Overprescribing psychiatric medication in Uganda – is there method behind the madness?   


Simon Ruffell

Jan 4 2017

  
I first visited Uganda six years ago as a medical student, which led me to an HIV clinic in Kewempe, Uganda. Six years later I returned, my main interest now in psychiatry, spending 10 weeks as a volunteer on a psychiatric ward in Gulu, Northern Uganda.

Although many similarities exist between psychiatry in Uganda and the UK, there are also notable differences. The hardest of these to swallow is the amount of potentially dangerous ‘psychotropic’ medication used. It is extremely common for patients on the wards in Uganda to be given doses of such medicines that are in some cases up to twice the amount recommended by our own national guidance.

A large proportion of the work I was involved in when working in Gulu (and indeed after I had left) was concerning the reduction of the amount of antipsychotic medication utilized on the wards. After compiling data from the last four years, I conducted a further audit to look at trends in doses of psychotropic medicine prescribed, as well as to assess the effect (if any) of previous interventions on dose quantity. Although the quantities had reduced over the years, doses that would no doubt result in disciplinary action in the UK were still being administered on a regular basis.

The most notable issues were that of  multiple drugs used together, antipsychotics being given to sedate patients as well as doses that significantly exceeded recommended levels.

This lead me to ask the question, why? Is there method behind the madness?

The responses I obtained after asking this question were indeed enlightening. Senior members of staff often admitted that Africans required high doses than “mzungus” (East African slang for “white person”) and that the protocols used in the west just don’t work in Uganda; the doses are too small. It has to be admitted that although the length of stay in such wards is often shorter than that in the UK, is this practise dangerous? The death on the ward earlier in the year where a double dose of psychotropic medicine was given by mistake would suggest so.

Research has been conducted into the potential differences in metabolism of psychotropic medicines in regards to race.  The activity of cytochrome P450 enzymes - known to metabolise a wide variety of drugs in humans including psychotropic medications - is known to vary between different races, providing one potential explanation for the increased need for such medications in African populations1. This being said, other factors cannot be ignored. Members of staff on the ward in Gulu also admitted that delivering large doses of such drugs is often the only way to manage patients.

With staffing levels that would make the NHS baulk, patients who are thought to have the potential to cause trouble are regularly sedated to allow the often solitary staff member to keep control of the ward.

Uganda is not the only country in Africa noted to be using such large doses of psychotropic medications: past studies in Nigeria also found high doses of psychotropic drugs prescribed. The evidence however does not support the use of high dose antipsychotics3. In fact, recent neuroimaging studies have suggested that therapeutic response can be achieved at even lower doses than are currently recommended.

Given the evidence listed above, at least for now, emphasis should be placed on helping mental health professionals reduce the amount of medication they prescribe. This is easier said than done, especially in countries such as Uganda which currently has 25 psychiatrists to cover the entire country. Mindfulness of cultural differences is obviously of supreme importance in this situation.

Our team in Gulu have developed a revised protocol which hopes to achieve higher levels of adherence than the previously ignored version, by advocating the use of doses higher than previously suggested, whilst still being significantly smaller than those currently utilized. The next audit cycle should help to show how effective the implementation of these guidelines has been.

I am sure the patients receiving the medicines that I spoke to would certainly appreciate such a reduction, one of them exclaiming “the drugs take my personality and my soul”.
  
Any opinions above are the author's alone and may not represent those of the NHS or Mind and Medicine. Any comment is based on the best available evidence at the time of writing.  All data is based on externally validated studies unless expressed otherwise. Novel data is representative of sample surveyed. Online recommendation is no substitute for seeing your own doctor and should not be taken as medical advice.
  
Sources
 
McGraw J, Waller D. Cytochrome P450 variations in different ethnic populations. Expert opinion on drug metabolism & toxicology. 2012 Mar 1;8(3):371-82.
Famuyiwa OO. Psychotropic drug prescription in Nigeria. Acta Psychiatrica Scandinavica. 1983 Aug 1;68(2):73-81.
Harrington M, Lelliott P, Paton C, Okocha C, Duffett R, Sensky T. The results of a multi-centre audit of the prescribing of antipsychotic drugs for in-patients in the UK. The Psychiatrist. 2002 Nov 1;26(11):414-8.
Heinz A, Knable MB, Weinberger DR. Dopamine D 2 receptor imaging and neuroleptic drug response. J Clin Psychiatry 1996;57(Suppl 11):84-8; discussion 89-93.