South African Psychiatry - February 2018 Edition

ISSN 2409-5699 

ABOUT the discipline FOR FOR the the discipline discipline issue 14 • February 2018 

MUSIC THERAPY 

AND THE NEGATIVE SYMPTOMS 

OF SCHIZOPHRENIA 

THE US/UCT MRC UNIT 

ON RISK AND 

RESILIENCE 

IN MENTAL DISORDERS 

SASOP PARTICIPATES 

IN THE PUBLIC DEBATE 

ON HEALTHCARE 

WORKER 

ADVOCACY 

PUBLISHED IN ASSOCIATION WITH THE SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS 

TRANSCRANIAL 

MAGNETIC STIMULATION 

TO TREAT 

MENTAL ILLNESS? 

PREJUDICE, 

DISCRIMINATION 

and mental illness 

www.southafricanpsychiatry.co.za 

SOUTH AFRICAN PSYCHIATRY ISSUE 14 2018 * 1

ADHD should not be a barrier 

to realising my potential 

I can t 

focus 

I procrastinate 

I feel 

different 

Emotional 

I STRUGGLE 

TO REMEMBER 

THINGS 

I CAN’T 

SIT STILL IN 

MEETINGS 

Time management 

is a challenge 

for me 

Unlocking potential 

FIRST GENERIC 

methylphenidate ER 

TO MAR KET 

S6 CONTRAMYL XR 18 mg (Extended Release Tablets). Reg. No. 49/1.2/1137. Each extended release tablet contains 18 mg 

methylphenidate hydrochloride. Contains sugar (sucrose). S6 CONTRAMYL XR 27 mg (Extended Release Tablets). Reg. No. 49/1.2/1138. 

Each extended release tablet contains 27 mg methylphenidate hydrochloride. Contains sugar (sucrose). S6 CONTRAMYL XR 36 mg 

(Extended Release Tablets). Reg. No. 49/1.2/1139. Each extended release tablet contains 36 mg methylphenidate hydrochloride. Contains 

sugar (sucrose). S6 CONTRAMYL XR 54 mg (Extended Release Tablets). Reg. No. 49/1.2/1140. Each extended release tablet contains 

54 mg methylphenidate hydrochloride. Contains sugar (sucrose). 

For full prescribing information refer to the package insert approved by the medicines regulatory authority. 

Mylan (Pty) Ltd. Reg. No.: 1949/035112/07. Building 6, Greenstone Hill Office Park, Emerald Boulevard, Modderfontein, 1645. 

Tel: (011) 451 1300. Fax: (011) 451 1400. www.mylansa.co.za 

M1617 Dec-17. 

2 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 2018

Features 

PREJUDICE 


7 

AND MENTAL 

ILLNESS 

A MIXED-METHODS STUDY 

ON GROUP MUSIC THERAPY 

13 

AS AN INTERVENTION FOR 

THE NEGATIVE SYMPTOMS 


THE US/UCT MRC UNIT 

ON RISK 

19 

AND RESILIENCE 

IN MENTAL DISORDERS 

THE 4TH BIENNIAL 

NATIONAL FORENSIC 

22 

MENTAL HEALTH SERVICE 

(FMHS) CONFERENCE 

CAN TRANSCRANIAL 

MAGNETIC STIMULATION 

27 

BE USED TO TREAT 




30 

ON HEALTHCARE 

WORKER ADVOCACY 

NOTE: “instructions to authors” are available at www.southafricanpsychiatry.co.za 


CONTENTS 

CONTENTSFebruary 2018 

5 FROM THE EDITOR 

SCHIZOPHRENIA 

MENTAL DISORDERS 

21 WPA NEWS 

SERVICE (FMHS) CONFERENCE 

26 GMHPN NEWS 

TREAT MENTAL ILLNESS? 


CONGRESS 

34 PMHP NEWS 

FIRST AID - OVERVIEW AND REFLECTIONS 

HEALTH PROFESSIONAL 

42 DEPARTMENTS OF PSYCHIATRY NEWS 

AFRICA” - EXECUTIVE SUMMARY 

50 CULINARY CORNER 

& ELEGANCE 

57 MOVIE REVIEW: VICTORIA & ABDUL 

7 PREJUDICE, DISCRIMINATION AND MENTAL ILLNESS 

13 A MIXED-METHODS STUDY ON GROUP MUSIC THERAPY AS 

AN INTERVENTION FOR THE NEGATIVE SYMPTOMS OF 

19 THE US/UCT MRC UNIT ON RISK AND RESILIENCE IN 

22 THE 4TH BIENNIAL NATIONAL FORENSIC MENTAL HEALTH 

27 CAN TRANSCRANIAL MAGNETIC STIMULATION BE USED TO 

30 SASOP PARTICIPATES IN THE PUBLIC DEBATE ON HEALTHCARE 

32 LEADING PSYCHOLOGISTS FROM AFRICA CONGREGATE IN 

DURBAN FOR FIRST-EVER PAN-AFRICAN PSYCHOLOGY 

35 A WORKSHOP ON COMMUNITY-BASED PSYCHOLOGICAL 

38 THE ROLE OF MELATONIN IN TREATING INSOMNIA 

40 THE PROVISION OF EXPERT OPINION AND EVIDENCE AS A 

47 WPA WHO AFRICAN MENTAL HEALTH FORUM: “CONTINENTAL 

ALLIANCE FOR INTEGRATED MENTAL HEALTH CARE IN 

55 WINE FORUM: LE RICHE: DECADES OF QUALITY, CONSISTENCY 

59 RECOVERY PLAN FOR THE GAUTENG DEPARTMENT OF HEALTH 

61 SASOP POSITION STATEMENT ON CANNABIS 

64 SASOP SPECIAL INTEREST GROUP FOR ADULT ADHD 

65 SASOP HEADLINE 

* PLEASE NOTE: Each item is available as full text electronically and as an individual pdf online. 

Disclaimer: No responsibility will be accepted for any statement made or opinion expressed in the publication. 

Consequently, nobody connected with the publication including directors, employees or editorial team will be held liable for any 

opinion, loss or damage sustained by a reader as a result of an action or reliance upon any statement or opinion expressed. 

© South African Psychiatry This magazine is copyright under the Berne Convention. In terms of the South African 

Copyright Act No. 98 of 1978, no part of this magazine may be reproduced or transmitted in any form or by any means, 

electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, 

without the permission of the publisher and, if applicable, the author. 

COVER PHOTOGRAPH: Adobe Stock Imge 

Design and layout: The Source * Printers: Imagine It Print It 


FROM THE EDITOR 

Dear Reader, 

Welcome to our first publication of 2018. It is a landmark issue in that we 

are publishing data from a successfully examined higher degree for the 

first time - in this instance related to music therapy and schizophrenia. 

Further such content is anticipated for the May 2018 issue, more specifically 

the literature reviews of successfully examined MMeds. This will see the 

publication reach one of its intended goals, namely to provide a fast track 

for publication of such content. Following the publication of the May 2018 

issue the previously mentioned application for DoHET accreditation will 

take place (South African Psychiatry, August 2017). I had hoped to submit 

the application sooner but noted that submissions needed to be received by the 30th June in a 

given year so held back until closer to that date. If successful, we will indeed enter a new era for the 

publication. 

The current issue carries a number of Reports – all once again demonstrating the range of activities 

taking place across the country that speak to the vibrancy of psychiatry and related disciplines, 

and the commitment of authors to ensuring that such content reaches the widest possible 

audience. One in particular deals with a public debate related to healthcare worker advocacy, 

with specific reference to the Life Esidimeni tragedy. Of note was the position of Ms Tendai Mafuma, 

Legal Researcher of Section 27, on the issue of dual loyalty whereby health professionals may find 

themselves pulled in different directions under certain circumstances i.e. loyalty to patient versus 

institution. In a previous Dear Reader column (South African Psychiatry, November 2017) I stated 

that …clinicians have only one focus – optimal patient care… Ms Mafuma advances the position 

that actually we all have only one loyalty i.e. to the Constitution…hence there is actually no dual 

loyalty. An important pronouncement, and certainly an appropriate filter for decision making and 

responding to institutional demands that conflict with clinical judgement. We have not heard the 

last of deliberations regarding responsibility for the Tragedy and no doubt by the time the May 2018 

issue goes to press the situation will have unfolded further. 

A special mention for our regular contributors, something I have omitted to do previously – Franco 

Visser, Dave Swingler, Ian Westmore (and more recently Ethelwyn Rebelo). They have consistently 

delivered content that adds richness and information that is much valued…thanks and looking 

forward to further such content. It goes without saying that as readers, your contributions are most 

welcome as per the Instructions to Authors content. 

A final thanks… to industry…your involvement in 2017 was much valued and we look forward to 

your company as we continue this journey . 

All the best for the year ahead and I hope you will enjoy the issue ! 

Zuki Zingela - Head, Department of Psychiatry, Walter Sisulu University 

Bonga Chiliza - Head Department of Psychiatry UKZN; President Elect South African Society of Psychiatrists 

Bernard Janse van Rensburg - President South African Society of Psychiatrists 

Headline Editor: Ian Westmore 

Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading 

Design and Layout: Rigel Andreoli Printer: Imagine It Print It 


Fast growing CNS portfolio. 1 

A CLEAR BLUE SKY 

FAST-ACTING 

ANTIDEPRESSANT 2 

OPEN THEIR EYES TO FACE 

THE COLOUR OF LIFE 

For further product information contact 

PHARMA DYNAMICS P O Box 30958 Tokai Cape Town 7966 

Tel 021 707 7000 Fax 021 701 5898 

Email info@pharmadynamics.co.za CUSTOMER CARE LINE 0860 PHARMA (742 762) www.pharmadynamics.co.za 

DYNA SERTRALINE 50, 100. Each tablet contains 50, 100 mg sertraline respectively. S5 A43/1.2/0339, 0340. NAM NS3 14/1.2/0627, 0628. ZYTOMIL 10, 20 mg. Each 

tablet contains 10, 20 mg escitalopram respectively. S5 A42/1.2/0912, 0914. NAM NS3 10/1.2/0479, 0481. SERRAPRESS 20. Each tablet contains paroxetine hydrochloride 

equivalent to 20 mg paroxetine. S5 A38/1.2/0069 NAM NS3 08/1.2/0101. For full prescribing information, refer to the package insert approved by the Medicines Control 

Council. 1) IMS Data, March 2017. 2) Kasper S, et al. “Onset of action of escitalopram compared with other antidepressants: results of a pooled analysis. International Clinical 

Psychopharmacology. 2006;21:105-110. CNSRC365/05/2017. 


FEATURE 

PREJUDICE, 


AND MENTAL 

ILLNESS 

Hemant Nowbath 

“THE TRUE TEST OF A CIVILISED SOCIETY IS THE WAY IT TREATS ITS MOST 

VULNERABLE CITIZENS” (DINESH BHUGRA, PAST PRESIDENT, WORLD PSYCHIATRIC ASSOCIATION) 1 

The stigma suffered by those with mental illness 

is well documented… “It’s difficult to work with 

people who don’t understand your illness. 

They pick on you. I’m labelled because I see 

a psychiatrist. I lie to keep appointments with you. 

I may have a mental illness but I’m not stupid” (A 

patient’s words)… 

The rights of the mentally ill are grossly neglected 

as demonstrated by the deaths of over a hundred 

patients of Life Esidimeni Hospital when they were 

transferred to unregistered non-governmental 

facilities as part of a cost cutting exercise by the 

Gauteng Department of Health. The investigation 

by the health Ombudsman Professor Malegapuru 

Makgoba found gross neglect and despite the 

resignation of the MEC for Health Qedani Mahlangu 

no criminal prosecution has been started. This 

incident has served to highlight the lack of provision 

of services for those with mental illness and the 

criminal neglect of their needs. 

The World Psychiatric Association 

(WPA) has advocated the 

formulation of a Bill of Rights for the 

mentally ill. 2 Amongst the provisions 

included are the rights to: 

• Accessible and affordable 

mental and physical healthcare 

• Work, training and education 

• Accessible, integrated and 

affordable housing 

Hemant Nowbath 

• Freedom of movement 

• Equality before the law 

• Freedom from cruel, inhuman degrading 

treatment and punishment 

These are basic human rights that should be the 

preserve of all citizens. The mentally ill, however, have 

been discriminated against for centuries. Historically 

they were isolated and placed in asylums. They were 

subjected to cruel and inhumane treatments and 

their needs were neglected. 


FEATURE 

The current paper explores various aspects of 

discrimination and mental illness. The substance 

has been derived from a talk presented at the Dr 

Reddys academic weekend in June 2017. Based 

on specific terms that will be used it is important to 

define them 3 : 

Bigotry - an obstinate or intolerant devotion to one’s 

own opinions and prejudices. 

Prejudice – an irrational attitude of hostility directed 

against an individual, a group, a race or their 

supposed characteristics. 

Discrimination - the practice of unfairly treating 

a person or group of people differently from other 

people or groups of people. 

There are many issues to consider: Does prejudice 

cause mental illness? What is the nature of such 

illness? Do people with mental illness suffer prejudice? 

What are the consequences of this prejudice? This 

paper explores these and associated issues, looks at 

some of the relevant literature, and tries to shed light 

on the way forward. 

DISCRIMINATION IS DEROGATORY, 

DAMAGING AND DEMEANING. IT 

STOPS PEOPLE FROM REACHING 

THEIR FULL POTENTIAL. THE 

DISCRIMINATION SUFFERED BY 

THOSE WITH MENTAL ILLNESS IS 

WORSE THAN THAT SUFFERED 

BECAUSE OF RACE, AGE, 

GENDER, RELIGION AND SEXUAL 

ORIENTATION. 1 THE RELATIONSHIP 

BETWEEN VARIOUS FORMS OF 

DISCRIMINATION AND MENTAL 

ILLNESS HAS BEEN THE SUBJECT OF 

MUCH DISCUSSION AND DEBATE. IT 

IS A COMPLEX ONE. 

Funding for mental health lags behind that for 

physical illness. This is largely as a result of stigma. 1 

Substance use disorders are seen as self- induced 

and not taken seriously. These disorders are neglected 

despite their significant impact on individuals, family 

and society. 

Patients with mental illness suffer more physical 

illness and have shorter lives. They are poorer, 

have more stressors, less education and are more 

likely to be victims of domestic violence. This filters 

through generations. In many countries they have 

do not have the right to vote or to engage in legal 

contracts. 4 

Corrigan and Watson (2002) held that people with 

mental illnesses were doubly challenged. 5 They 

struggled with symptoms and disabilities of the 

disease and were challenged by stereotypes and 

prejudices that stemmed from misconceptions 

of mental illness. As a result they were denied 

good jobs, safe housing, satisfactory healthcare 

and social affiliation. The stigma suffered is 

twofold (1) self- stigma: prejudice which people 

with mental illness have against themselves, 

(2) public-stigma: A reaction that the general 

population has towards people with mental illness. 

PREJUDICE CAN CAUSE MENTAL 

ILLNESS DUE TO MANY FACTORS – 

UNEQUAL POWER RELATIONSHIPS, 

PERSONAL INSULT, DEROGATORY 

ACTS, DEVALUING THE VICTIM. THIS 

PROVOKES FEELINGS OF LOW SELF- 

ESTEEM AND POWERLESSNESS AND 

CAN CAUSE ANGER, DEPRESSION 

OR ANXIETY. 

Prejudice may lead to emotional responses to 

stigmatised groups and prejudice turned inwards 

leads to self-discrimination. Prejudice, which 

is a cognitive and affective response, leads to 

discrimination, a behavioural reaction. 5 

Misconceptions about mentally ill people are many 

and include the following – they are violent and 

should be feared; they are irresponsible; they are 

childlike and need to be cared for. 

Corrigan and Watson (2002) 5 also describe 

4 forms of discrimination - withholding help; 

avoidance; coercive treatment and segregated 

institutions. 

Allport’s seminal work defined the nature of 

prejudice. 6 He determined a 5-point scale of 

increasingly dangerous acts: 

1. Verbal expression of antagonism 

2. Avoidance of members of disliked groups 

3. Active discrimination 

4. Physical attack 

5. Extermination – lynchings, massacres, genocide. 

RACE 

In a country that emerges slowly from a past 

bedevilled by racial discrimination and inequality of 

immeasurable proportions it would be expected that 

the incidence of mental illness is disproportionately 

high. Research in this regard however is scant. 

Many facets of racism have been explored over 

the years. Leopold Sedar Senghor (1906-2001), 

Senegalese poet and cultural theorist, first President 


FEATURE 

of Senegal, coined the term ‘’negritude’’ in response 

to the racism present in France. He tried to turn 

the racial slur ‘’negre’’ into a positive celebration of 

African culture and character. 

Franz Omar Fanon (1925-1961), psychiatrist, 

philosopher and revolutionary writer analysed 

the negative psychological effects of colonial 

subjugation upon Black people in ‘’Black skin, 

White masks” published in 1952. He radically revised 

methods of treatment and started ‘’sociotherapy’’ to 

connect with patients’ cultural backgrounds. 

In ‘’The Wretched of the Earth” (1961) Fanon 

defended the rights of a colonised people to use 

violence to gain independence. He felt that those 

who were not considered human could not be 

bound by principles that apply to humanity. Fanon 

influenced amongst others Malcolm X, Che Guevara 

and Steve Biko. 

A conference at the University of the Witwatersrand 

in February 2017 explored the social determinants 

of health. Amongst issues it examined was the role 

of doctors in addressing health inequities in South 

Africa and the need to identify solutions. 7 

This conference was held against a background of 

crucial issues that confront the country and have a 

marked impact on health delivery. There is an ever 

widening Gini coefficient (a measure of inequality), 

with service delivery protests occurring almost 

daily as disadvantaged communities grapple 

with the ravages of poverty. As levels of crime 

increase exponentially, minority groups experience 

xenophobia, and revelations of “State Capture” 

shake confidence in the economy and the political 

stability of the country. All these issues add to the 

burden of disease. 

THE STARK REALITY OF LIFE IN SOUTH 

AFRICA TODAY IS THAT 35% OF THE 

LABOUR FORCE IS UNEMPLOYED 

AND 14 MILLION PEOPLE GO TO 

BED HUNGRY. THE SPIRAL OF UNMET 

BASIC NEEDS, POVERTY, CRIMINAL 

BEHAVIOUR AND VIOLENCE IS A 

FERTILE BREEDING GROUND FOR 

A VARIETY OF MENTAL ILLNESSES 

INCLUDING ANXIETY, DEPRESSION 

AND POST- TRAUMATIC STRESS 

DISORDER. ADVERSITY MAY MOTIVATE 

PEOPLE, STIMULATE GROWTH 

AND FOSTER RESILIENCE. THE RISK 

HOWEVER IS POOR MENTAL HEALTH. 

Many people in South Africa have been victims 

of racism. Entire communities were discriminated 

against under the iniquitous system of Apartheid 

after the National party assumed power in 1948. The 

enactment of the Group Areas Act (1950), the Job 

Reservation Act and the Immorality Act determined 

where people lived and worked and whom they 

married. 8 The unwritten social discrimination of the 

colonial power was now law. 

Apartheid had a major impact on the lives of 

all South Africans. Black South Africans suffered 

discrimination in all spheres of life. The social 

and economic deprivation, lack of proper 

housing, education and health care proved a 

rich breeding ground for a host of physical and 

mental illnesses. 

Post democracy very little has changed for many 

people. The socio-economic barriers to good 

mental health remain. The unmet expectations 

have led to anxiety and depression. Substance 

abuse is rife in impoverished communities. 

In addition many people are disillusioned by 

affirmative action. They feel unfairly discriminated 

against because of race. There is a belief that 

affirmative action, as practised, is racism in reverse. 

HUYNH (2012) 9 FOUND THAT 

THOSE WHO WERE DISCRIMINATED 

AGAINST ON THE GROUNDS OF 

RACE SUFFERED SIGNIFICANT 

NEGATIVE CONSEQUENCES 

INCLUDING AN IMPACT ON 

GENERAL WELL-BEING, SELF- 

ESTEEM, SELF-WORTH, AND 

SOCIAL RELATIONS. THIS LED TO 

INCREASED LEVELS OF STRESS, 

ANXIETY AND DEPRESSION. 

Fisher 10 explored the case of Dylan Roof who killed 

nine Black people in a church in Charlestown. 

He holds that racism is not a mental illness but 

some aspects are similar, for example, thoughts 

of superiority are delusional or there may be 

paranoia that the ‘superior’ race is under threat. 

Racism does not have a biological basis but it 

is learned then accepted as the truth. Hate too 

is learned and its behavioural manifestations, 

bigotry and prejudice, are socialised in people 

when they are young by the adults who raise them. 

Terrorism, the use of violence to achieve political 

objectives, is a vehicle to eliminate the object 

of hate. Mental illness however has a biological 

basis. Racism, hate and terrorism may cause 


FEATURE 

mental illness. 9 Poussaint 11 differs in that he feels 

that extreme racism is a mental illness and not to 

regard it as such and not to see it as pathological 

gives it legitimacy. Poussaint sees it as a delusional 

disorder. 11 The counter argument is that if racism is 

seen as a mental illness it would provide an excuse 

for prejudiced behaviour. 

Poussaint 11 concludes “Clinicians need guidelines 

for recognising delusional racism in all its forms 

so that they can provide appropriate treatment. 

Otherwise extreme delusional racists will fall through 

the cracks of the mental health system, and we 

can expect more of them to explode and act out 

their deadly delusions.” This was written some years 

before Dylan Roof exploded. 

VULNERABLE GROUPS 

Vulnerable groups of people have higher than 

expected rates of psychiatric disorders. These groups 

include the following: lesbians, gays, bisexual, 

transgender and intersex(LGBTI), migrants, prisoners, 

minorities and women. 12 They have higher rates of 

suicide. Discrimination is also associated with higher 

rates of depression, anxiety and psychosis. 13 

SEXUAL ORIENTATION 

HOMOSEXUALITY WAS REGARDED 

AS A MENTAL ILLNESS UNTIL ITS 

REMOVAL FROM THE SECOND 

EDITION OF THE DIAGNOSTIC AND 

STATISTICAL MANUAL FOR MENTAL 

ILLNESS (DSM) IN 1973. 

The LGBTI community has been the victim of 

prejudice for centuries. They have borne the brunt 

of the anger and discrimination by those who see 

them as lesser beings because of misguided belief. 

There are those, who, bereft of current scientific 

knowledge, who use ancient religious texts to brand 

gays and lesbians “sinners.’’ Anti-gay prejudice is rife 

in many areas and homosexuality is regarded as a 

crime in many African countries and religious states 

in the Middle East. 

There have been psychiatrists who have attempted 

to ‘’treat’’ homosexuals by cruel and inhumane 

procedures. South African psychiatrist, Aubrey 

Levine, who “treated’’ recruits in the South African 

Defence Force in this manner was subsequently 

found guilty of abusing male patients in Canada 

and imprisoned. 

The LGBTI community is particularly vulnerable and 

prone to a range of psychiatric illnesses. 

Meyer (2003) 12 held that the LGB community 

had a higher prevalence of mental disorders. 

The conceptual framework to understand this 

was ‘’minority stress’’ – stigma, prejudice and 

discrimination create a hostile and stressful social 

environment that causes mental health problems. 

AS A STIGMATISED MINORITY 

GROUP THEY SUFFER MORE 

MENTAL HEALTH ISSUES INCLUDING 

SUBSTANCE USE DISORDERS, MOOD 

DISORDERS AND HIGHER RATES 

OF SUICIDE. FAMILY SUPPORT AND 

ACCEPTANCE IS OFTEN LACKING. 

PSYCHOLOGICAL MECHANISMS 

EXPLAIN THE ASSOCIATION 

BETWEEN VICTIMISATION AND 

PSYCHOLOGICAL DISTRESS. 

WOMEN 

Women experience gender discrimination despite 

widespread efforts to educate and enlighten people. 

In patriarchal societies they still suffer prejudice and 

abuse. They are denied the vote and regarded as 

minors. Even in matters religious many faiths bar 

them from the priesthood, limit their growth and 

education and prevent their movement. 

AGE 

There are other forms of discrimination that contribute 

to mental illness. Ageism is an often unrecognised 

problem. The elderly are a particularly vulnerable 

population. They suffer abuse as a result of omission, 

neglect or ignorance. Their needs are ignored and 

at times they suffer physical abuse too. 

ADDRESSING 

DISCRIMINATION: 

TREATMENT 

Prevention is paramount. Children should be 

raised with broad value systems and taught to 

respect all people of different races, gender 

and religious belief. They need to be exposed to 

all belief systems and not trained to think that 

theirs is a superior faith or the only one. Efforts to 

engage with people of all cultures and creeds 

must be encouraged and artificial barriers that 

separate eliminated. 

Egbe et al (2014) 14 explored psychiatric stigma and 

discrimination in South Africa and offered, amongst 

others, the following recommendations: 

• psychoeducational interventions to address the 

myths and traditional beliefs in the causes of 

mental illness which influence stigma 


FEATURE 

• media campaigns to create awareness and 

supportive community environments to reduce 

stigma and discrimination in communities 

• advocacy interventions to the development of 

policy and services. 

To paraphrase erstwhile rector of the University of 

the Free State, Jonathan Janssen – “invite to your 

next braai people who don’t look the same way as 

you do… pray the same way as you do… dress the 

same way as you do….” This would help break down 

barriers and engender respect and tolerance. 

Psychiatrists have been trained to treat patients 

holistically. Medicine, especially psychiatry, 

cannot be practised in a vacuum. We need 

to consider the social, economic and political 

realities that affect health. It is now imperative 

that psychiatrists become advocates on behalf 

of patients. There is a need to get involved and 

address root causes of mental illness, a need to 

move from the hallowed halls of academia and 

become active citizens. 

CONCLUSION 

The cause must be treated and delusions of belief 

addressed. It is necessary to confront, challenge and 

if need be, legislate against discrimination. There 

can be no better justification for getting involved 

in the struggle to support human rights for patients 

than the case presented by Protestant pastor, Martin 

Niemoller (1892-1984), who spent 7 years in Nazi 

concentration camps: 

“FIRST THEY CAME FOR THE 

SOCIALISTS, AND I DID NOT 

SPEAK OUT BECAUSE I WAS NOT A 

SOCIALIST. 

THEN THEY CAME FOR THE TRADE 

UNIONISTS, AND I DID NOT SPEAK 

OUT BECAUSE I WAS NOT A TRADE 

UNIONIST. 

THEN THEY CAME FOR THE JEWS, 

AND I DID NOT SPEAK OUT BECAUSE 

I WAS NOT A JEW. 

THEN THEY CAME FOR ME, AND 

THERE WAS NO ONE LEFT TO SPEAK 

FOR ME.” 

REFERENCES 

1. Bhugra D. Social discrimination and social 

justice. International Review of Psychiatry 2016. 

28.4 336 – 341 

2. Bhugra D. Bill of Rights for Persons with mental 

illness. International Review of Psychiatry. 2016. 

28.4 335 

3. Merriam-Webster online dictionary. 2017. 

Merriam-Webster Inc. 

4. Bhugra D. Mental Health for Nations. 

International Review of Psychiatry 2016 28.4 342 

– 374 

5. Corrigan PW, Watson AC. Understanding the 

impact of stigma on people with mental illness. 

World Psychiatry 2002.1.1 16-20 

6. Allport GW. The Nature of Prejudice. 1954. 

Addison-Wesley 

7. Mutsago R, Mametja S. International Conference 

on social determinants of health tackles huge 

inequities in SA. SAMA Insider 2017 April 6-9 

8. Meer I. A Fortunate Man. Zebra Press 2002 

9. Huynh Q-L. The Psychological Costs of 

Painless but Recurring Experiences of Racial 

Discrimination. Cultural Diversity and Ethnic 

Minority Psychology 2012; 18(1): 26-34 

10. Fisher MB. Racism, hate, terrorism and mental 

illness: Roanoke Times (Opinion) 2015 

11. Poussaint AF. Is Extreme Racism a Mental Illness? 

Western Journal of Medicine 2002; 176 (1): 4 

12. Meyer IH. Prejudice, Social Stress and Mental 

Health in Lesbian, Gay and Bisexual Populations: 

Conceptual Issues and Research Evidence. 

Psychological Bulletin 2003; 129(5): 674-697 

13. Bhui K. Discrimination, poor mental health, and 

mental illness. International Review of Psychiatry 

2016 28.4 411-414 

14. Egbe CO, Brooke-Summer C, Kathree T, Selohilwe 

O, Thomicroft G, Petersen I. Psychiatric stigma 

and discrimination in South Africa: perspectives 

from key stakeholders. BMC Psychiatry 2014; 14 

(191): 14-19 

Hemant Nowbath is a psychiatrist in private practice in Durban. He sees no ethical conflict between 

the socialist ideology of his youth and his current taste for good whisky and golf. A Wits undergraduate he 

specialised in Natal. Despite an undistinguished academic career, bereft of any honours, he is the President 

of the South African Addiction Medicine Society and sits on the executive of the Durban Chess Club. 

Correspondence: hemant@saol.com 


Specialised dementia care in luxurious surroundings 

Livewell Villages are luxurious memory-care communities designed with the health and well-being of a person living with 

dementia in mind. Inspired by the tranquil setting of a country village and shaped by extensive research, Livewell Villages 

offer a safe, serene and stimulating environment where everyone feels included, can remain independent for longer, and 

can enjoy a sense of choice and control over their lives. 

Our residents’ families can find peace of mind in the knowledge that their loved ones enjoy a good quality of life for 

longer, and move forward in their lives with dignity and purpose. 

∙ Professional health care and medication management 

∙ Luxurious surroundings and personalised comfort 

∙ Therapeutic activities and exercise programme 

∙ Nutritious meals 

∙ Pet-friendly 

∙ Support groups for families and caregivers 

Contact us: 

Somerset West 

Bryanston 

41 Lourens Street 113 Mount Street 

Tel: 021 851 6886 Tel: 011 463 8212 

enquiriesct@livewell.care 

enquiriesjhb@livewell.care 

www.livewell.care 


ORIGINAL 

A MIXED-METHODS STUDY ON 

GROUP MUSIC THERAPY 

AS AN INTERVENTION FOR 

THE NEGATIVE SYMPTOMS 


Bruce Malcolm Muirhead, Andeline Julia Dos Santos, Marc Roffey 

T 

his 

article is a summary of a mixed-methods research study that was conducted by 

the first author in 2017. It includes some introductory material on music therapy, for 

readers new to the discipline. The study was a requirement to fulfill music therapy training 

needs at a Masters level at the University of Pretoria (UP), and the full version of it was 

successfully submitted as a dissertation. 

ABSTRACT 

The study, which was small in terms of participants and duration, explored group music therapy as an 

intervention for negative symptoms of in-patient forensic clients with schizophrenia, and was conducted at 

the forensic unit at Valkenberg Hospital. Negative symptoms are a clinical group of symptoms that may be 

present in schizophrenia, and include apathy, social withdrawal, blunted emotional responses and reduction 

in speech. A closed group of eight participants attended a total of eight music therapy sessions over a 

period of six weeks. Qualitative data consisted of session video footage, and semi-structured interviews 

that were conducted with each participant after the intervention. Quantitative data were generated both 

pre- and post-intervention using the Positive and Negative Syndrome Scale (PANNS). Qualitative data were 

analysed thematically, and indicated that group music therapy afforded benefits for these participants’ 

negative symptoms during sessions, although these were still present to a degree. The quantitative data did 

not demonstrate a statistically significant change before and after the study. The qualitative and quantitative 

data were mixed at the interpretative stage of the analysis process, enabling an in-depth exploration of the 

relationship between both data sets. Although participants continued to present with negative symptoms 

in day-to-day life, there was a temporary relief from these during the music therapy sessions. 

MUSIC THERAPY 

Since 1999 music therapy has been offered as a Master’s degree at UP, which is currently the only university 

in South Africa offering this qualification. The UP music therapy course is held over two years, and includes 

theoretical and practical modules and placements. Entrance requirements are either a four-year music degree 

with at least a third year level of psychology, or another, non-music four-year degree with at least three years 

of psychology, together with a satisfactory level of musical proficiency. Students rotate through various hospital 

placements, including the acute-care and forensic units at Valkenberg Hospital, where the current study was 

conducted. Others, either historically or currently, include Lentegeur and Weskoppies psychiatric hospitals, 

the Port Elizabeth Mental Health organisation, and Cecilia Makiwane, Rob Ferreira and Windhoek Hospitals. 

Other sectors include paediatric oncology, special needs, autism, neuro-rehabilitation, psycho-geriatric and 

intellectual disability. At the conclusion of the training period a dissertation must be submitted. 

Music therapy is recognised by the HPCSA and BHF bodies as a health discipline, and practitioners require 

registration with the HPCSA. Music therapy consultations can be claimed from those medical aids that pay for 

the Arts Therapies. To date there are no government-funded music therapy posts in the state sector. It is hoped 

that this will change, especially with regard to state-sector provision of mental health care, as awareness of 

evidence-based studies increases. 


ORIGINAL 

Music therapy itself is an intervention that has been 

in existence as an academic discipline since the 

mid-twentieth century. 1 It is gaining credibility as an 

evidence-based intervention, as a result of significant 

gains in understanding the neural processes 

involved in musical activity (perception, auditory 

and cognitive processing, performance etc.), and 

how these may be applied in a therapeutic way. 

The strongest music therapy research, with 

accumulating evidence for its effectiveness in 

these fields, has been in dementia, Parkinson’s 

disease, autistic spectrum disorders, behavioural 

and developmental disturbances in childhood, and 

cancer care. 2 A review of the literature reveals that 

research into its effectiveness as an intervention in 

severe mental illness, including major psychotic and 

mood disorders, is ongoing. 

An often-quoted definition of music therapy is that it 

is “a systematic process of intervention wherein the 

therapist helps the client to promote health, using 

music experiences and the relationships that develop 

through them as dynamic forces of change.”. 3 As 

this definition implies, music therapy is primarily nonverbal, 

which is helpful for clients who may have 

difficulties addressing issues through the use of words 

alone, and it also suggests that the therapeutic 

process extends beyond the passive listening of music 

- there is a therapist, a client-therapist relationship, 

and the music experience, which usually includes 

participating in making music. 

The music therapy process may be conducted 

singly, or in groups. Typically, the act of making 

music includes playing or singing, which clients are 

invited to participate in with the music therapist. 

Musical activities range from free improvisation, 

to reproducing or creating songs. Commonly 

used instruments include drums and percussion 

instruments, keyboards, thumb pianos, guitars, and 

the human voice. It is important to emphasise that 

the music therapy process does not require or presuppose 

any formal musical training or ability in 

participants. 

STUDY INTRODUCTION 

The effective management of the negative symptoms 

of schizophrenia is a therapeutic obstacle. 4,5,6 , the 

efficacy of medication is limited, and symptom 

specificity is unsatisfactorily targeted.7,8 In 

addition, the negative symptoms themselves 

make conventional speech-based psychological 

interventions difficult to implement. 

A 2017 Cochrane review of music therapy and 

schizophrenia reviewed eighteen trials in which 

people with schizophrenia or schizophrenialike 

disorders were randomised to receive either 

music therapy or standard care. 9 Symptom-related 

outcomes, using standard instruments and rating 

scales, were typically measured in these studies. The 

currently available evidence is of low to moderate 

quality, with bias in these studies reported as being 

low. Results suggest that music therapy improves 

global state, mental state, functioning, and quality 

of life if a sufficient number of music therapy sessions 

are provided. The duration of the studies was 

between one and six months, and greater benefits 

were found with studies of a longer duration, and 

with a higher frequency of sessions. 

With respect to specific symptom groups, the 

Cochrane review revealed overall significant short, 

medium, and long-term effects in favour of music 

therapy on negative symptoms. Trials focusing on 

positive symptoms or combined symptomatology 

were of better quality, and revealed significant 

effects on general functions in the short, medium 

and long term, and poor short term effects on 

positive symptoms. 

Current research therefore suggests support for 

music therapy as a potential therapeutic intervention 

for a group of symptoms in which pharmacological 

approaches have been less successful. 

To further contribute to this body of knowledge, the 

main research question of the current study was: 

How can service users in a psychiatric hospital 

who are diagnosed with schizophrenia benefit 

from group music therapy sessions in relation to 

their negative symptoms? Sub-questions were 

then generated which specified the negative 

symptoms that were investigated: How can music 

therapy sessions contribute as an intervention 

for i) emotional withdrawal and blunted affect?, 

ii) relational withdrawal and conversational flow?, 

iii) difficulties in abstract and stereotyped thinking?, 

and iv) anhedonia? 

METHOD 

An embedded design 10 was used in this exploratory 

study. Qualitative data were predominant, and 

quantitative data were integrated into the study 

supportively. 

CONTEXT 

This study took place at the forensic unit at 

Valkenberg Psychiatric Hospital in Cape Town. 

The forensic psychiatry unit assesses adult male 

defendants referred by the courts, and treats and 

rehabilitates offenders diagnosed with severe mental 

illness. Patients undergoing rehabilitation are known 

as ‘state patients’. Female forensic patients are 

not treated at Valkenberg Hospital, and none were 

therefore represented in this study. As the length of 

admission for forensic patients is significantly longer 

than for acute patients, the forensic population is a 

better suited group for a six-week study, and this was 

a principal reason for the study being conducted 

within this group. 

PARTICIPANTS 

Eight ‘state patients’ with schizophrenia, each with 

prominent negative symptoms, were included in 

the study. Potential participants were identified by 

the hospital’s forensic staff, based on the prominent 

presentation of negative symptoms, and the 

sampling method used was therefore a purposive 

one. 11 Informed consent forms were signed by the 

participants, and ethical permission to conduct the 

study was granted by the University of Cape Town’s 

faculty of Health Sciences ethics committee. 

INTERVENTION 

Eight group music therapy sessions were held 

regularly over a six-week period. Music therapy 

was offered as complementary to standard 


ORIGINAL 

pharmacological treatment, and to standard 

occupational therapy and nursing programs. 

The sessions included the following elements: 

i) listening to recorded music while participating 

in physical stretching exercises, ii) group djembe 

drumming, including opportunities for participants 

to lead, iii) semi-structured improvisations involving 

singing, chanting, and the playing of pitched 

and non-pitched percussion instruments, iv) freeimprovisation, 

and v) song-writing. Goals included 

providing opportunities for collaboration, interactive 

communication, free self-expression, and the fostering 

of creativity. 

DATA COLLECTION 

QUALITATIVE DATA COLLECTION 

Quantitative data were collected from two sources: 

the music therapy sessions, which were video 

recorded, and from audio recorded semi-structured 

interviews, which were conducted at the end of 

the intervention. Three excerpts were selected from 

video recordings taken from the first, fourth and 

last session. Thick descriptions were then written for 

each excerpt, as a rich articulation of the observed 

event 12 . 

Semi-structured interviews were conducted with 

participants after the final music therapy session. Nine 

open questions were presented to each participant, 

including: i) how they experienced making music 

together in sessions, ii) how they experienced 

themselves in the group, iii) how they experienced 

communicating with others in the group, and iv) 

how they experienced their levels of motivation 

during sessions and after sessions. Interviews were 

audio recorded and then transcribed verbatim. 

QUANTITATIVE DATA COLLECTION 

The Positive and Negative Syndrome Scale (PANSS) 

is a well-validated clinical symptom scale and 

consists of three subscales, viz. positive symptoms, 

negative symptoms, and general psychopathology 

symptoms, such as anxiety, motor abnormalities 

and poor insight. 13,14 The scale was used to collect 

quantitative data on the patients. 

The PANSS questionnaire was completed for each 

participant before and immediately after the group 

music therapy process. Seven negative symptoms 

are represented in the questionnaire (blunted 

affect, emotional withdrawal, poor rapport, passive/ 

apathetic social withdrawal, difficulty in abstract 

thinking, lack of spontaneity and flow of conversation, 

and stereotyped thinking), and each is graded from 

one to seven, where 1 is ‘absent’, and 7 is ‘extreme’. 

DATA ANALYSIS 

The qualitative data were analysed using thematic 

analysis, which consists of specifying, examining 

and assembling themes in a data set. 15,16 The thick 

descriptions of the video data were analysed in this 

way, and this process led to the initial identification 

of over a hundred codes, which are main ideas 

that emerge from studying the transcripts. Codes 

captured: key concepts expressed verbally by the 

participants; affective material; and interactional 

dynamics that became evident through the making 

of music. Codes that shared similarities were 

then grouped into forty-four categories, finally the 

categories were grouped together, and six emergent 

themes were identified. The same procedure was 

used to analyse the thick descriptions that had 

been written for the interview data. Throughout 

these processes cognizance of the negative 

symptoms specified in the study’s sub-questions, 

and their resonance with the thematic analysis, was 

maintained. 

RESULTS 

QUALITATIVE RESULTS 

Examples of codes generated by the analysis 

included: 

• motivation to keep personal stability, 

• rhythmic continuity, 

• the sessions being a safe space where “there is 

no violence in the joy”, 

• medication as not the “end of being”, 

• affirmative lyrical content, 

• mpassive affect, 

• narrowing of melodic range. 

Examples of categories included: 

• warmth and safety, 

• physical wellbeing, 

• equality, 

• sense of freedom, 

• positive group experience, 

• irritability, 

• stunted musical exchange. 

Six themes were generated by these categories, as 

follows: 

‘Holding’ related to a sense of emotional security 

and stability that was experienced within the music 

therapy group. 

‘Positive experiences of music therapy’ included 

categories relating to favourable and beneficial 

experiences during the sessions. 

‘Togetherness’ comprised processes of experience 

in the group, and adjustments in the group context, 

that arose from empathic cooperation. 

‘Activation’ included instances where motivation, 

energy, leadership and agency emerged through 

participating in the music therapy intervention. 

‘Flexibility’ referred to how participants could sustain 

variation in a healthy and constructive manner. 

‘Inflexibility’ incorporated the presentation of 

stagnated or immobilised characteristics that 

were evident in the data, including blunted affect, 

emotional withholding, relational withdrawal, lack 

of conversational flow, stereotyped thinking and 

anhedonia. 

Table I details two examples of the relationships 

between the codes, categories and themes, and 

the sub-questions to which they relate. 


ORIGINAL 

CODE EXAMPLES 

CATEGORY 

EXAMPLES 

THEMES 

SUB – QUESTIONS 

Silent participant drawn into 

group expression; 

Participant initiates singing 

again; 

Responsiveness; 

Leadership. 

ACTIVATION 

Emotional withdrawal 

and blunted affect; 

Relational withdrawal 

and conversational flow; 

(Music) requires devotion. 

Anhedonia. 

Impassive affect; 

Narrowing melodic range. 

Stunted musical 

exchange; 

Irritability; 

Music therapist’s 

communication 

challenges. 

INFLEXIBILITY 

Emotional withdrawal 

and blunted affect; 

Relational withdrawal 

and conversational flow; 

Abstract thinking and 

stereotyped thinking; 

Anhedonia. 

Table I: Two examples of the emergence of themes from categories and codes, and the sub-questions to which 

they relate. 

QUANTITATIVE RESULTS 

The PANSS scores confirmed that all the participants 

in the study presented with negative symptoms of 

schizophrenia. The pre-intervention mean score for 

the negative symptoms was 20. The mean postintervention 

score for negative symptoms was 19.1, 

which is not a statistically significant change. Within 

the negative symptom subscale, no striking preand 

post-intervention changes were present in the 

specific negative symptom scores. The maximum 

attainable score is 49. 

Lower mean scores were obtained for the positive and 

general psychopathology subscales, suggesting 

that negative symptoms were well represented in 

the selected patients. No significant mean changes 

were recorded post-intervention for the positive and 

general psychopathology symptoms. 

DISCUSSION 

A viewing of the video recordings, from the first to 

the final music therapy session revealed a notable 

trajectory from poor to enthusiastic engagement. 

Session one was characterised by long periods of 

perseveration and withdrawal, while session eight 

revealed enhanced interconnecting, cohesion and 

creative expression. 

Examples of participant responses, as related to 

the themes of ‘holding’ and ‘positive experiences of 

music therapy’, included the following: when asked 

how he experienced relating to group members, 

one participant answered, “I think about a band 

around say, on me, who are back in now here by 

me. There’s no violence. And there’s no violence in 

the joy.” Music therapy was similarly described as 

being enjoyable by other participants. One of the 

participants frequently left sessions smiling and 

laughing, whereas he entered them in a withdrawn, 

sullen and reluctant manner. 

Within these themes of ‘holding’ and ‘positive 

experiences of music therapy’ the category 

‘organisation, stability and structure’ portrayed a 

regulated and ordered state. Several codes within 

this category made reference to the observed 

musical receptivity of the group to highly structured 

activity, such as successive turn-taking in group 

drumming with a steady pulse. This is an interesting 

finding, in the context of the difficulties that people 

with schizophrenia frequently display in their ability to 

maintain structure and organisation, both internally 

and externally. 17 

The theme of ‘activation’ included instances where 

motivation, energy, leadership and agency emerged 

through participating in the intervention. The theme 

relayed a sense of awakening and emergence, 

reflecting a change in the manner that participants 

would hear and see themselves and one another. 

One of the categories in this theme, ‘sense of 

achievement and self-belief’, arose from activities 

such as workshopping individual poems into one 

group song, or featuring all the participants as drum 

soloists. ‘High energy’ is an example of a category 

within this theme that derived from codes expressing 

raised vigour and vitality. 

Codes and categories within the theme of 

‘flexibility’ indicated that participants could sustain 

musical variation in a healthy and constructive 

way, could flexibly negotiate playing an instrument 

communicatively with others, and could engage 

in congruent, creative expression. One of the 

categories included in this theme was abstract 

thinking, and one participant related that music is like 

a romantic partner he had keenly felt the absence 

of since being hospitalised. The theme of ‘inflexibility’ 

was juxtaposed with this, and incorporated 

the presentation of stagnated or immobilised 

characteristics that were evident in the data. Its 

presence indicated that negative symptoms were 

still present in sessions. Interestingly however, codes 

in the category ‘disjointed relational responses and 

engagement’, within this theme, mainly stemmed 

from the interviews. This suggests that there were 

more cohesive relational interchanges when 

participants were engaged in music, rather than 

when communicating verbally in the interview. 


ORIGINAL 

In conclusion, the themes ‘holding’, ‘positive 

experiences of music therapy’, ‘togetherness’, 

‘activation’ and ‘flexibility’ indicate that within the 

sessions the participants were afforded opportunities 

to experience themselves in more vibrant and 

socially interactive ways, and in this way music 

therapy was seen to have a beneficial impact on 

the negative symptoms. 

The post-intervention interviews revealed that little 

change in the experience of negative symptoms 

was reported in daily life on the ward after the 

music therapy had concluded. Given the small 

number of participants (n=8), no statistically 

significant changes were expected, nor present, in 

the pre- and post-intervention PANSS scores (the 

quantitative data). A principal value of the PANSS 

evaluation was to confirm that the participants, 

who were selected on clinical grounds, did indeed 

have significant negative symptoms. In order for 

a study to prove, quantitatively, the hypothesis 

that music therapy can have enduring effects 

outside of the sessions, there would need to be a 

far greater number of participants, and the study 

would need to be conducted over a much longer 

period of time. 

LIMITATIONS 

The number of participants in the current study was 

small, the duration of the intervention was short, 

and there was no control group. The diagnosis 

of schizophrenia, in all of the participants, was 

established clinically, and not through the use 

of diagnostic research instruments such as SCID 

(Structured Clinical Interview of DSM-5). Addressing 

anhedonia was a specific aim of one of the subquestions 

of the study: as this symptom is not 

specifically measured in the PANSS, its analysis was 

only addressed qualitatively. 

CONCLUSION 

This pilot study suggests that reductions in the 

experience of some negative symptoms, in people 

with a diagnosis of schizophrenia, are possible 

during music therapy sessions. It is the first such 

study to be conducted in this country, and supports 

the findings of other, larger studies. 

In view of the lack of available therapeutic 

interventions that significantly improve negative 

symptoms, including medication, the question 

of whether music therapy can address this in an 

enduring way is an important one. A larger study 

would be needed to address this question. 

Finally, as stated earlier, it would be desirable if 

state mental health service administrators in 

South Africa would gain an increasing awareness 

of the status of music therapy: as a formal HPCSA 

accredited discipline, and as an increasingly 

evidence-based intervention for a range of 

mental health problems. 

REFERENCES 

1. Karhou V, Sanderson P. Arts therapies: A researchbased 

map of the field. London: Elsevier. 2006 

2. The Nordoff Robbins Evidence Bank , 3rd Edition. 

2014 

3. Bruscia KE. Defining Music Therapy. 2nd Edition. 

Gilsum, NH: Barcelona Publishers.1998 

4. Chue P, Lalonde JK. Addressing the unmet needs 

of patients with persistent negative symptoms 

of schizophrenia: emerging pharmacological 

treatment options. Neuropsychiatric disease and 

treatment 2014; 10: 777-789. 

5. Fusar-Poli, P, Papanastasiou , Stahl D, Rocchetti 

M, Carpenter W, Shergill S, McGuire P. Treatments 

of negative symptoms in schizophrenia: Metaanalysis 

of 168 randomized placebo-controlled 

trials. Schizophrenia Bulletin 2014; 41(4): 892-899. 

6. Millan M J, Fone K, Steckler T, Horan WP. 

Negative symptoms of schizophrenia: clinical 

characteristics, pathophysiological substrates, 

experimental models and prospects for improved 

treatment. European Neuropsychopharmacology 

2014; 24(5): 645-692. 

7. Barnes SA, Der-Avakian A,Young JW. Preclinical 

models to investigate mechanisms of negative 

symptoms in schizophrenia. Schizophrenia 

Bulletin 2017; 43(4): 706-711. 

8. Buchanan RW. Persistent negative symptoms in 

schizophrenia: an overview. Schizophrenia Bulletin 

2007; 33(4), 1013-1022. 

9. Cochrane Library (2017): Music therapy for 

schizophrenia or schizophrenia-like disorders. 

Music therapy for people with schizophrenia 

and schizophrenia-like disorders (Review), 

Geretsegger M, Mössler KA, Bieleninik, Chen XJ, 

Heldal TO, Gold C. 

10. Creswell JW, Plano Clark VL. Designing and 

conducting mixed methods research (2nd ed.). 

Thousand Oaks, CA: Sage Publications, Inc. 2011 

11. Onwuegbuzie A, Collins K. A typology of mixed 

methods sampling designs in social science 

research. The Qualitative Report 2007; 12(2): 281- 

316. 

12. Tracy S. Qualitative quality: Eight “big tent” criteria 

for excellent qualitative research. Qualitative 

Inquiry 2010; 16(10): 837-851. 

13. Blanchard JJ, Cohen AS. The structure of negative 

symptoms within schizophrenia: implications for 

assessment. Schizophrenia Bulletin 2006; 32(2): 

238-245. 

14. Kay SR, Flszbein A, Opfer LA. The positive 

and negative syndrome scale (PANSS) for 

schizophrenia. Schizophrenia Bulletin 1987; 13(2): 

261-276. 

15. Braun V, Clarke V. Using thematic analysis in 

psychology. Qualitative Research in Psychology 

2006; 3(2): 77-101. 

16. Grbich C. Qualitative data analysis: an 

introduction. London: Sage.2007 

17. Breier A, Schreiber JL, Dyer J, Pickar D. National 

Institute of Mental Health longitudinal study of 

chronic schizophrenia: prognosis and predictors 

of outcome. Archives of General Psychiatry 1991; 

48(3): 239-246. 

Bruce Malcolm Muirhead obtained a Masters degree in Music Therapy , Music Therapy Unit, University of Pretoria, Tshwane, 

South Africa, in 2017. Correspondence: bmmuirhead@gmail.com 

Andeline Dos Santos is a co-director of the Music Therapy unit at University of Pretoria, Tshwane, South Africa, and supervised 

Mr Muirhead’s research. 

Marc Roffey is a psychiatrist and holds a consultant post in Forensic Psychiatry at Valkenberg Hospital as well as being affiliated 

to the Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa. 


Help Shape A Future for 

Your Patients with Schizophrenia 

Xeplion ® is an option for any patient for whom long-term 

treatment is needed; it is effective, well-tolerated and 

promotes adherence 1,2,3 

ONCE-MONTHLY 

prolonged release 

suspension for injection 

XEPLION 

paliperidone palmitate 

Preventing relapse, enabling futures 

S5 XEPLION® 50 mg. Reg. No.: 44/2.6.5/0866. XEPLION® 75 mg. Reg. No.: 44/2.6.5/0867. XEPLION® 100 mg. Reg. No: 44/2.6.5/0868. XEPLION® 150 mg. Reg. No.: 44/2.6.5/0870. Prolonged release suspension for intramuscular injection. Containing 50mg, 75mg, 100mg, 150mg 

paliperidone palmitate resprectively. Further information available on request from Market Authorisation Holder. JANSSEN PHARMACEUTICA (PTY) LTD/(EDMS) BPK; (Reg. No./Regnr. 1980/011122/07); Building 6, Country Club Estate, 21 Woodlands Drive, Woodmead, 2191. 

www.janssen.co.za. 

18 * SOUTH AFRICAN Medical Info PSYCHIATRY Line: 0860 11 11 ISSUE 17. For full 14 prescribing 2018 information refer to package insert (June 2013). Cert. No.:PHZA/XEP/0616/0001. 

References: 

1. Javitt DC. Balancing therapeutic safety and efficacy to improve clinical and economic outcomes in schizophrenia: Exploring the treatment landscape. Am J Manag Care 2014;20:S166-S173. 2. Attard A, Olofinjana O, Cornelius V, et al. Paliperidone palmitate long-acting injection – 

prospective year-long follow-up of use in clinical practice. Acta Psychiatrica Scandinavica 2013:1-6. 3. Newton R, Hustig H, Lakshmana R, et al. Practical guidelines on the use of paliperidone palmitate in schizophrenia. Curr Med Res & Opin 2012;28(4):559-567.

REPORT 

THE US/UCT 

MRC UNIT 

ON RISK AND RESILIENCE 

IN MENTAL 

DISORDERS 

Nienke Pannekoek 

The Medical Research Council of South 

Africa aims to improve the health and 

quality of life of the nation trough research. 

The MRC has nearly 50 Units; some are 

intramural (based at the MRC) while others are 

extramural (based at Universities). Given that a 

substantial proportion of the country’s disease 

burden came from mental, neurological and 

substance use disorders, the MRC support work 

devoted to these conditions. In particular, in 

South Africa there are 2 units with such foci, i.e. 

an intramural Unit on substance use and related 

disorders, and an extramural unit focused on risk 

and resilience in mental disorders. 

The MRC Unit on Risk and Resilience in Mental 

Disorders is a cross-university unit at the 

Department of Psychiatry and Mental Health 

at the University of Cape Town (UCT) and the 

Department of Psychiatry at Stellenbosch 

University (SU). This unit builds on the legacy of 

the MRC Unit on Anxiety and Stress Disorders 

that was initiated at SU in 1997. The vision of the 

original Unit was a translational one; moving from 

bench to bedside, and from bedside to bundu 

– with work including a focus 

on animal models of anxiety 

disorders, on clinical research on 

these conditions, and on public 

health aspects. 

The MRC Unit on Risk and 

Resilience in Mental Disorders 

which came into effect 1 

April 2017, headed by Profs Nienke Pannekoek 

Dan Stein (UCT) and Christine 

Lochner (SU), builds on past achievements. 

These include the South African Stress & 

Health Study (SASH), the first nationally 

representative study of mental disorders 

on the continent; work on OCD and related 

disorders that played an important role in 

providing a rationale for the new chapters in 

DSM-5 and ICD-11 on obsessive-compulsive 

and related disorders; and some of the first 

genetic and brain imaging studies in key areas 

of neuropsychiatry locally, including work on 

HIV/AIDS and substance use disorders. The 

current unit goes beyond anxiety and stress, to 

embrace a number of additional conditions. 


REPORT 

RISK AND RESILIENCE 

Going forwards, it is the mission of the MRC Unit 

on Risk and Resilience in Mental Disorders to 

undertake research that encompasses two interlinked 

areas: 

a) PROMOTING CLINICAL RESEARCH AND 

THE TRANSLATION OF BASIC SCIENCE INTO 

CLINICAL RESEARCH, TO IMPROVE DIAGNOSIS, 

PREVENTION AND MANAGEMENT OF MENTAL 

DISORDERS IN SOUTH AFRICA WITH A FOCUS 

ON RISK AND RESILIENCE FACTORS, AS THEY 

APPLY TO KEY CONDITIONS IN THE LOCAL 

CONTEXT. 

b) TRANSLATING CLINICAL EVIDENCE INTO 

POPULATION-LEVEL INTERVENTIONS TO 

IMPROVE MENTAL HEALTH THROUGH PRIMARY 

HEALTH CARE AND COMMUNITY INITIATIVES 

THAT CAN BE APPLIED IN DIVERSE SETTINGS 

ACROSS THE COUNTRY AND THE CONTINENT, 

WITH A FOCUS ON PRIORITY ILLNESSES GIVEN 

THE LOCAL BURDEN OF DISEASE. 

In their commitment to fulfilling this mission, 

researchers at the Unit collaborate with researchers 

around South Africa, Africa, and the world on 

a number of projects. For example, ENIGMA is 

a worldwide network that aims to understand 

brain structure and function in neuropsychiatric 

disorders, using various neuroimaging 

modalities as well as genetic information. The 

Drakenstein Child Health Study follows motherchild 

pairs from pregnancy, and aims to map 

potential risk factors that impact child health. 

NeuroGAP (Neuropsychiatric Genetics in African 

Populations), investigates psychosis across 

several African countries. Under the umbrella 

COMPIMP (compulsivity/impulsivity), the Unit 

has ongoing studies on obsessive-compulsive 

disorder (OCD), trichotillomania (TTM; hairpulling 

disorder), Parkinson’s Disease, gambling 

disorder, and methamphetamine abuse disorder, 

aiming to shed light on compulsivity-impulsivity 

phenotypes that cut across traditional diagnostic 

categories. In addition, the Unit is part of a global 

collaboration on University student health and 

wellness, utilizing e-surveys to identify students at 

risk of disorders and dysfunctional behaviours. 

The Unit continues to welcome referral of patients 

suffering from anxiety and related disorders, as 

such individuals may be eligible for genetic and 

other studies. OCD and TTM patients receive a 

comprehensive evaluation at the Unit, and can 

participate in a number of different studies. The 

Unit is one of the sites of the first international 

NIH-funded project aimed at identifying brain 

signatures of OCD using standardized methods 

across the world. Similarly, the Unit collaborates 

with sites abroad on clinical, genetic and brain 

imaging underpinnings of TTM, again using 

standardized methods. 

THE UNIT ALSO CONTINUES TO 

PUT SIGNIFICANT EFFORT INTO 

MENTORSHIP AND TRAINING. SEVERAL 

POSTGRADUATE STUDENTS AND 

POSTDOCTORAL FELLOWS ARE BEING 

TRAINED ON THE UNIT, AND MANY 

HAVE BECOME NATIONAL AND 

INTERNATIONAL LEADERS IN THEIR 

RESPECTIVE FIELDS OF INTEREST. 

STEIN AND LOCHNER EMPHASIZE 

THAT SUCH STUDENTS ARE THE 

DRIVING FORCE OF SCIENCE, AND 

THEY ARE ALWAYS ON THE LOOK-OUT 

FOR YOUNG SCIENTISTS WHO ARE 

INTERESTED IN THE NEUROSCIENCE OF 

MENTAL DISORDERS, AS WELL AS FOR 

CLINICIANS WHO ARE INTERESTED IN A 

CAREER AS CLINICIAN-SCIENTISTS. 

Stein and his team are thankful to the MRC for 

the resources that the Unit has provided them, 

and remain passionate about the possibilities 

for future work in psychiatry and clinical 

psychology. And they are always open to referral 

of individuals suffering from anxiety and related 

disorders, who may be eligible for one of the 

Unit’s studies. 

Justine Nienke Pannekoek (PhD) is a Research Fellow, SU/UCT MRC Unit on Risk & Resilience in Mental DisordersStellenbosch 

University/University of Cape Town Brain-Behaviour Unit, Department of Psychiatry and Mental Health, University of Cape 

Town, Western Cape, South Africa. She is currently working on various neuroimaging projects involving vulnerable adult 

and child patient groups, varying from methamphetamine use to obsessive-compulsive disorder, and Parkinson’s Disease. 

Correspondence: nienke@sun.ac.za 


WPA NEWS 


REPORT 

THE 4TH BIENNIAL 

NATIONAL FORENSIC 

MENTAL HEALTH 

SERVICE (FMHS) 

CONFERENCE 

(5 th - 6 th OCTOBER 2017) 

Sean Kaliski 

In 2009, when the first conference was held, 

forensic psychiatry was not a registrable subspecialty 

and the number of practitioners solely 

dedicated to the discipline was small. At the 4th 

conference, held at Valkenberg hospital on 5th - 6th 

October 2017, we could congratulate ourselves on 

having at least 20 psychiatrists now registered as 

forensic psychiatrists with the HPCSA. The week after 

the conference the College of Psychiatry graduated 

the first psychiatrist (and Wits standard bearer), 

Dr. Cassimjee, with the new Certificate in Forensic 

Psychiatry. The next stage obviously is to establish 

similar sub-specialty registrations for psychologists, 

occupational therapists, social workers and nursing. 

The heartening consequence of this progress has 

been the impressive depth and variety of research 

and expertise that were displayed by members of 

multidisciplinary teams around the country during 

a full 2 days. Some commented that there is now so 

much activity and interest among all mental health 

colleagues that the conference in future could be 

held over several days. 

The talks were clustered into themes. There were 

sessions on Human Rights, Women & Children, 

Rehabilitation, Novel Therapeutic Interventions, 

Fitness to Stand Trial, Sex offending and Interesting 

case presentations. Dr. Liza 

Grobler, a criminologist with the 

Department of Correctional 

Services, opened proceedings 

with a fascinating narrative of how 

prison gangs are structured and 

function. Even those who have 

been in the field (sometimes known 

as the coalface) for decades 

Sean Kaliski 

were astonished at the complexity 

of their organisation, although 

apparently in recent years new recruits have diluted 

their strict discipline and secret codes. Sean Kaliski 

attempted to convince all that the forensic mental 

health service structurally abuses the rights of those 

referred for observation and state patients, and 

complained that no one seems to care. Seems he 

was wrong as a task team has now been formed by 

the Department of Justice to study these issues. 

Not enough attention has been focussed on female 

offenders. Mo Nagdee reported on his multisite 

national survey of offenders who had been referred 

for a 30-day observation. He noted that although 

women comprise about 3% of inmates they are 

increasingly being convicted for serious violent 

offences (usually against people they know). Almost 


REPORT 

Some delegates were intrigued by the straitjacket they found in 

a restored padded cell in the Valkenberg hospital museum 

half suffer from either a psychotic or mood disorder. 

Filicide is a leading cause of death of children, 

although the incidence seems to be declining in 

developed countries. Ugash Subramaney noted that 

there are no overriding theories or classifications to 

explain why parents kill their children. Nevertheless, 

she emphasised that most filicidal parents 

had psychiatric and psychological problems 

beforehand. Amanda Edge described the Graphic 

Family Sculpting programme at Sterkfontein hospital 

that aims to overcome obstacles that state patients 

often experience in re-engaging with their families. 

WHILE THEY ARE INPATIENTS THEIR 

YOUNG CHILDREN CANNOT VISIT FREELY 

AND THERE ARE FEW FRIENDLY SPACES 

TO ACCOMMODATE FAMILIES WHEN 

THEY DO VISIT. STERKFONTEIN HOSPITAL 

IS PROBABLY THE ONLY PSYCHIATRIC 

HOSPITAL THAT HAS A UNIT DEDICATED TO 

CONDUCT ASSESSMENTS OF CHILDREN 

BETWEEN THE AGES OF 10 AND 14 

YEARS THAT ARE REFERRED UNDER 

THE CHILD JUSTICE ACT. INCREASING 

NUMBERS OF CHILDREN ARE BEING 

CHARGED WITH OFFENCES, WHICH ARE 

OFTEN VIOLENT. NICOLE RAUTENBACH 

AND BARRY VILJOEN OUTLINED 

THE PANOPLY OF DIFFICULTIES THAT 

CONFRONT THEM WHEN CONDUCTING 

THESE ASSESSMENTS. THESE RANGE 

FROM GEOGRAPHICAL (CASES ARE 

BROUGHT FROM FAR AWAY AND 

CANNOT BE ADMITTED), LANGUAGE 

DIFFICULTIES, RECALCITRANT FAMILIES 

AND THE FREQUENT INACCESSIBILITY OF 

COLLATERAL INFORMATION. APPARENTLY 

CHANGES TO THE LEGISLATION ARE 

ENVISAGED BUT THEY WERE UNCERTAIN 

WHETHER THEIR ASSESSMENTS ARE 

ADDRESSING LEGAL REQUIREMENTS. 

Rehabilitation of forensic patients has generally 

been almost indistinguishable from traditional 

long term chronic care. The re-integration into the 

community of forensic patients who are doubly 

stigmatised, firstly because of their mental illness 

and secondly because of their criminality, identifies 

them as a group with special needs. Among the 

many considerations that must be addressed 

their risk assessment for violence, ability to work 

and placement in the community are among the 

most important. Virtually no FMHS in SA routinely 

performs formal risk assessments, and there are 


REPORT 

THE 4TH BIENNIAL NATIONAL FORENSIC MENTAL HEALTH 

SERVICE (FMHS) CONFERENCE (5 th - 6 th OCTOBER 2017) 

Many forensic patients respond well to non-verbal therapies. 

Every forensic unit has an active occupational therapy 

service and also offers art therapy. A music therapy graduate 

student from the University of Pretoria, Bruce Muirhead, 

presented the findings of a study he conducted with Marc 

Roffey in which they conducted 8 music therapy sessions 

to forensic patients. Although their sample was small and 

the intervention too brief they demonstrated that after 

the course patients’ negative symptoms showed some 

improvement. It is hoped that this treatment modality can 

be used routinely. Similarly, under the aegis of Equinox, Marc 

Roffey, Nafisa Abdullah and Rowdah Hawtrey introduced 

a novel use of Equine Assisted therapy. Horses apparently 

are exquisitely sensitive to human behaviour and provide 

direct honest feedback to patients who interact with them. 

Many patients were able to display affection to and enjoyed 

easier verbal communication with horses. This led some to 

speculate whether the head of the unit should also be a 

horse. Or at least behave like one. 

Dr. Nyameka Dyakalashe, UCT 

few tools available that specifically can monitor 

the progress of high risk state patients as they 

traverse through the service. Tania Swart presented 

the findings from her PhD, which confirmed that 

the stronger the therapeutic alliance between 

patients and the multidisciplinary team the 

less likely they were to have acted violently in 

the preceding year. Therefore it is possible that 

measuring the quality of the therapeutic alliance 

may be a reasonable surrogate measure of risk. 

Theoca Moodley & Nafisa Abdullah reported on 

their ongoing programmes of supported learning 

and supported employment. Most forensic 

patients lack important basic work skills, and even 

when they find employment, need occupational 

therapists to interact with their employers and to 

provide them with ongoing support. In the Cape 

there is are people who provide board and 

lodging for groups of forensic patients under the 

supervision of the hospital social workers. They are 

called Rose Parents. Kay Cikiswa presented on 

the planning at Alexandra Hospital to recruit Rose 

Parents for their learning disabled residents. 

THE CRIMINAL PROCEDURE ACT IS 

UNDERGOING CHANGES. ADV CARINE 

TEUNISSEN FROM THE DPP OUTLINED THE 

CHANGES TO SECTIONS 77 & 78, UNDER 

WHICH COURTS HAVE NOW BEEN GRANTED 

DISCRETION CONCERNING THE REFERRAL 

OF THOSE WHO ARE UNFIT TO STAND TRIAL 

BUT WOULD NOT BE WELL SERVED BY BEING 

DECLARED STATE PATIENTS. THESE PROVISIONS 

ARE ESPECIALLY AIMED AT ASSISTING THOSE 

WHO ARE JUVENILES OR LEARNING DISABLED. 

OBSOLETE TERMINOLOGY WAS REPLACED, 

SUCH AS “INTELLECTUAL DISABILITY” FOR 

THE ARCHAIC “MENTAL DEFECT”. THERE IS 

NO LONGER A REQUIREMENT TO APPOINT A 

PSYCHIATRIST NOT IN STATE EMPLOY TO PANELS. 

THIS WILL LIGHTEN THE BURDEN IN PLACES 

WHERE THERE IS A DEARTH OF PSYCHIATRISTS. A 

3RD PSYCHIATRIST CAN ONLY BE APPOINTED ON 

BEHALF OF THE ACCUSED IF GOOD CAUSE CAN 

BE ADVANCED. THANKFULLY PSYCHOLOGISTS 

CAN STILL BE APPOINTED TO PANELS AS THEIR 

CONTRIBUTIONS ARE VALUABLE. CANDICE 

JACOBSON COMPLETED HER MMED THESIS 

THAT AUDITED WHETHER THE FORENSIC 

TEAM ACTUALLY INVESTIGATES WHETHER ALL 

IMPORTANT ASPECTS OF COMPETENCE TO 

STAND TRIAL ARE CANVASSED BY THE FORENSIC 


REPORT 

UNIT DURING THE OBSERVATION PERIOD. 

MANY, SUCH AS THE ROLE OF COURT 

OFFICIALS AND WHAT THEY INTENDED 

TO PLEAD, WERE ALMOST ALWAYS ASKED, 

WHEREAS OTHERS, SUCH WHAT THE 

MEANING OF A “NOT GUILTY” OR THAT 

THEY WERE WARNED THAT THEY HAD THE 

RIGHT TO REMAIN SILENT WERE ALMOST 

NEVER ASKED. 

Another highlight was Eddie Pak’s presentation 

on mental illness and the SA civil aviation industry. 

Designated Aviation Medical Examiners (DAMES) 

assess pilots for fitness to fly for the Aeromedical 

committee. He reassured the audience that the 

odds of dying in an aircrash are 1:11 million (but 

100% if you are in a crash). Although neurological 

and cardiovascular illnesses remain the most 

important causes of unfitness, psychiatric disorders 

are increasingly the leading cause. In 2013 a 

“Mood Disorder Protocol” was published in which 

strict guidelines about which and how many 

drugs a pilot could be prescribed. Pilots who are 

psychotic, severely depressed, need ECT, on more 

than one antidepressant or other psychotropics are 

not allowed to fly. A pilot may not fly if he/she has 

consumed alcohol less than hours before reporting 

for duty. A pity that the same rules do not apply to 

leaders of countries. 

Our forensic units are awash with sexual offenders, 

yet we generally pretend they are like the others and 

do not need special attention. Nyameka Dyakalashe 

presented data noting that 40% of women report 

having been sexually assaulted at least once. Less 

than 25% of rapes are estimated to be reported, and 

of these only 14% result in convictions. Between 1979 

and 2015 117 defendants were certified as state 

patients following charges of rape. She pointed out 

that some DSM diagnoses, such as paedophilia, 

are regarded as criminal, whereas many others 

are regarded merely as disorders. Funeka Sokudela 

concluded the session by discussing the common 

breaches of human rights surrounding the rights 

of those charged with sexual offences, especially if 

mentally ill. These included the conditions in prisons, 

the attitudes of officials and court procedures. 

The conference ended with two case presentations. 

Claudia de Clercq presented a case of 

psychogenic catatonia that highlighted the 

difficulties in distinguishing between factitious and 

real disorders in forensic settings, especially when 

there is some urgency to provide timeous opinions 

to the courts. Marc Roffey similarly presented a case 

of pseudologica fantastica in which grandiose 

tall stories could easily have been confused with 

delusions. 

Every biennial conference has been supported by 

Sanofi, whose representative, Greg Sinovich, has had 

a long dedicated association with our service, and 

have indicated that they would like us to hold this 

event more often... 

THE NEXT CONFERENCE SHOULD 

BE SOMETIME IN 2019. SEE YOU 

THERE! 

Sean Kaliski is a Forensic Psychiatrist at Valkenberg Hospital, Cape Town and an Associate Professor in the Department of 

Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa. Correspondence: sean.kaliski@uct.ac.za 

The Sterkfontein Team 


GMHPN NEWS 

26 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 2018 * Full text is available at www.globalmentalhealth.org

REPORT 

CAN TRANSCRANIAL 

MAGNETIC 

STIMULATION 

BE USED TO TREAT 


Tanya Calvey 

Dr. David Pitcher (lecturer and neuroscientist 

at the Department of Psychology, University 

of York) presented a seminar on the topic: 

‘Can Transcranial Magnetic Stimulation be 

used to Treat Mental Illness?’ The event, organised 

by the Wits Cortex Club, was held on Monday, 4 

December 2017, at the Adler Museum of Medicine, 

Wits Medical School. The event was well attended 

by psychiatrists, neuropsychologists, neuroscientists, 

epidemiologists and students of medicine, science 

and the humanities. 

SUMMARY OF THE SEMINAR: 

Transcranial magnetic stimulation (TMS) is a noninvasive 

neuro-stimulation technique using a 

magnetic coil to create an intracranial electrical 

field. The electrical field induces local depolarization 

of the neurons leading to measurable changes in 

the local macroscopic neuronal activity, blood flow 

and metabolism which leads to changes in function 

and ultimately, behaviour. TMS can, therefore, 

modulate human brain activity and is widely used 

in psychology and neuroscience departments 

around the world to study basic cognitive and motor 

functions. 

Since the late 1990s there has been growing 

interest in using TMS as a treatment for a variety of 

different mental health disorders. This interest was 

significantly strengthened in 2008 when the US 

Federal Drug Administration (FDA) approved TMS 

as a treatment for depression. TMS is also approved 

as a treatment for depression in Canada, Germany, 

Japan, Australia and the United Kingdom. Following 

clinical trials and research, the current scientific 

and clinical consensus is that repetitive TMS (rTMS) 

is a safe, effective treatment for major depression. 

rTMS over the pre-frontal cortex results in significant 

improvements in symptom scores measured by 

the Montgomery-Asberg Depression Rating Scale 

(MADRS), the Beck Depression Inventory (BDI) and 

the Hamilton Depression Rating Scale (HAMD) 

in drug-resistant depression with effect sizes and 

numbers needed to treat (NNT) similar to antidepressant 

medications and cognitive behavioural 

therapy (CBT). rTMS also results in a significant 

increase in remission rates after 6 weeks of treatment. 

Recent improvement to the method (theta-burst 

stimulation, TBS) further improves the efficacy by 

improving symptoms in patients non-responsive to 

10Hz TMS. Recent research has shown that TMS to the 

pre-frontal cortex might also be effective in treating 

substance use disorder (SUD) but further research 

needs to be conducted to verify these findings. 

THE EFFICACY OF TMS IN TREATING 

DEPRESSION AND POSSIBLY SUD 

LIES, PARTLY, IN ITS ABILITY TO ALTER 

CONNECTIVITY BETWEEN THE PRE- 

FRONTAL CORTEX AND SUBCORTICAL 

REGIONS. THIS ASPECT OF TMS HAS 

EXCITING POSSIBILITIES FOR RESEARCH 

INTO BRAIN CONNECTIVITY AS THE 

STIMULATION CAN EITHER INCREASE 

OR DECREASE CONNECTIVITY WITH THE 


REPORT 

UNDERLYING STRUCTURES. THE CHANGES 

IN CONNECTIVITY ARE ASSESSED USING 

FUNCTIONAL MAGNETIC RESONANCE 

IMAGING (FMRI). THIS RESEARCH 

COULD UNCOVER THE SPECIFIC BRAIN 

CONNECTIONS IMPLICATED IN SPECIFIC 

MENTAL HEALTH DISORDERS AND ALSO 

THE CONNECTIONS IMPLICATED IN THOSE 

RESPONSIVE AND NONRESPONSIVE 

TO TREATMENT. TMS IS NOT ONLY AN 

EFFECTIVE TREATMENT FOR CERTAIN 

MENTAL HEALTH DISORDERS BUT ALSO 

A USEFUL RESEARCH TOOL TO UNCOVER 

THE UNDERLYING NEUROBIOLOGY OF 

THE DISORDERS. 

If you would like to stay up-to-date with the activities 

of the Wits Cortex Club, please send an email to 

witscortexclub@gmail.com. 

Dr David Pitcher and audience members 

Standing at the back, Dr David Pitcher. Front row, the Wits Cortex Club, from left to right: Mr Joseph Tewson (medical student, MSc neuroscience candidate), Dr Tanya 

Calvey (co-founder, anatomy lecturer and neuroscience researcher), Ms Victoria Williams (PhD neuroscience candidate), Ms Funiwe Mkele (BHSc student), Ms Danika 

McElhenny (co-founder, medical student, BSc Hons neuroscience). 

Tanya Calvey is a Lecturer, Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 

South Africa.Correspondence: Tanya.Calvey@wits.ac.za; Website: www.wits.ac.za/anatomicalsciences 


Don’t miss AfCNP 2018 

4 th African College of Neuropsychopharmacology Congress 

www.afcnp2018.com 

The smart choice for all your ECT needs 


REPORT 



ON HEALTHCARE 


Mvuyiso Talatala, Lesley Robertson 

The South African Society of Psychiatrists 

(SASOP) represented by Dr Mvuyiso Talatala, 

Past President of SASOP, and Dr Lesley 

Robertson, Pubsec Convener, participated 

in a public debate hosted by Rural Health 

Advocacy Project (RHAP), Section 27 and Wits 

School of Public Health on the 22 November 2017. 

The public debate was titled, “Raising alarm and 

being heard. What is the change we need to 

promote and support Healthcare Worker (HCW) 

Advocacy?” 

THE DEBATE WAS HELD AT THE WITS 

SCHOOL OF PUBLIC HEALTH AND 

PROVED TO BE A VERY INTERACTIVE 

FORUM WITH A PRIMARY FOCUS ON 

HCW ADVOCACY FOLLOWING THE 

LIFE ESIDIMENI TRAGEDY WHERE OVER 

141 MENTALLY ILL PATIENTS DIED 

IN GAUTENG PROVINCE AFTER THE 

CLOSURE OF LIFE ESIDIMENI FACILITIES. 

THE DEBATE TOOK NOTE THAT THERE 

ARE OTHER EVENTS LIKE LIFE ESIDIMENI 

TRAGEDY THAT ARE HAPPENING IN THE 

COUNTRY AND HEALTHCARE WORKERS 

NEED TO BE STRENGTHENED IN THEIR 

DUTY OF ADVOCACY. DURING THE 

TERMINATION OF THE LIFE ESIDIMENI 

CONTRACT AND THE SUBSEQUENT 

CLOSURE OF THE LIFE ESIDIMENI 

FACILITIES, HEALTHCARE WORKERS 

(HCWS) WERE IGNORED IN THEIR 

ATTEMPT TO WARN GOVERNMENT OF 

THE CONSEQUENCES OF RAPIDLY 

MOVING THE SEVERELY MENTALLY ILL 

PATIENTS TO FACILITIES THAT WOULD 

OFFER INFERIOR CARE. 

Other members of the panel were Mr Anele 

Yawa from Treatment Action Campaign 

(TAC); Ms Tendai Mafuma from Section 27, Ms 

Shelly Wilsnach, an Occupational Students’ 

Representative and Prof Letitia Rispel from the 

Wits School of Public Health. Ms Marije Versteeg- 

Mojanaga, Director of RHAP, welcomed everyone 

and opened the debate. She spoke of the need 

for HCWs to overcome intimidation by senior 

health care staff, management and political 

structures to advocate for their patients and 

contribute to an improved health care system. 

She explained how The Voice Project, established 

by RHAP in partnership with Section 27, Medecins 

Sans Frontiers and various South African clinical 

Mvuyiso Talatala 


REPORT 

associations, hoped to equip HCWs in providing 

more effective advocacy through such debates 

and more structured training workshops. 

DR TALATALA GAVE A THOROUGH REVIEW 

OF ACTIONS TAKEN BY SASOP AND 

HCWS IN ORDER TO PREVENT THE LIFE 

ESIDIMENI TRAGEDY. THESE INCLUDED 

LETTERS WRITTEN TO THE GAUTENG 

DEPARTMENT OF HEALTH BY SASOP 

AND CLINICIANS IN GAUTENG, SEVERAL 

MEETINGS HELD WITH THE GAUTENG 

DEPARTMENT OF HEALTH AS WELL AS 

SEVERAL LITIGATION STEPS TAKEN BY 

SASOP TOGETHER WITH SOUTH AFRICAN 

DEPRESSION AND ANXIETY GROUP, 

SECTION 27, SOUTH AFRICAN MENTAL 

HEALTH FEDERATION AND PATIENTS’ 

FAMILIES. MEDIA ENGAGEMENT WAS 

ANOTHER TOOL USED BY SASOP 

WITH ITS PARTNERS. DR ROBERTSON, 

REFLECTING ON WHAT HCWS HAVE 

LEARNT ABOUT HCW ADVOCACY FROM 

LIFE ESIDIMENI TRAGEDY, DESCRIBED HER 

PERSONAL JOURNEY ON ADVOCACY 

BOTH IN THE PRE- AND POST-1994 ERA. 

SHE HIGHLIGHTED THE NEED FOR THE 

HCWS TO OWN THE PROBLEMS OF 

OUR COUNTRY AND THE HEALTHCARE 

AGENDA, THEN ADVOCACY FOLLOWS 

INSTINCTIVELY. IT WAS OBVIOUS IN THIS 

DEBATE THAT HCWS NEED TO ACTIVELY 

ENGAGE WITH HEALTHCARE ADVOCACY 

AND THEY NEED TO BE REMINDED OF 

THEIR ETHICAL RESPONSIBILITIES. MR 

ANELE YAWA REMINDED PARTICIPANTS 

THAT HEALTHCARE IS A POLITICAL ISSUE 

THAT NEEDS POLITICAL INTERVENTIONS. 

HCWS CANNOT DISTANCE THEMSELVES 

FROM ADVOCACY AS WELL AS ANY STEP 

THAT WILL IMPROVE THE HEALTHCARE 

SYSTEM. 

Other speakers and the audience made very 

critical contributions. Ms Tendai Mafuma, the 

Legal Researcher of Section 27, brought an 

interesting argument in which she disputed the 

existence of Dual Loyalty in the post 1994 period. 

Dual Loyalty is the situation in which HCWs feel 

conflicted between the need to provide treatment 

to a patient as expected and guided by their 

ethics and the need to satisfy the needs of the 

administrator or funder such as government. 

This conflict must have been experienced by the 

HCWs of Life Esidimeni who had to discharge 

patients to inferior conditions because the 

government demanded so. Ms Mafuma argued 

that all HCWs and the government itself must own 

one allegiance and that is to the Constitution of 

the Republic of South Africa. If all South Africans 

appreciate that they live in a Constitutional 

democracy under the prescriptions of the 

Constitution they will not feel conflicted as their 

loyalty should be to the Constitution. 

That all HCWs can be a patient advocates was 

made real in Ms Shelley Wilsnach’s testimony. She 

described an incident in which she and a fellow 

occupational therapy student felt it necessary to 

confront a senior medical officer in a case where 

they felt a hand injury had been neglected. The 

difficulty in confronting seniority and gender 

roles was illustrated clearly in this incident. This 

theme was continued by Prof Rispel, who referred 

to the Lourdes hospital enquiry in Ireland. The 

enquiry was of unnecessary hysterectomies 

and oophorectomies performed by a male 

obstetrician in the 1980s and ‘90s until finally a 

group of midwives drew attention to the unethical 

practice. A central question of the investigation 

was “Why did it take so long for someone to say 

‘STOP!’?” 

Panel Discussion (Lesley Robertson Holding microphone) 

Mvuyiso Talatala is a psychiatrist in private practice, Dr SK Matseke Memorial Hospital, Soweto, as well as an honorary lecturer 

in the Department of Psychiatry, University of the Witwatersrand, Johannesburg, South Africa, He is also the immediate past 

president, South African Society of Psychiatrists. Correspondence: mvuyiso@talatala.co.za 

Lesley Robertson, is a psychiatrist working in the Sedibeng District as well as a lecturer in the Department of Psychiatry, University 

of the Witwatersrand, Johannesburg, South Africa. She is also the Convenor of the Public-Sector Psychiatrists, South African 

Society of Psychiatrists. 


REPORT 

LEADING 

PSYCHOLOGISTS 

FROM AFRICA 

CONGREGATE IN 

DURBAN FOR 

FIRST-EVER 

PAN-AFRICAN 

PSYCHOLOGY 

CONGRESS 

Sumaya Laher 

The Pan-African Psychology Union (PAPU) and 

the Psychological Society of South Africa 

(PsySSA) hosted the first-ever continental 

Psychology Congress from 18th to 21st 

September 2017 at the International Convention 

Centre in Durban, South Africa. 

PAPU2017 represented a historic moment in which 

local, regional and international collaborations 

set the scene for a more responsive Psychology 

that speaks to issues of social justice and equity. 

The comprehensive Congress programme 

included a wide range of scholarly and practiceoriented 

presentations. The programme included 

over 60 keynote presentations and 50 symposia 

by leading African and international scholars, 

pre-congress workshops, and several hundred 

paper and poster presentations (see http:// 

papu2017.com/programme/). These addressed 

key focal areas within the broad discipline of 

psychology, including African psychologies, 

human rights, public health, gender and sexuality, 

and violence. The Congress abstract book may be 

accessed at http://papu2017.com/wp-content/ 

uploads/2017/10/PAPU-Durban-abstracts-21- 

September-2017.pdf. The Congress chair, Prof 

Anthony Pillay commented: “This gathering 

of psychology scholars and practitioners is 

particularly significant given colonial histories in 

Africa. It is for this reason that the decolonisation 

of psychology and knowledge production feature 

prominently in the Congress programme and 

offer exciting opportunities for critical discussion, 

interrogation and debate.” 

Members of the PAPU Executive - representing 

psychological associations in Ghana, Botswana, 


REPORT 

Cameroon, Zimbabwe, Nigeria, South Africa 

and Ethiopia – participated in deliberations 

at the Congress. They were joined by leaders 

of the American Psychological Association, 

the Association of Black Psychologists, the 

International Union of Psychological Science, the 

International Association of Applied Psychology, 

the International Test Commission, the British 

Psychological Society, the Forum for African 

Psychology together with Chinese, Russian and 

other Psychological Associations in Africa and 

others further afield. SADAG and MHIN-Africa were 

also visible at the Congress.Prof Saths Cooper 

delivered the welcome address at the Congress. 

To view click https://www.youtube.com/ 

watch?v=Pxqom0RkFpo 

SOME CONGRESS HIGHLIGHTS INCLUDED: 

• Psychology in meta-colonised Africa: New challenges in a new era 

- Prof Hussein Bulhan, President and Professor of the Frantz Fanon University, Somaliland – 

see https://www.youtube.com/watch?v=c7ndD-cYA78 

• Psychology and the public interest in Africa: Breakthroughs and setbacks 

- Prof Andrew Zamani, President of the Nigerian Psychological Association 

• Clinical supervision through a global lens 

- Prof Carol Falender, UCLA Department of Psychology, USA 

• Disability and African Psychology: Some dilemmas and an agenda for action 

- Prof Leslie Swartz, Distinguished Professor, Stellenbosch University, SA 

• Potential for psychology to improve the lives of Africans and what needs to be done 

- Dr Yogan Pillay, Deputy Director-General, National Department of Health, SA 

• Collaboration between Western trained medical practitioners and traditional healers 

- Prof Tholeni Sodi, President – PssySSA, HOD – Psychology, University of Limpopo, SA 

• Early intervention in psychosis in Africa: Time to implement early intervention services 

- Prof Bonginkosi Chiliza, HOD – Dept of Psychiatry, University of Kwazulu-Natal, SA 

• Competency to testify and the intellectually disabled rape survivor 

- Prof Anthony Pillay, Nelson Mandela School of Medicine, University of Kwazulu-Natal, SA 

• Treatment of Post-traumatic Stress Disorder: Where do we currently stand? 

- Prof Suraya Seedat, HOD - Dept of Psychiatry, University of Stellenbosch, SA 

PAPU Congress highlights are available at: 

https://www.youtube.com/watch?v=C2agtCN_9Ks 

In a province that predates written history, PAPU offered an opportunity to draw on knowledge systems and ideas 

from the often-marginalized communities of Psychology practice, to engage in deliberation and dialogue to 

create a Psychology for all. The ancestors of the KZN region would often say, ‘The bones must be thrown in three 

different places before the message must be accepted.’ PAPU2017 certainly lived up to this with the diversity of 

discussion in every session. 

About PAPU and PsySSA: 

• PAPU is the representative body for the science and profession of psychology in Africa. Its mission is to be a 

collaborative union of psychological societies and psychologists in Africa committed to scholarship and 

human development in our communities, countries, Africa and the World. 

• PsySSA, formed in 1994, is Africa’s largest scientific and professional psychology organisation and is the 

representative body of the profession in South Africa. 

• For more on the Congress visit https://www.youtube.com/watch?v=BDXSi1iP6tc&feature=youtu.be 

• Download the full Congress programme at http://papu2017.com/programme/ 

Sumaya Laher is an Associate Professor – Psychology School of Human & Community Development, University of the Witwatersrand, 

Johannesburg, South Africa and Past President, Psychological Society of South Africa Correspondence: sumaya.laher@wits.ac.za 


NEWS PMHP 

Dear colleagues, supporters, partners 

and friends of PMHP 

2017 has mostly been a successful year for the 

PMHP with some major achievements. We have 

seen our strategic model realised in concrete 

terms in many of the arenas where we work: we 

identify key service gaps - conduct research 

- develop policy - support the widespread 

implementation by others. 

THE GOOD: A HIGHLIGHT 

A highlight has been the recent agreement by 

the DoH’s National Committee for the Confidential 

Enquiries into Maternal Deaths to mandate 

mental health screening as part of routine 

maternity care, where referral resources are 

available. PMHP has been invited to write a new 

chapter for the National Guidelines: Maternity 

Care in South Africa in which our validated, ultrashort 

screening tool will be incorporated. This 

represents a fitting example of the success of the 

PMHP strategic model 

THE SAD: DECLINE IN FUNDING 

Significant funding constraints have required that 

we make several critical changes. There will be a 

shift away from providing direct services that do 

not allow full cost recovery. It is thus, with enormous 

regret that we will be closing our Mowbray 

Maternity Hospital and False Bay Hospital service 

sites, which we hope will be absorbed by the 

DoH. We have been motivating strongly for this 

to occur over many years. Several of our beloved 

staff will be retrenched, some of whom will be reemployed 

on a consultancy basis, according to 

the specifications of particular income streams. 

While some income sources have been confirmed 

in the past few months, others are pending in early 

2018 and more will be applied for throughout the 

year. Donations are welcome and the details for 

donations are at the end of this article. 

THE WAY FORWARD 

We have reflected very seriously on the structure 

and sustainability of the PMHP. Over several 

months, we undertook a series of consultations 

with our board, academic and DoH colleagues, 

NGO partners, our donors and with strategic 

consultants. We developed a range of potential 

scenarios for moving forward and spent much time 

fundraising. Although not complete, our strategy 

is evolving towards becoming an organisation 

that is based on three core elements, all of which 

will be supplemented by resource development: 

1. training and capacity building, 

2. advocacy and policy development 

3. implementation research. 

In order to achieve universal access to mental 

health care for all mothers in the first 1000 days 

by 2030, the PMHP will continue to work to change 

and build the health and social development 

systems in the country and beyond. 

With your help, we know this can be achieved. 

Thank you for your support. 

UNIVERSITY OF CAPE TOWN 

DONATIONS ACCOUNT 

Contact: Sally Field 

Position: Project Coordinator 

Tel: +27 21 689 8390 

Fax: +27 86 6482844 

Email: sally.field@uct.ac.za 

BANKING DETAILS: 

Bank: Standard Bank of South Africa Limited 

Account Name: UCT Donations Account 

Branch: Rondebosch 

Branch Code: 02 50 09 

Branch Address: Belmont Road, 

Rondebosch, 7700 Cape Town, Republic of 

South Africa 

Account Number: 07 152 2387 

Type of Account: Current 

Swift address: SBZAZAJJ 

Reference: PMHP donation – ‘your name/ 

company’ 

Once a deposit or electronic payment has 

been made, please notify UCT by email 

at giving@uct.ac.za explaining what the 

donation is for. 

Tax exemption: Section 18A(1)(a) of the 

Income Tax Act 

www.pmhp.za.org 


REPORT 

A WORKSHOP ON 

COMMUNITY-BASED 

PSYCHOLOGICAL 

FIRST AID - OVERVIEW 

AND REFLECTIONS 

Nabeelah Bemath 

On the 18th September 2017, the inaugural 

Pan-African Psychology Union Congress 

hosted a pre-Congress workshop on 

community-based psychological first 

aid (CBPFA). The workshop was presented by Prof. 

Gerard A. Jacobs from the Disaster Mental Health 

Institute at the University of South Dakota. 

The workshop was structured into three components: 

an overview of CBPFA and its link to traumatic stress, 

community development in CBPFA, and an overview 

of the CBPFA training component on traumatic 

stress. 

Prof. Gerard A. 

Jacobs 

Jacobs starts with the premise that 

traumatic stress can negatively affect 

the functioning of the exposed person 

and indirectly affect the community 

they are contact with. CBPFA teaches 

general community members how to 

provide basic psychological support 

to others within their community who 

are experiencing traumatic stress, and 

to manage their own stress more effectively. Far 

more people experience traumatic (as opposed to 

psychopathological) stress, and so focusing on this 

can help the community recover much more quickly. 

Hence the first component of the workshop began 

with Jacobs discussing the concept of traumatic 

stress; or normal, and not pathological, reactions 

to extraordinary events. In this component of the 

workshop, he outlined the 7 foundation principles of 

CBPFA, namely: 1) Non-maleficence; 2) Communitybased 

(design and day-to-day running); 3) 

Sustainable in terms of ease of operation, cost and 

usefulness; 4) Develop on community’s strengths; 

5) Use local skills and knowledge; 6) Concentrate 

on common reactions to extraordinary events; 7) 

Serve each community member who is (directly 

or indirectly) affected by traumatic stress (see 

Psychological First Aid: Clarifying the concept) 

JACOBS ALSO BRIEFLY DISCUSSED THE 

8 GENERAL COMPONENTS OF CBPFA 

TRAINING, NAMELY: 1) HOW TO BE A HELPER; 

2) TRAUMATIC STRESS; 3) THE NEED, AND 

SKILLS, REQUIRED FOR ACTIVE LISTENING; 

4) COPING AND PROBLEM-SOLVING 

STRATEGIES; 5) BEREAVEMENT; 6) WHEN 

AND HOW TO REFER TO PROFESSIONALS; 

6) CARING FOR ONESELF; 7) ETHICS; 8) A 

WRAP-UP SESSION IN WHICH AN OVERVIEW/ 

SUMMARISATION OF THE TRAINING IS 

PROVIDED (SEE COMMUNITY-BASED 

PSYCHOLOGICAL FIRST AID: A PRACTICAL 

GUIDE TO HELPING INDIVIDUALS AND 

COMMUNITIES DURING DIFFICULT TIMES) 


REPORT 

The second component of the workshop focused 

on describing the community-based nature of 

CBPFA. The importance of evaluating the feasibility 

of a CBPFA programme in a community was 

emphasised. He argued that the design of a CBPFA 

programme specifically occurs through working 

with a committee of members who represent all 

sectors of the community. This is done in order to 

adapt the general CBPFA programme such that it 

fits everyone within that community, corresponding 

with the community’s strengths and requirements. 

This leads to the community owning the programme, 

and being equipped to run the programme upon 

the professionals’ exit from the community. It was 

interesting to hear Jacobs’ personal experiences in 

implementing various adapted CBPFA programmes 

in various countries, and the success that these 

programmes have had. 

More information can be obtained from Jacob’s 

book titled ‘Community-Based Psychological First 

Aid: A practical guide to helping individuals and 

communities during difficult times’. 

IN THE THIRD COMPONENT OF THE 

WORKSHOP, ATTENDEES WERE EXPOSED 

TO WHAT JACOBS REFERRED TO AS THE 

“TWITTER VERSION” OF THE CBPFA’S 

TRAINING ON TRAUMATIC STRESS. THE 

TRAINING IN THIS COMPONENT COVERS 

COMMON EMOTIONAL, PHYSICAL, 

BEHAVIOURAL AND COGNITIVE 

REACTIONS TO TRAUMATIC STRESS. 

THIS ENABLES TRAINEES TO RECOGNISE 

WHAT THESE REACTIONS CAN BE. 

FURTHERMORE, TRAINEES ARE EDUCATED 

ON WHAT SYMPTOMS INDICATE THE 

NEED FOR PROFESSIONAL REFERRAL. 

TRAINEES ARE ALSO EDUCATED WITH 

REGARDS TO THERE BEING INDIVIDUAL 

DIFFERENCES IN RESPONSES TO 

TRAUMATIC STRESS, THE FACTORS THAT 

MAKE EVENTS MORE TRAUMATIC AND 

THOSE THAT MAKE TRAUMATIC EVENTS 

LESS STRESSFUL. 

While time constraints prevented covering the 

topic within the workshop, notes were provided on 

the active listening aspect of the CPBFA training. 

This focuses on exposing trainees to the skills and 

attitudes involved in using effective listening in 

order to provide others with psychological support. 

Jacobs at CBPFA training in Nepal, which occurred after the 2015 earthquake 

The workshop overall was extremely valuable. 

Insightful and interesting examples of the 

implementation of CBPFA models were highlighted, 

particularly in terms of how models have been 

adopted in different communities. The importance 

of using community psychology principles when 

entering a community to implement a CBPFA 

programme was also discussed and examples 

of CBPFA implementation in Muslim-Thailand 

and Native American communities were used to 

highlight this. However, only one example of how 

CBPFA has been used within the African context 

was provided; most examples came from North 

American, European or Asian contexts. It would be 

interesting to see if and how this model can work in 

different African contexts, including South Africa. 

The content presented in the workshop suggests 

that CBPFA would be valuable in the South African 

context, particularly given the high exposure to 

traumatic stress, yet limited mental health care 

resources and personnel, in the country. The CBPFA’s 

sustainable nature and flexibility in being adapted 

for cross-cultural use further suggests that this would 

be a practically and ethically feasible solution to the 

challenges that South African mental health care 

professionals face in trying to address the mental 

health of the population. In this way, communities 

affected with traumatic stress can be empowered to 

psychosocially support themselves, decreasing their 

sense of fear and helplessness while promoting their 

mental wellbeing. Mental health care professionals 

should take cognisance of the potential offered by 

CBPFA programmes for South African communities. 

Nabeelah Bemath is an intern research psychologist in the Department of Psychology at the University of Witwatersrand, 

Johannesburg, South Africa. The details provided in relation to the components of the workshop were paraphrased from the notes 

provided by Jacobs during the workshop and the authors own notes taken during the course of the workshop. Correspondence: 

Nabeelah.Bemath@wits.ac.za 



UPDATE 

THE ROLE OF 

MELATONIN 

IN TREATING 

I N S O M N I A 

Alison Bentley 

THE SECRETION OF MELATONIN HAS BEEN LINKED TO SLEEP FOR MANY YEARS AND IN THE CORRECT 

PATIENTS, ITS EXOGENOUS ADMINISTRATION CAN BE VERY USEFUL IN IMPROVING SLEEP. HOWEVER, 

AS THERE ARE MANY DIFFERENT CAUSES OF INSOMNIA, MELATONIN IS UNLIKELY TO BE EFFECTIVE IN 

ALL OF THEM. 

Melatonin is linked to circadian rhythms – 

the rest-activity patterns, which extend 

over 24 hours and which are common to 

all living things. In humans the rest period 

is usually at night and is associated with sleep. Restactivity 

cycles in humans are driven by melatonin, a 

hormone secreted by the pineal gland during times 

of darkness. During the day melatonin release is 

inhibited by light falling on the retina. 

Melatonin secretion begins in the early evening, after 

which the level rises signifi cantly. Melatonin binds 

to M1 and M2 receptors on the suprachiasmatic 

nucleus in the hypothalamus. This leads to a drop 

in body temperature, during which the ability to fall 

asleep increases quite dramatically. The melatonin 

levels remain high for a few hours and contribute 

to sustained sleep during the night. A rise in body 

temperature in the morning, due to a reduction in 

melatonin, indicates the natural waking up time. 

Insomnia occurs when there is insuffi cient or 

poor quality sleep. People suffering from insomnia 

complain of one or more of the following symptoms: 

diffi culty falling asleep, diffi culty maintaining sleep 

and/or early morning wakening. More importantly, 

for insomnia to be diagnosed there needs to be a 

defi cit in daytime functioning, with symptoms such 

as fatigue, poor concentration and decreased 

memory being linked to the lack of sleep. 

THERE ARE MANY CAUSES OF 

INSOMNIA INCLUDING: 

• Medical causes: Most commonly insomnia 

occurs in the psychiatric disorders of depression 

and mania. Other medical conditions that 

can cause insomnia include; endocrine 

disorders, and conditions that cause either 

nocturnal pain or breathing problems. Many 

medications such as statins, ARVs, cortisol 

and anti-depressants can cause sleep 

disruptions severe enough to cause clinical 

insomnia. 

• Environmental causes: Many people 

lucky enough to be able to control 

sleeping environment so that it 

is warm, dark, quiet and safe. 

are 

their 

Alison Bentley 

In situations where this is not possible, insomnia 

may result. 

• Restless legs syndrome: This neurological 

disorder presents with an urge to move the legs, 

often in relation to a strange sensation in the 

legs. These sensations are particularly severe 

in the evening, are worse with rest and can be 

relieved, at least temporarily, by moving. Patients 

struggle to fall asleep and are often only able 

to fall asleep in the early hours of the morning 

after the sensation eases. During sleep, periodic 

leg movements can fracture sleep, leading to 

a disturbance during the night. The disorder 

is often successfully treated with dopamine 

agonists. 

• Psychophysiological insomnia: This is the most 

common type of insomnia and is often triggered 

by an organic cause such as acute and severe 

stress. In this situation, insomnia is a symptom 

of that external stress. When the stress resolves 

the insomnia often also resolves. However, any 

concern or anxiety about not being able to 

fall asleep is likely to lead to a self-sustaining 

insomnia - the severe anxiety about falling asleep 

actually creates an independent insomnia 

disorder. Poor sleep hygiene usually ensues, 

including spending an increasing amount of 

“awake time” in bed, trying to fall asleep, in 

an attempt to increase the sleep opportunity. 


UPDATE 

During these prolonged attempts to fall asleep, 

people experience catastrophising and 

dysfunctional thoughts regarding sleep, which 

help to sustain the insomnia for many years. 

Cognitive behavioural therapy (CBT), which 

aims to improve the behaviours and thoughts 

relating to sleep, and thereby improving sleep 

itself, is the most useful treatment. 

• Circadian rhythm disorders: there are two 

main types -The first group have normal 

melatonin secretion and a normal length of 

sleep, but the timing of their sleep is out of 

phase with night and day. Patients present with 

a clear history of a good period of sleep (up 

to 8 hours) as long as they can sleep at the 

times they prefer. Examples include: delayed 

sleep phase syndrome, shift work and jet lag. 

Delayed sleep phase syndrome is most 

common in adolescent men. Sleep is 

delayed by 2-3 hours, with the earliest sleep 

onset time being from 12 to 2 am, and a 

wake up time delayed until 10 am or later. 

Advanced sleep phase syndrome is most 

common in the elderly. Sleep onset is very early 

in the evening and person wakes up at 2 or 3 

am. 

The second group have abnormal or lowered 

melatonin secretion, which leads to disturbed sleep 

with difficulties in falling asleep and staying asleep. 

This group includes elderly people, blind people, 

people with Alzheimer’s disease and children with 

neurodevelopmental disorders such as autism 

spectrum disorder and ADHD. 

Insomnia is often considered an inconvenience 

rather than a medical disorder and hence no 

treatment is sought or offered. There is, however, 

good evidence that untreated insomnia increases 

the risk of other disorders such as anxiety, depression 

and cardiovascular disease such as hypertension. 

Poor daytime function due to fatigue, decreased 

concentration and poor executive functions 

may lead to an increased number of errors and 

accidents. Together with increased amounts of 

sick leave, these consequences of insomnia have 

negative economic consequences. 

Ageing is an important risk factor for the 

development of insomnia with the prevalence of 

poor sleep increasing from 36% in middle-aged 

adults to 50% in the elderly. Specific changes in the 

sleep stages, such as a loss of slow wave sleep, more 

awakenings and shorter overall length of sleep 

may be related to a gradual drop in the amount 

of melatonin produced after young adulthood. Of 

the people affected by insomnia, at least two thirds 

will be women. Women are more prone to insomnia 

possibly due to loss of hormones after menopause, 

although sleep is lighter in women even at younger 

ages.Patients who have insomnia request relief 

from their most troublesome symptoms. They may 

request help to reduce their sleep latency (so 

that they fall asleep easier/faster), to reduce their 

number of awakenings during the night, to lengthen 

their hours of sleep, to improve the quality of their 

sleep, or to reverse their daytime symptoms without 

causing other side effects. 

Natural sleep remedies, such as chamomile and 

valerian teas and over-the-counter tablets, are often 

tried first by patients, but they are not usually effective. 

Apart from specific treatment for particular disorders, 

such as dopamine for RLS, the most studied and 

approved treatments are either CBT or hypnotics. 

CBT involves a process using sleep restriction 

(reducing sleep by 2-3 hours every night), stimulus 

control (which prevents long periods spent in 

bed trying to sleep) and keeping a sleep diary 

to gradually improve sleep over a period of a few 

weeks. CBT works very well but requires patient 

cooperation and commitment. Hypnotics improve 

sleep by decreasing sleep onset and decreasing 

awakenings but they are associated with the 

problems of dependence and adverse side 

effects. Patients often find it very hard to stop taking 

hypnotics due to psychological dependence, 

even when taking the less physically dependent 

z drugs. Significant side effects include memory 

lapses and increased body sway (particularly 

with benzodiazepines), which could lead to falls, 

especially if the patient has to get up in the middle 

of the night. The two treatment methods can be 

combined by using hypnotics infrequently e.g. 

every third night to assist in keeping patients on the 

CBT programme. 

As the nocturnal melatonin levels decrease 

progressively with age the elderly have the lowest 

melatonin levels. Replacing melatonin in these 

patients therefore provides a more natural solution. 

Immediate-release melatonin, while offering a small 

hypnotic effect and shortened sleep latency, has 

a short duration of action and may not improve 

symptoms occurring during the night. A prolongedrelease 

melatonin (such as Circadin®), which 

more closely mimics the natural melatonin levels 

in early adulthood, is preferred. Prolonged-release 

melatonin has been shown to shorten sleep onset 

latency, reduce wakefulness and improve both 

quality of sleep and daytime functioning without 

necessarily increasing total sleep time. The side 

effect profile of both types of melatonin is similar 

to that of placebo with, particularly, no increase in 

body sway. 

Despite these positive effects on sleep in patients 

who have reduced melatonin levels, it is important 

to realise that melatonin does not have the global 

effect on sleep that hypnotics do. Taking melatonin 

can only return sleep to the natural state and will not 

replace a hypnotic in patients who have high levels 

of anxiety. Therefore, careful selection of patients 

is important. Circadin® is registered for patients 

over the age of 55 years with insomnia. The 2 mg 

tablet should be taken once a day, about 2 hours 

before the desired bedtime, to allow for an increase 

in melatonin plasma levels and the subsequent 

drop in body temperature. The extended release of 

melatonin throughout the night contributes to good 

quality sleep. 

Dr Alison Bentley is the Medical Director for AHC and 

SleepMD. Correspondence: dralisonbentley@gmail.com 


REPORT 

THE PROVISION OF 

EXPERT OPINION 

AND EVIDENCE AS 

A HEALTH PROFESSIONAL 

Kathy Malherbe 

THERE IS NO DOUBT THAT ‘EXPERT’ 

WITNESSES, PARTICULARLY THOSE IN THE 

MEDICAL FRATERNITY, HAVE COME UNDER 

THE SPOTLIGHT RECENTLY – FOR THE WRONG 

REASONS. EXPERT MEDICAL WITNESSES 

ARE NOT BORN THAT WAY, NOR DO YEARS 

OF CLINICAL EXPERIENCE IN THE FIELD 

QUALIFY THEM TO TESTIFY. IT IS A FIELD WHERE 

THE STATUS IS ACHIEVED ONLY THROUGH 

EXPERIENCE, HARD WORK AND SKILLS 

TRAINING. IT ALSO REQUIRES KNOWLEDGE 

OF THE CONSTITUTION, THE LAW IN OUR 

COUNTRY, THE COURT PROCEDURES, REPORT 

WRITING AND LEGAL PROCEDURES. 

The identified need for expert witness training 

as a health professional was what led to the 

inaugural course on the Provision of Expert 

Opinion as a Health Professional that took 

place in November 2017. The week-long program was 

designed by Burns-Hoffman Consulting, accredited 

by and presented at UCT medical school. A number 

of health professionals completed the course, 

which judging by their feedback was a resounding 

success. The professionals who attended the course 

evaluated the content and level of presentation as 

being excellent, noting that the practical sessions 

were invaluable. 

The course was the brain-child of Elise Burns-Hoffman, 

owner of Burns-Hoffman Consulting. Burns- 

Hoffman is an Occupational Therapist (OT) with 

30 years’ experience who actively engaged in the 

development of the program at the start of 2016, 

commenced discussions with UCT Health Sciences 

Faculty in late 2016 and from early 2017 onwards has 

been working with and alongside the UCT Faculty of 

Health Sciences’ Continuing Education Unit in order 

to roll it out last month. 

The course program was designed to ensure that 

health professionals gain proper understanding of 

their professional role in the non-clinical contexts, 

such as business and law, alongside providing 

practical guidance and advice on running one’s own 

business. It included the following topics: business 

principles and strategic planning; an understanding 

of the Constitution as a health professional; the law 

of contract; the law of delict; an overview of the civil 

and criminal legal procedure; expert witness training 

via a ‘court day’ and professional report writing. 

Burns-Hoffman says that, added to her own 

professional experience in this line of work, her 

research included discussions with various 

professionals and investigations into what other 

suitable courses are on offer. In her discussions she 

spoke to numerous attorneys; health professionals; 

advocates; risk companies and related disciplines. 

She says that the course is unique in a number of 

ways, the most pertinent of which is the hands on, 

practical approach taken, with the specific intention 

of imparting skills – not attained by merely listening, 

but rather via interaction and roleplay. To quote 


REPORT 

Benjamin Franklin: “Tell me and I forget, teach me 

and I may remember, involve me and I learn” – 

quoted on the course. 

The lecturers engaged in this course have all 

enjoyed extensive exposure to the provision of expert 

opinion and evidence in their particular professional 

environment(s) and included a highly respected 

retired judge of the SCA; senior and junior counsel; 

independent business practitioners and others. 

ALTHOUGH THE VISION FOR THIS COURSE WAS 

INITIALLY TAKEN TO THE UCT OCCUPATIONAL 

THERAPY DEPARTMENT FOR THE SPECIFIC 

PURPOSE OF PROVIDING RELEVANT TRAINING 

FOR OTS (BURNS-HOFFMAN’S PROFESSIONAL 

AREA OF DISCIPLINE) THERE WAS SUCH 

SUPPORT FOR THE PROPOSAL THAT IT WAS 

DECIDED TO MAKE IT AVAILABLE TO ALL HEALTH 

PROFESSIONALS WHO WISH TO BECOME AND 

OR ARE ALREADY INVOLVED IN THE PROVISION 

OF EXPERT OPINION AND EVIDENCE TO SOCIETY; 

GOVERNMENT; BUSINESS AND THE COURTS. 

Health professionals working in the areas of medical 

negligence; MVAs; employee incapacity; relevant 

contractual and incapacity / disability claims 

assessments are encouraged to attend the course. 

The course is suited to all claims and other life 

insurance personnel who have a heath professional 

qualification. Burns-Hoffman says, ‘it is by no means 

limited to those in independent practice and 

business.’ 

The request for follow up courses from the delegates 

is testimony to the need for the continuing education 

of health professionals in a domain in that is not 

necessarily discipline based, but draws on the 

experience of such disciplines in the resolution of 

conflict and attainment of justice. 

FOR MORE INFORMATION CONTACT: 

Elise Burns-Hoffman 

e: elise@b-h.co.za 

t: +27 21 785-2878 

c: 083-627-5584 

w: www.b-h.co.za 

Kathy Malherbe is a Freelance Writer for Du Maurier Communications, Rondebosch, Cape Town, South Africa. 

Correspondence: Kathy@iafrica.com Website: www.kathymalherbe.co.za 


NEWS 

STERKFONTEIN HOSPITAL OPENS FAMILY RELATIONS UNIT 

Lebogang Legobye , Amanda Edge & Prudence Baloyi 

Children under 12 years whose mothers are pa-tients 

in the hospital are set to benefit signifi-cantly from the 

Family Relation Unit (FRU) called Wendy house that 

was launched at Sterk-fontein Psychiatric Hospital on 

7 November 2017. Because children under the age 

of 12 are not allowed in the wards, the purpose of 

the unit is to allow the children of state patients to 

visit their mothers and this where they can meet and 

bond together. 

Professor Subramaney officially opened the occasion 

and welcomed all saying “I am excited to in troduce 

you briefly to how this unit and Programme came 

into being and what we as Ward 3 Multi-Disciplinary 

Team (MDT) hope it will offer. Building Wendy’s house 

has been exciting for all of us who have been 

involved and are happy with this achievement. She 

extended her gratitude to all the sponsors for giving 

the hospital resources to assist in constructing the 

new structure. 

With a smile the CEO said “I am glad to have 

witnessed and be part of this opening, this is truly the 

first of it’s kind”. He emphasised and encouraged the 

crowd about the culture of change, “you can not 

do the same thing every day and expect different 

results, let this be the beginning of good things to 

come” added. Mapunya. He then declared the 

house officially open. 

Social worker Yandisa Xundu, psychologist Amanda Edge and Ugash 

Subramaney inside the family relations unit. 

An in-house Psychologist Amanda Edge mentioned 

that because of the physical distance that the 

women experience from their families, and not taking 

enough measure to facilitate the enhancement of 

family bonds is an injustice to the patients as they 

are separated from their previous roles. 

Thus a need arose to establish a programme 

including a space that would involve most members 

of the Multi Disciplinary Team (MDT) to formally 

psycho-educate families on the process of being 

declared a state patient, facilitate the family 

adjustment process, provide mothers with mothering 

skills and help with mother-child attachment. 

Before the programme could kick start, hur-dles had 

to be overcome. Initially, the hospital regulations 

stipulated that children under the age of 12 are not 

allowed in the ward and many of the women have 

young children. However, the Chief Executive Officer 

Mr. Jim-my Mapunya granted the permission to have 

this changed for those [patients] participating in 

the programme. 

Management realised the importance of a family 

friendly space and that is how Wendy House a family 

relations unit was birthed. The FRU is fully set up with 

furniture, second hand toys, therapeutic books and 

resources. 

Dr Niki Eklektos (senior registrar in the unit at the time and budding forensic 

psychiatrist; Ugash Subramaney (Consultant in charge of the female forensic 

unit); Yandisa Xundu (social worker in the unit); Dr Dani Hoffman (principle 

psychologist in the ward and HOD(Psychology) at STKN; Ms Alicia Myburgh 

(OT attached to the unit) and Amanda Edge (psychologist in the unit and 

head of the project) 

Dr K Moloi, clinical manager; Ms M Sono, nursing manager; Ms Amanda 

Edge, psychologist, Mr Jimmy Mapunya, CEO and Mr H Shuping, Corporate 

manager of STKN hospital inside the family relations unit. 

PhD 

Ethelwyn Rebelo graduated on the 7th December 2018. The title of 

her PhD was: An investigation of parental attachment relationships; 

perceived parental gender attitudes; and respondents’ gender-role 

behavior in the formation of gender attitudes. 

MMed 

Dr A Anic graduated with the MMed degree, 7 th December 

2017, entitled: “Prevalence and Patterns of Substance Use 

amongst Psychiatric Inpatients at Helen Joseph Hospital”. 

42 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 2018 

GRADUATIONS

NEWS 

EUROPEAN EATING DISORDERS CONFERENCE- VILNIUS, LITHUANIA 

Dr’s Nkokone Tema and Thebe Madigoe (Eating 

disorders unit, Tara Hospital) were invited to present 

an overview of the eating disorders landscape in 

South Africa as part of a symposium entitled Eating 

Disorders in a Multicultural Setting at The European 

Council of Eating Disorders conference held in 

Vilnius, Lithuania 7 th to 9 th September 2017. There 

were presentations from Mexico, UAE and Egypt. 

It was very encouraging to see that local services 

compare favourably despite the limited resources. 

Dr Tema 


NEWS 

CPMH CELEBRATES GRADUATES 

A key gap in current mental health professional 

training in Africa and globally is an orientation to 

public mental health. This means an orientation to 

the mental health needs of populations, and the 

policies, laws and services that are required to meet 

those needs. The WHO has highlighted this critical 

shortage and has put out an urgent call to improve 

and strengthen professional mental health capacity 

in Africa. The Alan J Flisher Centre for Public Mental 

Health has heeded this call and has produced a 

steady stream of graduates over the last few years. 

This year has been no different with 5 MPhil and 1 

PhD graduates. 

Japhet Myaba from Malawi focused his MPhil on 

the prevalence and predictors of antipsychotic 

medication non-adherence among clients with 

psychotic disorders in Mzimba, Malawi. Megan 

Malan from South Africa studied the prevalence 

and predictors of intimate partner violence among 

women attending a midwife and obstetrics unit 

in the Western Cape. Hailing from Ethiopia, Tigist 

Zerihun, conducted a qualitative study on family 

planning for women with severe mental illness 

in rural Ethiopia. Prasansa Subba from Nepal 

conducted a formative study on the adaptation of 

mental health promotion programmes for perinatal 

depression in West Chitwan. Also conducting a 

qualitative study, Winifred Nalukenge from Uganda, 

focused on mental health explanatory models, 

and the perceived impact of life experiences on 

mental health, in HIV-infected adolescents in rural 

and urban Uganda. Maxine Spedding from South 

Africa made the CPMH proud by obtaining her 

PhD. She focused her doctorate on the prevalence 

and predictors of intimate partner violence among 

women attending a midwife and obstetrics unit in 

the Western Cape. 

CPMH’s MPhil students attend a two-week workshop to secure basic research 

knowledge. 

Graduates from all over Africa attend the workshop to hone their research 

skills and to learn from the Centre’s celebrated researchers. 

THE HIV MENTAL HEALTH RESEARCH UNIT BRAND LAUNCH AND REVIEW 

The HIV Mental Health Research Unit (HIVMHRU) 

brought its research project leaders together for an 

annual review process and launch of its new brand. 

The event was chaired by Prof John Joska who 

opened with a brief background of the unit and the 

vision for the future. He highlighted the importance 

of using these review meetings to share ideas and 

establish advisory committees to shed light, and assist 

in addressing challenges experienced by the various 

projects. The unit was established in response to the 

growing recognition of the burden of mental disorders 

in people living with HIV – including depressive, anxiety, 

substance abuse and neurocognitive disorders. 

The rebranding process is part of the vision to 

maintain this position and to become a good 

contender for current mental health research. There’s 

growing interest and investment to increase mental 

health awareness across the country, therefore with 

more visibility and presence, this opens a window 

of opportunity for collaboration and the unit to 

become a carrier of this message through scientific 

research. This requires collective effort and where 

possible sharing resources and time. Through reports 

presented by the project managers, it is evident that 

the unit has had quite a productive year and the 

possibilities for the future are endless. 

Prof John Joska and Assoc. Prof Jackie Hoare with the team 

after presentations. 

Goodman Sibeko, a doctoral 

student in the Dept, has been 

appointed co-Director of the 

newly formed Addictions 

Technology and Transfer 

Centre, a new SAMHSA and 

PEPFAR initiative focused on 

training of frontline clinicians 

in the area of addictions 

psychiatry. He will bring his 

experience as a clinician and 

researcher to bear in leading this venture forwards. 


Depression can 

make keeping 

on top of daily 

tasks a struggle 

Brintellix can help with her mood, 

concentration and fatigue, so she is able 

to organise her day again 

10 mg once daily 

Lundbeck South Africa (Pty) Ltd. Unit 9, Blueberry Office Park, Apple Street, Randpark Ridge Extension 114 Tel: +27 11 699 1600 S5 Brintellix 10 mg film-coated tablets. 

Each tablet contains vortioxetine hydrobromide equivalent to 10 mg vortioxetine. Reg No. 48/1.2/0430 Namibia: NS 3:15/1.2/0071 Botswana: S2: BOT 1502705 MO 08/17 


UCLA/South African Trauma 

Training Research (Phodiso) Scholars 

Programme 

Project Narrative: 

The UCLA/South African Trauma Training Research (Phodiso) Programme has received 5 

additional years of funding to prepare future investigators to conduct research on 

psychological trauma and injury exposure in the context of South Africa’s high levels of 

interpersonal and community violence and intentional injuries. As an international 

collaboration between UCLA and the South African Research Consortium (SARC), which 

includes the Human Sciences Research Council (HSRC), North-West University (NWU), 

and University of Cape Town (UCT), Phodiso’s public health mission is to: 1) Increase the 

number of well-trained South African trauma researchers; 2) Translate research findings to 

culturally congruent trauma and injury prevention and treatment programmes and; 3) 

Facilitate building of community capacity and infrastructure that benefit the people of 

South Africa. 

We will be recruiting every year for 1 candidate for a 2 year post-doctoral Scholar position. 

The Scholar will train at the University of California in Los Angeles for 3 months, be 

mentored by Phodiso faculty in both South Africa and USA, conduct their own research in 

South Africa with supervision, collect data, and publish their data. The selected Scholar 

will receive a stipend for research and full time salary support. Upon completion of the 

program, the candidate will be encouraged to work in areas related to research. 

Minimum Requirements: 

Ph.D. degree or MB ChB degree and a South African citizen or permanent resident 

Deadline for Applications: May 15, 2018 

Programme begins: September 2018 

Please send any questions or a summary of your research experience, CV, and a two 

page research concept paper that has to do with trauma and health or mental health 

that you would want to pursue to Ms. Amber Smith via email 

(Ambersmith@mednet.ucla.edu). Interviews will be scheduled for June 22nd and 23rd in 

Durban, South Africa and transportation will be provided, if required. 


REPORT 

WPA WHO AFRICAN MENTAL HEALTH FORUM: 

“CONTINENTAL ALLIANCE FOR INTEGRATED 

MENTAL HEALTH CARE IN AFRICA” 

DURING THE WPA INTERNATIONAL CONGRESS IN CAPE TOWN, 18-22 NOVEMBER 2016 

EXECUTIVE SUMMARY 

Roof Terrace CTICC, Friday, 18 November 2016 08h15-15h00 

Bernard J van Rensburg Chair - Local Organizing Committee WPA 

International Congress in Cape Town 2016 

The WPA-WHO Africa Mental Health Forum was 

organized as a round table discussion on the 

18th November 2016 in Cape Town, with plenary 

presentations, as well as four break away panel 

discussions. 

The panels were set up in terms of the four objectives 

of the WHO MENTAL HEALTH ACTION PLAN 2013- 

2020: 1 (1) PANEL I. Leadership and governance; 

(2) PANEL II. Health and social services; (3) PANEL 

III. Prevention and promotion; and (4) PANEL IV. 

Information, evidence and research. 

The participants in this round table discussion 

included WPA Executive Committee and Board 

Members, Psychiatric Associations in Africa and 

elsewhere, National Directors of Mental Health 

Programs and Mental Health Advocacy Groups. 

The three background policy documents for the 

Forum were: (1) The WHO MH Care Action Plan 2013- 

2020; 1 (2) The Africa Health Transformation Program 

2015-2020; 2 and (3) WPA Action Plan 2014-2017. 3 

Chairs and Panel Leaders were encouraged to liaise 

with the proposed panel members beforehand, 

but also to consider and advise on any other 

participants which they thought would be able to 

contribute to these discussions. Panel Leaders were 

invited to coordinate and prepare in advance a brief 

background section on each subtheme of about 1-2 

pages, including 2-3 potential recommendations. 

They were also invited to forward any documentation 

for the meeting that should be considered as 

context. (Both the leaders’ background documents 

and submitted documents are included/listed in 

the Addenda to the “Documentation” document for 

the forum.) 

The round table program consisted of three plenary 

sessions and four breakaway sessions. The session 

on the report back session by the four breakaway 

panels was audio-recorded and transcribed. (The 

1 

http://www.who.int/mental_health/publications/action_plan/en/ 

2 

http://www.afro.who.int/en/rdo/reports/4928-the-africa-health-transformation-programme-2015-2020-a-vision-foruniversal-health-coverage.html 

3 

http://www.wpanet.org/detail.php?section_id=25&content_id=1132 


REPORT 

EXECUTIVE 

transcription has been included as an Addendum 

to the “Documentation” document for the forum.) 

Presentations. The plenary presentations were 

delivered under the program headings of: (1) 

“Overview of Mental Health Care Policy in Africa”; 

(2) “Service delivery, training and research”; and 

(3) “Alliance of stake holders for integrated care” 

The different presentations were either included in 

the Addenda to the “Documentation” document for 

the forum, or a short summary was included in the 

text of the document: 

1. Dr Shekhar Saxena – “The Global Mental Health 

Action Plan” 

2. Dr Matshidiso Moeti – “The Transformation 

Agenda and the Global Mental Health Action 

Plan: Policies and targets for Africa” 

3. Prof Dinesh Bhugra – “WPA Action Plan 2014- 

2017” 

4. Prof Dinesh Bhugra – “Social contracting of 

Psychiatry and psychiatrists for mental Health in 

Africa” 

5. WPA African Regions overview: Northern Africa – 

Zone 11: Central and Western Africa – Zone 13; 

Eastern and Southern Africa – Zone 14 

• Prof David Ndetei (Kenia) - Eastern & Southern 

Africa (Zone 14) 

6 Dr Mvuyiso Talatala – “WPA and an African 

Federation of Psychiatric Associations” 

7. Prof Dinesh Bhugra and Panel – “Continental 

alliance for integrated mental health care in 

Africa - WHO, WPA, professional societies” 

THE OUTCOME OF THE MEETING 

WAS FORESEEN TO BE A REPORT 

ON THE FOUR PANELS’ INPUTS WITH 

PARTICULAR RECOMMENDATIONS 

ON THE IDENTIFIED FOUR AREAS, 

WHILE ALSO TO INCORPORATE 

AND CONSOLIDATE A POSITION 

STATEMENT ON A CONTINENTAL 

ALLIANCE FOR INTEGRATED MENTAL 

HEALTH CARE IN AFRICA. 

Recommendations by four panels. The following 25 

recommendations were made by the four panels: 

1. PANEL I.Leadership and governance 

1. To involve all stake holders in all (planning) 

meetings at all levels, including consumers, 

while enabling and supporting consumers to 

participate meaningfully 

2. To achieve a systematized approach in mental 

health leadership and governance, so that not 

all effort and support depends on one individual 

in a particular Ministry - the approach should 

include different departmental officials from the 

chief medical officer to administrative staff, but 

also reach beyond and across departments and 

governments 

3. To obtain comprehensive data on all aspects in 

order to have information and provide evidence 

for the financing required for different mental 

health programs 

4. To retain the “bigger picture” with regard to CRPD, 4 

namely to achieve humane mental health care, 

and not to be side-tracked in the debate while 

considering applicable options for mental health 

in a step-by-step way 

5. To mobilize resources for training in public mental 

health from national to district level; in order to 

have understanding that resources must be 

identified and systems created beyond hospital 

care, e.g. not only to advocate for hospitals, but 

for systems of care 

6. To utilize “Mental Health Innovations - Africa” as 

a platform for role players to continue discussion 

and communication between role players in 

Africa 

2. PANEL II. Health and social services 

7. To reorganize and reform the whole mental health 

care system by integrating available resources 

(e.g. psychiatrists in private practice with other 

role players), while clearly identifying the roles of 

mental health care workers involved 

8. To achieve integration and role identity through 

training of current and future practitioners and 

students - all need to know more about each 

other; an integrated model of practice must be 

promoted e.g. Psychiatry and other disciplines, 

mental and physical health care. 

9. To broaden the treatment pyramid base 

through self-care and getting people to be able 

to care for themselves - at least, with regard 

to minor problems, while people with severe 

neuropsychiatric problems per se should still be 

further treated in specialized centers 

10. To clarify the roles of the different role players in the 

field in a specific catchment area, while people 

in a certain catchment area must also be aware 

of what the referral route is for emergencies, or 

the correct way to address problems 

11. To address this communication and logistical 

aspects will require leadership, while these 

basics may have to be addressed to achieve 

a reorganization and reformation of the mental 

health care system 

3. PANEL III. Prevention and promotion 

12. To incorporate the interests of service users, 

which must be at the heart of all mental health 

care, including promotion and prevention - their 

voice must be recognized in order to bring the 

richness and strength of their experience to the 

table; particular areas of concern include: 

- that a holistic approach is adopted when 

addressing comorbid physical illnesses of users 

in view of the known increased risk of morbidity 

4 

Convention on the Rights of Persons with Disabilities 


REPORT 

SUMMARY 

and mortality associated with being a mental 

health care user 

- involvement in the evaluation of service provision 

in order to achieve services that care and 

support, rather than stigmatize 

13. To achieve different competencies, such as 

cultural, (health) educational, service delivery 

and policy competency 

14. To involve the media to address stigma, e.g. 

through advertisement, while also addressing 

cultural aspects of stigma and constantly 

recognizing the voice of service users 

15. To revise training curricula of under and post 

graduate programs to ensure inclusion of the 

minimum required content on mental health, 

including on promotion and prevention 

4. PANEL IV. Information, evidence and research 

16. To acknowledge the critical importance of 

collaboration and networks 

17. To share information and experiences 

18. To address stigma, including stigma in mental 

health workers and the systems in which they 

work 

19. To incorporate the use of technology in screening 

and intervention delivery 

20. To consider cultural idioms of distress and 

appropriate interventions 

21. To accommodate the qualification of new cadres 

of mental health workers through creating posts 

and career paths 

22. To teach research methods and dispel myths 

about research, while refocusing the emphasis 

on scientific curiosity to answer questions 

23. To embrace a range of research methods 

in mental health from quantitative, systems, 

mixed to qualitative; from basic neuroscience 

to implementation research; also, to develop 

“clinician researchers” 

24. To conduct further epidemiological research, as 

there are relatively few data for example on the 

prevalence and associations of mental disorders 

in primary care settings in the African context 

25. To conduct research on the effectiveness 

and cost-efficiency of integrated care and 

collaborative care in the African context, as well 

for further work on moderating and mediating 

factors 

HEALTH FOR ALL AND INTEGRATED MENTAL 

HEALTH CARE IN AFRICA, WE WILL NEED 

TO WORK TOGETHER WITH COLLECTIVE 

STRENGTH AND ACTIVE COLLABORATION. 

SUCH AN ALLIANCE FOR INTEGRATED 

MENTAL HEALTH CARE IN AFRICA, WITH 

EMPHASIS ON PUBLIC MENTAL HEALTH, 

INCLUDES: INDIVIDUAL AND COLLECTIVE 

PSYCHIATRISTS; AS WELL AS ALL MEMBERS 

OF THE MULTIDISCIPLINARY MENTAL HEALTH 

TEAM (PSYCHOLOGISTS, NURSES, SOCIAL 

WORKERS, OCCUPATIONAL THERAPISTS); 

OTHER HEALTH PROFESSIONALS IN PRIMARY 

AND SPECIALIST HEALTH CARE; COMMUNITY 

MENTAL HEALTH WORKERS AND SELF-HELP 

RESOURCES; OUR PATIENTS OR SERVICE 

USERS AND THEIR FAMILIES; THE PUBLIC AT 

LARGE THROUGH THE MEDIA; TRAINING 

INSTITUTIONS; AS WELL AS GOVERNMENTS’ 

MINISTRIES OF HEALTH AND PRIVATE SERVICE 

PROVIDERS OF MENTAL HEALTH CARE 

SERVICES. WHILE DIFFERENT COUNTRIES 

AND GROUPS MAY HAVE DIFFERENT ENTRY 

POINTS, STRENGTHENING OF THIS ALLIANCE 

MUST BE SOUGHT WITHIN COUNTRIES 

NATIONALLY, PROVINCIALLY AND LOCALLY, 

BUT ALSO ON SUBCONTINENTAL AND 

CONTINENTAL LEVELS. 

Bernard Janse van Rensburg 

Johannesburg 

April 2017 

Position statement on a continental alliance for 

integrated mental health care in Africa 

IN ORDER TO ACHIEVE THE COMMUNICATED 

VISION, OBJECTIVES AND TARGETS FOR 

ACHIEVING THE POTENTIAL OF MENTAL 


CULINARY CORNER 

A MEANINGFUL MEAL 

OF PSYCHIATRIC AND 

PSYCHOLOGICAL 

INFORMATION 

Our meal today is themed around the 

notions that we humans need to 

construct a sense of belonging and that 

we also construct our realities, even our 

physical realities. These constructions may interfere 

with the way we cope with our world and the way 

we understand it. 

We start with some thoughts regarding lingering PTSD 

and depression. The main meal consists of research 

which highlights the importance of belonging and 

enjoying being part of a group. An essay by Oliver 

Sacks, published posthumously, reflecting on his 

‘mishearings’ will provide a refresher. This will be 

accompanied by another essay by Sacks which 

touches on a possible consequence of being on 

the outside - if one is a scientist. Dessert will consist of 

Nicholas Humphrey’s Illusionist view of consciousness 

as art and Martin Rees’ question regarding whether, 

given our cognitive limitations, we will ever be able 

to totally comprehend the universe 

STARTER 

PTSD AND TRIBE 

Sebastion Junger, a prize-winning 

journalist and author, published 

a book in 2017 called ‘Tribe’. In 

this work, Junger makes some 

use of psychological, sociological, political and 

anthropological data to develop his argument that 

long-term PTSD in American war veterans is more 

associated with a loss of the connectedness and 

purpose they enjoyed as soldiers - than the injuries 

of battle. 

Junger notes that for millions of years, our hominid 

ancestors functioned within tribes and it remains 

part of human nature to desire the interpersonal links, 

rituals and economic equality that characterised 

these types of societies. For this reason, in the early 

years of the European occupation of America, there 

were multitudes of examples of Europeans fleeing to 

live with the Native American or First People, but very 

few examples of the latter willingly joining the settlers. 

He points out that while modern civilisation has 



much to recommend it in terms of increased 

autonomy and wealth, it deprives us of a sense of 

community and interdependence. It is only during 

times of adversity or war that we recreate that lost 

sense of fellowship with others in our society. Junger 

argues that lingering PTSD in American War Veterans 

is thus more the result of problems with re-entry into 

society than trauma. In essence, it is associated with 

the break up of the ‘band of brothers’ that existed in 

the war zone. 

Junger recommends that soldiers rejoin a society 

with reasonably equal and decent opportunities 

for everyone. All veterans need to be made to feel 

that they are just as necessary and productive 

in society as on the battlefield. It is important that 

people remember that they are warriors and are 

not defined solely as victims. Veterans need to rejoin 

a society which possesses a collectively greater 

understanding of what they have been through 

and what they have lost - in their homecoming - 

regarding their sense of belonging. 

Junger’s argument is convincing. He himself has 

covered several wars as a war correspondent. 

However the links between the claims he makes and 

the evidence which may bolster these claims is not 

always evident. It is also possible that in analysing 

the ongoing trauma of returning soldiers he neglects 

an important intervening variable, namely resilience. 

PTSD AND RESILIENCE 

Wingo et al (2017) assessed resilience in 264 

American war veterans suffering from PTSD 

or Depression using the Connors-Davidson 

Resilience Scale. The authors found that childhood 

maltreatment, gender, marital status, education 

and employment did not predict social functioning. 

However, resilience, which includes the capacity 

to manage stress, bounce back from adversity 

and adapt to new circumstances, was positively 

associated with a more intact engagement with 

the world - regardless of the severity of the PTSD or 

Depression. 

MAIN MEAL 

POSITIVE RELATIONSHIPS AND 

SEMANTIC MEMORY 

An experimental group of thirty-one superagers 

and a control group of individuals with averagefor-their 

age semantic memories completed the 

Ryff 42-item Psychological Well-Being Questionnaire. 

This inventory comprises six subscales measuring: 

Autonomy, Positive Relations With Others, 

Environmental Mastery, Personal Growth, Purpose 

in Life and Self-Acceptance. Both groups were 

matched for demographic factors and estimated 

premorbid intelligence. 

Results revealed that the superagers endorsed 

greater levels of positive relations with others. There 

were, however, no other significant differences. The 

authors conclude by questioning whether this 

psychological feature impacts on the development 

of a thicker anterior cingulate gyrus and on the 

denser levels of Von Economo neurons which 

characterise the brains of superagers (associated 

also with empathy, social awareness and selfcontrol). 

Maher et al (2017) have been involved with a 

‘SuperAging’ programme at Northwestern University 

studying a cohort of individuals who are over eighty 

years old and whose episodic memory ability is 

equal to or superior to those of normal middle-age 

adults. It is known that psychological well-being is 

positively correlated with cognitive performance in 

older adults. The present study therefore sought to 

further explore the psychological factors associated 

with the participants’ contentment. 



OSTRACISM AND BREAKING RULES 

Following social rules are important if one is to 

gain social acceptance. It appears that once a 

person is ostracised, their desire to follow rules may 

be even more weakened. Poon and Teng (2017) 

carried out three studies, making use of a multimethod 

approach, to determine whether ostracism 

was positively associated with rule negligence and 

aggression. Their motivation for the research lay in 

prior studies which had revealed a causal effect 

between ostracism and aggression. The authors 

accordingly wondered whether rule negligence 

might be a psychological mechanism mediating 

the relationship between ostracism and aggression. 

Results confirmed their hypothesis. However they 

found that priming ostracised people with the 

importance of social rules weakened the effect of 

ostracism on aggression. 

the brain’s processing of music is more robust than 

that of spoken language. Playing or hearing music 

involves not only the analysis of tone and rhythm, but 

also an engagement with the emotional centres of 

the brain and with procedural memory. Speech too 

relies on these areas of the brain. It is also dependant 

on systems for semantic memory and syntax. More 

significantly, however, speech is open, inventive, 

improvised and rich in ambiguity and meaning. 

He refers to Freud’s explanation that slips of 

the tongue and mishearings are moulded by 

unconscious motivations. While he does not 

disagree that wishes, fears, motives and conflicts may 

play a part on occasion, he cautions that Freud’s 

understanding underestimates the power of neural 

mechanisms. The open and unpredictable nature of 

language furthermore causes it to be susceptible 

to a sabotage of meaning and a generation of 

mishearings that are irrelevant both to context and 

subconscious motivation. 

One can easily attribute the uncertainty surrounding 

spoken language to his substitution of ‘choir practice’ 

for ‘chiropractor’ and ‘cuttlefish’ for ‘publicist’, 

although one imagines that Professor Freud might 

have enjoyed his substitution of ‘Christmas Eve’ with 

‘Kiss my feet’ and may have wanted to know more.. 

SCIENTIFIC JUMPS AND FALLS 

REFRESHER 

MISHEARINGS 

Ever the scientific observer, even in his last days, 

the well-known neurologist and writer, Oliver Sacks, 

noted his responses to the world. In a chapter of 

his posthumous book: ‘The River of Consciousness’ 

(2017), he leaves us with his thoughts around 

‘mishearings’ to which his growing deafness made 

him more and more susceptible. When a friend 

told him she was going to a ‘chiropractor’, Sacks 

understood her to say she was going to ‘choir 

practice’. A ‘big-time publicist’ was heard as a ‘bigtime 

cuttlefish’, ‘Christmas Eve’ as ‘Kiss my feet’. 

Sacks observed that while he often misheard words, 

he rarely misheard music. The reason for this is that 

In the same book, Sacks also writes about how 

there have been discoveries in science which 

have been forgotten or neglected and then later 

recreated. For example, oxygen was discovered in 

the 1670s by John Mayow a century before Scheele 

and Priestley identified it. John Frederick Herschel 

identified hallucinatory patterns accompanying 

visual migraines in 1858, long before the concepts 

he attempted to elucidate re-emerged in the 1970s 

and 1980s with chaos theory. Gilles de la Tourette 

identified the syndrome which takes his name in 1885 

and 1886, it was later written about again by Henry 

Meige and E Feindel in 1907. However awareness of 

the syndrome was largely lost until the 1970s. 

Sacks cites many other instances of the loss of 

scientific conclusions. One of the most astounding 

is that Galileo’s ‘revolutionary’ picture of the solar 

system was, in fact, identified by Aristarchus in the 

third century BC. His heliocentric view was not only 

well understood but also accepted by the Greeks 

until it was rejected by Ptolemy five centuries later. 

Why are there these sorts of scotoma in science? 

Based on the numerous such incidents he has 

noted, he summarises that they appear to be due 

to the following possible factors: a resistance to new 

ideas which might constitute a threat to cherished 

belief systems; an absence of a requisite level of 

technology; and insufficient funding, opportunity, 

health or social support. 

Sacks, termed ‘the poet laureate of medicine’ by 

the New York Times, wrote this essay when he was 



old and sick. One suspects that in healthier days 

he might have referred to certain philosophers of 

science such as Thomas Kuhn (see‘The Structure 

of Scientific Revolutions, first published in 1962) in 

elaborating on his discussion of these regressions 

and neglects. 

DESSERT 

CONSTRUCTING REALITY 

It is well known that jumping spiders and pigeons 

are able to see broader spectrum of colours than 

human beings. Spiders, in particular, can identify 

greater detail in the world around them. Dragonflies 

see movement as if in slow motion. The world is 

experienced differently depending on anatomy and 

sense modalities. 

As Beau Lotto (2017) puts it, we are unable to 

experience the world as it is because our brains did 

not evolve to do so. Our brains give us the impression 

that our perceptions are objectively real, but our 

sensory processes separate us from ever accessing 

that reality directly. There has been much writing in 

psychology on the sorts of perceptual tricks that 

our brain plays on us and the illusions created (see 

Macknik and Martinez-Conde, 2015). For example, 

the brain can be fooled into seeing the wrong 

colour, perceiving motion in stationary objects and 

misjudging length and perspective. 

These findings have influenced certain theorists 

of consciousness, who fall into two camps. The first 

camp believes that the contents of our subjective 

experience, the special qualities of our sensations or 

qualia, are inherent in the fabric of the universe. The 

second camp, the Illusionists, are more suspicious. 

They argue that consciousness may be more like 

a conjuring show in which our brains trick us into 

believing in qualities that do not exist. One such 

Illusionist, Nicholas Humphreys, has written an article 

in the Summer 2017 edition of the Scientific American 

in which he presents the notion of consciousness 

as art - in which we are both the artist and the 

recipient. Humphrey hopes that if we try to view our 

perceptions as artistic constructs, it may be easier to 

come to terms with the fact that reality is not entirely 

as we perceive it to be. The function of our particular 

human qualia may be that they create in us a sense 

of self and self-attachment. 

WILL WE EVER BE ABLE TO 

UNDERSTAND THE UNIVERSE? 

Martin Rees, the Astronomer Royal and an emeritus 

professor of cosmology and astrophysics at 

Cambridge has written an article in the online 

newsletter: ‘Aeon’ on his concerns regarding the 

limits of scientific understanding. His concern is that 

while human brains have evolved to be adaptable, 

our neural architecture has barely changed since 

our ancestors roamed the savannah. There is thus 

the possibility that we may reach the limits of what 

our brains are able to grasp. 

Scientific understanding has been envisaged as a 

building, the base of which is mathematics. Moving 

upwards from mathematics are sciences based 



on increasingly complex systems, with the social 

sciences at the top. Rees argues that the analogy 

between science and a building is a poor one. 

Comprehension of the more complex systems is not 

curtailed by deficiencies in understanding of the 

more simple systems such as subnuclear physics. 

Each layer is limited by a lack of understanding 

of the particular system involved and has its own 

distinct explanations. Different phenomena with 

varying levels of complexity have to be understood 

in terms of associated, irreducible concepts. 

This does not mean that we may not be able to 

compute processes with the help of electronic 

machines. Rees predicts that the future may be 

dominated by intellects formed via the intelligent 

design of computers. However computing is not the 

same as having an insightful comprehension and it 

may be unduly anthropocentric to believe that a full 

understanding of physical reality is within humanity’s 

grasp. He may have a point. Many of us already 

struggle to truly understand how gravity may be the 

curving of the fabric of spacetime. 

On the other hand his words also remind one, and 

are perhaps contradicted by, Einstein’s explanation 

of his achievement to his son, Eduard: 

WHEN A BLIND BEETLE CRAWLS OVER THE 

SURFACE OF A CURVED BRANCH, IT DOESN’T 

NOTICE THAT THE TRACK IT HAS COVERED IS 

INDEED CURVED. I WAS LUCKY ENOUGH TO 

NOTICE WHAT THE BEETLE DIDN’T NOTICE 

(ISAACSON, 2015). 

One suspects and hopes that our species will 

continue to produce those who can see what the 

rest of us cannot see. 

INGREDIENTS 

Cook Maher, A., Kielb, S., Loyer, E., Connelley, M., Rademaker, 

M-M., et al. (2017). Psychological well-being in elderly adults with 

extraordinary episodic memory. PLos ONE, 12(10): e0186413. 

https://doi.org/10.1371/journal.pone.0186413. 

Humphreys, N. (2017) Consciousness as Art. Scientific American, 

26(3), pp 5-9. 

Isaacson, W. (2015). How Einstein Reinvented Reality. Scientific 

American, 313(3), pp 28-34. 

Junger, S. (2017). Tribe, On Homecoming and Belonging, 4th Estate, 

London. 

Kuhn, T.S. (1996). The Structure of Scientific Revolutions, University of 

Chicago Press, Chicago. 

Lotto, B. (2017). Deviate, The Science of Seeing Differently, Weidenfeld 

& Nicolson, London. 

Macnik, S.L., & Martinez-Conde, S. (2015). Scientific American Mind, 

26(3), pp 20-22. 

Poon, K., & Teng, F. (2017). Feeling unrestricted by rules: ostracism 

promotes aggressive responses. Aggressive Behavior, 43(6), pp. 558-567. 

Rees, M. (2017). Is There a Limit to Scientific Understanding? 

Aeon - in association with the Centre for the Study of Existential Risk, 

https://aeon.co/ideas/black-holes-are-simpler-than-forests-andscience-has-its-limits. 

Sacks, O. (2017). Scotoma: Forgetting and Neglect in Science, in The 

River of Consciousness. Picador, New York, pp 185-217. 

Sacks, O. (2017). Mishearings, in The River of Consciousness. Picador, 

New York, pp 123-127. 

Wingo, A., Briscione, M., Norrhelm, S.D., Jovanovic, T., Mc Cullough, 

S.A., et al. (2017). Psychological Resilience is associated with more 

intact social functioning in veterans with post-traumatic stress 

disorder and depression, Psychiatry Research, (249)1, pp 206-211. 

Ethelwyn Rebelo is a clinical psychologist working in private practice and completing a PhD through the 

Department of Psychiatry. Faculty of Health Sciences, University of the Witwatersrand. She has spent a good 

part of her professional life based in psychic wards in psychiatric clinics. A full reference list is available from the 

author Correspondence: ethelwyn@live.co.za 


WINE FORUM 

Le Riche 

DECADES OF QUALITY, 

CONSISTENCY & ELEGANCE 

We were on the wagon in the bleachers 

at the New Year Newlands cricket test, 

my friend and me. Not that we’d overindulged 

during the festivities mind (well, 

not really…), but we’re not partial to the sponsor’s 

brew, and the wine on offer in the public bar was, 

well, unpotable. It was simple plonk from the 

country’s biggest volume brand which, considering 

we’re not wine snobs, was not the problem, but all 

three variants – white, pink and red – were sweet. Very 

sweet. Not for quenching a thirty-degree thirst… 

So, we sipped expensive, reverse-osmosis (‘pure’) 

water as we chewed the cud. Conversation turned to 

wine, as it does. My guest, who heads a well-known, 

top-end wine estate, mused that the journalistic 

space had been captured by the Young Guns, of 

whom I’ve written here before. Swartland grapes 

from ‘rediscovered’ old vineyards made into wine 

‘naturally’ with minimal intervention and without 

the addition of any of the multitude of permissible 

additives that can shape wine flavours, aged in old 

oak if any, and sold in minute tranches with usually 

heavy swing tickets. And attitude. Don’t forget the 

attitude… 

Well, it’s easy to sell small quantities of handreared 

wine at premium prices, suggested my 

guest in between overs, but producing and selling 

larger, economic volumes of high quality wine, 

consistently over time, is, well, more demanding. And 

to do it at an industry-sustaining premium – witness 

Boekenhoutskloof The Chocolate Block or Waterford’s 

The Jem – is quite astonishing. 

Which got me thinking of Etienne Le Riche. Now 

in the twilight of his cellar days, Le Riche has long 

advocated for both Cabernet Sauvignon and its 

home in Stellenbosch, regardless of contemporary 

fad or fashion. His mantra of ‘Quality, Consistency and 

Elegance’ has carried him through four decades of 

quality wine making. 

Le Riche spent twenty years 

as winemaker at the historic 

Rustenberg Estate, where he 

crafted the legendary 1982 

Cabernet Sauvignon and the 

famous, now erstwhile, Dry Red 

(a pre-crush blend of Cabernet 

Sauvignon and Cinsaut, if memory 

serves), and during which time he 

was named Wine Man of the Year 

by John Platter in his 1990 SA Wine Guide. But the 

winds of change blew through the property in the 

mid-Nineties, and Etienne went solo. Many felt at 

the time he was unfairly ‘pinged’ for the problems 

at Rustenberg and, whatever may have gone on 

behind the scenes, what followed showed it had 

nothing to do with his vintner’s expertise. 

Le Riche Wines has just celebrated its 21st year. 

Etienne and long-time assistant winemaker Mark 

Daniels set up shop at a modest cellar in the 

Jonkershoek Valley named Leef op Hoop – Live on 

Hope – which was most appropriate considering 

their financial context! They needn’t have worried; 

accolades flowed for the wines they made from 

bought-in grapes – classic Stellenbosch Cabernet 

Sauvignon, quiet and retiring, even somewhat 

austere, but never obvious or fruity. A series of Platter 

5-stars commenced with the maiden 1997 Reserve, 

and the 2005 Reserve was Platter’s Red Wine of the 

Year. 

Duly qualified with both local and international 

cellar experience under the belt, son Christo joined 

dad as winemaker in 2010. Sister Yvonne, herself a 

Cape Wine Master who graduated in politics and 

economics and who had valuable experience in 

the cutting-edge British wine market, boarded the 

ship to look after marketing, sales and exports. All 

the while long-time cellarman Mark Daniels kept a 

meticulous eye on the tiller… 


WINE FORUM 

In 2013 the Le Riche family built a winery at Raithby 

on the lower slopes of the Helderberg between 

Stellenbosch and Somerset West. There are no cabernet 

vines on the property; grapes continue to be sourced 

through now well-established relationships with growers 

in Jonkershoek, Firgrove and the Simonsberg. Le Riche 

likes the established model; each parcel is made into 

wine with care, respect and minimal intervention so that 

it can add its own personality to the final blend that is 

the better for the complexity multi-source grapes bring. 

Never sweet in the mouth, a bone-dry finish is taken as 

read. 

The Le Riches produce a creditable (and good 

value) Chardonnay (R130) because sometimes 

one needs a white wine, and then a brace of 

cabernets. Richesse (R140) is a lighter styled 

cabernet-led blend offering refreshment, while 

the more serious Cabernet Sauvignon (R210) 

and top-of-the-pile Cabernet Sauvignon Reserve 

(R500) reward cellaring. Indeed, there is currently 

a mature 2008 Reserve available at the cellar 

door for R950. Etienne is a founder member of the 

Cape Winemakers Guild and his CWG bottling 

of cabernet is highly contested at auction, 

averaging around R1000 in youth. 

Reams have been written about inter-generational 

farming and its succession planning. How do the 

Le Riche family manage it? ‘We have discussions, 

not arguments,’ offers Etienne. Christo – due to 

marry his New Yorker bride Whitney Ross before 

the 2018 harvest – is sage for his years: ‘A lot has 

changed over the past twenty years, but nothing 

is new…’ 

LE RICHE WINES 

Address: 8 Raithby-Annandale Road, 

Raithby, 7130 

Email: wine@leriche.co.za 

Telephone: 021 842 3472 

Open for tastings and sales: 

Monday to Friday: 9:00 – 16:30 (Closed 

12:30 – 14:00) 

Saturday: By appointment 

www.leriche.co.za 

Left: Le Riche Cabernet Sauvignon 2014 

Right: Le Riche Cabernet Sauvignon Reserve 2014 

Christo, Etienne and Yvonne Le Riche 

Le Riche Wine Cellar, built in 2013 on the lower slopes of the Helderberg Mountain 

David Swingler is a writer and taster forPlatter’s South African Wine Guide for 21 years to date. 

Dave Swingler has over the years consulted to restaurants, game lodges and convention 

centres, taught wine courses and contributed to radio, print and other media. A psychiatrist 

by day, he’s intrigued by language in general, and its application to wine in particular. 

Correspondence: swingler@telkomsa.net 


MOVIE REVIEW 

Victoria & Abdul 

a review by Franco P. Visser 

A BBC Films / Cross Street Films / 

Perfect World Pictures Presentation 

Lee Hall Screenplay 

Stephen Frears Director 

For almost 15 years Queen Victoria enjoyed 

an exceptionally close, platonic relationship 

with an Indian attendant named Abdul 

Karim. This caused such a great upheaval 

in the conservative and regimental structure, that 

characterised her household in the late1800s, that 

many historians today regard the behaviour of the 

Queen’s household and family members towards 

Abdul as being racist and socially prejudiced. 

Not since Queen Victoria’s close relationship with 

another servant by the name 

of John Brown, that followed the 

untimely death of her husband 

Prince Albert on 14 December 

1861, have any of the Queen’s 

relations caused such a big stir. 

As the nearly 80 year-old 

monarch approached her 

golden jubilee in 1887, she 

showed a particular interest 

in the Indian subcontinent of 

which she was Queen Empress 

at the time. She requested 

that Indian servants attend to 

her and her guests at official 

state banquets, and it was 

during this time that Abdul 

along with a fellow compatriot 

found their way to England. 

Chosen to present a golden 

medal to Queen Victoria on 

the occasion of her golden 

jubilee, Abdul quickly found 

himself being in favour with the 

aging monarch. Such was the 

spark in their relationship that 

the Queen elevated Abdul from a mere servant in 

the royal household to the position of ‘Munshi and 

Indian Clerk to the Queen Empress’. 

This did not go down well with 

Queen Victoria’s Court, and family 

members and household staff 

alike made every attempt to thwart 

their growing relationship. Born the 

son of a lowly hospital assistant, 

Abdul hailed from a very humble 

background in Agra, too humble 

for the likes of the Queen’s eldest 

son and the senior household command. The film 

Victoria & Abdul is a portrayal of Abdul’s fascinating 

life at Court, a life that was not at all easy for him 

most of the time. Queen Victoria (played by Judi 

Dench) felt Prince Albert’s death all too keenly, and 

her grief and persistent mourning for her husband 

are well documented. It was 

clear that the prince Consort’s 

death left a huge gap in Queen 

Victoria’s life, leaving her feeling 

very lonely and isolated, even 

though she was surrounded by 

family members and a large 

Court contingent. She sought 

solace in the company of those 

who were removed from what 

she was used to on a daily 

basis, and the film portrays this 

vulnerable side of the formidable 

old Queen quite well. Abdul 

(played by Ali Fazal) on his part 

took on an almost paternal role 

towards the Queen and he was 

highly protective of her. Queen 

Victoria showered Abdul with 

praise and honours, bestowing 

upon him the Order of the Indian 

Empire and the Royal Victorian 

Order. She also provided servants 

for him, a private carriage, 

personal gifts in addition to 

commissioning several portraits 

of Abdul, all much to the chagrin of her family and 

household. Abdul taught the Queen the Urdu (then 

Hindustani) language. She kept meticulous notes in 


MOVIE REVIEW 

special diaries that she kept on the instructions of 

her beloved Munshi. 

Playing the role of Queen Victoria is not Judi Dench’s 

first portrayal of the Queen, as she also played the 

role of the monarch in a film made about the Queen 

Victoria’s relationship with her Scottish servant John 

Brown. Titled ‘Mrs. Brown’, the film was released back 

in 1997. Historically speaking, one of the biggest 

injustices occurred shortly following the death of 

Queen Victoria, as her son, with the assistance of his 

family and senior courtiers, immediately set about 

erasing all traces of Abdul’s existence from court life. 

Queen Victoria’s own daughter, Princess Beatrice for 

example proceeded to re-write all of the Queen’s 

daily journals, some 121 volumes in total. In so doing, 

a wealth of information about the Queen was forever 

lost to history. 

IT IS INTERESTING TO NOTE THAT THE 

NEW KING ALSO ENGAGED IN THE SAME 

BEHAVIOUR AS HEIR APPARENT SHORTLY 

FOLLOWING THE DEATH OF JOHN BROWN IN 

1883. IN HIS MIND BOTH JOHN AND ABDUL 

POSED SERIOUS THREATS TO HIS POSITION 

AS THE HIGHEST-RANKING MALE IN THE 

LAND AND IT IS WELL KNOWN THAT QUEEN 

VICTORIA’S RELATIONSHIP WITH HER ELDEST 

SON WAS STRAINED AT BEST. EDWARD VII DID 

ALLOW ABDUL TO BE THE LAST PERSON TO 

SEE THE QUEEN’S BODY BEFORE THE CASKET 

WAS CLOSED. HE ALSO ALLOWED HIM TO 

FORM PART OF THE GROUP OF PRINCIPAL 

MOURNERS AND THE FUNERAL PROCESSION, 

ALTHOUGH THE REQUESTS FOR THESE 

CONCESSIONS CAME FROM HIS MOTHER 

BEFORE HER DEMISE AND WERE NO KIND 

GESTURES ON HIS PART TOWARDS ABDUL. 

Victoria & Abdul is mainly set in the beautiful 

surroundings of Osborne House on the Isle of 

Wight, the Italianate summer residence designed 

by Prince Albert and built between 1845 and 1851. 

It is at Osborne House that Queen Victoria died in 

January 1901, and it was here that a little more than 

a hundred years following her death a journalist 

started uncovering clues as to their special 

relationship. These clues ultimately led to the story of 

Queen Victoria and Abdul Karim being written into 

its rightful place in history – and obviously the basis 

of this film, one well worth viewing. 

Franco Visser is a psychologist and lecturer in Neuro- 

& Forensic Psychology at UNISA, Pretoria, South Africa. 

Correspondence: Visserp@unisa.co.za 

Victoria & Abdul 


SASOP MEDIA STATEMENT 

South African Society of Psychiatrists 

RECOVERY PLAN FOR THE 

GAUTENG 

DEPARTMENT OF HEALTH 

The South African Society of Psychiatry (SASOP) 

welcomes the announcement on the 26th 

November 2017 by the Gauteng Premier, Mr 

David Makhura, together with National Minister 

of Health, the Honorable Dr Aaron Motsoaledi and 

Gauteng MEC of Health, Dr Gwen Ramakgopa, of the 

high-level intervention team to coordinate a recovery 

plan for the Gauteng Department of Health. Especially 

in view of the SASOP’s own calls in February 2017 and 

again in June 2017, for the complete overhaul of health 

and mental health care systems in Gauteng, but also 

in other provinces, such as Eastern Cape, Limpopo, 

Free State and Kwazulu-Natal . These calls, at the time, 

was based on Recommendation 16 of the Health 

Ombud’s report into the Life Esidimeni (LE) deaths, 

which recommended that deinstitutionalization 

should occur with the integration, strengthening 

and resourcing of both the primary and specialist 

multidisciplinary mental health teams in districts and 

hospitals. 1 

The SASOP’s June statement on the state of mental 

health services in South Africa, based on reports from 

SASOP’s regional Subgroups at our Public Sector 

Group’s annual strategic meeting, attempted to also 

provide information on the state of affairs in other 

provinces and not only in Gauteng, as the first phase 

of completing the move of the surviving LE patients 

back to safe placements, were still in process. This 

statement was, however, unusually heavily criticized 

by the National Minister, both for the accuracy of the 

information it referred to, as well as for the fact that a 

professional body such as SASOP has communicated 

this information publicly. 2 The Honorable Minister also 

alluded to the challenges in recruiting and retaining 

specialists, in this case psychiatrists to, in particular, 

more rural provinces such as Limpopo Province. 

In response to this criticism, the SASOP was 

subsequently able to meet with the national Ministerial 

Advisory Committee in August 2017, as well as with the 

MEC’s and Departments of Health of Mpumalanga 

and Eastern Cape, after requesting meetings with 

the Minister’s office as well as with MECs of Health of 

five provinces. On these occasions, it was confirmed 

that the information from the provinces reported on 

by the SASOP, actually concurred not only with these 

visited provinces’ own assessments, but also with 

the report on the audit of provincial mental health 

services, conducted by the National Department of 

Health itself. Similar information was also released by 

the provincial departments of health who all made 

submissions and presentations to the South African 

Human Rights Commission earlier in November 2017, 

during its recent national hearing held on the status 

of mental health in South Africa. 

As the collective professional body representing 

more than 90% of the about 700 psychiatrists and 

psychiatric registrars in the country, the SASOP has 

been reporting on mental health care conditions 

in the rest of the country, in lieu of its incorporated 

objectives and responsibility to monitor, evaluate and 

advise on policies related to the delivery of clinical 

services and the protection of patients’ rights; and to 

promote and uphold the principles of human rights, 

dignity and ethics in the practice of Psychiatry. While 

the SASOP understands and uphold the principle of 

1 

Office of Health Standard Compliance. Health ombudsperson report into the ‘Circumstances surrounding the death 

of mentally ill patients: Gauteng Province’. http://ohsc.org.za/wp-content/uploads/2017/09/FINALREPORT.pdf 

p 55. This investigation has clearly shown that for deinstitutionalisation to be undertaken properly, the primary and specialist 

multidisciplinary teams that are community based mental health care services must be focused upon, must be resourced and must 

be developed before the process is started. It will most probably require more financial and human resource investment initially for 

deinstitutionalisation to take root. Sufficient budget should be allocated for the implementation 

2 

Minister Aaron Motsoaledi: Media briefing on matters of National importance in Health. 29 Jun 2017 Statement by 

Minister of Health, Dr Aaron Motsoaledi on matters of National Importance in Health. https://www.gov.za/speeches/ 

minister-aaron-motsoaledi-media-briefing-national-health-insurance-white-paper-29-jun-2017 


SASOP MEDIA STATEMENT 

available “internal mechanisms” in terms of which its 

individual state employed members will attempt to 

resolve issues and report problems, the SASOP as a 

national professional organization, is also expected 

to resort to “external mechanisms” to address issues. 

It is therefore compelled to provide direct support for 

health professionals in high-risk situations under the 

auspices of the professional association; to establish 

an independent oversight and reporting structure to 

play a monitoring role, as well as engage publicly to 

raise awareness in the profession and the public of 

possible dual-loyalty problems, and to advocate for 

legal, administrative and social changes that will 

enable professionals and service providers to respect, 

protect and fulfil the human rights of their patients. 

The SASOP further concurs with the notion that 

not enough psychiatrists are currently available or 

trained and that an urgent review of the number 

of psychiatrists needed in the country should be 

undertaken. The current estimated about 1 psychiatrist 

per 100,000 of the South African population, and 

even less, 0.4 (state sector psychiatrists) per 100,000 

according to the WHO Global Health Observatory 

data, seemed to be grossly inadequate. 3 To train 

more psychiatrists than the average number of 35 

who currently qualify annually in order to achieve a 

modestly improved ratio of 1.5/100,000, the current 

training capacity and number of available registrar 

training posts at the eight medical schools countrywide, 

may have to be increased drastically. 

The SASOP also supports the development of new 

business models for delivering integrated care 

by available public and private practitioners in 

innovative public-private partnership projects where 

uniform baskets of care have been determined, in the 

context of realistic and fair remuneration of services 

rendered on different levels of care. 

The SASOP therefore also recently strongly supported 

and participated in the Gauteng MEC of Health, Dr 

Gwen Ramakgopa’s initiatives to further develop 

the narrative on mental health care in Gauteng 

following the LE disaster, through the Gauteng Mental 

Health Summit held on the 31st October 2017. A new 

declaration was adopted and a renewed pledge 

was undertaken at this occasion to prioritize mental 

health care and to put it firmly onto the health 

agenda, to eradicate the stigma still associated with 

mental health illness and care, to recognize that 

mental health is the cornerstone of people’s health 

and also, importantly, to break the silence about 

mental health issues and about issues in the mental 

health care delivery system. 

SASOP Board 

Johannesburg 

3 

WHO. Global Health Observatory (GHO) data. Updated 2015. http://apps.who.int/gho/data/node.main. 

MHHR?lang=en 

JOIN OUR TEAM 

NELSPRUIT 

The Akeso Group has a national footprint 

of psychiatric hospitals. Its newest hospital, 

based in Nelspruit, is seeking to expand its 

team by inviting all interested SA-registered 

psychiatrists to consider setting up a practise 

within the hospital, enjoying full admission 

rights. The team is still small, and there is a 

great opportunity to grow a practice in this 

medically under-resourced but fast-growing 

area. There are just a few psychiatrists 

covering an extensive region, and there is a 

great opportunity to establish a practise in 

the area, especially now that there is a 75 

bedded specialist psychiatric hospital offering 

comprehensive treatment. 

60 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 2018 

For all enquiries, please contact the Hospital Manager, 

Maggie Oberholzer on maggie.o@akeso.co.za or +27 (0) 87 098 0460

SASOP ANNOUNCEMENT 

SOUTH AFRICAN SOCIETY OF PSYCHIATISTS 

SASOP POSITION 

STATEMENT ON 

CANNABIS 

Compiled by the Addictions SIG 

South Africa, like many other countries, has 

recently found itself having to re-assess 

current laws pertaining to the availability and 

safety of the cannabis plant and its products. 

SASOP notes with concern a growing public 

perception of cannabis as a ‘harmless’ plant, and 

that few measures have been instituted to address 

this. 

The Global Burden of Diseases Study (2010) 

estimates that 2 million years lived with disability were 

attributed to cannabis (Degenhardt et al, 2013). The 

South African Community Epidemiology Network 

on Drug Use (SACENDU) reports that, during the 

2nd half of 2016, cannabis was the most common 

primary substance of abuse for persons younger 

than 20 years presenting to treatment facilities in all 

areas across South Africa, except for the Free State, 

Northern Cape and North West. It is estimated that 

1 in 6 teenagers who experiment with cannabis will 

become addicted to it (Volkow et al, 2014). 

Human brain development and maturation is a 

process that is guided by the body’s endogenous 

cannabinoid system and occurs until the early 20’s. 

Exposure to phyto-cannabinoids (cannabinoids 

obtained from the cannabis plant) during this 

vulnerable period may disrupt the process of brain 

maturation and affect aspects of memory, attention, 

processing speed and overall intelligence (WHO, 

2016). Cannabis use during the adolescent period 

may cause lasting cognitive deficits, even after 

sustained abstinence (Meier et al, 2012). 

A review article by the WHO (2016) concluded that 

current evidence points to a modest contributory 

causal role for cannabis in schizophrenia and 

that a consistent dose-response relationship exists 

between cannabis use in adolescence and the risk 

of developing psychotic symptoms or schizophrenia. 

RECOMMENDATIONS 

1. Any change to the legislation regulating 

cannabis use should be undertaken in 

consultation with all the relevant stakeholders, 

be based on good quality scientific evidence 

and take into consideration the availability and 

accessibility of current drug addiction treatment 

resources in South Africa. 

2. SASOP concurs with the Executive Committee 

of the Central Drug Authority (CDA) of South 

Africa that the approaches to combat the use 

and abuse of psychoactive substances should 

include harm reduction (interventions aimed at 

reducing the harmful consequences associated 

with substance use), supply reduction and 

demand reduction/preventative strategies 

(Stein, 2016). 

3. SASOP agrees with the Executive Committee 

of the CDA that there is currently insufficient 

evidence to predict the long-term 

consequences of the legalization of cannabis. 

The ease of accessing an intoxicating substance 

may have an underestimated impact on the 


SASOP ANNOUNCEMENT 

SOUTH AFRICAN SOCIETY OF 

PSYCHIATRISTS 

initiation, frequency and amount of use, and 

the subsequent risk of developing a substance 

use disorder (Budney et al, 2017). Legalization 

should therefore not be considered at this point. 

4. The decriminalisation of cannabis removes the 

criminal penalty related to the use of cannabis; it 

allows for a distinction between a drug dealer and 

an individual experimenting with or addicted to 

a drug. While SASOP supports the human rights 

of all individuals, we argue that a decision to 

protect those addicted to substances should not 

be viewed as a simple binary decision based on 

criminal penalties. In 2001 Portugal augmented 

the decriminalization of illicit substances with 

drug dissuasion commissions, increased the 

number of facilities offering detoxification and 

therapeutic admissions, increased the number 

of drug education campaigns and refocused 

policing efforts on large scale trafficking 

operations. The decriminalization of cannabis 

must be preceded by and augmented with 

similar socially responsible strategies for it to be 

successful in South Africa. 

5. Available evidence does not support the 

strong positive public opinion and anecdotal 

reports favouring medicinal cannabis, except 

for its demonstrated benefits for chronic pain, 

spasticity due to Multiple Sclerosis and weight 

loss associated with HIV (Whiting et al, 2015). 

Good quality evidence does however exist 

regarding the frequently occurring side effects of 

cannabis such as confusion, dizziness, diarrhea, 

euphoria, fatigue and hallucinations (Whiting et 

al, 2015). 

Any potential benefit obtained from cannabis 

must therefore be weighed against its risk 

of causing addiction, psychosis, cognitive 

impairments and a 2.6 times greater likelihood 

of motor vehicle accidents (Li et al, 2012). SASOP 

further notes with concern the growing evidence 

linking cannabis use with an increased risk of an 

acute myocardial infarction (Mittleman et al, 

2001; Goya et al, 2017) as well as an ischaemic 

stroke (Wolff et al, 2011; Hackam et al, 2015; 

Rumalla et al, 2016). 

6. SASOP commends the Medical Control 

Council’s decision to limit the use of cannabis 

for medicinal purposes to registered prescribers 

and for individuals in which an acceptable 

justification is provided. 

7. SASOP supports ongoing research on the use 

of cannabis for medicinal purposes to ensure 

that its purported and potential benefits can 

be scientifically measured against medical and 

societal risks. 

December 2017 

REFERENCES: 

Budney, A.J., Borodovsky, J.T., The potential impact 

of cannabis legalization on the development of 

cannabis use disorders, Prev. Med. (2017), http:// 

dx.doi.org/10.1016/j.ypmed.2017.06.034 

Degenhardt L, Ferrari AJ, Calabria B, et al. The 

global epidemiology and contribution of cannabis 

use and dependence to the global burden of 

disease: results from the GBD 2010 study. PLoS One. 

2013;8(10):e76635. 

Goyal H, Awad HH, Ghali JK. Role of cannabis 

in cardiovascular disorders. Journal of Thoracic 

Disease 2017;3(2). 

Hall W, Renström M, Poznyak V. The health and social 

effects of nonmedical cannabis use.: World Health 

Organization; 2016. 

Hackam DG. Cannabis and stroke: systematic 

appraisal of case reports. Stroke 2015;46:852-6 

http://www.mrc.ac.za/adarg/sacendu/ 

SACENDUBriefJuly2017.pdf 

Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong 

KY, Li G (2012). Marijuana use and motor vehicle 

crashes. Epidemiol Rev. 34(1):65–72 

Meier MH, Caspi A, Ambler A, Harrington H, Houts 

R, Keefe RS, et al. (2012). Persistent cannabis users 

show neuropsychological decline from childhood 

to midlife. Proc Natl Acad Sci U S A. 109(40):E2657– 

64. 

Mittleman MA, Lewis RA, Maclure M, et al. Triggering 

myocardial infarction by marijuana. Circulation 

2001;103:2805-9 

Rumalla K, Reddy AY, Mittal MK. Recreational 

marijuana use and acute ischemic stroke: A 

population-based analysis of hospitalized patients 

in the United States. J Neurol Sci 2016;364:191-6 

Stein DJ. Position statement on cannabis. SAMJ: 

South African Medical Journal 2016;106(6):569-570. 

Volkow ND, Baler RD, Compton WM, Weiss SR. 

Adverse health effects of marijuana use. N Engl J 

Med. 2014;370(23):2219-2227. 

Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy 

S, Hernandez AV, et al. Cannabinoids for medical 

use: a systematic review and meta-analysis. JAMA 

2015;313(24):2456-2473. 

Wolff V, Lauer V, Rouyer O, et al. Cannabis use, 

ischemic stroke, and multifocal intracranial 

vasoconstriction: a prospective study in 48 

consecutive young patients. Stroke 2011;42:1778- 

80. 


TRUSTCONCERTA ® 

REPUTATION. CONSISTENCE. 

CONFIDENCE. RESPONSIBLE. 

HOPE. COURAGE. 

For full prescribing information, refer to the latest package insert (April 2013). 

JANSSEN PHARMACEUTICA (PTY) LTD, (Reg. No. 1980/011122/07), Building 6, Country Club Estate, 

21 Woodlands Drive, Woodmead, 2191. www.janssen.co.za. Medical Info Line: 0860 11 11 17. 

S6 Concerta® 18, 27, 36 or 54 mg extended release tablets containing 18 mg, 27 mg, 36 mg or 54 mg of 

methylphenidate hydrochloride respectively. Reg. Nos. 37/1.2/0322; 42/1.2/0282; 37/1.2/0323 and 37/1.2/0324. 

PHZA/CONC/1116/0003(1) 


SASOP REPORT 

ON THE 17 th AND 18 th FEBRUARY, THE 

SASOP 

S P E C I A L 

INTEREST GROUP 

FOR ADULT ADHD 

HOSTED A TRAIN-THE-TRAINER WORKSHOP AT 

THE EVERTSDAL GUEST HOUSE, DURBANVILLE. 

The purpose of the Train-the-trainer workshop 

was to provide training to members of 

the SASOP adult ADHD SIG, and a few 

colleagues with a special interest in 

ADHD, to ensure alignment in diagnostic and 

management aspects of adult ADHD. Attendance 

and participation in this workshop provided 

endorsement to individual SIG members to act 

as trainers. This enables the SIG to decentralise 

training of other health care providers 

(psychiatrists, registrars, general practitioners, 

and other health care professionals). 

The venue and refreshments were kindly provided 

by Shire. 

Congratulations to the newly 

endorsed adult ADHD trainers! 

Presentations included: 

Dr Renata Schoeman (co-convenor of the 

SIG): the neurobiology of ADHD, the diagnosis 

of adult ADHD, pharmacological and nonpharmacological 

interventions for ADHD, 

workplace interventions for ADHD 

Dr Eleanor Holzapfel: neuropsychology of ADHD, 

adult ADHD and substance use disorders, and 

psychotherapeutic interventions for adult ADHD 

Dr Rykie Liebenberg (convenor of the SIG): 

comorbidity in adult ADHD, lifestyle intervention 

for adult ADHD and ethical considerations in 

adult ADHD 

Front (from left to right): Drs Rudolph Hiemstra, Ralph Gilbert, Rykie Liebenberg, 

Chanakya Jonnalagadda, Renata Schoeman 

Back (from left to right): Drs Annelise Groenewoud, Suntheren Pillay, Eleanor 

Holzapfel, Anton Kruger, Michelle King, Michael Reid, Chris Verster 


SASOP HEADLINE 

FEBRUARY2018 

As I write, people all over the 

country are returning from their 

annual summer break and are 

preparing for a new year. I trust 

that most of you have had a 

good break and wish you all 

the best for 2018. 

The month of January derives 

its name from the Latin word 

Januarius (mensis ) ‘(month) 

of Janus’, the Roman god who 

presided over doors and beginnings. He is typically 

depicted with two faces – one looking back, and the 

other looking forward. As a Society of Psychiatrists, 

we look back on a year that was eventful for various 

reasons, and one that saw many of our colleagues 

addressing issues specifically in the media (e.g. 

regarding the Life Esidimeni tragedy). We can 

expect to see much more of this work as we look 

forward to 2018, and continue with our mandate 

to “promote, maintain and protect the honour and 

interests of members, the discipline of Psychiatry as 

a medical speciality and to serve the community”. 

Our “outbound communication” has certainly been 

stepped up. 

This SASOP newsletter, Headline, that is published 

four times a year forms part of our “inbound 

communication”. Its purpose is to keep members 

informed about what SASOP is doing as an 

organization. A great deal of important work is 

undertaken by members at various levels, and 

communication amongst ourselves is vital if we are 

to present a co-ordinated approach to the issues 

that concern us and our patients. In 2018, I hope 

to present a modified (and hopefully more relevant) 

Headline to you, so that SASOP will benefit from the 

interaction of its diverse membership. I look forward 

to receiving your comments and input. 

Dr Ian Westmore (Editor) 

January 2018 

BEST WISHES FOR 2018 ON BEHALF OF THE 

SASOP BOARD AND MYSELF. 

Looking back on 2017, we had quite an eventful 

year with the Life Esidimeni tragedy still dominating 

the news throughout until November, when the 

arbitration hearings - chaired by retired deputy chiefjustice 

Digkang Moseneki, went into recess. Mvuyiso 

Talatala did an excellent job in his testimony to the 

arbitration tribunal, highlighting the pertinent issues 

preceding the decision by the Gauteng Department 

of Health officials to terminate the care contract of 

more than 1700 long-term service users. Through his 

and others’ evidence it was possible to show how 

the Department continued to dismiss all warnings, 

despite being engaged by SASOP, Section 27, SADAG 

and the SAMHF in legal action to appoint a curator 

and subsequently an interdict to prevent the move. 

These hearings will recommence later in January 

2018, with the much anticipated testimony of the 

previous MEC for Health, Ms Qedani Mahlangu. 

THE SASOP BOARD ALSO CONTINUED 

WITH OUR ATTEMPTS TO ENGAGE HEALTH 

DEPARTMENTS OF OTHER PROVINCES, 

AFTER THE SASOP PRESS RELEASE IN JUNE 

2017 ON THE APPALLING STATE OF MENTAL 

HEALTH SERVICES ACROSS THE COUNTRY. 

AS A RESULT, DISCUSSIONS WERE HELD WITH 

THE MINISTERIAL ADVISORY COMMITTEE IN 

AUGUST, AS WELL AS WITH THE PROVINCIAL 

MECS FOR HEALTH OF MPUMALANGA AND 

THE EASTERN CAPE. WE RECEIVED A RATHER 

STANDARD WRITTEN RESPONSE FROM THE 

WESTERN CAPE DEPARTMENT OF HEALTH, 

WHILE SASOP BOARD MEMBERS WERE ALSO 

INVITED TO MEET WITH THE NEW GAUTENG 

MEC OF HEALTH, DR GWEN RAMAKGOPA IN 

DECEMBER 2017. 



Since the Biological Congress in September, there 

was another very successful Registrar Finishing 

School in November 2017 - as before, very well 

organized and overseen by Ian Westmore, Chair of 

the Mentorship Division. While we had another Board 

meeting on the 4th November, a new initiative to 

explore closer collaboration between SASOP’s public 

and private sector groups has also been started. This 

happened by means of a joint meeting between 

the SASOP and the PsychMG Boards, facilitated by 

Prof Arnold Smit from the University of Stellenbosch 

Business School. The meeting explored the future 

of public-private collaboration in psychiatric and 

mental healthcare in South Africa. The conversation 

was set against the background of the changing 

national healthcare landscape on the one hand 

and existing SASOP and PsychMG structures and 

processes on the other. In these communications, 

a number of parallel processes concurrently 

happening in both sectors were recognized and it 

is being argued that, if such common streams can 

be identified, both the SASOP vocational groups will 

eventually be better positioned towards and within 

the context of implementing the NHI, as well as in 

the different respective efforts to engage with public 

sector employer(s) and private sector funders. 

A DECISION WAS THUS MADE BY THE 

COMBINED BOARDS TO FORM A SASOP 

PUBSEC-PSYCHMG WORKING GROUP 

(SASOP PP-WG) ON PROMOTING ACCESS 

TO APPROPRIATE PSYCHIATRIC AND 

MENTAL HEALTH CARE IN SOUTH AFRICA. 

THIS WORKING GROUP WILL CONTINUE 

ITS DISCUSSIONS DURING 2018 AND WILL 

REPORT TO THE SASOP MEMBERSHIP DURING 

THE NATIONAL SASOP CONGRESS IN 

SEPTEMBER 2018. 

A final press statement for 2017 was released on the 

1st December, following the Gauteng Department 

of Health’s high-level intervention team appointed 

to coordinate a recovery plan for the Department. 

Although the initiative was welcomed, it was noted 

that the Department should also not lose sight of 

the overall inadequate number of psychiatrists 

nationwide and the issues arising as a result on a 

provincial level across the country. On average, 

there is currently only 1 psychiatrist per 100,000 of 

the South African population, and in the state sector 

even less - according to the WHO Global Health 

Observatory data of 2015. To train more psychiatrists 

than the average about 35 who currently qualify 

annually in order to achieve a modestly improved 

ratio of 1.5/100,000, the current training capacity 

and number of available registrar training posts 

at the eight medical schools country-wide, would 

probably have to be increased drastically. 

THIS BRINGS US TO THIS YEAR, THE SECOND 

PART OF THE CURRENT 2016-2018 TERM OF 

OFFICE, WITH THE FOLLOWING ITEMS ON THE 

AGENDA: 

• SASOP and the Rural Health Advocacy Project joint 

CPD meetings in different provinces to improve 

knowledge and awareness on how to advocate 

for mental health. 

• SASOP partnering to host a travelling exhibition 

raising awareness about abuse of the human 

rights of mental health care users. 

• SASOP governance and service delivery. 

• SASOPs continued media activity. 

• SASOP fundraising and sponsorship. 

• Participation in the 5th Global Mental Health 

Summit in February 2018. 

• Participating with the College of Psychiatry in a 

study on the need for, and training of psychiatrists 

in SA. 

• A SASOP position statement on cannabis. 

• A SASOP endorsed guide on disability assessment. 

• A review of the SASOP Strategic Business Overview 

for 2014-2018. 

We wish you a very prosperous and 

productive year ahead. 

Bernard Janse van Rensburg 

SASOP President 2016-2018 



3. THE REGISTRAR 

FINISHING SCHOOL 2017 

In November 2017, the fifth annual Registrar Finishing 

School (RFS) was held in Johannesburg. This year, 

the event was sponsored by Lundbeck and Adcock- 

Ingram, as well as SASOP/PsychMG. (This was the 

first time that the Society has not only been part 

of the organizing and presenting team, but also a 

sponsor). We had 27 enthusiastic registrars attending 

from various provinces. 

THE RFS HAS BECOME AN IMPORTANT EVENT 

IN THE SASOP MENTORSHIP PROGRAM, AND 

IN 2017 THE PROGRAM WAS ADJUSTED 

TO MAKE IT EVEN MORE RELEVANT TO THE 

NEEDS OF THE ATTENDEES. ITS AIM IS TO 

PROVIDE REGISTRARS IN THEIR FINAL YEAR 

WITH A “SNAPSHOT” OF WHAT TO EXPECT 

IN BOTH THE PUBLIC AND PRIVATE SECTORS 

UPON QUALIFYING AS PSYCHIATRISTS, AND 

TO PREPARE THEM FOR THE ROLES THAT 

THEY WILL BE UNDERTAKING IN BOTH. IT WAS 

A CONSIDERABLE CHALLENGE FOR THE 

ORGANIZERS IN THAT THE PROGRAM WAS 

CONDENSED TO 1.5 DAYS AND THERE WAS 

A MOVE BACK TO MORE GROUP ORIENTED 

WORK AND LESS DIDACTIC TEACHING. IN 

THE GROUP WORK SPECIFICALLY THERE WAS 

LIVELY DEBATE AROUND THREE SPECIFIC 

THEMES: RELATIONSHIPS (PERSONAL AND 

PROFESSIONAL); THE WORK-LIFE BALANCE, 

AND THE FUTURE OF SOUTH-AFRICAN 

PSYCHIATRY. 

A highlight for both the presenters and the registrars 

this year, was a presentation by Dr Hoepie Howell 

at the Friday night Dinner. Dr Howell was the coordinator 

of the RFS until 2016 and is an experienced 

psychiatrist who has worked in both the private 

and public sectors, the military, overseas and in 

the pharmaceutical industry. She reflected on her 

“dance” with Psychiatry over the decades and her 

talk was typically unique, moving and inspirational. 

We hope to share this with a broader audience in 

the next issue of South African Psychiatry. 

Every year, we are reminded of the need for such an 

event, as the feedback is overwhelmingly positive, 

and 2017 was no exception. We will be commencing 

for the planning for RFS 2018 shortly – this year we 

hope to offer an additional training event for newly 

qualified psychiatrists who enter private practice, 

and that follows on from the introductions of the RFS. 

A “Manual for Private Practice” will be compiled and 

be used as reference point in these workshops. 

Dr I Westmore 

FACILITATED JOINT MEETING OF SASOP 

AND PSYCHMG BOARDS ON A SASOP 

PUBLIC-PRIVATE ALLIANCE. 

A facilitated joint meeting of the combined Boards 

of Directors of SASOP and PsychMG was held on 

the 4th November 2017, at the Intercontinental 

Hotel, O.R. Tambo International Airport. The meeting 

was facilitated by Prof Arnold Smit, from the USB 

(University of Stellenbosch Business School) and 

explored the future of public-private collaboration in 

psychiatric and mental healthcare in South Africa. 

The conversation was set against the background 

of the changing national healthcare landscape on 

the one hand and existing SASOP and PsychMG 

structures and processes on the other. The 

facilitation of the meeting was guided by themes 

and questions such as the historic SASOP/PsychMG 

relationship, the current service delivery environment 

and envisioning the future. 

Bernard J/V Rensburg, 1,2 Indhrin Chetty, 1 Ian Westmore, 2 Peet Kotze (HM), 

Eugene Allers, 2 Amos Poto, 2 Thabo Rangaka, 2 Prof Arnold Smit (USB), Kali 

Tricoridis, 2 Mvuyiso Talatala, 1,2 Mpho Mhlongo, 2 Renata Schoeman, 2 Lerato 

Dikobe, 2 Bonga Chiliza, 1 Anusha Lachman, 1 Johann Serfontein (HM), Sebo 

Seape, 1,2 Lesley Roberson 1 ; 

HM – Healthman; 1 - SASOP Board ; 2 - PsychMG Board 

Prof Arnold Smit 

oint SASOP and PsychMG Board attending 



The fine art of mental health treatment 

HOLDING onto MEMORIES 

Ebitine 

MEMANTINE HYDROCHLORIDE 

S4 Ebitine 10 mg. Each film-coated tablet contains memantine hydrochloride 10 mg. Reg. No. 45/32.16/0496. 

For full prescribing information, refer to the package insert approved by the medicines regulatory authority. 

1046988 08/2017 Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021. Tel. 

+27 11 635 0000 www.adcock.com

Restored Sleep 

The 

Definition: 

• An effective hypnotic 1 

• ‘Intermediate’ half-life (6 - 8 hours) 1,2 

• Unaltered REM sleep 1,3 

• Rapid sleep onset and maintenance of sleep 1,2 

• Refreshed morning awakening 1 

• Helps reduce anxiety symptoms associated 

with insomnia 1,4,5 

- Caution should be exercised in patients suffering from anxiety 

accompanied by an underlying depressive disorder 

References: 1. Clark BG, Jue SG, Dawson GW, et al. Loprazolam - A Preliminary Review of its Pharmacodynamic Properties and Therapeutic Efficacy in Insomnia. Drugs. 1986:31(6):500-516. 2. Dormonoct ® 

2 mg package insert. 3. Salkind MR, Silverstone T. The Clinical and Psychometric Evaluation of a new Hypnotic Drug, Loprazolam, in General Practice. Curr Med Res Opin. 1983;8(5):368-374. 4. McInnes GT, 

Bunting EA, Ings RMJ, et al. Pharmacokinetics and Pharmacodynamics Following Single and Repeated Nightly Administrations of Loprazolam, a new Benzodiazepine Hypnotic. Br J Clin Pharmac.1985: 

19:649-656. 5. Botter PA. A comparative Double-blind Study of Loprazolam, 1 mg and 2 mg, Versus Placebo in Anxiety-induced Insomnia. Curr Med Res Opin. 183;8(9):626-630. 

For full prescribing information refer to the package insert approved by the medicines regulatory authority. 

SCHEDULING STATUS: S5 PROPRIETARY NAME (AND DOSAGE FORM): Dormonoct ® 2 mg. COMPOSITION: Dormonoct ® 2 mg: Each tablet contains 2,49 mg loprazolam mesylate, equivalent to 2 mg loprazolam. 

PHARMACOLOGICAL CLASSIFICATION: A 2.2. Sedatives, hypnotics. REGISTRATION NUMBER: Dormonoct ® 2 mg: Q/2.2/355. NAME AND ADDRESS OF THE HOLDER OF THE CERTIFICATE OF REGISTRATION: 

sanofi-aventis south africa (pty) ltd., Reg. No. 1996/010381/07, 2 Bond Street, Midrand, 1685, South Africa. Tel + 27 (0)11 256 3700, Fax +27 (0)11 256 3707. www.sanofi-aventis.com SAZA.LOME.16.11.0952

South African Psychiatry - February 2018 Edition

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?