperation will enrich both the Network and the programme.

Further information is available at http://ypsnet.org

Sir: It was disappointing to see that Africa was missing from the summaries of the mental health activities of the World Health Organization (WHO) in the thematic papers in International Psychiatry’s November 2012 edition, as this does not reflect the tremendous work that is being done on the continent by the WHO, governments and other groups.

Africa, which in WHO Regions mainly refers to sub-Saharan Africa, is estimated to have a mental health treatment gap of 85%, which of course constitutes a major barrier to the fight against poverty. It is therefore appropriate that during the development of the WHO’s Mental Health Gap Action Plan (mhGAP), significant attention was paid to ensuring the practical translation of the evidence on which it was based, so that it would be appropriate to the typical African context. This has started to bear fruit, with several large-scale mhGAP-based programmes taking root, for example in Ethiopia, Sierra Leone and Nigeria, and its use as an advocacy and teaching resource following local contextualisation. Africa also provided a strong voice in the campaign to include mental health in the United Nations High-Level Meeting on Non-Communicable Diseases, discussed by Vijay Ganju in Guest Editorial in the same issue (pp. 79–80).

There has also been a recent strengthening in research, which has become increasingly focused on the particular needs of Africa. The African Journal of Psychiatry, International Psychiatry’s sister publication, has provided an important platform for dissemination. This is essential, given the scarcity of research focused on African needs, and has contributed to an increase in resources for advocacy, for example to increase government prioritisation of mental health and its mainstreaming into other sectors. The PRIME programme, for instance, is starting to produce excellent policy briefs that help to make research evidence available for advocates (see http://www.prime.uct.ac.za).

Of course, there is much to do, but there is no doubt that Africa has taken significant steps to address its mental health treatment gap and made an important contribution to global mental health in recent years, and this should be acknowledged.