Dilemmas of a psychiatrist in a developing country

It was in early 1984 when, after receiving my basic postgraduate training in the UK, I returned to my home country, Pakistan. As I began to settle down in my professional work I soon realised that I was facing problems on more than one front. Whereas some of these I have been able to overcome with time, others remain largely unresolved. Psychiatrists from the developing world who receive their training in the West and subsequently return to their home countries may be facing similar dilemmas. Here 1would like to share some of my own. Pakistan is a developing country. With a population of over 133 million and less than 200 psychiatrists, the mental health services remain inadequate and underdeveloped. At pre sent, psychiatric services are limited to the major teaching centres only. The bulk of the population (70%) that lives in the rural setting is thus deprived of any form of modern psychiatric care. Almost all psychiatric manifestations are con sidered to be the result of possession by evil spirits or the effect of magic spells and the local faith healers are always there to confirm this. While some of the methods used to drive away these 'evil forces' may be harmless (e.g. reciting

Sir: Morgan's editorial on Continuing Profes sional Development (CPD) (Psychiatric Bulletin, September 1998, 22. 529-530) paints a picture of two contrasting groups of psychiatrists: one containing diligent, committed clinicians who have opted in to CPD, the other being made up of foolhardy cynics who ignore his warnings at their peril. An advertisement follows the article tempting us with free subscriptions to ajournai if we 'join' CPD. The product called CPD therefore sounds like something I can have if the price is right (but perhaps 1 should wait for the January sales).
I am sure, however, that the vast majority of psychiatrists are in favour of CPD as a process. 1 certainly am. The suggestion that those members who have not registered with the College's scheme are not participating in CPD is inaccu rate as well as somewhat insulting. The College should cease describing CPD as a kind of 'club' and, recognising that the process of on-going education is desired by most psychiatrists, make it available to all. Regular information about recommended articles, books and Web sites, together with notification of approved confer ences, would be useful. Informal re-testing of clinical knowledge via short answer questions and case vignettes would be one way of stimulat ing both clinicians and academics. The adminis trative costs could be met by dispensing with the British Journal of Psychiatry as an automatic membership entitlement since the relevance of the journal to sub-specialties like my own is debatable.  Sir: Dr Malik (Psychiatric Bulletin, September 1998, 22. 578-580) paints a very real picture of the challenges facing psychiatric services in developing countries. He stresses the need for high quality training programmes for foreign doctors in Western countries, which can be modified accordingly to suit the local needs. The launch of the Overseas Doctor's Training Scheme by the Royal College of Psychiatrists, about a decade ago aimed to achieve this goal. So far, hundreds of trainees from developing coun tries have benefited from this scheme, as it has provided very well organised and structured training. Unfortunately, the very problems which Dr Malik has mentioned have prevented more than 80% of these doctors from returning to their home countries.

Dilemmas of a psychiatrist in a developing country
In my opinion the College needs to review its training scheme. Perhaps there is a need to support local training in developing countries, incorporating local training models to improve the existing services. By adopting an approach which is compatible with the local culture and beliefs, and which involves close coordination between the College and the services in the developing world, it is possible to achieve training standards in those countries which will hopefully ensure better psychiatric care.

Attendance at child psychiatric clinics
Sir: We were interested to read the paper by A. Ubeysekara & N. Cox (Psychiatric Bulletin, July 1998, 22, 435-437). As the authors point out, there has been little research before into the reasons why patients do not attend. It was interesting to note some of the reasons high lighted by the paper. These seem to suggest that measures such as providing information about the service before the family attend, and helping with transportation, may help with attendance.
In the Shropshire Child and Family Service, we have also tried to tackle this problem from a slightly different angle. During the case allocation meeting, selected cases are sent 'opt in' letters, rather than appointments straight away. Such cases are selected, for example, if the problem seems to be of a less urgent nature, or if it is not clear from the referrer's letter that the family are committed to attending. The 'opt in' letter asks families to contact the service if they require an appointment. There are of course arguments for and against such letters; on the one hand there is the potential for reducing clinic non attendance while on the other hand there is the worry that such letters may alienate some families who are genuinely in need of help.
We are currently auditing the use of such letters. Initial results show 61% of recipients of such letters 'opt in', and of these 98% sub sequently attended their appointments. It would certainly appear that there are a large proportion of families referred to our service who are not actually interested in attending. We would be interested to hear from any other service with experience of using such letters. Psychiatrist,and C. FENW1CK,Senior House Officer. Shropshire's Community and Mental Health Services NHS Trust,Wrekin Hospital,Holyhead Road,Wellington,Telford,Shropshire TF1 2ED

Use of the Care Programme Approach register by an inner-city old age psychiatry team
Sir: We were interested to read the audit by Jeremy Wallace & Chris Ball (Psychiatric Bulletin, August 1998, 22, 489-491) and com pare their experience with our own. Part of our Trust lies within the same health authority as the service studied and we have a very similar Care Programme Approach (CPA) policy. Despite this there are some differences in our use of the CPA register. In a recent audit of our practice we examined the threshold of CPA registration. We included a random selection of patients placed on the register between January and March 1998 (n=21). The demographic features of this group were similar to those described in the paper. However, a larger proportion of our patients were suffering from dementia (48% compared with 7% in Wallace & Ball). The patient's refusal to accept care clearly raised the threshold of registration.
Our study included a randomly selected group of patients not placed on the CPA register but referred at about the same time. Twenty-seven per cent of the control group also fulfilled criteria for registration. Rates of registration differed markedly between individual consultant teams.
We agree with the authors' conclusion that their study may not be generalisable to other services. For example, we have learnt that some services are obliged to register nearly all their patients on the CPA to ensure that they are assessed by social workers. However, it ought to be possible to strive for more uniformity between services using similar policies if the latter are to be of any practical value.

Greg Wilkinson and Tom Brown
From April 1999 The Royal College of Psychiatrists is proposing to introduce into the MRCPsych Part II examination a critical review paper. One main reason for this introduction is the increasing recognition of the importance of developing critical appraisal skills and evidence-based practice. Candidates will be required to demonstrate knowledge of statistics and different kinds of research, and to develop skills in the systematic appraisal of papers. The book is unique in its coverage of psychiatric aspects of critical review papers and will be essential reading for all psychiatric trainees preparing for the MRCPsych exam.