South African Psychiatry - February 2019
South African Psychiatry - February 2019
South African Psychiatry - February 2019
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ISSN 2409-5699<br />
ABOUT the discipline FOR FOR the the discipline discipline issue 18 • FEBRUARY <strong>2019</strong><br />
THE GLOBAL<br />
B U R D E N<br />
OF DISEASE STUDIES AND<br />
MENTAL HEALTH IN<br />
SOUTH AFRICA<br />
D E A D L Y<br />
MEDICINE:<br />
PAYING THE PIPER<br />
THE CHALLENGES OF<br />
PERINATAL<br />
DEPRESSION<br />
PUBLISHED IN ASSOCIATION WITH THE SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS<br />
PHARMACOGENOMIC<br />
T E S T I N G<br />
IN SOUTH AFRICAN<br />
PSYCHIATRY<br />
C E L L U L A R<br />
NEUROSCIENCE<br />
OF PSYCHIATRIC DISORDERS<br />
www.southafricanpsychiatry.co.za
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Features<br />
THE GLOBAL BURDEN<br />
7<br />
OF DISEASE STUDIES AND<br />
MENTAL HEALTH IN<br />
SOUTH AFRICA<br />
DEADLY MEDICINE:<br />
17<br />
PAYING THE PIPER<br />
PHARMACOGENOMIC<br />
TESTING<br />
27<br />
IN SOUTH AFRICAN PSYCHIATRY<br />
THE CHALLENGES OF<br />
PERINATAL DEPRESSION<br />
34<br />
CELLULAR NEUROSCIENCE<br />
53<br />
OF PSYCHIATRIC DISORDERS<br />
NOTE: “instructions to authors” are available at www.southafricanpsychiatry.co.za<br />
Disclaimer: No responsibility will be accepted for any statement made or opinion expressed in the publication.<br />
Consequently, nobody connected with the publication including directors, employees or editorial team will be held liable for any<br />
opinion, loss or damage sustained by a reader as a result of an action or reliance upon any statement or opinion expressed.<br />
© <strong>South</strong> <strong>African</strong> <strong>Psychiatry</strong> This magazine is copyright under the Berne Convention. In terms of the <strong>South</strong> <strong>African</strong><br />
Copyright Act No. 98 of 1978, no part of this magazine may be reproduced or transmitted in any form or by any means,<br />
electronic or mechanical, including photocopying, recording or by any information storage and retrieval system,<br />
without the permission of the publisher and, if applicable, the author.<br />
COVER IMAGE: Shutterstock Image<br />
Design and layout: The Source * Printers: Imagine It Print It<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 3
CONTENTS<br />
CONTENTSFEBRUARY <strong>2019</strong><br />
5 FROM THE EDITOR<br />
34 THE CHALLENGES OF PERINATAL DEPRESSION<br />
38 DEPARTMENTS OF PSYCHIATRY NEWS<br />
61 THE IMPACT OF CLINICAL EXPOSURE<br />
63 TWO VINYL CHAIRS, PRISON, AND A PETAL<br />
68 BOOK REVIEW: SNOEK THE COUCH<br />
70 CULINARY CORNER<br />
74 WINE FORUM: HERITAGE, ROMANCE …OR BOTH?<br />
76 MOVIE REVIEW: THE WIFE<br />
79 SASOP HEADLINE<br />
7 THE GLOBAL BURDEN OF DISEASE STUDIES AND MENTAL<br />
HEALTH IN SOUTH AFRICA<br />
17 DEADLY MEDICINE: PAYING THE PIPER - THE PERVERSE<br />
PROTOPSYCHOTIC NATURE OF LIFE ESIDIMENI THROUGH A<br />
CONTEMPORARY FREUDIAN LENS<br />
27 PHARMACOGENOMIC TESTING IN SOUTH AFRICAN PSYCHIATRY<br />
45 SENSORY ROOM CALMING FOR THOSE WITH DEMENTIA WHO<br />
ARE SUFFERING FROM ANXIETY<br />
48 THIRD NATIONAL PUBLIC MENTAL HEALTH FORUM (PMHF)<br />
50 FEEDBACK FROM THE ROYAL COLLEGE OF PSYCHIATRISTS<br />
INTERNATIONAL CONFERENCE, JUNE 2018: ‘NEW HORIZONS’<br />
53 CELLULAR NEUROSCIENCE OF PSYCHIATRIC DISORDERS<br />
56 MAINTAINING YOUR PATIENCE AND COMPASSION FOR YOUR<br />
LOVED ONE WITH DEMENTIA<br />
58 UK BUSINESS LEADERS CALL TO GIVE MENTAL HEALTH ISSUES<br />
GREATER RECOGNITION<br />
* PLEASE NOTE: Each item is available as full text electronically and as an individual pdf online.<br />
Design and Layout: Rigel Andreoli Printer: Imagine It Print It<br />
4 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FROM THE EDITOR<br />
Dear Reader,<br />
Welcome to our first issue for <strong>2019</strong>. The year is well underway. Since the<br />
last issue I had a response from the Department of Higher Education and<br />
Training (DoHET) regarding accreditation. The outcome did not surprise –<br />
not recommended. At one level I can understand the DoHET’s requirement<br />
for a certain conformity of content - and process - that is recognized as<br />
scientific, and thus worthy of accreditation. However, the outcome got me<br />
wondering how much bad science is published in peer reviewed journals,<br />
accredited by the DoHET, that is subsequently rewarded with subsidy? I<br />
suppose that depends on one’s definition of bad science. Another way<br />
of looking at it is how much good science does not see the light of day?<br />
I suppose the distinction between good and bad rests at the foot of peer review – and editorial<br />
discretion. Certainly the merits of peer review are not infrequently discussed in the scientific literature.<br />
Clearly for good reason. The process is an area of contention albeit an accepted requirement for<br />
acceptance for publication and ultimately deemed an absolute requirement for a publication’s<br />
scientific credentials. The ability of a peer reviewer to reject or accept publication can have<br />
significant consequences for researchers. Bias is hard to control for, but I am not sure that we are<br />
ready for the move to non-peer reviewed content that is subject to the scrutiny of the consumer<br />
who decides whether an article has utility or not – subject to any such data having been the<br />
outcome of a valid review of both methodological and ethical components of the study protocol.<br />
And who controls for that I wonder? Then there is the thorny issue of the relationship with industry.<br />
Industry adverts are an absolute no-no in scientific publications deemed suitable for inclusion by<br />
the DoHET, but industry sponsored drug trials are seemingly ok…albeit that inherent bias in reporting<br />
has been consistently shown in terms of favouring the product of the sponsoring company. Most<br />
importantly such content must be peer reviewed, and should not be accompanied by an actual<br />
advert. Maybe so called drug trials should simply appear in a repository and not be published<br />
in journals? Maybe we should do away with journals altogether, and have repositories of studies<br />
conducted at universities or institutions freely available in the interests of science to all who would<br />
seek them out – but contained in a directory of such work that would direct clinicians or researchers<br />
accordingly. Can you imagine, a world without data driven journals who own the copyright of the<br />
work of others? No scientific publishing industry – noting that in a 2017 article the industry was worth<br />
19 billion USD annually https://www.theguardian.com/science/2017/jun/27/profitable-businessscientific-publishing-bad-for-science?<br />
The article in question went on to highlight the business<br />
model contributing to such turnover…it is worth a read. The democratization of science. No impact<br />
factors, no publish or perish and promotion by number of publications in ranked journals? Are these<br />
such dangerous ideas? To return data ownership to the owners, to make data freely available?<br />
What would replace these publications? Maybe those that publish articles that require thoughtful<br />
reflection by experienced clinicians (or researchers) to provide meaningful information and<br />
sharing of knowledge that truly enhances patient care – interpreting available data and fusing that<br />
with their lived experience of patient care, in the real world. When was the last time a data driven<br />
piece actually fundamentally changed the way you practiced? Of course I am being provocative,<br />
but when I consider the meaningful contributions to <strong>South</strong> <strong>African</strong> <strong>Psychiatry</strong> over the years of its<br />
existence I find so much of real value – that is both scientifically and, as importantly, experientially<br />
based. And yet, not scientific enough. Frankly, DoHET accreditation was never a have to have…but<br />
it would have been nice – for the authors of valuable content...and the subsidy their effort would<br />
have yielded them…at least a portion of whatever was awarded to their university. Another thorny<br />
issue…another time. I have been invited to speak at the forthcoming World Psychiatric Association<br />
Congress in Lisbon (August, <strong>2019</strong>) on the topic of… The Future of Publications…I think I have some<br />
talking points already. Audience response will be interesting. I might start out by simply using the<br />
word… imagine…and a recurring backing track…cue John Lennon.<br />
As always, the current issue has a range of content ranging from the psychodynamics of the Life<br />
Esidimeni Tragedy to pharmacogenomics and psychiatry… with quite a bit in between. Please feel<br />
free to submit…science is everywhere. Enjoy!<br />
Louw Roos - Department of <strong>Psychiatry</strong>, University of Pretoria<br />
Zuki Zingela - Head, Department of <strong>Psychiatry</strong>, Walter Sisulu University<br />
Bonga Chiliza - Head Department of <strong>Psychiatry</strong> UKZN; President <strong>South</strong> <strong>African</strong> Society of Psychiatrists<br />
Headline Editor: Bernard Janse van Rensburg<br />
Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading<br />
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FEATURE<br />
THE GLOBAL<br />
BURDEN<br />
OF DISEASE STUDIES<br />
AND MENTAL HEALTH<br />
IN SOUTH AFRICA<br />
Lesley Robertson<br />
The Feature is based on a lecture at the September 2018 Public Mental Health<br />
Forum – see Report by Richard J Nichol in this issue<br />
The global burden of disease (GBD) studies<br />
have irrevocably changed the perception of<br />
diseases and injuries in terms of population<br />
health, epidemiological research, and<br />
economics and development. 1 The first GBD study,<br />
commissioned for the 1993 World Bank report,<br />
estimated mortality and morbidity of 100 diseases<br />
and injuries by age, sex, and geography for eight<br />
world regions. The incorporation of morbidity, as<br />
measured by years lived with disability (YLD) and<br />
disability-adjusted life years (DALYs), highlighted<br />
the impact of neuropsychiatric illness, as its chronic<br />
disabling effects were better quantified than with<br />
conventional mortality measures. 2<br />
THE GBD STUDY 2015 REPORTED DALYS<br />
OF 315 DISEASES AND INJURIES FOR 195<br />
COUNTRIES 3 AND INTRODUCED ANOTHER<br />
HEALTH GAP MEASURE, THE HEALTHY<br />
LIFE EXPECTANCY (HALE), AS WELL AS<br />
A SOCIO-DEMOGRAPHIC<br />
INDEX (SDI).<br />
The SDI, calculated from income<br />
per capita, average years of<br />
schooling and total fertility rate,<br />
provides a measure of a country’s<br />
development. Thus, the GBD<br />
studies quantify the burden of Lesley Robertson<br />
diseases and injuries and enable<br />
comparisons to be made across time, between<br />
countries, and against a nation’s own rate of socioeconomic<br />
development.<br />
HEALTH GAP MEASURES<br />
The GBD studies use various health gap measures<br />
(Table I) rather than mortality measures. These<br />
capture the difference between a population and<br />
a normative standard, such as a maximum lifespan<br />
in full health.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 7
FEATURE<br />
Health Gap Measure<br />
Years lost to life (YLLs)<br />
Years lived with disability<br />
(YLDs)<br />
Disability-adjusted life-years<br />
(DALYs)<br />
Healthy life expectancy (HALE)<br />
Health gap<br />
quantified<br />
The difference between<br />
observed mortality and a<br />
normative life expectancy<br />
Years of non-fatal<br />
health loss according to<br />
prevalence of conditions<br />
and the severity of those<br />
conditions.<br />
Represent the sum of YLLs<br />
and YLDs<br />
Functional health loss<br />
experienced before death<br />
Table I<br />
Health Gap Measures<br />
YEARS LOST TO LIFE (YLLs)<br />
A standard reference life table (Table II) is used to<br />
calculate the expected years of life lost. This has<br />
varied with the different GBD studies. The 1990 study<br />
used potential maximum life span in good health<br />
and drew from life expectancy of the Japanese<br />
population where the life expectancy of females<br />
was 82.5 years and of males was 80 years. The GBD<br />
2010 study used a normative loss of years to life from<br />
average death rates, giving a figure of 87.1 years for<br />
both females and males. For the GBD 2015 study, the<br />
highest projected life expectancy in 2050 was used.<br />
This is known as a global health estimate (GHE) and<br />
gives a life expectancy of 91.9 years for females and<br />
males. Thus, the death of two-year-old translates to<br />
89.41 YLLs, whereas that of a 65-year-old equates to<br />
25.59 YLLs.<br />
Source: WHO methods and data sources for global burden of disease<br />
estimates 2000-20151<br />
Table II Standard loss functions used in the Global Burden<br />
of Disease Studies and for WHO Global Health Estimates<br />
Table III summarises the distribution of global YLLs<br />
for the year 2011. The additional two points for<br />
noncommunicable diseases between the GBD<br />
2010 and the WHO GHE are accounted for by the<br />
capturing of a longer life expectancy, and therefore<br />
more years in which to develop disease, by the WHO<br />
GHE. In contrast to using a crude death rate (see<br />
section on mortality below), YLLs capture the burden<br />
of premature mortality. Thus, it is seen that over 90%<br />
of this burden is borne by low- and middle- income<br />
countries (LMICs), related to people dying at a<br />
younger age in these countries.<br />
Source: WHO methods and data sources for global burden of disease estimates 2000-20151<br />
Table III Distribution of global YLLs for 2011 by major cause group, sex, income group, and age<br />
8 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
YEARS LIVED WITH DISABILITY (YLDs)<br />
The GBD studies use the term ‘disability’ to refer to a<br />
loss of optimal health in any of the important health<br />
domains. YLDs quantify functional health loss utilising<br />
the prevalence of a disease or injury state and a<br />
measure of the severity of disability (a disability<br />
weight) caused by that state (i.e. YLD = prevalence<br />
of the disease x disability weight for that disease).<br />
The 1990 GBD study used incidence of disease and<br />
injury but this was changed to prevalence by 2010,<br />
as the use of incidence involved calculations of<br />
prospective average duration of disease. Prevalence<br />
data capture the loss of health at the age at which<br />
it occurs rather than the age at which the disease<br />
is incident.<br />
ADDITIONALLY, PREVALENCE DATA ARE<br />
MORE COMMONLY COLLECTED AT<br />
COUNTRY-LEVEL, AND BETTER ENABLE<br />
ADJUSTMENTS FOR COMMONLY<br />
COMORBID CONDITIONS TO PREVENT<br />
OVERCOUNTING OF DISEASE BURDEN.<br />
THE HIGH COMORBIDITY BETWEEN<br />
DEPRESSION, ANXIETY AND SUBSTANCE<br />
USE DISORDERS IS INCORPORATED BY<br />
COMBINING THE YLDS CALCULATED FOR<br />
EACH OF THE CONDITIONS.<br />
The disability weight is numerical value determined<br />
by using surveys of the general population, where 0<br />
= a state of perfect health, and 1 = a state equivalent<br />
to death (Table IV). It is similar to a Quality Adjusted<br />
Life-Year (QALY), a measure related to loss or gain<br />
of quality of life used by health economists. It<br />
should reflect or quantify the loss of “healthfulness”<br />
caused by the disease or injury. It should not be<br />
a value judgement related to quality of life, the<br />
worth of a person, social undesirability or stigma.<br />
Nevertheless, there is still uncertainty around the<br />
weighting of a disability. For example, substance<br />
dependence, although better defined in the GBD<br />
2015 study to prevent the influence of social values,<br />
may still be affected by perception of disability. It<br />
is possible the more severe weighting for heroin vs<br />
amphetamine dependence may be related to the<br />
distressing withdrawal symptoms reported by heroin<br />
users. However, while amphetamine users may not<br />
perceive their addiction to be so disabling, it may<br />
result in greater psychiatric symptomatology, violent<br />
behaviour, and medical and psychiatric hospital<br />
admissions, which might not be captured in the<br />
disability weight.<br />
Another aspect of the disability weight is the<br />
adaptation by society to that disease state. Hence,<br />
it is possible that where there is a high level of<br />
adaptation to, for example, visual or hearing<br />
impairment, these states may not be as disabling as<br />
in societies which offer little or no assistance to blind<br />
Source: WHO methods and data sources for global burden of disease estimates 2000-2015 1<br />
Table IV Comparison of GBD2010, GBD2015 and revised GHE disability weights.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 9
FEATURE<br />
and deaf. Therefore, it is important to understand the<br />
context of the disability and the population among<br />
whom the disability weight is determined.<br />
THIS CONCEPT COULD ALSO SPEAK TO<br />
SEVERITY OF PSYCHOSOCIAL DISABILITY<br />
EXPERIENCED BY PEOPLE WITH MENTAL<br />
ILLNESS WHERE TREATMENT IS LESS<br />
ACCESSIBLE, OR IN HIGHLY VERSUS LESS<br />
STIGMATISING SOCIETIES.<br />
DISABILITY-ADJUSTED LIFE YEARS (DALYs)<br />
The DALY combines time lost through premature<br />
death (YLLs) and time lived in a state of less than<br />
optimal health (YLDs). The calculation has been<br />
simplified since the 1990 GBD study, so that in the<br />
2010 and 2015 GBD studies, a DALY = YLLs + YLDs,<br />
and YLDs = prevalence x disability weight with<br />
calculations combined for comorbid conditions.<br />
HEALTHY LIFE EXPECTANCY (HALE)<br />
Like DALYs, HALE is a single summary measure of<br />
population health. It was introduced because of<br />
the aging population and the need to account<br />
for health loss before death, as measured against<br />
a lifespan in optimal health. A problem that<br />
occurred in this population was the high level<br />
of independent and dependent comorbidities,<br />
such that the sum of multiple YLDs resulted in<br />
more years lost to disability than possible in one<br />
lifetime. The HALE provides a measure of functional<br />
health loss at the level of the individual rather<br />
than at the level of the disease or injury. It weights<br />
the years lived with a measure of functional<br />
health loss before death and includes more<br />
comprehensive adjustments for comorbidity than<br />
YLDs. These include combining calculations for<br />
independently occurring comorbid conditions<br />
and for dependent comorbidities (e.g. a stroke<br />
secondary to hypertension).<br />
BURDEN OF DISEASE IN SUB-SAHARAN AFRICA<br />
AND SOUTH AFRICA<br />
As a single summary measure of population health<br />
which combines both YLLs and YLDs, DALYs are<br />
extremely useful for establishing disease priorities<br />
for health planning and funding. A comparison<br />
between high income countries and the different<br />
regions in sub-Saharan Africa (Table V) reveals<br />
the extremely high burden of poor obstetric and<br />
child health in Africa. The high number of YLLs<br />
outweigh YLDs due to chronic diseases. Notably,<br />
depression does not feature in sub-Saharan Africa<br />
when using DALYs. Using all three measures gives a<br />
more complete understanding of disease burden,<br />
and the top ten causes in YLLs, YLDs and DALYs for<br />
<strong>South</strong> Africa are shown in Table VI. Of note is that<br />
both depression and anxiety are amongst the top<br />
ten YLDs, but because of the impact of premature<br />
mortality by other prevalent conditions, they do not<br />
account for any of the top ten DALYs.<br />
Source: Robertson LJ, Szabo CP. Implementing Community Care in Large Cities and Informal Settlements: An <strong>African</strong> Perspective. 4 Data source: GBD 2015 DALYs and<br />
Hale Collaborators. 3<br />
COPD=chronic obstructive pulmonary disease; LRTI=lower respiratory tract infections; PEM=protein energy malnutrition. a due to birth asphyxia/trauma<br />
Table V Top ten causes of disease burden in DALYs, globally, in high-income countries, and in sub-Saharan Africa (SSA)<br />
1 2 3 4 5 6 7 8 9 10<br />
YLLs<br />
HIV/AIDs<br />
Interpersonal<br />
Violence<br />
LRTIs<br />
Road<br />
Injuries<br />
Tuberculosis<br />
Ischaemic<br />
Heart Disease<br />
Diabetes<br />
Mellitus<br />
Stroke<br />
Diarrhoea<br />
Neonatal<br />
preterm delivery<br />
YLDs<br />
HIV/AIDs<br />
Back & neck<br />
pain<br />
Sensory<br />
deficits<br />
Depression<br />
Diabetes<br />
Mellitus<br />
Skin problems<br />
Iron<br />
deficiencies<br />
Migraine Asthma Anxiety<br />
DALYs<br />
HIV/AIDs<br />
Diabetes<br />
mellitus<br />
Interpersonal<br />
violence<br />
LRTIs Tuberculosis Road Injuries<br />
Ischaemic<br />
Heart Disease<br />
Back &<br />
neck pain<br />
Stroke<br />
Diarrhoea<br />
Source of data: GBD 2015 Mortality and causes of death collaborators. 5 GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. 6 GBD 2015 DALYs and<br />
Hale Collaborators. 3<br />
LRTI=lower respiratory tract infections; DALYs=Disability-Adjusted Life Years; YLDs=Years Lived with Disability; YLLs=Years Lost to Life;<br />
Table VI Top ten causes of disease burden in <strong>South</strong> Africa, in YLDs, YLLs, and DALYs<br />
10 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
FACTORS AFFECTING BURDEN OF DISEASE<br />
ESTIMATES FOR MENTAL HEALTH<br />
PRIMARY DATA<br />
The extent and quality of country-level data is the<br />
most important factor affecting the GBD estimates. 1<br />
To be included in the GBD analyses, adherence to<br />
minimum standards around data transparency and<br />
methodology and data sharing is needed. While<br />
clinical data may be incorporated with sophisticated<br />
epidemiological modelling and statistical inference,<br />
it cannot fully make up for scarce primary population<br />
level data.<br />
CHANGES IN METHODOLOGY TO<br />
ACCOMMODATE POOR QUALITY DEATH<br />
CERTIFICATION AND OTHER DEFICITS IN<br />
DATA WERE MOST MARKED BETWEEN THE<br />
1990 AND 2010 STUDIES. NEVERTHELESS<br />
AVAILABLE, HIGH QUALITY DATA LEAD TO<br />
CONSISTENT HEALTH ESTIMATES BETWEEN<br />
INSTITUTIONS, WHEREAS SCARCE, LOW<br />
QUALITY DATA LEAD TO DISCREPANCIES<br />
BETWEEN INSTITUTIONS.<br />
A lack of primary data is particularly prominent in<br />
LMICs and for serious mental illness. Baxter et al.<br />
(2013) 7 analysed epidemiological data used in the<br />
2010 GBD study for high prevalence (depression<br />
and anxiety) and low prevalence (schizophrenia,<br />
bipolar disorder and eating disorders) mental<br />
illness. Globally, less than 1% of identified studies<br />
met inclusion criteria, and even those included had<br />
methodological limitations. Only North America had<br />
a 75-100% population coverage for both low and<br />
high prevalence disorders. Australasia had a 75-<br />
100% for high prevalence and 50-74% population<br />
coverage for low prevalence disorders. <strong>South</strong><br />
Africa’s population coverage was 25-49% for high<br />
prevalence disorders, possibly largely related to<br />
the <strong>South</strong> <strong>African</strong> Stress and Health Study, with no<br />
coverage for low prevalence disorders. Thus, these<br />
disorders may be perceived as not contributing to<br />
the burden of disease in the country.<br />
the behaviour is directly due to the mental illness is<br />
not so simple. Similarly, causal directionality is difficult<br />
to prove with medical causes of death.<br />
BOX 1. ILLUSTRATIVE EXAMPLE<br />
The following news report describes an incident in<br />
Kwa Zulu Natal in which a 20-year-old, on treatment<br />
for a psychotic disorder, killed his two-year-old niece<br />
and three year-old-nephew, injured his 57-year-old<br />
mother, and then was killed as he ran in front of a<br />
truck.<br />
https://www.sowetanlive.co.za/news/southafrica/2018-02-19-why-did-he-kill-his-mother-andthe-children-ask-family-of-mental-health-patient/<br />
Estimated burden of disease<br />
Death YLLs Cause of death<br />
Niece, 2 years<br />
old<br />
Nephew, 3<br />
years old<br />
Patient, 20<br />
years old<br />
Disability<br />
89.4 + 89.4 =<br />
178.8 YLLs<br />
69.7 YLLs<br />
(Total = 248.5<br />
YLLs)<br />
YLDs<br />
Interpersonal<br />
violence<br />
Road injury or<br />
Suicide (injury<br />
due to self-harm)<br />
(Psychotic<br />
disorder)<br />
Cause of<br />
disability<br />
ATTRIBUTION OF CAUSE OF DEATH<br />
The cause of death attribution affects understanding<br />
of disease burden due to mental illness, as the<br />
immediate cause of death is documented, and<br />
underlying cause(s) may not be reported. Deaths<br />
attributed to mental illness are usually due to<br />
substance use or neurocognitive disorders. Suicide<br />
is not recorded as being due to a mental illness but<br />
rather to death by injury due to self-harm. Hence, the<br />
vulnerability of people with mental illness to premature<br />
death is not recognised in YLLs estimates. A note is<br />
made in the 2015 GBD study that mortality related<br />
to schizophrenia will be explored more closely in<br />
future studies. However, cause of death might not be<br />
unequivocally caused by mental illness. For example,<br />
it is easy to quantify the YLLs in violent behaviour of<br />
one individual, as illustrated in Box 1, but certainty that<br />
Mother, 57<br />
years old<br />
(depression<br />
assumed)<br />
Patient, 20<br />
years old<br />
DW=Disability Weight<br />
Prevalence of<br />
trauma x DW<br />
+ Prevalence of<br />
depression x DW<br />
(note, HALE<br />
should count<br />
these as<br />
independent<br />
comorbidity)<br />
Prevalence of<br />
psychosis x DW<br />
(Total DALYs =<br />
Total YLLs + YLDs)<br />
Interpersonal<br />
violence<br />
Bereavement/<br />
depression<br />
Psychotic disorder<br />
(Psychotic<br />
disorder)<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 11
FEATURE<br />
FOR 2016, STATISTICS SOUTH AFRICA<br />
FOUND MENTAL ILLNESS TO ACCOUNT<br />
FOR 0.5% OF DEATHS, 8 USING THE ICD-10<br />
DEFINITION OF UNDERLYING CAUSE OF<br />
DEATH AS ‘THE DISEASE OR INJURY THAT<br />
INITIATED THE SEQUENCE OF EVENTS<br />
LEADING DIRECTLY TO DEATH’ OR ‘THE<br />
CIRCUMSTANCES OF THE ACCIDENT OR<br />
VIOLENCE THAT PRODUCED THE FATAL<br />
INJURY’.<br />
However, in their meta-analysis on mortality among<br />
people with mental illness, Walker et al, 9 calculated<br />
a pooled relative risk of 2.22 (95% CI, 2.12–2.33)<br />
compared to the general population, with a median<br />
of 10 years of potential life lost. Two-thirds of deaths<br />
were due to natural causes, mainly cardiopulmonary<br />
disease; 17.5% were of unnatural cause and the<br />
remainder were unknown. They estimated that<br />
mental illness could account for 14.3% of the global<br />
burden of disease through higher rates of premature<br />
mortality.<br />
MORTALITY STATISTICS<br />
IT WAS THE DEATH OF 36 PEOPLE WHICH<br />
CAUSED THE INVESTIGATION INTO LIFE<br />
ESIDIMENI. WHEN THE OMBUD RELEASED<br />
HIS REPORT, 94 PEOPLE HAD DIED. A FEW<br />
MONTHS LATER, THE MEDIA REPORTED<br />
OVER 140 DEATHS. ALL THESE FIGURES<br />
ARE MEANINGLESS WITHOUT CONTEXT<br />
(THE HUMAN RIGHT TO DIGNITY) AND<br />
WITHOUT COMPARISON TO THE NUMBER<br />
OF DEATHS EXPECTED (THE HUMAN<br />
RIGHT TO LIFE).<br />
Most mortality analyses among people with mental<br />
illness are cohort studies where a group of people<br />
are followed over at least one year, with comparison<br />
of the cohort death rate to that of the general<br />
population.<br />
CRUDE DEATH RATE<br />
The crude death rate is calculated as the number of<br />
deaths for a given year per 1000 people. 10<br />
IN 2016, THE CRUDE DEATH RATE FOR<br />
SOUTH AFRICA WAS 10/ 1000 PEOPLE, 11<br />
TWO POINTS HIGHER THAN THE WORLD<br />
CRUDE DEATH RATE OF 8/ 1000 PEOPLE.<br />
Other countries with a crude death rate of 10/ 1000 in<br />
2016 include Belgium, Finland, Italy, Poland, Slovenia,<br />
the Democratic Republic of the Congo, Cameroon<br />
and Mozambique. At 9/ 1000 people, the crude<br />
death rate of high-income countries was greater<br />
than that of LMICs, which stood at 7/ 1000 people<br />
for 2016. Context is necessary to give meaning to the<br />
crude death rate. For example, a country with a low<br />
birth rate and aging population may have a higher<br />
crude death rate than a low-income country with a<br />
high infant and child mortality rate but a growing,<br />
predominantly young population.<br />
AGE-ADJUSTED DEATH RATE AND<br />
STANDARDISED MORTALITY RATIO<br />
A life-table provides the death rate of the general<br />
population in age categories for a period of time<br />
(usually a calendar year). The age-adjusted death<br />
rate reflects the number of deaths that would have<br />
occurred if the general population had of died at the<br />
same rate as the study population within the same<br />
age categories and over the same time period. The<br />
Standardised Mortality Ratio (SMR) is the ratio of the<br />
observed deaths in the study population in each<br />
age group to the deaths (the expected deaths) in<br />
the general population in the same age group and<br />
over the same time period. Thus, in Life Esidimeni, the<br />
overall SMR was found to be highly significant at 4.9<br />
(95% confidence interval 3.92 - 5.80). 12<br />
THIS MEANS THAT, OVERALL THERE WERE<br />
ALMOST 5 MORE OBSERVED DEATHS<br />
THAN WHAT WAS EXPECTED FOR EACH<br />
AGE GROUP.<br />
However, for those over the age of 80 years, although<br />
observed deaths were more than double the<br />
expected deaths, this was not significant (SMR 2.3:<br />
95% confidence interval 0.32 - 4.28).<br />
In essence, the emergence of measures to more<br />
accurately quantify the impact of illness on affected<br />
individuals has led to a more comprehensive<br />
understanding of burden of disease.<br />
REFERENCES<br />
1. World Health Organisation. WHO methods and<br />
data sources for global burden of disease<br />
estimates 2000-2015 Geneva: WHO; 2017 [cited<br />
2018 20 September]. Available from: http://www.<br />
who.int/healthinfo/global_burden_disease/<br />
GlobalDALYmethods_2000_2015.pdf.<br />
2. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ,<br />
Ferrari AJ, Erskine HE, et al. Global burden of<br />
disease attributable to mental and substance<br />
use disorders: findings from the Global Burden of<br />
Disease Study 2010. Lancet. 2013;382(9904):1575-<br />
86.10.1016/S0140-6736(13)61611-6<br />
3. GBD 2015 DALYs and Hale Collaborators. Global,<br />
regional, and national disability-adjusted life-years<br />
(DALYs) for 315 diseases and injuries and healthy<br />
life expectancy (HALE), 1990-2015: a systematic<br />
analysis for the Global Burden of Disease Study<br />
2015. Lancet. 2016;388(10053):1603-58.10.1016/<br />
S0140-6736(16)31460-X<br />
4. Robertson LJ, Szabo CP. Implementing<br />
Community Care in Large Cities and Informal<br />
Settlements: An <strong>African</strong> Perspective. In: Okkels N,<br />
12 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
Kristiansen CB, Munk-Jorgensen P, editors. Mental<br />
Health and Illness in the City. Singapore: Springer<br />
Singapore; 2017. p. 1-24.10.1007/978-981-10-<br />
0752-1_16-1<br />
5. GBD 2015 Mortality and causes of death<br />
collaborators. Global, regional, and national<br />
life expectancy, all-cause mortality, and<br />
cause-specific mortality for 249 causes of<br />
death, 1980-2015: a systematic analysis for the<br />
Global Burden of Disease Study 2015. Lancet.<br />
2016;388(10053):1459-544.10.1016/S0140-<br />
6736(16)31012-1<br />
6. GBD 2015 Disease and Injury Incidence and<br />
Prevalence Collaborators. Global, regional,<br />
and national incidence, prevalence, and<br />
years lived with disability for 310 diseases and<br />
injuries, 1990-2015: a systematic analysis for the<br />
Global Burden of Disease Study 2015. Lancet.<br />
2016;388(10053):1545-602.10.1016/S0140-<br />
6736(16)31678-6<br />
7. Baxter AJ, Patton G, Scott KM, Degenhardt<br />
L, Whiteford HA. Global epidemiology of<br />
mental disorders: what are we missing?<br />
PloS one. 2013;8(6):e65514.10.1371/journal.<br />
pone.0065514<br />
8. Statistics <strong>South</strong> Africa. Mortality and causes<br />
of death in <strong>South</strong> Africa, 2016: Findings from<br />
death notification 2017 [cited 2018 8 October].<br />
Available from: http://www.statssa.gov.za/<br />
publications/P03093/P030932016.pdf.<br />
9. Walker ER, McGee RE, Druss BG. Mortality<br />
in mental disorders and global disease<br />
burden implications: a systematic review<br />
and meta-analysis. JAMA psychiatry.<br />
2015;72(4):334-41.https://doi.org/10.1001/<br />
jamapsychiatry.2014.2502<br />
10. Naing NN. Easy way to learn standardization:<br />
direct and indirect methods. Malysian Journal of<br />
Medical Sciences. 2000;7(1):10-5., PMC3406211<br />
11. The World Bank: Data. Death rate, crude<br />
(per 1,000 people) [cited 2018 8 October].<br />
Available from: https://data.worldbank.org/<br />
indicator/SP.DYN.CDRT.IN.<br />
12. Robertson LJ, Makgoba MW. Mortality analysis<br />
of people with severe mental illness transferred<br />
from long-stay hospital to alternative care in the<br />
Life Esidimeni tragedy. SAMJ. 2018;108(10):813-<br />
7.https://doi.org/10.7196/SAMJ.2018.<br />
v108i10.13269<br />
Lesley Robertson is a community psychiatrist working in the Sedibeng District and is jointly appointed in the Department of<br />
<strong>Psychiatry</strong>, University of the Witwatersrand, Johannesburg, <strong>South</strong> Africa. Correspondence: Lesley.Robertson@wits.ac.za<br />
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SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 15
HCL
FEATURE<br />
DEADLY MEDICINE:<br />
PAYING THE PIPER<br />
- THE PERVERSE PROTOPSYCHOTIC<br />
NATURE OF LIFE ESIDIMENI THROUGH<br />
A CONTEMPORARY FREUDIAN LENS<br />
Coralie Trotter<br />
“<br />
Psychoanalysis begins in wonder that the<br />
unintelligibility of the events that surround<br />
one do not cause more wonder” writes<br />
Jonathan Lear (1998, p. 28). This paper is<br />
about such an event: the Life Esidimeni tragedy in<br />
<strong>South</strong> Africa.<br />
In October 2015 the Gauteng Health Department or,<br />
as retired Deputy Chief Justice Dikgang Moseneke<br />
(Moseneke, 2018) put it, ‘an admittedly delinquent<br />
provincial government’ embarked on an avoidable<br />
mass relocation of psychiatric patients. This<br />
Gauteng Mental Health Marathon Project (GMHMP),<br />
supposedly in line with <strong>South</strong> Africa’s policy of<br />
deinstitutionalisation, imploded into a bitter humaninduced<br />
trauma. Over one and a half thousand<br />
mental health care users were unlawfully, irrationally,<br />
and hurriedly dispatched from psychiatric institutions<br />
mostly without their identity documents, medical files<br />
and support systems and sometimes with changed<br />
names. The relocation process left human wreckage<br />
in its wake.<br />
THE GAUTENG HEALTH DEPARTMENT<br />
OR, THE DEPARTMENT, AS THE FAMILIES<br />
REFERRED TO IT, ALSO CALLED IT<br />
THE DECANTING. IRONICALLY AND<br />
TRAGICALLY, ONE MEANING OF THE<br />
WORD DECANTING IS TO TEMPORARILY<br />
TRANSFER PEOPLE FROM ONE PLACE<br />
TO ANOTHER. THIS PROVED TO BE<br />
PERVERSELY TRUE.<br />
One hundred and forty four<br />
patients died silently soon after the<br />
shambolic and reckless endeavour<br />
from dehydration, starvation,<br />
exposure, injury and medical<br />
neglect rendering their transfers<br />
truly temporary. Patients were<br />
moved from place to place: from<br />
one unlicensed non-governmental<br />
organisation (NGO) to another or<br />
Coralie Trotter<br />
to hospitals or to morgues forcing<br />
concerned family members to engage in a perverse<br />
process of ‘hide and seek’ in order to locate their<br />
loved ones while alive and then their actual bodies<br />
after death. The whereabouts of some mental health<br />
care users are still unknown and unidentified bodies<br />
remain in limbo - or ‘decanted’. The survivors have<br />
been, again ironically, returned to the original facility.<br />
The implication of this is sobering: The Department<br />
used a term to describe a range of temporary<br />
human transfers before the Marathon Project had<br />
even been set in motion.<br />
On 22 nd August 2017 I received an email from a public<br />
interest law firm, Section27, requesting assistance to<br />
assess the impact of the Life Esidimeni relocation on<br />
a group of, at that stage, fifty five families who had<br />
lost a family member due to the project. The aim<br />
was to produce a report that could be presented as<br />
evidence for an Alternative Dispute Resolution (ADR)<br />
or arbitration process under Justice Moseneke. This<br />
was done with the assistance of a team (LETEAM)<br />
of twenty registered mental health professionals<br />
with diverse clinical qualifications and a range<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 17
FEATURE<br />
of experience in psychoanalytical work who spoke<br />
English, Zulu, Sotho, Xhosa, Afrikaans, Swazi, Shona<br />
and Tswana among them.* The LETEAM committed<br />
to participate pro bono in the project. I subsequently<br />
either attended or viewed the forty six-day arbitration<br />
process.<br />
I WILL ILLUSTRATE THE ARGUMENT<br />
PRESENTED IN THIS PAPER CLINICALLY<br />
WITH INFORMATION DERIVED FROM<br />
THE CONSULTATIONS WITH THE FAMILY<br />
MEMBERS (TROTTER ET AL., 2017),<br />
TRANSCRIBED MATERIAL FROM THE<br />
ARBITRATION ITSELF AND THE ARBITRATION<br />
AWARD REPORT PRODUCED BY JUSTICE<br />
MOSENEKE (2018).<br />
There is a trail of events in this catastrophe that<br />
defies comprehension. Vulnerable, dependant,<br />
poor, impaired people were stripped of their human<br />
status and essentially tortured to death. For example,<br />
Deborah Phehla, Maria Phehla’s daughter, was the<br />
first person to die a few days after being transported.<br />
She was locked in a filing cabinet and choked on<br />
her own blood after swallowing plastic and paper.<br />
The bodies of some individuals were then degraded<br />
further after death. For example, Solly Mashego’s<br />
body was found by his sister, Phumzile Motshegwa,<br />
in the cold storage room of an old butchery piled<br />
between other naked bodies. Both Phumzile and<br />
Justice Moseneke could not believe their own eyes<br />
looking at Solly’s face in death, now without eyes.<br />
The state of affairs was further compounded by<br />
treating the families of these patients with contempt<br />
and disregard for their pain, dignity and humanity.<br />
These families endured profound, unacknowledged,<br />
ongoing mental suffering because of the lack of<br />
disclosure and accountability on the part of The<br />
Department before and during the arbitration.<br />
And this took its toll. Two family members whom the<br />
LETEAM consulted in order to write up the expert<br />
testimony subsequently died of heart failure during<br />
the ADR process: Yvonne Mosiane and Shanice<br />
Machpelah. Shanice had turned twenty one the day<br />
before she died.<br />
There is something unbearable and ineffable<br />
in terms of what motivated and enabled the<br />
Decanting. For the families and those involved in<br />
this experience the metaphor of fitting the pieces<br />
of a jigsaw puzzle together is an apt one. What was<br />
needed emotionally and psychologically during the<br />
arbitration was to be presented by The Department<br />
with the completed jigsaw puzzle. That is, a full<br />
disclosure and rationale regarding the transfers with<br />
the gaps filled in. No one, however, took full ownership<br />
of the atrocity or provided a compelling explanation<br />
for the harrowing and catastrophic events in spite of<br />
Justice Moseneke’s repeated and persistent efforts<br />
with each witness to achieve this. This was particularly<br />
the case with the leading triumvirate who initiated<br />
and orchestrated the tragedy: the former Member of<br />
the Executive Council (MEC) Ms Qedani Mahlangu,<br />
Dr Tiego “Barney” Selebano and Dr Makgoba<br />
Manamela. As Counsel Dirk Groenewald said with<br />
puzzlement during the arbitration: “There is a jigsaw<br />
puzzle piece missing here.”<br />
We are thus left with a turgid silence and an<br />
emptiness in our understanding of the Life Esidimeni<br />
tragedy. This is not an ordinary break in knowledge<br />
filled with a necessary uncertainty and curiosity<br />
which may prove fruitful over time but, rather, a dark,<br />
heavy, opaque and impenetrable void. It is clear that<br />
Justice Moseneke carries this burden as this question<br />
posed twice to Dr Manamela during the arbitration<br />
indicates: “You know I sat here for weeks and I still<br />
deeply worry and wonder what was this marathon<br />
project about. What were you trying to do? Why did<br />
you go along with that plan that was bound to prove<br />
murderous?” Many of the family members, however,<br />
have made up their minds regarding motivation.<br />
Suzen Phoshoko (Trotter et al., 2017) states: “The<br />
death was a murder. It was planned, intentional<br />
murder because they must have known these<br />
people couldn’t be moved. Was Terence starved to<br />
death? Was he dehydrated? Was he poisoned? Did<br />
they give him an injection to kill him?” Sophie and<br />
Boitumelo Mangena (Trotter et al., 2017) agree: “It is<br />
one thing to say your mother has passed. It’s another<br />
to say she was tortured and killed.”<br />
A FEW SHORT PAPERS WRITTEN BY FREUD<br />
WILL BE DRAWN ON IN THIS PAPER IN AN<br />
ATTEMPT TO THINK ABOUT WHAT MADE<br />
IT POSSIBLE FOR THIS EXTRAORDINARY<br />
PROCESS TO PLAY ITSELF OUT ACROSS<br />
GAUTENG IN SEVENTEEN NGOS EVEN<br />
THOUGH THERE WAS NO FORMAL LINK<br />
OR COORDINATION BETWEEN THESE<br />
VARIOUS SITES.<br />
Neuropsychologically reality itself is unknowable<br />
as we only have access to a representation of<br />
it. In addition, the unstoppable play of the work<br />
of an ‘internal foreign body’ - the unconscious<br />
- mercilessly interrupts our being. Essentially,<br />
psychological health implies some emotional<br />
knowledge that the mind cannot always be<br />
trusted. Any number of psychological states and<br />
processes - autistic, neurotic, perverse, psychotic,<br />
narcissistic - may amplify the illegitimacy of how<br />
we represent and mediate reality. In Neurosis and<br />
Psychosis (1924) and The Loss of Reality in Neurosis<br />
and Psychosis (1924) Freud proposes that the ego<br />
has to serve more than one master simultaneously.<br />
The conflict which inevitably emerges is managed<br />
by the mind using mechanisms which result in<br />
further distortion and loss of contact with external<br />
or internal reality.<br />
* Coralie Trotter, Karen Gubb, Zamakhanya Makhanya, Geordie Pilkington, Junior Manala, Justin Scott, Kelly Bild, Natalie<br />
Solomon, Lesley Rosenthal, Dana Labe, Rachel Makoni, Vossie Goosen, Zama Radebe, Batetshi Matenge, Johanna Maphosa,<br />
Nina Lloyd-Geral, Michael Benn, Ntshediseng Tlooko, Kathy Krishnan, Vanessa Gaydon<br />
18 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
Neurosis, Freud argues, is the result of a fracture in the<br />
ego’s relationship with its broiling, immoral id while<br />
psychosis is indicative of a warring faction between<br />
the ego and the external world. In neurosis, the ego<br />
avoids the internal pressure exerted by a powerful<br />
wish through repression. The forbidden desire,<br />
however, struggles against this fate and a sign to the<br />
forgotten is created as a compromise. In psychosis,<br />
we witness not only the refusal of new perceptions<br />
from external reality but also the decathexis of the<br />
memory store of lived experience so that it loses its<br />
significance and can no longer be of use. There<br />
is a cost both ways says Freud (1924). A neurosis<br />
contents itself with replacing a piece of reality with<br />
a fantasy which attaches itself to a current situation<br />
lending it a hidden meaning, whereas in psychosis<br />
the ego interrupts its relationship with reality to<br />
the point where a new imaginary world is created<br />
in accordance with wishes as a substitute which<br />
can be patched over the original breach as if it<br />
originated from the outside.<br />
NO ONE WHO TOOK THE STAND DURING<br />
THE ARBITRATION APPEARED TO SUFFER<br />
FROM A PSYCHOTIC DISORDER IN<br />
THE WAY DESCRIBED BY FREUD. IT<br />
IS EQUALLY DIFFICULT TO VIEW THE<br />
MARATHON PROJECT AS A NEUROTIC<br />
PROCESS. YET, THE REALITY TESTING AND<br />
JUDGEMENT OF THOSE IMPLICATED<br />
IN THE DECANTING ALLOWED NEARLY<br />
ONE HUNDRED AND FIFTY PEOPLE WHO<br />
COULD NOT ADEQUATELY TAKE CARE OF<br />
THEMSELVES TO DIE DAILY AND CRUELLY<br />
ON THEIR WATCH. HOW CAN WE BEGIN<br />
TO UNDERSTAND THIS?<br />
In Negation (1925), Freud argues that the earliest<br />
developmental process the infant negotiates<br />
rests on two levels of judgement. The first of these<br />
relates to a fundamental and spontaneous sensory<br />
and visceral process of determining whether an<br />
experience feels good or bad.<br />
TO PARAPHRASE FREUD, IF WE WERE TO<br />
EXPRESS THIS IN THE LANGUAGE OF THE<br />
OLDEST ORAL INSTINCT, THE JUDGEMENT<br />
WOULD READ AS FOLLOWS: ‘THIS<br />
TASTES GOOD. IT IS GOOD AND SWEET.<br />
I WOULD LIKE TO TAKE THIS IN. IT SHALL<br />
THEN BE INSIDE ME. I WANT TO BE THAT<br />
THING. I BE THE GOOD THING. IT IS ME.’<br />
OR, ALTERNATIVELY: ‘THIS TASTES BAD. IT<br />
IS BAD AND BITTER. I NEED TO KEEP THIS<br />
OUT. I WILL SPIT IT OUT. IT SHALL THEN BE<br />
OUTSIDE ME. I DO NOT WANT TO BE<br />
THAT THING. IT IS NOT MY BAD. IT IS NOT<br />
ME.’<br />
THIS NEGATION ARGUES MARILIA<br />
AISENSTEIN (2017) “IS NOT MERELY A<br />
REFUSAL, BUT THE ROOT OF THE SUBJECT.<br />
THE INITIAL “NO” IS A REJECTION WHICH<br />
DISTINGUISHES THE INSIDE AND THE<br />
OUTSIDE AND BRINGS THE “I” INTO BEING.<br />
SAYING “NO” IS FIRST AND FOREMOST AN<br />
AFFIRMATION OF IDENTITY” (P. 204). AN<br />
INFANT INITIALLY ALLOWED THE PRIVILEGE<br />
OF SAYING NO IS POTENTIALLY ABLE TO<br />
INHABIT HIS SKIN AND EMBODY A SENSE<br />
OF SELF.<br />
In these early stages of making a mind a ‘purified<br />
pleasure ego’ is shaped by incorporating that which<br />
is gratifying, nurturing and exciting and ejecting all<br />
unpleasure, discomfort and frustration.<br />
THIS OMNIPOTENCE IS PROTECTIVE<br />
EMOTIONALLY, PSYCHOLOGICALLY<br />
AND COGNITIVELY FOR THE NEWBORN.<br />
IT IS CHARACTERISED BY A STATE OF<br />
UNDIFFERENTIATION.<br />
There is a definitive mix up between experiences<br />
in the form of bits and pieces which belong in<br />
an interior space and those which originate in<br />
an external one: a me and a not-me, and, more<br />
significantly, an illusion of a good me and a bad<br />
not-me. Judgement of experience is based on what<br />
feels good or bad regardless of whether external<br />
events align with the internal landscape. The baby<br />
may very well be wired to attach to caregivers and<br />
make sense of the environment neurologically but<br />
this does not mean that the status quo is being<br />
represented in the mind accurately in terms of<br />
objects and reality being separate and distinct.<br />
THE INFANT TAKES GOOD FROM SUPPLIES<br />
IN THE WORLD OUTSIDE AND, THROUGH<br />
IDENTIFICATION, MAKES THESE PART OF<br />
THE SELF AS IF THE GOOD THING WERE<br />
NEVER OUTSIDE TO BEGIN WITH. THE<br />
‘BAD’ IS SPAT OUT AND ALL THAT IS SPAT<br />
OUT IS PERCEIVED AS BELONGING TO A<br />
DIFFUSE NOT-ME ENVIRONMENT. “WHAT<br />
IS BAD, WHAT IS ALIEN TO THE EGO AND<br />
WHAT IS EXTERNAL ARE, TO BEGIN WITH,<br />
IDENTICAL” (FREUD, 1925, P. 369).<br />
It is because the antithesis between subjective<br />
and objective does not exist initially that our first<br />
experience of the world is confused and draws<br />
sustenance from the realm of wishes and affective<br />
storms. Yet it is essential that the infant is not aware of<br />
this paradox. Of course, this early forging of mental<br />
solids is an illusion. The reality is that what is spat out<br />
begins to assemble as the primitive superego in an<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 19
FEATURE<br />
unseen corner of the mind. The baby attempts to live<br />
in a state of bliss and preside over an omnipotent<br />
objectless ‘imaginary heaven’ but, in truth, has<br />
constructed a paranoid Kafka-like dominion though<br />
introjection and projection with the return of the<br />
projected and dislocation by objects in reality<br />
imminent.<br />
OF COURSE, IT IS JUST A MATTER OF TIME<br />
BEFORE THE BLOW OF THE FALL FROM<br />
GRACE INTO THE DISILLUSIONMENT<br />
OF ACTUAL REALITY OCCURS. FAILING<br />
THIS, THE BABY WILL BE ILL-EQUIPPED TO<br />
ADAPT TO THE ORDINARY WORLD FROM<br />
WHICH HE IS, AFTER ALL, NOT EXEMPT. AS<br />
ESSENTIAL AS IT IS FOR THE INFANT TO<br />
INITIALLY JUDGE FOR HIMSELF WHETHER<br />
AN OBJECT OF SATISFACTION POSSESSES<br />
THE GOOD, DESIRABLE ATTRIBUTE AND SO<br />
DESERVES TO BE TAKEN INTO HIS EGO, IT<br />
IS EQUALLY IMPORTANT FOR THE INFANT<br />
TO REGISTER THAT THE OBJECT IS ‘OUTSIDE<br />
OVER THERE’ SO THAT IT CAN BE SOUGHT<br />
OUT WHENEVER IT IS NEEDED (FREUD,<br />
1925). THE PLEASURE EGO CAN DO<br />
NOTHING BUT WISH, WORK FOR A YIELD<br />
OF PLEASURE AND AVOID UNPLEASURE<br />
(FREUD, 1911). THE BABY HAS TO<br />
LEARN TO USE HIS APPETITES, IMPULSES,<br />
DESIRES, WISHES, NEEDS AND FEELINGS<br />
TO LATCH, TO WORK, TO RETRIEVE THE<br />
GOOD THAT IS ACTUALLY IN A WORLD<br />
BEYOND OMNIPOTENT CONTROL. THIS<br />
ORGANISES THE EGO AND ALLOWS LINKS<br />
TO BE ESTABLISHED SO THAT THE OBJECTS<br />
OF THE PSYCHE - REPRESENTATIONS -<br />
CAN BE PRODUCED AND THE EXTERNAL<br />
OBJECT CAN BE DISTINGUISHED FROM<br />
THE PHENOMENOLOGICAL JUDGEMENT<br />
OF IT. THE REALITY EGO CAN THEN<br />
STRIVE FOR WHAT IS USEFUL WHILE<br />
SAFEGUARDING THE EXPERIENCE OF<br />
PLEASURE (FREUD, 1911).<br />
How does this first developmental achievement<br />
occur? “The baby,” writes Donald Winnicott (1945)<br />
“has instinctual urges and predatory ideas. The<br />
mother has a breast and the power to produce milk,<br />
and the idea that she would like to be attacked by<br />
a hungry baby. These two phenomena do not come<br />
into relation with each other till the mother and child<br />
live an experience with each other…I think of the<br />
process as if two lines came from opposite directions,<br />
liable to come near each other. If they overlap there<br />
is a moment of illusion – a bit of experience which the<br />
infant can take as either his hallucination or a thing<br />
belonging to external reality” (p. 152). This requires<br />
a particular type of environment: a caregiver who is<br />
able to reduce the impingements of internal forces<br />
and outside demands for the infant and facilitate<br />
a manageable negotiation of reality and recovery<br />
from collision with it over time (Winnicott, 1945, 1960,<br />
1988). Green (1999) elaborates that in order to be<br />
able to say yes to himself the baby must be able to<br />
say no to the object. The mother must accept that<br />
he can say no to her. And not only in the form of ‘you<br />
are BAD’, but also ‘you don’t exist’. In other words,<br />
states Green, the object must take the place of the<br />
undifferentiated space in order to take in what is<br />
spat out by the baby.<br />
THE CARETAKER MUST NOT ONLY<br />
ATTEMPT TO SPARE THE BABY EXCESSIVE<br />
UNPLEASURE BUT CANNOT HAVE MORE<br />
BELIEF IN THE BABY’S BADNESS THAN IN HER<br />
OWN. THE NATURE OF THIS ENVIRONMENT<br />
IS A SUBJECT DESERVING OF A PAPER<br />
IN ITS OWN RIGHT PARTICULARLY IN<br />
THE SOUTH AFRICAN CONTEXT WITH<br />
THE LEGACY OF COLONIALISM AND<br />
APARTHEID AND THE DESTRUCTIVE<br />
IMPACT OF BOTH ON FAMILY BONDS AND<br />
UNITS AND MATERNAL AND PATERNAL<br />
FUNCTIONING.<br />
However, in an ordinary environment the infant is<br />
allowed the privilege of gradually taking a bit of<br />
experience as a thing actually belonging to external<br />
reality, that is, of refinding the object that was always<br />
there which has already been incorporated by the<br />
ego and convincing the self that it is still there even<br />
though it belongs in the real world (Freud, 1925). This<br />
is a critical emotional and psychological leap for<br />
the baby as he begins to recognise and ‘re-cognise’<br />
his dependence on external provision and objects<br />
and the necessity of engaging with the unfairness,<br />
arbitrariness, ordinariness and social contracts of a<br />
big wide indifferent world. Freud (1925) states: “What<br />
is not real, what is merely imagined or subjective, is<br />
only internal; while on the other hand what is real<br />
is also present externally” (p. 369). Re-discovering<br />
the object and investing in it essentially equates<br />
to committing to and engaging with reality in a<br />
meaningful and relatively constant way with its<br />
implied disillusionments and losses. This allows a<br />
‘manageable distaste rather than a bitter hatred’ for<br />
reality to develop. And, critically, mourning becomes<br />
an inevitable part of life.<br />
OF COURSE, AS WITH ALL THINGS<br />
PSYCHOLOGICAL, THIS IS NOT SIMPLY<br />
A MATTER OF ONE MOMENT IN TIME.<br />
RENEGOTIATING A RELATIONSHIP WITH<br />
REALITY IS AN ONGOING, LIFELONG TASK<br />
WHICH MAY BE RE-EVOKED WITH EACH<br />
DEVELOPMENTAL THRUST, CRITICAL<br />
INCIDENT OR SIGNIFICANT RELATIONSHIP.<br />
20 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
Nevertheless, failure to initially refind the object<br />
that was always present in reality implies that at<br />
a fundamental level the person can essentially<br />
continue to base judgements of the external world<br />
on what feels good or bad regardless of whether<br />
actual events concur with this illusory narrative or<br />
not. Freud (1925) explains: “All images originate from<br />
perceptions and are repetitions of them. So that<br />
originally the mere existence of the image serves<br />
as a guarantee of the reality of what is imagined...<br />
The reproduction of a perception as an image is<br />
not always a faithful one...The process for testing<br />
the thing’s reality must then investigate the extent of<br />
these distortions” (pp. 369-370). Failure to interrogate<br />
these distortions means that the vagaries of thought<br />
can be equated with external phenomena and the<br />
tenacity of internal desire with magical fulfilment:<br />
‘I wish it! Therefore it IS so!’ then dominates the<br />
relationship with reality and decision making. This<br />
elevates thinking to an idiosyncratic and concrete<br />
belief in mind over matter. In the real world, of<br />
course, things are not absolute and we all revert to<br />
a problematic relationship with reality intermittently<br />
and then, hopefully, ‘return to our senses”.<br />
THIS PSYCHOLOGICAL FLUX IN TERMS OF<br />
ONGOING ATTEMPTS TO RECOVER AS<br />
MUCH REALITY AS POSSIBLE IS DIFFERENT<br />
FROM FORECLOSURE OF THE REALITY<br />
PRINCIPLE AT A SUBSTANTIVE LEVEL. THE<br />
LATTER RESULTS IN A DISREGARD FOR<br />
MEANINGFUL REALITY-TESTING EVEN IF<br />
COGNITIVE AND INTELLECTUAL ABILITIES<br />
ARE SUBSEQUENTLY WELL-DEVELOPED<br />
PRECISELY BECAUSE ESSENTIALLY THE<br />
PSYCHE IS NOW A CLOSED, REGRESSIVE<br />
SYSTEM AT ITS CORE. THIS PROCESS<br />
IS AN UNCONSCIOUS ONE AND SO<br />
THE INDIVIDUAL AFFECTED HAS LITTLE<br />
INSIGHT INTO IT.<br />
This type of thinking is more common than we<br />
imagine and can appear in many disguises. This<br />
hallucinatory fulfilment of wishes (wunscherfüllung),<br />
as noted by Freud (1900) takes place in dreams<br />
and, unfortunately, in the waking state too. The earth<br />
is flat and there is no global warming are obvious<br />
examples. Others follow. Dr Hendrik Verwoerd, the<br />
architect of Apartheid in <strong>South</strong> Africa, stated in 1961<br />
that Apartheid had been much misunderstood and<br />
that it could just as easily have been described<br />
as a policy of ‘good neighbourliness’. In 1985 P. W.<br />
Botha, the Prime Minister who declared the states of<br />
emergency in <strong>South</strong> Africa, addressed the National<br />
Party congress with these words: “I am not prepared<br />
to lead <strong>South</strong> <strong>African</strong>s and other minority groups<br />
on a road to abdication and suicide.” After the<br />
destruction of the twin towers in New York, the 2003<br />
invasion of Iraq under the presidency of George<br />
Bush, took place triumphantly in spite of insufficient<br />
evidence that there were, in fact, weapons of mass<br />
destruction in Iraq. Thabo Mbeki’s adamant denial<br />
from 1999 to 2008 that HIV and AIDS were linked<br />
denied individuals antiretroviral drugs and cost<br />
nearly half a million <strong>South</strong> <strong>African</strong>s their lives. Donald<br />
Trump made numerous references to a wall during<br />
his 2015 to 2016 USA presidential campaign: “I will<br />
build a great wall - and nobody a builds wall better<br />
than me, believe me...I will build a great, great wall<br />
on our <strong>South</strong>ern border, and I will make Mexicans<br />
pay for that wall. Mark my words.” Kallie Kriel from<br />
Afriforum insisted in 2018 that Apartheid was not<br />
a crime against humanity because the death toll<br />
was too low and with one fell swoop negated the<br />
atrocities of Apartheid and the Rome Statute of 1998.<br />
THUS AN INDIVIDUAL’S LINK WITH<br />
DECISIONS AND BEHAVIOUR MAY NOT<br />
BE WELL GROUNDED IN REALITY BECAUSE<br />
THE SECOND LEVEL OF JUDGEMENT WAS<br />
NOT SIGNIFICANTLY ESTABLISHED AND<br />
CONSOLIDATED IN THE FIRST PLACE.<br />
Perceptions of reality persist but are eclipsed,<br />
disavowed and denied. Andre Green (1999)<br />
aptly expresses this: “The subject cannot believe<br />
his eyes, but it is precisely because he can see<br />
and not because he is blind” (p. 90). This creates<br />
a basic internal core upon which the rest of the<br />
psychic structure has to be put together. The more<br />
observable layers of psychological scaffolding may<br />
vary considerably but underneath an essentially<br />
primitive constellation is used to negotiate living in<br />
that the sense of self remains inflated, entitled and,<br />
most importantly, wish laden and oblivious of reality<br />
which cannot then be negotiated in a complex,<br />
reasonable, fluid and empathic way. The ideas<br />
in the mind are then beyond question and desire<br />
becomes the law for acting rather than judgement<br />
or emotional thoughtfulness. Moderation of the<br />
archaic representation of the object through<br />
learning from experience is inhibited and further<br />
development of the primitive superego is thwarted.<br />
THIS IS CLEARLY A FACTOR TO BE<br />
CONSIDERED IN THE GMHMP WHICH<br />
WAS SET IN MOTION ACCORDING TO<br />
INTERNAL PRESSURES IN TERMS OF WHAT<br />
FELT GOOD AND BAD REGARDLESS<br />
OF HOW OMNIPOTENT, UNINFORMED<br />
AND UNREASONABLE THE BASIS FOR<br />
THE THINKING HAPPENED TO BE. THE<br />
RATIONALE AND EXECUTION OF<br />
THE MARATHON PROJECT WAS NOT<br />
INTERROGATED BUT RATHER DRIVEN BY<br />
WISHING, FANTASY AND COMPULSION.<br />
This allowed realistic evidence-based concerns to<br />
be strenuously negated resulting in a life-threatening<br />
endeavour - a Decanting. The former MEC, Qedani<br />
Mahlangu, was able to verbalise exactly this but<br />
could not see the inherent problem in her thinking.<br />
When she was asked in an interview (2017) with<br />
Devi Sankaree Govender for Carte Blanche (MNet<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 21
FEATURE<br />
TV) why the patients had been transferred against<br />
all advice from others, her response was: “How<br />
could they know? Unless they are foretellers” with<br />
reference to the expert advice given by professional<br />
bodies. Again during the ADR process Ms Mahlangu<br />
stated: “If I were a prophet justice, I would have had<br />
foresight.”<br />
THIS, IN ESSENCE, IS THE DIFFICULTY: SOME<br />
FORESIGHT COMES FROM TAKING THE<br />
DICTATES OF REALITY AND KNOWLEDGE<br />
SERIOUSLY, LEARNING FROM HARD<br />
EARNED EXPERIENCE AND LISTENING TO<br />
OTHERS WITHOUT NECESSARILY ACCEPTING<br />
RECEIVED WISDOM UNCRITICALLY.<br />
In the report I wrote that The Decanting turned a<br />
blind eye to all available psychiatric, psychological<br />
and sociological research, evidence and theory<br />
regarding the likely negative impact of relocating<br />
such a large number of institutionalised patients and<br />
that it ignored all available expertise and knowledge<br />
gained from clinical and ordinary experience in the<br />
manner of relocation (Trotter et al., 2017). There was<br />
foresight in this case but the subject in question<br />
could not believe her eyes.<br />
Ten pages of Justice Moseneke’s award (Moseneke,<br />
2018) detail how this allowed the statutory substrate of<br />
social and cooperative living to carry no meaningful<br />
weight, authority or substance in actual reality:<br />
“What stands out is the breadth and depth and<br />
frequency of the arrogant and deeply disgraceful<br />
disregard of constitutional obligations, other law,<br />
mental health care norms and ethics by an organ<br />
of state, its leaders and employees” (p. 72). During<br />
the arbitration Dr Mvuyiso Talatala said that he knew<br />
time would tell when asked why further legal action<br />
had not been taken to halt the Marathon Project.<br />
And indeed it did as time is beyond omnipotent<br />
control.<br />
Once the infant has essentially turned away from<br />
reality and mourning the premature mind can<br />
further distort and reshape itself in various ways in<br />
order to deal with the incessant demand of internal<br />
forces. A few thoughts regarding this follow. Freud<br />
(1938) describes how the mind can cleave in two<br />
in the presence of intense conflict between wishing<br />
and reality: reality, on the one hand, is rejected and<br />
prohibitions are refused while, on the other hand, the<br />
danger of reality is simultaneously recognised. The<br />
mind both affirms and negates reality and nothing<br />
is given up. But, as Freud reminds us, we always have<br />
to pay the piper. The cost here is a rift in the ego<br />
which never heals. Rather two contrary reactions to<br />
the conflict persist as the centre-point of a splitting<br />
of the ego rather than as a dialectical tension<br />
because things never fit and have to be continually<br />
manipulated and distorted.<br />
This results in a double articulation or pivot in the<br />
mind which allows rotation and oscillation between<br />
contradictory points of view. Donald Trump refers to<br />
these as ‘alternative facts’ which can be used to spin<br />
reality rather than confront it.<br />
THIS WAY OF DEALING WITH REALITY<br />
DESERVES TO BE DESCRIBED AS ARTFUL<br />
AND INGENIOUS SAYS FREUD (1938). THE<br />
SLIPPERY SLOPE OF FUDGING REALITY<br />
RENDERS TRUTH OBSOLETE IN SUCH<br />
SCENARIOS. IF IT IS DISAGREEABLE IT IS<br />
‘FAKE NEWS’ WHICH ALLOWS AN EVEN<br />
MORE SPURIOUS VERSION OF EVENTS TO<br />
BE RELAYED AS HISTORICAL TRUTH.<br />
We could say that this way of dealing with reality is<br />
manipulative and perverse. This use of ‘alternative<br />
facts’ or misinformation was evident throughout<br />
the GMHMP. The Department perjured itself in court<br />
at the outset (March 2016) in order to push the<br />
Marathon Project forward against all opposition. Ms<br />
Mahlangu did not present the facts accurately to the<br />
provincial legislature in 2016 and Dr Manamela had<br />
compiled the response. Ms Mahlangu, Dr Selebano<br />
and Dr Manamela all pleaded ignorance regarding<br />
the fact that by August 2016 fifty one people had<br />
already died. As Justice Moseneke (2018) states:<br />
“This answer is as improbable as it is untrue.”<br />
Licensing fraud and unlawful licensing of NGOs<br />
became the new ethical norm. The families were<br />
subjected to relentless violations of trust, continual<br />
stonewalling and incessant deception.<br />
CROSS-EXAMINATION IS A TOUGH<br />
PROCESS AND YET THE TRIUMVIRATE<br />
WERE ABLE TO CONTRADICT THEMSELVES<br />
ON THE STAND, OBFUSCATE THE FACTS<br />
AND REMAIN UNTOUCHABLE IN TERMS OF<br />
AN IMPERATIVE TO TELL THE TRUTH EVEN<br />
UNDER OATH AND JUSTICE MOSENEKE’S<br />
WARNINGS: “IT IS JUST A MATTER OF TIME<br />
BEFORE I DECIDE WHETHER YOU ARE<br />
TELLING THE TRUTH OR NOT.”<br />
Essentially reality became plastic and could be<br />
manoeuvred and morphed at will. In his award Justice<br />
Moseneke (2018) described parts of the testimony<br />
of the triumvirate as misleading, improbable and<br />
inaccurate and finally stated that many of the reasons<br />
presented were “false, disingenuous, and advanced<br />
in order to conceal the true reasons for ending<br />
the contract and moving the patients” (p. 19). Ms<br />
Mahlangu was actually able to express the operation<br />
of the pivot in her mind. She said that if she answered<br />
yes or no it wouldn’t be good for her, a privilege not<br />
allowed many individuals who took the stand. She<br />
begged the indulgence of the court continually to<br />
present, explain and overelaborate a perspective<br />
of the relocation which was totally detached from<br />
what had transpired in the real world. And she clung<br />
tenaciously to discredited reasons for the relocation<br />
such as cost cutting, deinstitutionalisation and<br />
promoting community care.<br />
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IT STRIKES ME THAT WHAT FREUD (1938)<br />
DESCRIBES AS THE SPLITTING OF THE<br />
EGO IS AN ORGANISED STATE AND<br />
THAT THIS MAY NOT BE POSSIBLE FOR<br />
INDIVIDUALS WHO HAVE LOWER LEVELS<br />
OF INTERNAL STRUCTURE, INTEGRATION<br />
AND CONSTANCY AND WHO ARE THUS<br />
MORE ESSENTIALLY DISORGANISED<br />
PSYCHOLOGICALLY.<br />
Perhaps Wilfred Bion (1957) and Andre Green (1999,<br />
2001, 2003) offer pictures of the ‘psychic poverty’<br />
which may ensue in such situations. Green argues<br />
that it is possible early in life for primary identification<br />
to be soldered not in relation to an object but, rather,<br />
in relation to a black hole, a hole nevertheless with<br />
a potent charge. The original object then only has<br />
a negative existence. Green (2002) describes how<br />
thoughts, images, passions and impulses flicker on<br />
and off, often loaded with terror and dread looking<br />
for a name and a place, but, finding only a bleak,<br />
harsh, heavy, silent core. The mental activity which<br />
gives birth to substitute representations and free<br />
associative pathways in the mind is under the threat<br />
of being destroyed as the black hole in the mind<br />
attracts and destroys thoughts and substance and<br />
structure are swallowed up.<br />
THIS IS NEGATIVE NARCISSISM WHICH IS<br />
PERVERSE AND ALIENATING. THE DRIVES<br />
ARE THEN EXPRESSED THROUGH ACTION<br />
AND SOMATIC DISCHARGE RATHER<br />
THAN IN WORDS.<br />
Similarly, for Bion (1957) destructive attacks on<br />
links with feelings, parts of the self, objects and<br />
reality as a result of a certain set of circumstances<br />
during the initial developmental stage lead to the<br />
predominance of associations which appear to<br />
be logical, almost mathematical, but are seldom<br />
emotionally reasonable as a result of excessive<br />
projective identification. In Differentiation of the<br />
Psychotic from the Non-Psychotic Personalities Bion<br />
(1957) argues that the thoughts which arise are<br />
severed, fragmented, isolated and concrete and, yet,<br />
they are experienced with certainty and are devoid of<br />
true curiosity. This is actually a highly confused state.<br />
JUSTICE MOSENEKE TRIED REPEATEDLY<br />
TO ASSIST DR MANAMELA WITH HER<br />
DIFFICULTIES IN TERMS OF HER RIGID,<br />
ILLOGICAL, CIRCULAR THINKING. FOR<br />
EXAMPLE: “WE WILL NEED SOMEONE TO<br />
LEAD YOU IF YOU GO ON IN AN OPEN<br />
ENDED WAY,” AND LATER “I WANT BASIC,<br />
SIMPLE SENTENCES WITH A SUBJECT<br />
AND AN OBJECT.”<br />
This incoherent thinking and confounding of reality<br />
is clearly illustrated in the following transcript from<br />
the arbitration. Dr Manamela, appears to have no<br />
appreciation of cause and effect and thus problems<br />
cannot be stated let alone solved, as described by<br />
Bion (1957).<br />
Dr Manamela: ‘Justice I’m giving you the procedure<br />
as it happens. That’s what I’m trying to give to these<br />
proceedings. Because I felt I must tell you what<br />
events took place before I come to the questions.<br />
Now it’s two way. I must answer the question and tell<br />
you what happened. The unfortunate part some of<br />
the people who came before me some of them who<br />
didn’t understand the process they told you what<br />
they told you and it’s like now I come as an accused.’<br />
Justice Moseneke: ‘I’m going to ask the question<br />
again. What did you do?’<br />
Dr Manamela: ‘What I just explained is what we did.<br />
Should I explain again?’<br />
There is a sigh from Justice Moseneke: ‘I don’t know<br />
what you are saying. Yes you would have signed it or<br />
no I wouldn’t have signed it? What are you saying?’<br />
Dr Manamela: ‘Justice what I was saying is how did it<br />
happen. That’s the truth I know.’<br />
Counsel Groenewald: ‘I am putting it to you that you<br />
are shifting blame...Take responsibility. And say well<br />
there was a number of issues and I shouldn’t have<br />
issued these licences and I know it now.’<br />
Dr Manamela: ‘Counsel, it was presented to me that<br />
the NGOs can be able to manage..you don’t deliver<br />
by yourself all the time...’<br />
Justice Moseneke: ‘No, but listen to the question. Do<br />
you know now according to you what you did not<br />
know then? But do you know now that you should<br />
not have issued the licences? That’s what counsel is<br />
asking you. What is your response to that?’<br />
Dr Manamela: ‘I know now but I still saying I didn’t...’<br />
Justice: ‘No, no, do you know now that you should<br />
not have issued the licenses?’<br />
Dr Manamela: ‘That is what these proceedings are<br />
saying but I...’<br />
Justice: ‘No! No! No! No!’<br />
Dr Manamela: ‘But I..’<br />
Justice: ‘Counsel wants your answer. Do you know now?’<br />
Dr Manamela: ‘I know now although I don’t agree with<br />
the now because at the time when I issued the licenses<br />
the NGO were eligible to take care of the patients.’<br />
Justice: ‘No as you sit where you sit now knowing<br />
your statutory responsibilities... knowing that now do<br />
you think the right thing in issuing the licences where<br />
143 died? That is the question.’<br />
Dr Manamela: ‘But I said at that time I knew at that<br />
time it was right. Now I know that you are saying it<br />
was not right.’<br />
Justice: ‘You are saying that?’<br />
Dr Manamela: ‘I am saying according to the legal<br />
document I have I still know there that was no<br />
request that I be delegated. Last week I was told that<br />
what I know is not right. That’s what you said to me.’<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 23
FEATURE<br />
Retired Deputy Chief Justice Dikgang Moseneke<br />
bows his head and says ‘Aaah’ and speaks in the<br />
vernacular, then says: ‘Listen to the...Advocate<br />
Groenewald says to you do you now know that<br />
whatever you might have thought then you were<br />
wrong in issuing the licences? You won’t concede<br />
even that?’<br />
Dr Manamela: ‘That I was wrong in issuing the<br />
licences?’<br />
Justice: ‘Do you know now that was the wrong<br />
decision?’<br />
Dr Manamela: ‘I know now from you but then it was<br />
not wrong.’<br />
Justice with despair: ‘Counsel you go ahead.’<br />
ILLUMINATING IN THIS PART OF THE CROSS-<br />
EXAMINATION IS THAT DR MANAMELA<br />
STATES THAT SHE DOES NOT AGREE WITH<br />
THE NOW: NOW CAN BE DIVORCED<br />
FROM ACTUAL EVENTS THAT TRANSPIRED<br />
- REALITY - AND JUDGED ACCORDING<br />
TO THAT WHICH IS ONLY INTERNAL. IT IS<br />
NOT ONLY THAT THE INDIVIDUAL WITH<br />
FLAWED REALITY TESTING IS IMPERVIOUS<br />
TO REALITY AND OTHERS IN THAT REALITY<br />
WHICH DIMINISHES THE CAPACITY<br />
TO LEARN FROM EXPERIENCE AND<br />
RESPOND TO FEEDBACK BUT ALSO THAT<br />
EMPATHIC FAILURE ALLOWS PEOPLE -<br />
NOW TRULY OBJECTS - TO BE DEVALUED,<br />
DEPERSONALISED AND COLONISED.<br />
Bion (1957) states that the links with objects which<br />
survive are perverse, cruel, and sterile. This is partly<br />
because failure to re-discover the external object<br />
allows the baby to avoid ‘taking its bad property back’.<br />
JUSTICE MOSENEKE REMINDED DR<br />
MANAMELA REPEATEDLY TO TREAT<br />
OTHERS WITH RESPECT: “NO MA’AM! I<br />
DO INSIST. I INSIST YOU MUST CALL HER<br />
MRS FRANKS. WE DON’T GO RUNNING<br />
AROUND USING FIRST NAMES HERE.<br />
WE DON’T USE YOUR FIRST NAME. LET’S<br />
ACCORD RESPECT TO EVERYONE WE<br />
ARE DEALING WITH.’’<br />
The following statement by Dr Manamela illustrates<br />
not just the contempt for others but the conviction<br />
that there are no problems except those posed<br />
by the object: “Through you Counsel I think I’m<br />
answering to your questions. And I sense that there<br />
is a staring of family members that they should be<br />
angry continuously towards me and I believe I need<br />
protection for that. But my worry is that the staring of<br />
anger towards me might put my life and that of my<br />
family in danger. That I must record.” The problem<br />
here is not only the very concrete idea that looks<br />
could kill but that the source of danger is external.<br />
In an extraordinary turnaround Dr Manamela<br />
positioned herself as the victim throughout the<br />
arbitration to the point where she complained in her<br />
opening testimony that a drone was following her.<br />
SIMILARLY, EVEN THOUGH MS MAHLANGU<br />
WAS THE ARCHITECT OF A TORTUROUS<br />
AND MURDEROUS PROCESS, SHE ARRIVED<br />
AT THE ARBITRATION WITH SEVERAL<br />
BODYGUARDS AS IF SHE TOO WERE THE<br />
ONE WHO NEEDED PROTECTION. SHE<br />
PRESENTED HERSELF AS THE AGGRIEVED<br />
PARTY WHO HAD BEEN LET DOWN BY<br />
THE HEALTH PROFESSIONALS. HER FINAL<br />
WORDS WHERE ABOUT HERSELF AND<br />
NOT THOSE WHO DIED SILENTLY OR<br />
THOSE WHO SURVIVED OR THE FAMILIES.<br />
The dehumanisation which took place during this<br />
project is possible because, as is evident above,<br />
it is the object that is the problem. A failure to<br />
discriminate meaningfully between what is internal<br />
and what is external results in a fundamentally<br />
paranoid psychological world because every<br />
attempt is made to evacuate all bad experiences,<br />
states and parts into the external not-me. As a result<br />
others are not seen or are seen as threatening in<br />
spite of their vulnerabilities in reality. This is perverse.<br />
The tragedy with Life Esidimeni - a microcosm of the<br />
state of mental health and health in general in <strong>South</strong><br />
Africa and a portal or wormhole into the legacy of<br />
our history and its implications for the future - is that<br />
it allowed internal drivers, compulsions and fantasies<br />
to manifest in a manic project which in all likelihood<br />
had very little to do with people and their best<br />
interests from the beginning. Unfortunately, it is then<br />
the ‘other’ who has to pay the piper.<br />
Justice Moseneke stated in his final report and<br />
award on the 19 th March 2018: “This is also a story<br />
of the searing and public anguish of the families of<br />
the affected mental health care users and of the<br />
collective shock and pain of many other caring<br />
people in our land and elsewhere in the world” (p.2).<br />
We cannot hope to fully understand such an event<br />
without taking into account the unconscious forces<br />
operating in the key individuals implicated in the<br />
Decanting.<br />
PERHAPS ONE OF THE REASONS THE<br />
ADR PROCESS DID NOT HAVE GREATER<br />
EXPLANATORY POWER IS THAT THE<br />
ASSUMPTION WAS THAT THE MARATHON<br />
PROJECT WAS DRIVEN BY MOTIVES<br />
WHICH WERE REASONABLE RATHER THAN<br />
IRRATIONAL AND FANTASY BASED AS<br />
THE LATTER IS SIMPLY TOO UNBEARABLE<br />
TO CONTEMPLATE. WE TOO COULD NOT<br />
BELIEVE OUR EYES.<br />
24 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
THE 2018 OXFORD DICTIONARY<br />
WORD OF THE YEAR, A WORD JUDGED<br />
TO REFLECT THE ETHOS, MOOD OR<br />
PREOCCUPATION OF THE PASSING YEAR<br />
AND ONE WHICH MAY HAVE LASTING<br />
IMPACT AS A DESCRIPTOR OF CULTURAL<br />
SIGNIFICANCE, IS TOXIC.<br />
And toxic is a good word to describe the impact of<br />
individuals with sufficient power to determine the<br />
course of action of a family, group or society who<br />
appear to operate in a perverse protopsychotic<br />
manner.<br />
Justice Moseneke (2018) referred to the ‘toxic<br />
aftermath’ (p. 80) of the entire Marathon Project<br />
in his award. As mental health professionals we<br />
can refuse to collude with toxic practice and use<br />
our psychoanalytic knowledge to wrestle with the<br />
impact of unconscious forces which erupt in our<br />
communities. We can contradict perverse narratives<br />
which demand that those with less sociopolitical<br />
currency pay the piper for those who refuse to accept<br />
responsibility for their own actions. And we, like<br />
Justice Moseneke (2017), need to carry the weight of<br />
continuing to wonder about the unintelligibility of this<br />
event as a way of thinking about the psychological<br />
state of our society and world.<br />
REFERENCES<br />
Aisenstein, M. (2017). An analytic Journey: From the<br />
art of archery to the art of psychoanalysis. London:<br />
Karnac Books.<br />
Bion, W. R. (1957). Differentiation of the psychotic<br />
from the non-psychotic personalities. International<br />
Journal of Psychoanalysis, 38:266-275.<br />
Freud, S. (1900). The interpretation of dreams. The<br />
Standard Edition of the Complete Psychological<br />
Works of Sigmund Freud, Volume IV (1900): The<br />
Interpretation of Dreams (First Part), ix-627<br />
Freud, S. (1911). Formulations on the two principles<br />
of mental functioning. The Standard Edition of the<br />
Complete Psychological Works of Sigmund Freud,<br />
Volume XII (1911-1913): The Case of Schreber, Papers<br />
on Technique and Other Works, 213-226.<br />
Freud, S. (1924). Neurosis and psychosis. The<br />
Standard Edition of the Complete Psychological<br />
Works of Sigmund Freud, Volume XIX (1923-1925): The<br />
Ego and the Id and Other Works, 147-154.<br />
Freud, S. (1924). The loss of reality in neurosis and<br />
psychosis. The Standard Edition of the Complete<br />
Psychological Works of Sigmund Freud, Volume XIX<br />
(1923-1925): The Ego and the Id and Other Works,<br />
181-188.<br />
Freud, S. (1925). Negation. International Journal of<br />
Psycho-Analysis, 6:367-371.<br />
Freud, S. (1938). Splitting of the ego in the process<br />
of defense. The Standard Edition of the Complete<br />
Psychological Works of Sigmund Freud, Volume<br />
XXIII (1937-1939): Moses and Monotheism, An<br />
Outline of Psycho-Analysis and Other Works, 271-<br />
278.<br />
Green, A. (1999). The work of the negative. London:<br />
Free Association Books<br />
Green, A. (2001). Life narcissism death narcissism.<br />
London: Free Association Books.<br />
Green, A. (2002). A dual conception of narcissism:<br />
Positive and negative organizations. Psychoanalytic<br />
Quarterly, 71:631-649.<br />
Green, A. (2003). On private madness. London:<br />
Karnac.<br />
Lear, J. (1998). Open minded: Working out the logic<br />
of the soul. Boston, MA: Harvard University Press.<br />
Moseneke. D. (2018). Arbitral Report: Families of<br />
Mental Health Care Users Affected by the Gauteng<br />
Mental Health Marathon Project and the National<br />
Minister of Health of the Republic of <strong>South</strong> Africa.<br />
Trotter, C. et al., (2017). The mark of the Life Esidimeni<br />
decanting: Expert Testimony for the Alternative<br />
Dispute Resolution (ADR) Process with Justice<br />
Dikgang Moseneke.<br />
Winnicott, D. W. (1945). Primitive emotional<br />
development. International Journal of Psycho-<br />
Analysis, 26:137-143.<br />
Winnicott, D. W. (1960). The theory of the parent-infant<br />
relationship. International Journal of Psycho-Analysis,<br />
41:585-595.<br />
Winnicott, D. W. (1988). Human nature. Great Britain:<br />
Taylor and Francis Group.<br />
Coralie Trotter has an M. A (Clinical Psychology) WITS and is also registered as a Psychoanalyst with The International<br />
Psychoanalytic Organisation (SAPA/IPA). She has many years of clinical experience in a psychoanalytic private practice<br />
and supervising mental health professionals. Her supervision experience also includes ten years at both the 702 Crisis<br />
Centre and the University of the Witwatersrand. In addition, Coralie worked for the Detainees Counselling Service and was<br />
responsible for debriefing the clinical team at the Trauma Clinic of the Centre for Violence and Reconciliation for many<br />
years. She has been teaching for over twenty years.<br />
This includes the formal teaching and professional development of clinicians in various and numerous psychoanalytic<br />
groups in Johannesburg, most notably Groups for the Reading and Study of Psychoanalysis (GRASP) which is her initiative.<br />
In 2017 Coralie was asked by Section27 to be an expert witness for the Life Esidimeni Arbitration Hearing. This involved a<br />
consultation process with the families affected by the Gauteng Mental Health Marathon Project with the help of a professional<br />
team. The material which emerged was then analysed by Coralie to produce an expert report and oral testimony for the<br />
Alternative Dispute Resolution Process (2017). Coralie has presented papers at a number of local conferences and coorganised<br />
The Deadly Medicine - The Mark of the Life Esidimeni Decanting Conference in August 2018. Correspondence:<br />
coralie@tiscali.co.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 25
26 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
PHARMACOGENOMIC<br />
T E S T I N G<br />
IN SOUTH AFRICAN<br />
PSYCHIATRY<br />
Aron B. Abera a * and Pierre M. Durand b<br />
a<br />
Inqaba Biotechnical Industries, Hatfield, Pretoria, <strong>South</strong> Africa<br />
b<br />
Evolutionary Studies Institute, University of the Witwatersrand, Johannesburg, <strong>South</strong> Africa<br />
*Corresponding author: aron.abera@inqababiotec.co.za<br />
An area of increasing interest in psychiatry<br />
is the use (and sometimes abuse) of<br />
pharmacogenomic analyses. Globally,<br />
pharmacogenomics already play a role<br />
in psychiatry treatment guidelines in the so-called<br />
‘developed’ countries. This area of interest is poised<br />
to grow in <strong>South</strong> Africa, but there are important<br />
considerations for the local context that are largely<br />
unexplored. Perhaps the most pressing question is<br />
how appropriate the available pharmacogenomic<br />
analyses are for psychiatrists working in SA. To<br />
attempt to answer this all-encompassing question, a<br />
brief review of the aims, scope and methodologies in<br />
pharmacogenomics is warranted.<br />
PHARMACOGENOMICS: AIMS<br />
AND SCOPE<br />
An individual’s genetic make-up (the genotype)<br />
affects how their body responds to, and metabolises<br />
drugs (the phenotype). The term pharmacogenomics<br />
is a portmanteau of pharmacology and genomics<br />
and aims to match the individual’s genotype with<br />
the expected response to the prescribed drug. The<br />
majority of assays include both pharmacokinetic<br />
(PK) and pharmacodynamic (PD) genomic<br />
panels. Pharmacokinetic genes affect the body’s<br />
absorption, distribution, metabolism, and elimination<br />
of medications. The cytochrome P450 (CYP)<br />
enzyme family is the major PK mechanism and the<br />
genetic information used to assess<br />
variations in drug metabolism is<br />
most often based on this gene family.<br />
Approximately 90% of all drugs are<br />
metabolized by just seven different<br />
cytochrome enzymes including<br />
CYP1A2, CYP3A4, CYP3A5, CYPC19,<br />
CYP2D6, CYP2C9 and CYP2B69.<br />
CYP2D6, for example, contributes<br />
to the metabolism of 25% of most<br />
commonly prescribed medications<br />
including psychiatric medications like tricyclic antidepressants,<br />
opioids and anti-psychotics.<br />
Aron Berhanie Abera<br />
CYP2D6 IS A HIGHLY POLYMORPHIC GENE<br />
WITH OVER 130 SINGLE NUCLEOTIDE<br />
POLYMORPHISMS (SNPS) AND INCLUDES<br />
INSERTIONS, DELETIONS, DUPLICATIONS<br />
AND FRAME SHIFT MUTATIONS. THESE<br />
GENETIC VARIATIONS LEAD TO DECREASED,<br />
INCREASED OR NON-FUNCTIONAL<br />
ENZYMATIC ACTIVITY IN THE INDIVIDUAL.<br />
Allelic variants are sometimes very broadly<br />
classified as poor metabolizers (PM), extensive<br />
metabolizers (EM), intermediate metabolizers (IM)<br />
and ultra-rapid metabolizers (UM) according to the<br />
pharmacokinetics.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 27
FEATURE<br />
Pharmacodynamic genes affect what the medication<br />
does to the body and alter the efficacy or side-effect<br />
profiles. A well-known example is the correlation<br />
between carbamazepine-induced Stevens–Johnson<br />
syndrome (SJS) and toxic epidermal necrolysis (TEN),<br />
and the HLA-B*1502 allele in some Asian populations.<br />
The correlation in some ethnicities is very high (odds<br />
ratio for developing carbamazepine-induced SJS/TEN<br />
if positive for HLA-B*1502 is 2504 in the Han Chinese).<br />
SJS or TEN conditions are life-threatening, which has<br />
led to the FDA recommendation that patients of<br />
Asian ancestry be assessed for this allele prior to the<br />
initiation of carbamazepine therapy.<br />
PHARMACOGENOMICS: SOME<br />
COMMON METHODOLOGIES<br />
There is an abundance of pharmacogenetic testing<br />
options. These vary in their validity, costs, positive and<br />
negative predictive values, turn-around-times and<br />
the clinical usefulness of the information. Selecting a<br />
particular methodology depends on what information<br />
is being sought. It is always advisable to discuss the<br />
options with the pathologist overseeing the assays,<br />
because the methodology is matched to the<br />
information required by the clinician.<br />
TRADITIONAL SANGER SEQUENCING<br />
Sanger sequencing is the ‘gold standard’ for<br />
detecting genetic variants. The method evaluates<br />
variations in PCR-amplified fragments with optimal<br />
sensitivity and specificity. While it has an excellent<br />
accuracy and reasonable read length it is unsuitable<br />
to study multiple targets. The technique involves<br />
DNA synthesis in the presence of chain-terminating<br />
inhibitors followed by capillary electrophoresis,<br />
hence the throughput can be time-consuming and<br />
labour intensive. The cost is generally very low and is<br />
ideal for examining a few genetic variants, especially<br />
when they are in close proximity to each other.<br />
REAL TIME PCR<br />
Real time PCR-based SNP genotyping assays allow<br />
the detection of single genetic polymorphisms that<br />
are associated with a particular drug metabolism<br />
phenotype. The assay is usually a single real time<br />
PCR reaction that discriminates alleles based on<br />
sequence-specific oligonucleotide probes that<br />
carry a fluorescent reporter dye for identification.<br />
The reaction either occurs or fails depending<br />
upon the allele being amplified. The assay is rapid<br />
(a few hours) but does not involve sequencing of<br />
a particular region. The assay is relatively cheap<br />
and there are several commercial pre-designed<br />
SNP genotyping assays from Roche, ThermoFisher,<br />
Applied Biosystems, and many others.<br />
NEXT GENERATION SEQUENCING<br />
(NGS)<br />
NGS refers to the large-scale DNA sequencing<br />
technology that follows a ‘sequencing-by-synthesis<br />
principle’ to generate data from the entire exome<br />
or genome. The advantage of NGS over sanger<br />
sequencing or single PCR assays, is the capacity<br />
for high throughput. NGS can generate millions to<br />
billions of nucleotide sequence data in a single<br />
experiment. It may, therefore, identify multiple<br />
variants in a single individual and is commonly<br />
used in the discovery of novel genetic variants<br />
that influence drug response.<br />
Due to the massive amounts of data generated,<br />
the skills required for analyses, the infrastructure<br />
and technology requirements, and the costs<br />
associated with these analyses can be<br />
prohibitive).<br />
THE SHEER SCALE OF THE DATA<br />
PRODUCED BY NGS IS FAR MORE THAN<br />
ROUTINE PATHOLOGISTS AND CLINICAL<br />
SCIENTISTS ARE EQUIPPED TO DEAL WITH.<br />
These sorts of assays, therefore, are usually more<br />
appropriate for research institutions.<br />
MATRIX-ASSISTED LASER DESORPTION/<br />
IONIZATION TIME-OF-FLIGHT (MALDI-<br />
TOF) MASS SPECTROMETRY (MS)<br />
The MALDI-TOF MS technology is one of the<br />
methodologies that fills the gap between analyzing<br />
only a couple of variants by PCR or Sanger<br />
sequencing, and the huge amounts of data<br />
generated by NGS. This is clinically helpful, because<br />
clinicians often wish to have information concerning<br />
multiple variants (between five and several hundred),<br />
but not on the scale that NGS provides. Genetic<br />
variants are identified based on the differences in<br />
their molecular charge-mass ratios. PCR amplicons<br />
are generated that differ in their nucleotide<br />
sequences, which are identified by the time-of-flight<br />
of the molecules between two poles, rather than the<br />
sequencing of the fragments.<br />
The assay is as accurate and has the same positive<br />
and negative predictive values as the Sanger<br />
sequencing gold standard. The cost of the analysis<br />
is also comparable and there is currently at least<br />
one (Agena BioScience) commercially available<br />
product (Box 1).<br />
PHARMACOGENOMIC DATA<br />
In its most simplistic form, pharmacogenomic data<br />
are presented as the phenotype with the associated<br />
phenotype (for example, Table I).<br />
The patient’s genotype may be the allelic variant<br />
or a copy number variant and the corresponding<br />
phenotype listed as either poor, extensive or<br />
intermediate metabolizer of drugs. This, however,<br />
is only a very general approach and what is more<br />
typical is that the data are interpreted by the clinical<br />
scientist or pathologist with respect to a specific set<br />
of medications.<br />
28 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
Table II provides an example of a recommended<br />
psychiatric drug prescription panel based on<br />
pharmacogenetic data.<br />
Phenotype<br />
Genotype<br />
Poor metabolizer CYP2D6*3–*8, *11,*16, *18–<br />
*21, *38, *40, *42, *44, *56, *62<br />
Extensive<br />
metabolizer<br />
Intermediate<br />
metabolizer<br />
CYP2D6*2, *17 x 2, *27, *35, *39, *48<br />
CYP2D6*10, *14, *17, *18, *36, *41, *47,<br />
*49 –<br />
*51, *54, *55, *57<br />
Table I Genotype-based phenotype classifications<br />
The traditional PGx nomenclature system describes<br />
each haplotype with a unique label comprising the<br />
name of the gene followed by the major (*) allele<br />
assignment based on the genetic variant identified.<br />
These haplotypes are then linked to a specific<br />
phenotype and can be categorized in several<br />
groups such as ‘Poor Metabolizer’ (PM), ‘Extensive<br />
Metabolizer’ (EM) or ‘Intermediate Metabolizer’ (IM)<br />
according to the enzyme’s functionality. The table<br />
illustrates the variant alleles and their classification<br />
for CYP2D6 variants.<br />
Used as<br />
directed<br />
Citalopram<br />
(Celexa)<br />
Desvenlafaxine<br />
(Pristiq)<br />
Escitalopram<br />
(Lexapro)<br />
Fluvoxamine<br />
(Luvox)<br />
Selegiline (Emsam)<br />
Sertraline (Zoloft)<br />
Use with<br />
caution<br />
Duloxetine<br />
(Cymbalta)<br />
Mirtazapine<br />
(Remeron)<br />
Trazodone<br />
(Desyrel)<br />
Use with great<br />
increased<br />
caution and<br />
with more<br />
frequent<br />
monitoring<br />
Amitriptyline<br />
(Elavil)<br />
Bupropion<br />
(Wellbutrin)<br />
Clomipramine<br />
(Anafranil)<br />
Desipramine<br />
(Norpramin)<br />
Fluoxetine (Prozac)<br />
Imipramine<br />
(Tofranil)<br />
Nortriptyline<br />
(Pamelor)<br />
Paroxetine (Paxil)<br />
Venlafaxine<br />
(Effexor)<br />
Table II Example of the recommended psychiatric drug usage<br />
An individual was identified with the genotype<br />
CYP2D6*4/*4 (poor metabolizer) and CYP2C19<br />
1/*1 (extensive metabolizer). The recommendations<br />
associated with this combined genotype are listed.<br />
ARE THE PHARMACOGENOMIC DATA<br />
APPLICABLE IN SA, AND ARE THEY<br />
APPROPRIATE FOR PSYCHIATRISTS<br />
WORKING IN SA?<br />
We return to the question posed at the beginning<br />
of this article. There is no doubt that an individual’s<br />
genetic makeup is key to creating personalized<br />
drugs with greater efficacy and safety. The<br />
pharmacogenomic data published by reputable<br />
scientists and institutions are, of course, subject<br />
to the same peer review standards as any other<br />
scientific analyses.<br />
THEY ARE APPLICABLE. THE MORE<br />
IMPORTANT QUESTION, HOWEVER, IS<br />
HOW APPROPRIATE THEY ARE TO THE<br />
SOUTH AFRICAN CONTEXT. THIS IS<br />
THE CRUX OF THE MATTER. AS THINGS<br />
STAND, THERE IS UNFORTUNATELY NO<br />
SATISFACTORY ANSWER EXCEPT FOR<br />
THE ONE: “IT DEPENDS”.<br />
For example, the environment, diet, age, lifestyle,<br />
and state of health may all influence a person’s<br />
response to medicines. These factors are, in many<br />
instances, not comparable to the regions where<br />
the data were generated. In addition, even at<br />
the genetic level, the way a person responds to<br />
a drug (this includes both positive and negative<br />
reactions) is a complex trait that is influenced<br />
by many different genes and not just the typical<br />
analyses provided by the pharmacogenomic<br />
data. The complexity of the genotype-phenotype<br />
map was discussed in a previous issue (“Evolution<br />
and the molecular basis of psychiatric illness”<br />
Issue 5, November 2015). A good example of<br />
this is the association between carbamazepineinduced<br />
SJS/TEN and the HLA-B*1502 genotype<br />
alluded to above. In the Han Chinese the<br />
correlation is extremely strong (OR=2504), but<br />
the same genotype is not correlated with SJS or<br />
TEN in other Asian populations. In black <strong>South</strong><br />
<strong>African</strong>s, there is a dearth of information, although<br />
research institutions like the SBIMB (Sydney Brenner<br />
Institute for Molecular Bioscience, University of the<br />
Witwatersrand), the Genomics Research Institute<br />
(University of Pretoria), and others have research<br />
programmes underway to address this gap in<br />
knowledge.<br />
AS WITH SO MANY ASPECTS OF HEALTH<br />
IN SA, DECISION-MAKING TRENDS DIFFER<br />
BETWEEN THE PRIVATE AND PUBLIC<br />
SECTORS. THESE DIFFERENCES MIRROR<br />
THE EXTREME INEQUALITY AMONG<br />
DIFFERENT POPULATION GROUPS IN SA.<br />
IN THE IDEAL SCENARIO, KNOWING THE<br />
INDIVIDUAL’S GENOTYPE IS SOMETIMES<br />
HELPFUL, BECAUSE IT MAY PROVIDE AN<br />
ADDITIONAL LAYER OF INFORMATION TO<br />
PATIENT MANAGEMENT.<br />
This is especially true if the individual is not responding<br />
as expected to a particular drug regimen. In other<br />
instances, there is simply not enough information<br />
and knowing an individual’s genotype may<br />
have no bearing whatsoever on current patient<br />
management.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 29
FEATURE<br />
CONCLUDING REMARKS AND<br />
RECOMMENDATIONS<br />
The most sensible path to follow seems that (i)<br />
where there are sufficient supporting data, (ii) these<br />
are applicable to the ethnicity of the person in<br />
question, and (iii) the information will impact patient<br />
management, then pharmacogenetic testing is<br />
appropriate. This is, of course, resource permitting.<br />
IN OTHER SCENARIOS WHERE THERE<br />
ARE INSUFFICIENT DATA, STANDARD<br />
CLINICAL JUDGEMENT IS WARRANTED.<br />
THIS SECOND SCENARIO IS CURRENTLY<br />
LIKELY TO BE THE PREVAILING ONE IN<br />
MOST SOUTH AFRICAN PATIENTS.<br />
PHARMACOGENETICS<br />
SOLUTIONS IN PSYCHIATRY<br />
bonosi genomics, a division of Inqaba<br />
Biotechnical Industries (Pty) Ltd,<br />
offers several human molecular<br />
genetic assays.<br />
BOX 1. The Agena MassARRAY iPLEX platform for SNP<br />
genotyping<br />
Following DNA extraction, the sample is subjected<br />
to targeted PCR amplification of several regions<br />
of CYP gene family. This is followed by primer<br />
extension with the iPLEX extension reaction. The<br />
extension products are desalted and dispensed<br />
onto a SpectroCHIP Array and detected via mass<br />
spectrometry using the MassARRAY technology<br />
(credit: Agena Biosciences).<br />
Cost-effective solution for<br />
pharmacogenetics (PGx) testing using<br />
the Agena MassARRAY system. The<br />
assay provides simultaneous testing<br />
of key pharmacogenetics variants and<br />
copy number variation analysis.<br />
Aron Berhanie Abera is currently employed as a technical<br />
support manager at Inqaba Biotechnical Industries (Pty)<br />
Ltd, Pretoria, <strong>South</strong> Africa. He runs the MassARRAY SNP<br />
genotyping platform at Inqaba Biotechnical Industries.<br />
Originally from Eritrea he completed his undergraduate<br />
study at University of Asmara, Eritrea, in 2001 and was<br />
awarded a scholarship to pursue postgraduate studies in<br />
<strong>South</strong> Africa. He completed a Master’s degree in Human<br />
Genetics, a Doctoral degree in Medical Biochemistry and<br />
five-years of postdoctoral research in the Department of<br />
Medical Biochemistry all through the University of Cape<br />
Town. Correspondence: aron.abera@inqababiotec.<br />
co.za<br />
Inqaba Biotechnical Industries (Pty) Ltd.<br />
PO Box 14356, Hatfield 0028<br />
Pretoria, <strong>South</strong> Africa<br />
Tel: +27 12 343 5829<br />
E-mail: orders@bonosigenomics.co.za<br />
www.inqababiotec.co.za<br />
TECHNICAL ENQUIRIES<br />
Dr AB Abera<br />
Technical Support Manager<br />
aron.abera@inqababiotec.co.za<br />
PATHOLOGY ENQUIRIES<br />
Dr PM Durand<br />
Consultant Molecular Pathologist<br />
pierre.durand@wits.ac.za<br />
30 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
Biological <strong>Psychiatry</strong> Congress<br />
<strong>2019</strong><br />
‘The Changing Landscape of <strong>Psychiatry</strong>, Neuroscience and Technology’<br />
FRIDAY 20 SEPTEMBER – MONDAY 23 SEPTEMBER,<br />
CENTURY CITY CONFERENCE CENTRE, CAPE TOWN, SOUTH AFRICA<br />
Abstract Submissions:<br />
http://biopsychsa.co.za/index.php/<br />
abstracts-bio/abstract-submission<br />
The deadline for the submission of abstracts is<br />
20 April <strong>2019</strong><br />
Registrars and postgraduate students are specifically invited to present.<br />
OUTLINE OF PROGRAMME<br />
Friday 20 September <strong>2019</strong>:<br />
10:00 – 11:00 Registration for morning workshops<br />
11:00 – 13:30 Workshops<br />
13:30 – 14:30 Lunch for all workshop delegates<br />
14:00 – 14:30 Registration for afternoon workshops<br />
14:30 – 17:00 Workshops<br />
17:00 – 21:00 Registration for congress opens<br />
17:15 – 17:45 Official opening of congress<br />
17:45 – 18:30 Keynote address<br />
18:30 – 20:30 Welcome Cocktail Function in exhibition area<br />
Saturday 21 September <strong>2019</strong>:<br />
07:00 – 08:15 Trade sponsored breakfast symposia<br />
08:30 – 17:00 Scientific Sessions<br />
17:30 Trade sponsored dinner symposium<br />
Sunday 22 September <strong>2019</strong>:<br />
07:00 – 08:15 Trade sponsored breakfast symposia<br />
08:30 – 17:00 Scientific Sessions<br />
19:00 Congress Dinner & Awards<br />
Monday 23 September <strong>2019</strong>:<br />
07:00 – 08:15 Trade sponsored breakfast symposium<br />
08:30 – 11:00 Scientific Sessions<br />
11:00 – 11:15 Closing of congress<br />
FRIDAY 20 SEPTEMBER – MONDAY 23 SEPTEMBER,<br />
CENTURY CITY CONFERENCE CENTRE, CAPE TOWN, SOUTH AFRICA<br />
Register at: http://biopsychsa.co.za/index.php/registration/full-registration
Welcome to Vancouver<br />
14 th World Congress<br />
of Biological <strong>Psychiatry</strong><br />
Neuroscience Discoveries and<br />
Translation to Clinical Practice<br />
2 – 6 June <strong>2019</strong><br />
Vancouver, Canada<br />
Vancouver Convention<br />
Centre East<br />
PLENARY SPEAKERS<br />
a Elizabeth Blackburn, USA<br />
a Leroy Hood, USA<br />
a George Koob, USA<br />
www.wfsbp-congress.org<br />
Organised by: World Federation of Societies of Biological <strong>Psychiatry</strong><br />
Hosted by the Canadian Network for Mood and<br />
Anxiety Treatments (CANMAT)
FEATURE<br />
THE CHALLENGES OF<br />
PERINATAL<br />
DEPRESSION<br />
Carina Marsay<br />
Perinatal depression can be defined as<br />
depression occurring any time from conception,<br />
including during pregnancy and into the first<br />
postpartum year. Rates of perinatal depression<br />
in high income countries (HIC) are reported at<br />
about 13% of all perinatal women, but there is a<br />
significantly higher rate of perinatal depression in<br />
low and middle income countries (LMICs), ranging<br />
from approximately 15 to 20% . Studies conducted<br />
in LMICs report higher prevalence rates as socially<br />
and economically disadvantaged women are<br />
more vulnerable to perinatal depression. 1,2 Maternal<br />
depression has serious consequences, resulting in<br />
significant morbidity and even mortality for both<br />
mothers and infants.<br />
PARTICULARLY IN LMICs, MOTHERS FACE<br />
PHYSICAL AND LOGISTICAL CHALLENGES,<br />
INCLUDING CARING FOR AN INFANT<br />
IN CONTEXTS OF POOR SANITATION,<br />
OVERCROWDING, FOOD INSECURITY,<br />
AND POOR SOCIAL SUPPORT. THESE<br />
DIFFICULTIES ARE COMPOUNDED FOR<br />
WOMEN WITH DEPRESSION, IN WHOM THE<br />
SYMPTOMS − INCLUDING ANHEDONIA,<br />
IMPAIRED COGNITION, LOW MOOD AND<br />
ENERGY LEVELS − IMPACT ON THEIR<br />
ABILITY TO CARE FOR THEIR INFANTS’<br />
PHYSICAL AND EMOTIONAL NEEDS. 3<br />
The daily demands of early infant care are more<br />
difficult to negotiate when functioning is suboptimal<br />
as a result of depression. 4 As a result, infants and<br />
children of depressed mothers have poorer physical,<br />
cognitive and emotional outcomes. In these<br />
settings, poor maternal mental<br />
health during the antenatal period<br />
is a risk factor for low birth weight<br />
and preterm delivery. 5,6 Postnatally,<br />
malnutrition, poor infant growth,<br />
and increased frequency of infant<br />
diarrheal illness are prevalent,<br />
which may be related to the<br />
early cessation of breastfeeding<br />
in depressed mothers living in<br />
Carina Marsay<br />
poverty. 7 This can lead to an increase<br />
in child mortality. 8 The emotional development of<br />
infants is compromised because of a disturbed<br />
mother-infant relationship, where mothers are less<br />
sensitive towards their infants and infants are less<br />
responsive towards mothers. 9 This in turn leads to<br />
poorer quality attachment, resulting in behavioural<br />
and psychological difficulties that can last into<br />
adolescence and adulthood. 10 Compromised<br />
cognitive functioning and delayed development<br />
also affect infants and children of depressed mothers,<br />
impacting on their scholastic achievement. 11 In the<br />
context of chronic social and economic adversity, as<br />
experienced by poor women in both high and low to<br />
middle income countries, poor quality parenting as a<br />
result of maternal depression is especially harmful. 10<br />
These adverse outcomes further perpetuate social<br />
and economic inequality.<br />
Poverty and low-socioeconomic status affect more<br />
women numerically and as a proportion of a given<br />
population in low and middle income countries<br />
as compared to women in high income countries,<br />
making them vulnerable to depression. This is<br />
very clear in <strong>South</strong> Africa, where approximately<br />
40% of women living in relative poverty will<br />
experience perinatal depression -- three times the<br />
rate documented in high income countries. 12-14<br />
Historically significant racial and wealth disparities<br />
34 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
FEATURE<br />
in <strong>South</strong> Africa existed as a result of Apartheid, but<br />
these have yet to be redressed. The country still faces<br />
many social, political and economic challenges and<br />
is one of the most economically unequal countries<br />
in the world, with a Gini co-efficient of 0.7.<br />
THE TOP 10% OF THE POPULATION<br />
CONTRIBUTE (AND BENEFIT FROM)<br />
58% OF THE INCOME AND THE BOTTOM<br />
10% ONLY 0.5%. THIS IS RELEVANT AS<br />
ECONOMIC AND SOCIAL FACTORS<br />
CONTRIBUTE TO HEALTH EQUITY AND THE<br />
GENERAL HEALTH OF A SOCIETY. THIS<br />
IS SIGNIFICANT AS SOCIAL INJUSTICE<br />
IMPACTS NEGATIVELY ON HEALTH AND<br />
HEALTH EQUALITY. 15 THE HIGH RATES OF<br />
PERINATAL DEPRESSION MAY BE RELATED<br />
TO THE COMPOUNDING NATURE OF<br />
MULTIPLE ECONOMIC, SOCIAL AND<br />
PSYCHOSOCIAL STRESSORS.<br />
These including poverty and unemployment,<br />
intimate partner violence, lack of partner support,<br />
unplanned pregnancy, and the high prevalence<br />
of HIV in pregnant women (39-45%), including<br />
diagnosis of HIV infection in the course of antenatal<br />
care. 12,13,16-19 Similar associations have been found in<br />
other low and middle income countries.<br />
A SYSTEMATIC REVIEW CONDUCTED IN<br />
2012, INCLUDING VARIOUS COUNTRIES<br />
FROM BOTH ASIA AND AFRICA,<br />
FOUND THAT SOCIOECONOMIC<br />
DISADVANTAGE COMPRISING OF FOOD<br />
INSECURITY, FINANCIAL DIFFICULTIES,<br />
UNEMPLOYED PARTNER AND LOW<br />
INCOME WERE ASSOCIATED WITH<br />
PERINATAL DEPRESSION.<br />
In addition, social disadvantage comprising of<br />
poor emotional support and lack of empathy<br />
from partners, having hostile in-laws and having<br />
insufficient practical and emotional support,<br />
contributed to the risk of perinatal depression. 1<br />
From this, it is clear that maternal depression has<br />
multiple etiologies, and cannot be solely explained<br />
by women’s biological and psychological<br />
vulnerability. Rather, social and environmental<br />
factors are important contributing factors and<br />
determinants of risk and sociocultural context<br />
impacts both prevalence and presentation of<br />
perinatal depression. 20,21<br />
Recently there has been an increased awareness<br />
that mental health is a vital part of public health in<br />
<strong>South</strong> Africa. About 16.5% of <strong>South</strong> <strong>African</strong>s suffer<br />
from common mental disorders. 22 In responding<br />
to this, most provincial health services support<br />
the integration of mental health in primary health<br />
care, run by primary health care nurses who have<br />
undergraduate training in mental health. These<br />
nurses are able to continue prescriptions while<br />
primary health care doctors initiate prescriptions<br />
with drugs available on the essential medicines list.<br />
Mental illness cannot be viewed in isolation,<br />
however, as many social, political and economic<br />
factors, including those elucidated above, play a<br />
role in epidemiology of the illness. In <strong>South</strong> Africa,<br />
the country’s high rate of mental health disorders,<br />
including perinatal depression, is exacerbated<br />
by high levels of violence, social and economic<br />
exclusion and racial discrimination, as existed<br />
under colonialism and apartheid, and as a result of<br />
apartheid’s continued legacy.<br />
ONE OF THE KEY OBJECTIVES OF SOUTH<br />
AFRICA’S MENTAL HEALTH CARE ACT<br />
2002 (NO. 17 OF 2002) IS TO INTEGRATE<br />
THE PROVISION OF MENTAL HEALTH<br />
CARE SERVICES INTO THE GENERAL<br />
HEALTH SERVICES ENVIRONMENT. 23<br />
THIS IS FURTHER SUPPORTED BY THE<br />
SUBSEQUENT NATIONAL MENTAL HEALTH<br />
POLICY FRAMEWORK AND STRATEGIC<br />
PLAN 2013-2020, 24 IN WHICH MATERNAL<br />
MENTAL HEALTH IS INCORPORATED<br />
INTO THE GENERAL MENTAL HEALTH<br />
ENVIRONMENT, INCLUDING THROUGH<br />
THE TREATMENT OF PERINATAL<br />
DEPRESSION AND ANXIETY AT ANTENATAL<br />
AND POSTNATAL CLINICS.<br />
The policy states:<br />
• Specified micro and community level mental<br />
health promotion and prevention intervention<br />
packages will be included in the core services<br />
provided, across a range of sectors, to address<br />
the particular psychosocial challenges and<br />
vulnerabilities associated with different lifespan<br />
developmental stages. These will include:<br />
Motherhood: treatment programmes for maternal<br />
mental health as part of the routine antenatal<br />
and postnatal care package; and programmes<br />
to reduce alcohol and substance use during and<br />
after pregnancy. Infancy and Early childhood:<br />
programmes to increase maternal sensitivity and<br />
infant-mother attachment.<br />
• Introduce routine indicated assessment and<br />
management of common mental disorders in<br />
priority programmes at PHC level, among others,<br />
antenatal mothers and postnatal care.<br />
In addition, the <strong>South</strong> <strong>African</strong> National Development<br />
Plan 2030 (2012) 25 makes specific reference to<br />
early childhood development by emphasizing the<br />
importance of the first 1000 days of life, describing<br />
how pregnant women need access to both<br />
emotional and material support, and explaining<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 35
FEATURE<br />
that empowered mothers lay a solid foundation for<br />
healthy children. However, despite these policies, the<br />
establishment and provision of integrated mental<br />
health services into antenatal and postnatal clinics<br />
is non-existent in most areas. The Maternal Care<br />
Guidelines are also lacking in achieving these<br />
goals as they have no reference to screening,<br />
assessing or documenting current mental state nor<br />
recommendations regarding stepped referral for<br />
mental health care.<br />
SOUTH AFRICA HAS AN UNACCEPTABLY<br />
HIGH MATERNAL MORTALITY RATE OF<br />
269 PER 100 000 LIVE BIRTHS; OF THESE<br />
60% ARE AVOIDABLE IF EARLY ANTENATAL<br />
CARE IS SOUGHT. 26 ANTENATAL CARE IS<br />
FREE IN SOUTH AFRICA’S PUBLIC HEALTH<br />
SYSTEM AND 91% OF ALL PREGNANT<br />
WOMEN ATTEND AN ANTENATAL<br />
CLINIC AT LEAST ONCE DURING THEIR<br />
PREGNANCY. 26 ANTENATAL CARE IS AN<br />
OPPORTUNITY TO PROVIDE VITAL HEALTH<br />
INFORMATION TO WOMEN ON LIFESTYLE<br />
RISKS AND TO OFFER SOCIAL SUPPORT<br />
AND COUNSELING.<br />
Health promotion and screening can prevent the<br />
severe adverse effects of depression, including<br />
loss of quality of life and the risk of suicide and<br />
neonaticide in extreme cases. Given this, antenatal<br />
care may provide a good opportunity for health<br />
workers to intervene and offer screening and<br />
treatment for antenatal depression. This would be<br />
in line with the move to incorporate mental health<br />
services into primary health care. Preliminary<br />
evidence from a public obstetric facility in Cape<br />
Town suggests that it is feasible and acceptable<br />
to incorporate mental health screening and<br />
depression assessment, with referral, into antenatal<br />
clinics using a task-sharing approach. In another<br />
qualitative study conducted in Johannesburg,<br />
women found the screening process itself, to<br />
be helpful in building awareness and effecting<br />
behaviour change. 27<br />
HEALTH EQUITY SHOULD BE OUR AIM<br />
IN SOUTH AFRICA IN AN ATTEMPT TO<br />
ADDRESS HISTORICAL INEQUALITY. THIS<br />
CAN BE IMPROVED BY IMPLEMENTING<br />
UNIVERSAL SCREENING ON A NATIONAL<br />
LEVEL FOR COMMON MENTAL<br />
DISORDERS IN PERINATAL WOMEN. THE<br />
WHOOLEY CASE FINDING QUESTIONS<br />
ARE TWO CASE-FINDING QUESTIONS<br />
THAT REQUIRE ONLY A YES OR NO<br />
RESPONSE. THEY CAN IDENTIFY ANXIETY<br />
AND DEPRESSION WITH REASONABLE<br />
ACCURACY.<br />
They are short and do not require literacy, or scoring<br />
and interpretation like pencil and paper tests, and so<br />
are more time-effective. They have been validated in<br />
urban women attending a high-risk antenatal clinic<br />
in Johannesburg. 28 These two questions address<br />
symptoms of depression that are necessary but not<br />
sufficient to make a diagnosis of depression: “During<br />
the past month, have you often been bothered by<br />
feeling down, depressed or hopeless?” and “During<br />
the past month, have you often been bothered by<br />
little interest or pleasure in doing things?”<br />
A BRIEF AND VALIDATED SCREENING<br />
TOOL THAT CAN IDENTIFY DEPRESSION<br />
AND ANXIETY IN SOUTH AFRICAN<br />
PERINATAL WOMEN WOULD BE A<br />
VALUABLE ADDITION TO UPDATE THE<br />
ADULT PRIMARY CARE GUIDELINE AND<br />
FOR INCLUSION IN THE MATERNAL CARE<br />
GUIDELINES AND AMENDMENTS TO THE<br />
MATERNITY CASE RECORD (ANTENATAL<br />
CLINIC CARD).<br />
References<br />
1. Fisher J, Mello MCd, Patel V, Rahman A, Tran T,<br />
Holton S, et al. Prevalence and determinants of<br />
common perinatal mental disorders in women<br />
in low-and lower-middle-income countries: a<br />
systematic review. Bulletin of the World Health<br />
Organization. 2012;90(2):139-49.<br />
2. Witt WP, DeLeire T, Hagen EW, Wichmann MA,<br />
Wisk LE, Spear HA, et al. The prevalence and<br />
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3. Field T. Postpartum depression effects on early<br />
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4. Parsons CE, Young KS, Rochat TJ, Kringelbach<br />
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5. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar<br />
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7. Stewart RC. Maternal depression and infant<br />
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8. Deyessa N, Berhane Y, Emmelin M, Ellsberg<br />
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9. Cooper PJ, Tomlinson M, Swartz L, Woolgar M,<br />
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10. Stein A, Pearson RM, Goodman SH, Rapa E,<br />
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11. Murray L, Arteche A, Fearon P, Halligan S,<br />
Croudace T, Cooper P. The effects of maternal<br />
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12. Hartley M, Tomlinson M, Greco E, Comulada WS,<br />
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13. Manikkam L, Burns JK. Antenatal depression and<br />
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14. Rochat TJ, Tomlinson M, Bärnighausen T, Newell<br />
M-L, Stein A. The prevalence and clinical<br />
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15. Marmot M, Friel S, Bell R, Houweling TA, Taylor S,<br />
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Closing the gap in a generation: health equity<br />
through action on the social determinants of<br />
health. The lancet. 2008 Nov 8;372(9650):1661-9.<br />
16. Health Systems Trust. “ HIV prevalance %<br />
antenatal.” Health Statistics. 2013 [cited 2016<br />
June].Available from: http://www.healthlink.<br />
org.za/healthstats/13/data<br />
17. Davies TS, M; Nyatsanza, M; Lund, C. “The sun<br />
has set even though t is morning”: Experiences<br />
and explanatins of perinatal depression in<br />
an urban township, Cape Town. Transcultural<br />
<strong>Psychiatry</strong>.53(3):286-312.<br />
18. Kathree T, Selohilwe OM, Bhana A, Petersen I.<br />
Perceptions of postnatal depression and health<br />
care needs in a <strong>South</strong> <strong>African</strong> sample: the<br />
“mental” in maternal health care. BMC Women’s<br />
Health. 2014;14(1):140.<br />
19. Mathews S, Abrahams N, Martin LJ, Vetten L,<br />
Van Der Merwe L, Jewkes R. A national study<br />
of female homicide in <strong>South</strong> Africa. CiteSeeer.<br />
2004.<br />
20. Chen Y-Y, Subramanian S, Acevedo-Garcia<br />
D, Kawachi I. Women’s status and depressive<br />
symptoms: a multilevel analysis. Social Science<br />
& Medicine. 2005;60(1):49-60.<br />
21. Patel V, Lund C, Hatherill S, Plagerson S, Corrigall<br />
J, Funk M, et al. Mental disorders: equity and<br />
social determinants. Equity, social determinants<br />
and public health programmes. 2010;115.<br />
22. Herman AA, Stein DJ, Seedat S, Heeringa SG,<br />
Moomal H, Williams DR. The <strong>South</strong> <strong>African</strong> Stress<br />
and Health (SASH) study: 12-month and lifetime<br />
prevalence of common mental disorders. SAMJ:<br />
<strong>South</strong> <strong>African</strong> Medical Journal. 2009;99(5):339-<br />
44.<br />
23. Mental Health Care Act (No17 of 2002), (2002).<br />
24. National Department of Health. National<br />
mental health policy framework and strategic<br />
plan 2013-2020. Government Printer Pretoria;<br />
2012<br />
25. National Planning Commission. National<br />
Development Plan 2030: Our future–make it<br />
work. Pretoria: National Planning Commission.<br />
2012.<br />
26. Amnesty International. Struggle for maternal<br />
health: barriers to antenatal care in <strong>South</strong> Africa.<br />
London 2014. [cited 2017 November] Avaiable<br />
from: https://www.health-e.org.za/wp-content/<br />
uploads/2014/10/Struggle-for-Maternal-Heath-.<br />
pdf<br />
27. Marsay C, Manderson L, Subramaney U.<br />
Changes in mood after screening for antenatal<br />
anxiety and depression. Journal of reproductive<br />
and infant psychology. 2018 Mar 30:1-6.<br />
28. Marsay C, Manderson L, Subramaney U.<br />
Validation of the Whooley questions for<br />
antenatal depression and anxiety among lowincome<br />
women in urban <strong>South</strong> Africa. <strong>South</strong><br />
<strong>African</strong> Journal of <strong>Psychiatry</strong>. 2017;23(1).<br />
Carina Marsay is a specialist psychiatrist. She obtained her FC Psych (SA) in 2009 and her MMed (Psych) in 2010. Dr Marsay has a<br />
PhD from the University of Witwatersrand related to her work in perinatal psychiatry and is an honorary appointee in the Department<br />
of <strong>Psychiatry</strong> at Wits. She is a recipient of the MRC Clinician Researcher Programme Scholarship. Dr Marsay has an interest in perinatal<br />
psychiatry and is a member of the International Marcé Society, an organisation dedicated to perinatal mental health. Correspondence:<br />
carinamarsay@gmail.com<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 37
NEWS<br />
VISITING PROFESSOR – SEMINAR<br />
Christopher Paul Szabo, in his capacity as a<br />
Visiting Professor at the University of Belgrade’s<br />
School of Medicine and at the invitation of<br />
the Serbian Psychiatric Association and the<br />
Institute for <strong>Psychiatry</strong> in Belgrade, presented<br />
a seminar on eating disorders to specialist<br />
trainees on the 12 th <strong>February</strong> <strong>2019</strong><br />
Prof. Szabo – right, front row - with trainees<br />
Adj Prof. Ugash Subramaney has been<br />
appointed as the new Academic Head as<br />
of the 1 st March <strong>2019</strong> (until 28 th <strong>February</strong><br />
2024), succeeding Prof. Christopher Paul<br />
Szabo who served from 1 st November 2009<br />
until 28 th <strong>February</strong> <strong>2019</strong><br />
GRADUATIONS – PHD / DSc: DECEMBER<br />
2018<br />
Carina Marsay was awarded her PhD for her work on<br />
perinatal mental health and Christopher Paul Szabo a DSc<br />
for his work related to eating disorders<br />
ASSISTANT HEAD OF SCHOOL –<br />
NEW APPOINTMENT<br />
Ass Prof. Bernard Janse van Rensburg has<br />
been appointed as an Assistant Head of<br />
School in the School of Clinical Medicine as<br />
of the 1 st March <strong>2019</strong><br />
Carina Marsay, Christopher Paul Szabo<br />
38 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
NEWS<br />
TRIBUTE TO PROF BONGANI MAYOSI<br />
The HOD, Prof Dan Stein, paid tribute to the memory of Prof Bongani Mayosi, following his tragic suicide.<br />
Prof Mayosi represented many values that the Department and University hold dear, including mentorship,<br />
comradeship, and a true passion for knowledge.<br />
We owe Prof Mayosi’s family a huge debt of gratitude for immediately speaking about his depression. This has<br />
raised the awareness of the profession and the country of the importance of common mental disorders, and<br />
gives us hope for the future.<br />
Prof Mayosi, amongst his many contributions, advocated for more PhDs in <strong>South</strong> Africa, as well as increased<br />
specialty and sub-specialty training, within the context of the primary health care approach.<br />
WELCOME TO STAFF<br />
Dr Bhaskaran Charles as a Senior Registrar in Liaison <strong>Psychiatry</strong>.<br />
Dr Kokes Moloto as Psychiatrist Consultant in Male Admissions at Lentegeur hospital.<br />
Dr Nisaar Dawood as Community Psychiatrist at Mitchells Plain hospital<br />
GOODBYE TO GRAEME HENDRICKS<br />
The Division of Psychotherapy bade farewell to Clinical<br />
Psychologist Graeme Hendricks on 4 December. The<br />
Department thanked him for his invaluable contributions to<br />
the Addictions diploma and teaching and wished him well on<br />
his adventures abroad<br />
CONGRATULATIONS<br />
Congratulations to Nyameka<br />
Dyakalashe on passing<br />
the Certificate in Forensic<br />
<strong>Psychiatry</strong>.<br />
Prof Sean Kaliski is also<br />
congratulated for initiating<br />
this degree, a first in Africa<br />
and a key step forwards for<br />
the discipline.<br />
Fleur Howells has been<br />
Nyameka Dyakalashe<br />
promoted to Associate<br />
Professor, reflecting her<br />
significant contributions to translational<br />
neuroscience.<br />
Nastassja Koen has been promoted to Senior<br />
Lecturer. She has made significant contributions<br />
in psychiatric genetics with ongoing grants and<br />
work in epigenetics, particularly as related to<br />
psychological trauma.<br />
Simone Honikman has been promoted to<br />
Associate Professor, reflecting her significant<br />
contributions to perinatal mental health.<br />
Prof Dan Stein congratulated the following people<br />
on their respective academic achievements:<br />
Goodman Sibeko, John-Joe Dawson-Squibb,<br />
Tania Swart, Erica Breuer (thesis about theory<br />
of change in the context of the work of the<br />
Division of Public Mental Health on PRIME),<br />
Jean-Paul Fouche (thesis on brain imaging in<br />
adolescent HIV/AIDS), Stephanie Sieberhagen<br />
and Memory Munodawafa (thesis on “Filling<br />
the gap: development and qualitative process<br />
evaluation of a task sharing psycho-social<br />
counselling intervention for perinatal depression<br />
in Khayelitsha, <strong>South</strong> Africa”) for obtaining their<br />
PHDs.<br />
To Aubrey Kumm and Marisa Viljoen for obtaining<br />
their M Med (Neuroscience) degrees.<br />
To Judith Boshe, Jessica Stanbridge, John-Randal<br />
Vermaak Carmen Vlotman, Michelle Barnard,<br />
Nizaar Dawood, Nada Lagerstrom and Mwanja<br />
Chundu for passing their FCPsych (SA) Part II<br />
exams.<br />
To Deidre Pieterse for obtaining her M Phil in<br />
Liaison <strong>Psychiatry</strong> and Lisa Dannatt for obtaining<br />
her M Phil in Addictions1 <strong>Psychiatry</strong>.<br />
To Deirdre Pieterse and all those who contribute<br />
to the mentoring of interns; the HPCSA visited in<br />
July, and after speaking with interns about their<br />
experience in <strong>Psychiatry</strong>, gave the department a<br />
5/5 assessment.<br />
Thanks also to Peter Ashman who long led the<br />
internship program in the department<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 39
NEWS<br />
ADDICTION PSYCHIATRY - NEW HEAD<br />
OF DIVISION<br />
By Dan Stein<br />
A vote of thanks is given to key staff members of the<br />
Division of Addiction <strong>Psychiatry</strong>, namely Don Wilson<br />
as the first Head, Sharon Kleintjes as its first SFARS<br />
lecturer, Henk Temmingh succeeding Don Wilson,<br />
Graeme Hendricks SFARS, Lisa Dannatt and Bronwyn<br />
Myers, who have all contributed in strengthening the<br />
Division.<br />
CHILD AND ADOLESCENT PSYCHIATRY<br />
AND MENTAL HEALTH DCAP<br />
WORKSHOPS ON ODD<br />
By Willem de Jager<br />
Goodman Sibeko (SFARS, Director of the Addictions<br />
Training and Technology Centre), is succeeding<br />
Henk Temmingh as the new head of the Division,<br />
while the latter will continue as Deputy Head.<br />
Goodman and Henk are thanked for taking on their<br />
important portfolios<br />
EQUINE-ASSISTED PSYCHOTHERAPY<br />
The Forensic Unit at Valkenberg Hospital conducted<br />
an equine-assisted psychotherapy program for state<br />
patients for the past four years. The unit looks forward<br />
to continue with this innovative therapy in <strong>2019</strong> and<br />
beyond<br />
Two DCAP Psychologists, Jon Yako and Willem de<br />
Jager, organised a two-part workshop, respectively<br />
in November 2017 and October 2018, to assist<br />
clinicians and health workers in addressing the<br />
increase in referrals to Child and Adolescent Mental<br />
Health Services (CAMHS)<br />
GENERAL ADULT PSYCHIATRY - EARLY INTERVENTION, SUPPORT AND HEALTH – EISH!<br />
By Naaheeda Allie<br />
“EISH”, an outpatient program run by the Valkenberg Hospital Outpatient Department aims to assist mental<br />
health service users, and their families, who are in the earlier stages of severe mental illness, to come to terms<br />
with the condition.<br />
It shifts the focus of healthcare provision from a traditional biomedical perspective of wellness to a more holistic<br />
approach to wellness.<br />
INTELLECTUAL DISABILITY - SYMPOSIUM<br />
ON CHANGING THE PARADIGM TO<br />
ENABLE PARTICIPATION AND MEANINGFUL<br />
LIVES FOR PWID<br />
By Toni Abrahams<br />
At a symposium on 2 nd October 2018, the Division of<br />
Intellectual Disability co-convened a one-day seminar<br />
with UCT’s Division of Disability Studies, hosting a<br />
delegation from the American Association of Intellectual<br />
and Developmental Disabilities (ASIDD).<br />
The theme “Changing the paradigm: Enabling<br />
Participation and meaningful lives for people with<br />
Intellectual Disability” was highlighted through<br />
presentations from a wide array of stakeholders,<br />
including self-advocates and caregivers, NGO’s, health<br />
practitioners, managers and academics.<br />
Prof Sharon Kleintjes, Judith McKenzie and Colleen<br />
Adnams chaired the sessions. It was an inspiring<br />
symposium and one could not end the day without<br />
feeling re-energised to work towards actualising the<br />
mantras “leave no one behind” and “nothing about us,<br />
without us”<br />
40 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
NEWS<br />
NEUROPSYCHIATRY - TAKING INVENTORY ON 2018, HIV<br />
MENTAL HEALTH RESEARCH UNIT<br />
By Sybil Majokweni and Kareema Poggenpoel<br />
The HIV Mental Health Research Unit (HIVMHRU) achieved its goal in 2018 to<br />
foster more collaboration and enlarge its footprint in HIV and mental health<br />
research.<br />
New members were welcomed to the team while two study start-ups were<br />
initiated, namely The Inkumbulo study which was started in 2018. The aims are<br />
to investigate sex differences in HIV-associated neurocognitive impairment and<br />
the factors contributing to possible sex differences, as well as determining the<br />
relationship between depression, HIV-associated neurocognitive impairment<br />
and adherence to anti-retroviral therapy.<br />
The second study, a Hybrid Effectiveness-Implementation Trial for ART<br />
Adherence and Substance Use in HIV Care in <strong>South</strong> Africa, better known as<br />
Project Khanya, started in August 2018<br />
EXPANDING OUR FOOTPRINT<br />
By Sam Nightingale and Kareema Poggenpoel<br />
Sam Nightingale, a neurologist from the<br />
UK, joined Prof John Joska in the Division<br />
of Neuropsychiatry. Sam is expanding his<br />
footprint in the department as he has recently<br />
been awarded a large grant from the Newton<br />
Fund. The venture will run a collaborative <strong>South</strong><br />
Africa – UK project looking at cognition and<br />
neuropsychiatric symptoms in people living with<br />
HIV before and after switching from efavirenz to<br />
dolutegravir<br />
CPMH COMMEMORATES WORLD<br />
MENTAL HEALTH DAY WITH<br />
ROUNDTABLE DISCUSSION<br />
By Maggie Marx<br />
To commemorate World Mental Health Day,<br />
10 October 2018, the Alan J Flisher Centre for<br />
Public Mental Health (CPMH) and the Social<br />
Responsiveness Committee of UCT’s Division of<br />
Public Mental Health, arranged a roundtable<br />
discussion (event partly sponsored by the latter<br />
committee).<br />
PUBLIC AND COMMUNITY MENTAL HEALTH<br />
PRIME PRESENTS FINDINGS AROUND THE<br />
WORLD<br />
By Maggie Marx<br />
Over the last few months, led from the Alan J Flisher the<br />
Centre for Public Mental Health (CPMH) at the University of<br />
Cape Town, the Programme for Improving Mental Health<br />
Care (PRIME) saw its researchers busily disseminating<br />
their findings across the globe.<br />
This is, amongst other events, underscored by the fact<br />
that PRIME researchers, including UCT’s Prof Crick<br />
Lund, formed part of the Lancet Global Mental Health<br />
Commission which recently launched its report on World<br />
Mental Health Day at the Global Ministerial Mental Health<br />
Summit<br />
Three researchers, namely Dr Jason Bantjes, Dr<br />
Tara Carney and Dr Sarah Skeen, were invited<br />
to present on their work relating to this year’s<br />
theme: “Young People Mental Health in a<br />
Changing World.”<br />
Ms Bonnie Mbuli concluded the event by<br />
speaking candidly about her journey with<br />
clinical depression and anxiety<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 41
NEWS<br />
THE PERINATAL MENTAL HEALTH PROJECT’S (PMHP) NEW<br />
OPEN ACCESS RESOURCES<br />
By Sally Field and Simone Honikman<br />
The PMHP www.pmhp.za.org, located in the Alan J Flisher Centre for Public<br />
Mental Health, has been involved in developing three open access resources.<br />
The PMHP team produced a short training film “Empathic Engagement<br />
Skills”. Feedback from audience (psychiatrists, psychologists, NGO workers)<br />
attending the Malawi launch of the <strong>African</strong> Alliance for Maternal Mental<br />
Health, demonstrated that the film was relevant and appropriate for the<br />
Malawian setting.<br />
Together with Digital Medic <strong>South</strong> Africa, an initiative of the Stanford University Center for Health Education<br />
and “Grow Great” at the DG Murray Trust, the PMHP developed an animated film aimed at mothers and<br />
community level service providers in low-resource settings. All training videos are openly accessible on the<br />
PMHP YouTube channel<br />
ARTISTIC MURAL TO CHANGE NEGATIVE PERCEPTION OF MENTAL HEALTH<br />
By John Parker<br />
In an exciting collaboration, the Spring Foundation recently partnered with Arting Health For Impact (AFHI), a<br />
collaborative public engagement project that explores collaboration with artists to improve and engagement<br />
methods.<br />
The project involved 25 in- and outpatients from the Child and Adolescent Mental Health Service. It aimed to<br />
develop a collective understanding of participants experiences during their health journey.<br />
The mural was completed by experienced and professional muralists during a Mental Health Engagement<br />
Event and focused on relaying messages of support, recovery and hope. The completed mural would be visible<br />
by the community via Highlands Drive<br />
42 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
NEWS<br />
DRIVING THE LEGACY<br />
By Marina Lawrence (for the DCHS Social<br />
Responsiveness Team)<br />
On 18 th July 2018, we celebrated Mandela’s 100th<br />
birthday, and the Mandela Foundation encouraged us<br />
to live the legacy. UCT’s Drakenstein Child Health Study<br />
(DCHS) Social Responsiveness team partnered with<br />
local and international organizations to facilitate the<br />
construction of a library at an under-resourced school<br />
in Mbekweni, Paarl.<br />
The DCHS also partnered with the Val de Vie Foundation,<br />
Breadline Africa, Solomon Schechter Day School (USA),<br />
Biblionef, and West End United Methodist Church (USA)<br />
to construct and stock a library at Langabuya Primary<br />
School in Mbekweni.<br />
Learners now have access to books written in their<br />
home language, as well as in English, which provides an<br />
opportunity for reading and literacy skills development<br />
and potential improvement on long-term educational<br />
outcomes<br />
HEALING CHOCOLATES<br />
By John Parker<br />
In a beautiful collaboration, Chocolate Time and the Spring Foundation took students to the Peter Clarke Art<br />
Centre on a journey of self-discovery that involved thinking about mental illness and how this is dealt with in our<br />
society. Students were then challenged to produce designs for chocolate wrappers that reflected what they<br />
had learnt.<br />
The winning designs have been used to produce wrappers for a range of chocolates that will be sold to raise<br />
funds for the Spring Foundation. The beautiful artworks were exhibited to the public at Lentegeur Hospital’s<br />
adolescent unit and UCT Faculty of Health Sciences<br />
THE VOICE PROJECT / SOCIAL<br />
RESPONSIVENESS<br />
Valkenberg hosted a Voice Workshop which was<br />
arranged by the <strong>South</strong> <strong>African</strong> Society of Psychiatrists<br />
Western Cape Subgroup on 24 th July.<br />
The establishment of the social responsiveness<br />
committee within the UCT <strong>Psychiatry</strong> and Mental<br />
Health Department is a major achievement.<br />
This forum will be a platform for re-envisioning mental<br />
health in <strong>South</strong> Africa and questioning traditional<br />
methods of mental health service delivery which<br />
has compromised access.<br />
The years ahead are likely to be challenging and<br />
contentious. The question is not so much about<br />
whether the state has the will to address mental<br />
health services but rather – do we? And to what<br />
end?<br />
Left to right: ,Karessa Govender, John Parker and Mafoko Phomane who facilitated<br />
The Voice Workshop hosted by Valkenberg and arranged by the <strong>South</strong> <strong>African</strong><br />
Society of Psychiatrists Western Cape Subgroup on 24 th July.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 43
Specialised dementia care in luxurious surroundings<br />
Livewell Villages are luxurious dementia care villages designed with the health and well-being of a person living with<br />
dementia in mind. Inspired by the tranquil setting of a country village and shaped by extensive research, Livewell offers a<br />
safe, serene and stimulating environment where everyone feels included, can remain independent for longer, and can<br />
enjoy a sense of choice and control over their lives. At Livewell, our highest commitment is to the individual.<br />
Our residents’ families can find peace of mind in the knowledge that their loved ones enjoy a good quality of life for<br />
longer, and move forward in their lives with dignity and purpose.<br />
∙ Professional health care and medication management<br />
∙ Luxurious surroundings and personalised comfort<br />
∙ Therapeutic activities and exercise programme<br />
∙ Freedom of Movement and Pet Friendly<br />
∙ Individualised dietary needs<br />
∙ Support groups for families and caregivers<br />
Contact us:<br />
Somerset West<br />
Bryanston<br />
41 Lourens Street 113 Mount Street<br />
Tel: 021 851 6886 Tel: 011 463 8212<br />
enquiriesct@livewell.care<br />
enquiriesjhb@livewell.care<br />
www.livewell.care
UPDATE<br />
SENSORY ROOM<br />
CALMING<br />
FOR THOSE WITH DEMENTIA WHO<br />
ARE SUFFERING FROM ANXIETY<br />
A<br />
dementia care facility in Johannesburg has<br />
developed a ‘sensory room’, an innovative<br />
new international concept in the care of<br />
people with dementia, where light, textures,<br />
movement, sound and décor are used to create a<br />
calming, familiar and comforting environment.<br />
“THE IDEA BEHIND THE SENSORY<br />
ROOM IS TO CREATE A SPACE WHERE<br />
ENVIRONMENTAL FACTORS CAN BE<br />
CAREFULLY CONTROLLED IN ORDER TO<br />
ACHIEVE A CALMING EFFECT FOR THE<br />
INDIVIDUAL WITH DEMENTIA WHO MAY<br />
BE FEELING ANXIOUS OR OVERWHELMED,<br />
WHICH IS UNFORTUNATELY A RELATIVELY<br />
COMMON SYMPTOM OF MORE<br />
ADVANCED DEMENTIA,” EXPLAINS<br />
IVAN OOSTHUIZEN, CHIEF EXECUTIVE<br />
OFFICER OF THE LIVEWELL VILLAGES IN<br />
BRYANSTON AND SOMERSET WEST.<br />
“The considerable benefits of sensory rooms for<br />
people with dementia, which is characterised<br />
by symptoms such as progressive memory loss,<br />
have been demonstrated by some of the most<br />
pioneering dementia care services and practitioners<br />
internationally,” points out Oosthuizen.<br />
“Their experience has shown that for those with<br />
more advanced levels of dementia and Alzheimer’s,<br />
many of whom can suffer bouts of bewilderment<br />
and severe anxiety, a sensory room can greatly<br />
assist in relieving stress and create a sense of<br />
comfort and well-being. As stress commonly has a<br />
negative impact on memory, this form of therapeutic<br />
activity can therefore also often meaningfully assist<br />
in supporting the individual’s memory.”<br />
According to Oosthuizen, Livewell Villages is a<br />
dementia care service that is constantly monitoring<br />
the latest dementia care approaches and trends<br />
globally in order to provide leading-edge care<br />
to residents and those who are making use of its<br />
respite care services. Impressed by the sensory<br />
room concept, which was proving of therapeutic<br />
benefit for many people abroad, the team decided<br />
to investigate the possibility of developing its own<br />
sensory room at its Johannesburg care facility.<br />
“After research and consultations with appropriate<br />
experts, we were able to develop a sensory room<br />
that we believe is ideally suited to local conditions,<br />
as well as completely adaptable to meet the needs<br />
and varying requirements of each our residents with<br />
dementia.<br />
“THE LIVEWELL TEAM IS IMMENSELY<br />
PROUD OF THE RESULT, WHICH TO THE<br />
BEST OF OUR KNOWLEDGE IS THE FIRST<br />
FACILITY OF ITS KIND IN SOUTH AFRICA,<br />
AND AN EXPRESSION OF OUR HIGHLY<br />
INNOVATIVE APPROACH TO CARING<br />
FOR PEOPLE WITH DEMENTIA. WE ARE,<br />
HOWEVER, PARTICULARLY GRATIFIED TO<br />
HAVE BEEN ABLE TO CREATE A PLACE<br />
WHERE THOSE IN OUR CARE CAN SPEND<br />
MANY TRANQUIL AND HAPPY HOURS.”<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 45
UPDATE<br />
Corlia Schutte, occupational therapist at the<br />
Livewell Village in Bryanston, says that it is essential<br />
in dementia care to ensure that the person is<br />
adequately stimulated according to their individual<br />
and constantly evolving needs, but at the same time<br />
they should not feel overwhelmed by an overload of<br />
sensory information.<br />
“THE SENSORY ROOM IS PROVING<br />
POPULAR FOR THOSE RESIDENTS WHO<br />
REQUIRE A PEACEFUL RETREAT AFTER AN<br />
EXCITING DAY OF ACTIVITIES, OR WHO<br />
ENJOY A RICH SENSORY EXPERIENCE<br />
THAT PLEASANTLY STIMULATES THEM. IT<br />
IS ALSO MOST USEFUL IN THOSE CASES<br />
WHERE THE INDIVIDUAL MAY FEEL<br />
FRETFUL AND DISORIENTATED, WHICH<br />
QUITE COMMONLY OCCURS IN PEOPLE<br />
WITH DEMENTIA.”<br />
She says the team meticulously records which<br />
aspects of the room a particular person with<br />
dementia engages with, and what affects this has<br />
on their mood and behaviour. “This is enabling us<br />
to build up a very useful record that helps us to<br />
enhance the room and the experience it creates for<br />
our residents.<br />
WE CAN ALSO USE THIS INFORMATION TO<br />
TAILOR AND ADAPT THE ENVIRONMENT<br />
TO SUIT THE INDIVIDUAL’S MOOD AND<br />
PREFERENCES AT A PARTICULAR TIME.”<br />
The muted lighting in the room is accented with<br />
softly glowing coloured lights, and a soundtrack of<br />
melodious classical music incorporating natural<br />
sounds of birdsong, ocean waves and running water<br />
create a sense of serenity in the room. A soothing<br />
scent of lavender aromatherapy oil permeates the<br />
air – an aroma that is known for its relaxing qualities<br />
for many people, according to Schutte.<br />
Drapery on the ceiling creates the feeling of a<br />
sheltered, cosy womb-like environment, which is also<br />
aesthetically pleasing, while comfortable antique<br />
rocking chairs and ottomans, textiles of various<br />
textures and cool, pale blue green painted walls<br />
are familiar and evocative of peace and safety.<br />
She notes that the sensation of gently rocking in<br />
a rocking chair is particularly comforting for some<br />
people with advanced dementia.<br />
An array of old-fashioned toys, weighted cuddly toys<br />
and dolls are available in the room for people to<br />
hold. “The sensation of cradling a weighted doll is<br />
especially comforting for many of our residents and<br />
we have noted that it often serves to reduce feelings<br />
of agitation or stress. It is believed that certain people<br />
with dementia are drawn to such items because<br />
they replicate similar feelings to that of a parent<br />
caring for a baby.<br />
“Some of our residents are moved to caress and<br />
hum to a doll as a mother will comfort her infant, and<br />
this can be a welcome distraction if the person has<br />
become upset, as it replaces this emotion with more<br />
positive feelings of love and protective, nurturing<br />
instincts,” observes Schutte.<br />
“IN DIFFERENT MOODS, THE SAME<br />
RESIDENT MAY FIND DIFFERENT ASPECTS<br />
OF THE EXPERIENCE OF THE SENSORY<br />
ROOM ENTICING. A CERTAIN RESIDENT<br />
MAY BE FEELING LOW ONE DAY, AND WE<br />
BRING THEM TO THE SENSORY ROOM<br />
AND NOTICE THAT THEY CONCENTRATE<br />
DEEPLY ON THE MUSIC, BECOME MORE<br />
SUBDUED, AND LATER APPEAR TO BE<br />
MORE UPLIFTED AFTER SPENDING TIME<br />
THERE. IN ANOTHER MOOD, THE SAME<br />
RESIDENT MAY STROKE THE SOFT FABRICS<br />
AND HANDLE THE TOYS, AND BE LULLED<br />
INTO A CALMER MOOD.”<br />
She says that at other times, the Livewell team may<br />
find the person is not inclined to spend time in the<br />
room and may prefer to rather be out and about<br />
in the garden watching the birds or picking flowers,<br />
and this is also encouraged.<br />
“While people with dementia may not always be<br />
able to express what they feel like doing, we are so<br />
sensitive to their non-verbal cues that we can usually<br />
tell whether they are in the mood for a particular<br />
activity or environment at a given time, and can<br />
make adjustments for their comfort accordingly.”<br />
“The Sensory Room at Livewell Villages in Bryanston<br />
is proving to be an invaluable tool that is not only<br />
assisting in providing residents with appropriate<br />
levels of stimulation, but is also helping many to deal<br />
with their feelings of agitation and promoting an<br />
improved sense of wellbeing. While these benefits<br />
may seem somewhat intangible, we as carers can<br />
observe the very real difference this facility is making<br />
to the lives of many of our residents,” concludes<br />
Schutte.<br />
For more information about the Livewell Villages and the<br />
services available, please visit: https://livewell.care/<br />
Issued by Martina Nicholson Associates (MNA) on behalf of Livewell Villages Correspondence:martina@mnapr.co.za<br />
46 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
Treatment of psychiatric disorders for people 16 years & older<br />
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Professional and experienced multi-disciplinary team<br />
supervised by specialist psychiatrists<br />
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REPORT<br />
T H I R D<br />
NATIONAL PUBLIC<br />
MENTAL HEALTH<br />
F O R U M<br />
( P M H F )<br />
Richard J. Nichol<br />
This forum took place on the 21 st of September<br />
2018 at the conference venue of the Council<br />
of Scientific and Industrial Research (CSIR) in<br />
Pretoria. It was organized by the Department<br />
of <strong>Psychiatry</strong>, School of Health Sciences, of the<br />
University of the Free State (UFS) in collaboration<br />
with the <strong>Psychiatry</strong> Department of the School of<br />
Health Sciences of the University of Pretoria (UP).<br />
MORE THAN TWENTY PSYCHIATRY<br />
REGISTRARS IN THEIR THIRD YEAR FROM<br />
ALL THE MEDICAL SCHOOLS IN SOUTH<br />
AFRICA, WERE INVITED TO ATTEND THE<br />
FORUM WHICH INTERFACED WITH THE<br />
19 TH NATIONAL CONGRESS OF THE SOUTH<br />
AFRICAN SOCIETY OF PSYCHIATRISTS<br />
HELD AT THE SAME VENUE. A NUMBER<br />
OF HIGHLIGHTS OF THIS FORUM ARE<br />
PRESENTED.<br />
During his opening address Prof Christopher<br />
Paul Szabo (Academic Head – University of the<br />
Witwatersrand) alluded to the theme of the forum:<br />
Public Mental Health; Here, there and everywhere.<br />
He thanked the sponsors of the forum, Mr. Greg<br />
Sinovich on behalf of Sanofi Pharmaceuticals,<br />
SASOP and the Colleges of Medicine of <strong>South</strong><br />
Africa (<strong>Psychiatry</strong>). Prof Szabo continued with a<br />
presentation ‘Introduction to Public Mental Health’.<br />
He related how the first PMHF came<br />
into being in 2015 after he realised<br />
that most psychiatric curricula<br />
of the various medical schools<br />
in <strong>South</strong> Africa lacked adequate<br />
teaching on Public Mental Health.<br />
Subsequently the second PMHF<br />
took place in 2017 in Stellenbosch.<br />
Dr Andre Rose, a consultant in Richard J. Nichol<br />
Community Medicine and currently<br />
the Chairman of the Public Health Association of<br />
<strong>South</strong> Africa (PHASA), discussed Mental Health<br />
Economics. (The world population was estimated to<br />
be 7,7 billion people in December 2018). Quoting<br />
WHO statistics, published in 2018 he informed<br />
the audience of the numbers of people affected<br />
globally (Table I).<br />
Table I: Burden of mental illness:<br />
Disease<br />
Depression<br />
Anxiety Disorders<br />
Bipolar affective disorders<br />
Dementia<br />
Schizophrenia and other<br />
psychoses<br />
Source: WHO, 2018<br />
Number of people<br />
affected globally<br />
300 million<br />
275 million<br />
60 million<br />
50 million<br />
23 million<br />
48 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
REPORT<br />
THIRD NATIONAL PMHF<br />
The 2016 Institute for Health Metrics and Evaluation,<br />
(IHME) statistics concerning ‘the prevalence by<br />
mental and substance use disorder’ internationally,<br />
are noted in Table II.<br />
Table II: Share of the population with a given mental<br />
health or substance use disorder in 2016<br />
Disorder<br />
Prevalence<br />
Anxiety Disorders 3.83 %<br />
Depression 3.77%<br />
Alcohol Use Disorders 1.37%<br />
Drug Use Disorders 0,85%<br />
Bipolar Disorder 0.61%<br />
Schizophrenia 0.29 %<br />
Eating Disorders 0.14%<br />
Source: http://ghdx.healthdata.org/gbd-results-tool.<br />
THE FIGURES ATTEMPT TO PROVIDE<br />
A TRUE ESTIMATE OF THE FINDINGS,<br />
GOING BEYOND REPORTED DIAGNOSIS,<br />
OF DISORDER BASED ON MEDICAL,<br />
EPIDEMIOLOGICAL DATA SURVEYS<br />
AND MET-REGRESSION MODELLING.<br />
DR. ROSE WENT ON TO EXPLAIN THAT IN<br />
2014 A PERSON HAVING DEPRESSION<br />
AND ANXIETY FACED A REDUCTION<br />
OF PERSONAL INCOME OF $ 4798,<br />
(PER ADULT ANNUALLY) RESULTING IN<br />
A $3.6 BILLION ANNUAL NATIONAL<br />
LOSS IN SOUTH AFRICA. IN CONTRAST<br />
A NIGERIAN STUDY ESTIMATED THE<br />
NATIONAL LOSS TO BE $166.2 MILLION<br />
ANNUALLY. THE ANNUAL PRODUCTIVITY<br />
LOSS IN KENYA WAS $453 MILLION. IN<br />
GHANA PSYCHOLOGICAL STRESS WAS<br />
ASSOCIATED WITH A 6.8% LOSS IN GDP.<br />
A consultant in <strong>Psychiatry</strong> at the University of Pretoria,<br />
Dr Funeka Sokudela, discussed the role of stigma in<br />
mental health. She highlighted the fact that many<br />
Mental Health Care Users are still being discriminated<br />
against for a number of reasons including their<br />
mental illnesses, gender, ethnic background and<br />
sexual orientation. She stressed the importance of<br />
psychiatrists taking responsibility for combating this<br />
stigma.<br />
Dr Lesley Robertson, a community psychiatrist<br />
affiliated to the University of the Witwatersrand,<br />
discussed studies related to the Global Burden of<br />
Disease and their relevance to mental health in<br />
<strong>South</strong> Africa (see Feature article in this issue).<br />
Dr Michelle Nel of the Department of <strong>Psychiatry</strong> at<br />
the University of the Free State addressed the topic<br />
“The Mental Health of Refugees”. The population of<br />
our world is over 7,7 billion people of which tens of<br />
millions have been forced to flee their homes due to<br />
violent conflict.<br />
THE OFFICE OF THE UNITED NATIONS HIGH<br />
COMMISSIONER FOR REFUGEES (UNHC)<br />
CLAIMS THE WORLD IS CURRENTLY<br />
FACING ONE OF THE HIGHEST LEVELS<br />
OF DISPLACEMENT EVER IN HISTORY.<br />
ACCORDING TO UN STATISTICS, AN<br />
UNPRECEDENTED 65.3 MILLION PEOPLE<br />
HAVE BEEN FORCED FROM THEIR HOMES<br />
BY WAR, INTERNAL CONFLICTS, DROUGHT<br />
OR POOR ECONOMICS. AMONG THESE<br />
ARE 21.3 MILLION REFUGEES, OVER HALF<br />
OF WHOM ARE UNDER THE AGE OF 18;<br />
THE REST ARE ECONOMIC MIGRANTS<br />
AND INTERNALLY DISPLACED PERSONS.<br />
THE MENTAL CONDITIONS FACING<br />
REFUGEES INCLUDE MAJOR DEPRESSION,<br />
POST-TRAUMATIC STRESS DISORDER,<br />
ADJUSTMENT DISORDERS, ANXIETY<br />
DISORDERS, PSYCHOTIC DISORDERS<br />
AND GRIEF AND BEREAVEMENT. THERE<br />
IS COMPELLING EVIDENCE THAT<br />
SCHIZOPHRENIA AND OTHER PSYCHOTIC<br />
DISORDERS ARE MORE PREVALENT<br />
AMONGST REFUGEES RESETTLED IN<br />
HIGH-INCOME COUNTRIES, COMPARED<br />
TO OTHER IMMIGRANTS AND HOST<br />
POPULATIONS.<br />
Dr Carla Kotze, consultant in <strong>Psychiatry</strong> at the<br />
University of Pretoria concluded the forum by<br />
thanking all the speakers and everyone who made<br />
it possible. It is anticipated that the Public Mental<br />
Health Forum for senior registrars will continue<br />
annually or at least bi-annually in future.<br />
Richard J. Nichol is an Associate Professor and a Principal Specialist (Head: Childand Adolescent <strong>Psychiatry</strong>) in the Department<br />
of <strong>Psychiatry</strong>, University of the Free State, Bloemfontein, <strong>South</strong> Africa.Correspondence: NicholR@fshealth.gov.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 49
REPORT<br />
FEEDBACK FROM<br />
THE ROYAL COLLEGE<br />
OF PSYCHIATRISTS<br />
INTERNATIONAL CONFERENCE,<br />
JUNE 2018:<br />
‘NEW HORIZONS’<br />
Lesley Robertson<br />
I<br />
represented the <strong>South</strong> <strong>African</strong> Society of<br />
Psychiatrists (SASOP) at the Royal College<br />
of Psychiatrists (RCPsych) 2018 international<br />
conference. A “tripartite” agreement exists<br />
between the <strong>South</strong> <strong>African</strong> College of Psychiatrists,<br />
the SASOP, and the RCPsych. Unlike <strong>South</strong> Africa,<br />
where the College is responsible for conducting<br />
national examinations and the SASOP furthers other<br />
objectives of the profession, the RCPsych combines<br />
both functions in one organisation.<br />
WITH ITS MISSION STATEMENT OF<br />
“IMPROVING THE LIVES OF PEOPLE<br />
WITH MENTAL ILLNESS”, THE RCPSYCH<br />
IS GOVERNED BY A BOARD OF TEN<br />
TRUSTEES, WHICH INCLUDES THREE LAY<br />
PEOPLE. AT PRESENT THE LAY TRUSTEES<br />
INCLUDE A RETIRED BUSINESSMAN, A<br />
LAWYER AND A PERSON WITH EXPERIENCE<br />
AS A NON-EXECUTIVE DIRECTOR AND IN<br />
STRATEGIC MANAGEMENT.<br />
The Board is supported and advised by the Council,<br />
which has overall responsibility for education and<br />
training, policy, professional practice, professional<br />
standards, public engagement, quality improvement<br />
and research. A far larger body, the Council includes<br />
a patient and a carer representative as well as four<br />
members of the Board, academic and divisional<br />
representatives.<br />
The theme of the congress was<br />
“New Horizons”, and the first<br />
new horizon discussed was the<br />
prospect of a new Mental Health<br />
Act, to be aligned with the United<br />
Nations Convention on the Rights<br />
of Persons with Disabilities (CRPD).<br />
Baroness Hale, the president of<br />
the supreme court, outlined the<br />
complexities around the comment Lesley Robertson<br />
on article 12 of the CRPD, legal<br />
capacity, involuntary mental health care and<br />
insanity defence. The difficulties she raised were like<br />
those raised by Freeman et al (2015), 1 and are highly<br />
relevant to <strong>South</strong> Africa, also signatory to the CRPD.<br />
I BELIEVE WE COULD GAIN BY CLOSELY<br />
WATCHING THE PROCESSES FOLLOWED<br />
BY THE UK IN DRAFTING THEIR NEW<br />
LEGISLATION.<br />
In view of the Essential Medicines List, I opted to<br />
attend presentations by the British Association<br />
of Psychopharmacology (BAP), which publishes<br />
evidence-informed treatment guidelines. They<br />
presented on the management of the aggressive<br />
patient, on schizophrenia, and on the use of valproate.<br />
Their approach differs from the NICE guidelines<br />
in their inclusion of observational studies. Of note,<br />
RCTs may not recruit severely ill people, leading to<br />
small effect sizes and a lack of generalisability. So, to<br />
inform the BAP guidelines, observational studies with<br />
50 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
REPORT<br />
hard, patient-oriented outcomes (e.g. readmission<br />
or repeat offending) may be upgraded, and RCTs<br />
downgraded, for strength of evidence. Their updated<br />
schizophrenia guidelines should be published soon.<br />
I ATTENDED AN NHS TRUST AUDIT OF<br />
PSYCHIATRIC CARE, SOMETHING<br />
WHICH, IN THEORY AT LEAST, NHI WOULD<br />
INTRODUCE IN SOUTH AFRICA. THE AUDIT<br />
WAS MAINLY AROUND PRESCRIBING<br />
PATTERNS; REFLECTING ON THE VARYING<br />
PROPORTIONS OF MEDICINES USED AND<br />
CHANGES OVER TIME. THERE WAS SOME<br />
DISCUSSION AROUND THE PRESENCE<br />
OF AND PRESCRIBING FOR PHYSICAL<br />
COMORBIDITIES. HOWEVER, THERE<br />
WAS LITTLE RELATION OF PRESCRIBING<br />
PATTERNS TO CARE OUTCOMES. THIS I<br />
THINK MAY BE RELATED TO A GLOBAL<br />
UNCERTAINTY REGARDING OUTCOME<br />
MEASURES IN PSYCHIATRIC CARE, BUT<br />
NEVERTHELESS IT RENDERS A CLINICAL<br />
AUDIT SOMEWHAT LACKING IN MEANING.<br />
PHYSICAL HEALTH IN PEOPLE WITH<br />
SEVERE MENTAL ILLNESS ALSO FEATURED<br />
IN A SESSION IN WHICH RESULTS OF THE<br />
HOME, STEPWISE AND PRIMROSE TRIALS<br />
WERE PRESENTED. THESE TRIALS ARE<br />
WELL WORTH LOOKING OUT FOR AND<br />
WILL PROBABLY REINFORCE THE NEED<br />
FOR HEALTH SYSTEMS WHICH PROMOTE<br />
COLLABORATIVE AND INTEGRATED<br />
CARE.<br />
Deinstitutionalisation also featured, with symposiums<br />
on residential facilities and community-based<br />
mental health care. Although highly pertinent to<br />
<strong>South</strong> Africa, I was unfortunately unable to attend<br />
these. I did however speak to members of the<br />
National Collaborating Centre for Mental Health, the<br />
organisation presenting on community psychiatry.<br />
Interestingly, they are having to re-examine their<br />
mental health system as those with severe illness<br />
are falling through the cracks. This was evident in the<br />
numbers of homeless people in both London and<br />
Birmingham, some of whom were clearly unwell. With<br />
a comprehensive welfare system and ample shelters<br />
in the cities, it’s possible that mental illness and<br />
personality factors perpetuate the homelessness.<br />
One of the plenary sessions was given by a journalist,<br />
Sathnam Sanghera, author of “The Boy with the Top<br />
Knot and Marriage Material”. He spoke of how, in his<br />
early twenties, he realised his father and sister had<br />
schizophrenia.<br />
HE TERMED SCHIZOPHRENIA AS THE<br />
LEPROSY OF TODAY AND DESCRIBED<br />
GREAT DIFFICULTY IN ACCESSING<br />
APPROPRIATE CARE FOR HIS FATHER<br />
WITHIN THE NATIONAL HEALTH SYSTEM,<br />
WHICH HE FELT NEGLECTED SEVERE<br />
MENTAL ILLNESS EXCEPT DURING<br />
PERIODS OF AGGRESSION.<br />
His words of wisdom conveyed caution regarding:<br />
• awareness campaigns which have inadvertently<br />
led to the prioritisation of mild to moderate<br />
common mental illness;<br />
• a recovery orientated approach which may<br />
cause false expectations and a sense of<br />
personal failure among people with severe<br />
illness and their carers;<br />
• the reluctance to use the risk of violence as a<br />
lobbying tool for better mental health services<br />
and preventative care.<br />
A meeting of the RCPsych Africa Division included<br />
representatives from Kenya and Ghana. Discussion<br />
revolved mainly around UK training opportunities<br />
for psychiatry registrars. At the gala dinner, I had the<br />
pleasure of meeting Dr Altha Stewart, the APA chair,<br />
who remembered all the <strong>South</strong> <strong>African</strong>s she had<br />
met at the APA congress in May.<br />
I SAT WITH THE RCPSYCH TREASURER AND<br />
ONE OF THE LAY TRUSTEES, AND LEARNT<br />
MORE ABOUT THE RCPSYCH, AND OF THE<br />
GAPS IN MENTAL HEALTH CARE IN THE<br />
UK, WHICH ARE VERY SIMILAR TO MANY<br />
OF OUR ISSUES.<br />
Overall, the congress was excellent and very<br />
enlightening. I am grateful to my SASOP colleagues<br />
for the sponsorship. Among all the lessons I learnt is<br />
the certainty that we will also become, in the words<br />
of Professor Sir Simon Wessely of the RCPsych for<br />
the UK, the “calm, trusted, and authoritative voice in<br />
mental health” for <strong>South</strong> Africa.<br />
REFERENCE:<br />
1. Freeman MC, Kolappa K, de Almeida JM,<br />
Kleinman A, Makhashvili N, Phakathi S, et al.<br />
Reversing hard won victories in the name<br />
of human rights: a critique of the General<br />
Comment on Article 12 of the UN Convention<br />
on the Rights of Persons with Disabilities. Lancet<br />
<strong>Psychiatry</strong>. 2015;2(9):844-50.<br />
Lesley Robertson is a community psychiatrist working in the Sedibeng District and is jointly appointed in the Department of<br />
<strong>Psychiatry</strong>, University of the Witwatersrand, Johannesburg, <strong>South</strong> Africa. Correspondence: Lesley.Robertson@wits.ac.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 51
REPORT<br />
CELLULAR<br />
NEUROSCIENCE<br />
OF PSYCHIATRIC<br />
DISORDERS<br />
Tanya Calvey<br />
On the 23 rd of November, 2018, the Wits<br />
Cortex Club hosted two prominent<br />
neuroscientists (Profs. Harry Steinbusch<br />
and Marie-Ève Tremblay) to address<br />
the Wits Faculty of Health Sciences on cellular<br />
mechanisms involved in various psychiatric<br />
disorders. The lunch time seminar took place in<br />
the Adler Museum of Medicine and was funded<br />
by the National Research Foundation and the Wits<br />
Department of <strong>Psychiatry</strong>.<br />
Marie-Ève Tremblay is an Associate Professor of<br />
Molecular Medicine at Université Laval, Québec,<br />
Canada. Her research focuses on elucidating the<br />
roles of microglia in the loss of synapses, which<br />
is one of the best pathological correlates of<br />
cognitive decline across chronic stress, aging, and<br />
neurodegenerative diseases.<br />
Her seminar ‘Dark microglia across contexts of health<br />
and disease’ uncovered the recent characterization<br />
by her laboratory of an ultra-structurally distinct<br />
microglial subtype that is predominantly associated<br />
with pathological states. These cells are rare in<br />
steady state conditions, but become prevalent<br />
upon chronic stress, aging, and Alzheimer’s disease<br />
pathology, where they account for two-thirds of the<br />
normal microglial population. They exhibit several<br />
signs of cellular stress including a condensed,<br />
electron-dense cytoplasm and nucleoplasm giving<br />
them a ‘dark’ appearance in electron microscopy,<br />
accompanied by endoplasmic reticulum dilation,<br />
mitochondrial alterations, and a loss of nuclear<br />
heterochromatin pattern. The physiological<br />
significance of these dark<br />
microglia has yet to be elucidated<br />
but they appear extremely active,<br />
frequently reaching for synaptic<br />
clefts, while extensively encircling<br />
axon terminals, dendritic spines,<br />
and excitatory synapses with their<br />
highly ramified and extremely thin<br />
processes. In addition, her recent<br />
work revealed the occurrence<br />
Tanya Calvey<br />
of these dark microglia in a<br />
schizophrenia mouse model induced by a prenatal<br />
immunological challenge, as well as in early<br />
postnatal brain development, two conditions where<br />
synaptic pruning is exacerbated.<br />
THESE FINDINGS INDICATE THAT DARK<br />
MICROGLIA COULD REPRESENT A SUBSET<br />
OF CELLS THAT BECOME STRESSED<br />
AS A RESULT OF THEIR HYPERACTIVE<br />
INVOLVEMENT WITH THE REMODELING<br />
OF NEURONAL CIRCUITS ACROSS<br />
DEVELOPMENT, PLASTICITY, AND DISEASE.<br />
Prof. Harry Steinbusch is appointed as Professor in<br />
Cellular Neuroscience, chairman of the Department<br />
of Translational Neuroscience, past-director of the<br />
School for Mental Health and Neuroscience, current<br />
Director of the European Graduate School for<br />
Neuroscience at Maastricht University and President<br />
of the Neurotoxicity Society. He is the founding editor of<br />
the Journal of Chemical Neuroanatomy. His research<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 53
REPORT<br />
is focused on neurodevelopmental influences<br />
towards depression and neurodegenerative<br />
diseases studied in animal models.<br />
His seminar was on ‘Brainstem Dysfunction in<br />
Neuropsychiatric Disorders’ such as Alzheimer’s<br />
Disease, Parkinson’s Disease and depression.<br />
Despite the fundamental role of the brainstem in<br />
regulating vital functional abilities such as arousal,<br />
breathing, autonomic nervous system activity as<br />
well as regulating all higher cerebral functions via<br />
neurotransmitter projection systems originating in<br />
the brainstem, the role of the brainstem has received<br />
relatively little attention in most neuropsychiatric<br />
disorders. His seminar reviewed the neuroanatomy<br />
of the brainstem as well as the current status on<br />
findings, derived from a wide range of studies using<br />
molecular, cellular and imaging technologies, of<br />
brainstem involvement in neurodevelopmental (i.e.<br />
autism, schizophrenia) and neurodegenerative<br />
disorders (Alzheimer’s and Parkinson’s disease).<br />
Besides the dorsal and median raphe nuclei<br />
complexes comprising mainly of serotoninproducing<br />
neurons, the brainstem also contains<br />
noradrenalin, dopamine and histamine-producing<br />
nuclei, i.e. the locus coeruleus, the substantia<br />
nigra and the mamillary bodies respectively. The<br />
brainstem is furthermore the relay station of afferent<br />
and efferent projections between the autonomic<br />
nervous system in the peripheral body and higher<br />
cerebral brain regions.<br />
Over the past decades, the incidence of agerelated,<br />
neurological and psychiatric disorders such<br />
as Alzheimer’s disease, Parkinson’s disease, but<br />
also depression has increased considerably. Mood<br />
disorders are strongly related to exposure to stress.<br />
THE HIPPOCAMPUS AND OTHER<br />
FOREBRAIN STRUCTURES ARE THE<br />
APEX OF STRESS HORMONE CONTROL<br />
MECHANISMS AND DAMAGE TO THEM<br />
MAY BE ONE WAY IN WHICH STRESS<br />
HORMONE SECRETION ESCAPES FROM<br />
INHIBITORY CONTROL IN DEPRESSION.<br />
In turn, stress, probably through toxic effects of<br />
glucocorticoids, decreases neurogenesis and<br />
cell survival while antidepressants enhance these<br />
processes in experimental animals. Therefore,<br />
since treatment strategies are not yet available,<br />
primary prevention in these age-related and stressrelated<br />
neurological disorders is of importance.<br />
As mentioned before most of the focus on<br />
neurobiological questions on the above mentioned<br />
diseases are related to forebrain structures since<br />
they are often associated with cognitive dysfunction.<br />
The brainstem is a highly neglected brain area in<br />
neurodegenerative diseases, including Alzheimer’s<br />
and Parkinson’s disease and frontotemporal lobar<br />
degeneration. Likewise, despite a long-standing<br />
recognition of brainstem involvement, relatively few<br />
studies have addressed the exact mechanisms that<br />
underlie brainstem autonomic dysfunction. Improved<br />
insight in the cellular and molecular characteristics of<br />
brainstem function is pivotal to study developmental<br />
origins. In the area of depression, several observations<br />
have been made in relation to changes in one<br />
particular brain structure: the dorsal raphe nucleus.<br />
In addition, dysfunction of the cerebellum is also<br />
observed in Alzheimer’s disease and associated with<br />
pulmonary deregulation. The dorsal raphe nucleus<br />
is also involved in the circuit of stress regulated<br />
processes and cognitive events. In order to gain<br />
more information about the underlying mechanisms<br />
that may govern neurodegeneration, e.g. amyloid<br />
plaques, neurofibrillary tangles, and impaired<br />
synaptic transmission in Alzheimer’s disease, a rat<br />
dissociation culture model was established by Prof<br />
Steinbusch and his colleagues that allows mimicking<br />
of certain aspects of autopsy findings. They observed<br />
a similar phenomenon in brains from patients<br />
suffering from neurodegenerative disease since this<br />
also related to changes in brain derived neurotropic<br />
factor (BDNF) levels. The ascending projections and<br />
multi-transmitter nature of the dorsal raphe nucleus<br />
in particular and the brainstem in general stress its<br />
role as a key target for research into Alzheimer’s and<br />
Parkinson’s disease and autonomic dysfunction.<br />
It also points towards the increased importance<br />
and focus of the brainstem as a key area in various<br />
neurodevelopmental and age-related diseases.<br />
Prof Steinbusch taking questions from the audience.<br />
Profs. Steinbusch and Tremblay with Wits Cortex Club members, students and staff<br />
members.<br />
Tanya Calvey has a background in evolutionary neurobiology and lectures morphological anatomy in the Faculty of Health<br />
Sciences, University of the Witwatersrand. Tanya studies the neuropsychopharmacology of SUDs in humans and animals.<br />
Her research team is multidisciplinary and her research is funded by the <strong>South</strong> <strong>African</strong> Medical Research Council, the<br />
National Research Foundation and the International Society for Neurochemistry. Tanya is also actively involved in developing<br />
neuroscience research in Africa. She is the Secretary of the <strong>South</strong>ern <strong>African</strong> Neuroscience Society and the co-founder of the<br />
Wits Cortex Club. Correspondence: Tanya.Calvey@wits.ac.za<br />
54 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
10<br />
“How beautifully<br />
leaves grow old.<br />
How full of light<br />
and colour are<br />
their last days.”
UPDATE<br />
MAINTAINING YOUR PATIENCE<br />
AND COMPASSION<br />
FOR YOUR LOVED ONE<br />
WITH DEMENTIA<br />
People with more advanced dementia,<br />
which is associated with symptoms such as<br />
progressive memory loss, may lack the ‘social<br />
filters’ that keep most of us from honestly<br />
expressing what we really think out of politeness for<br />
other people.<br />
This was noted by Corlia Schutte, an occupational<br />
therapist who works with residents at Livewell Villages<br />
in Bryanston, Johannesburg, which places a focus<br />
on providing the highest levels of care to people<br />
with dementia. She points out that many people<br />
with advanced dementia become less inhibited,<br />
lose a sense of social norms and may consequently<br />
express themselves rather more candidly than is<br />
generally considered acceptable.<br />
“There is certainly no intention to be hurtful to others,<br />
this is just one of the effects that can be associated<br />
with more advanced dementia and cognitive<br />
decline. Nevertheless, this kind of behaviour may<br />
be challenging to families who care for people<br />
with dementia and Alzheimer’s within the home<br />
environment,” adds Schutte.<br />
She says that the experienced and trained staff<br />
at Livewell Villages, a pioneer in dementia care in<br />
<strong>South</strong> Africa with care facilities in Bryanston and<br />
Somerset West in Cape Town, understand and<br />
have learned not to take offence at some of their<br />
residents’ eccentricities or idiosyncrasies, and often<br />
very forthright observations.<br />
THESE CAN, HOWEVER, SOMETIMES BE<br />
HURTFUL FOR FAMILY MEMBERS AND<br />
CAREGIVERS WHO ARE LOOKING AFTER<br />
PEOPLE WITH DEMENTIA, AND WHO MAY<br />
NOT UNDERSTAND THE CHANGES THAT ARE<br />
OCCURRING IN THEIR LOVED ONE.<br />
“It can be easy for anyone who is taking care of a<br />
person with dementia to forget that their loved one<br />
is suffering from memory loss and other cognitive<br />
problems, and assume that they are just being<br />
difficult. After all it can be extremely challenging<br />
to come to terms with the fact that their parent or<br />
grandparent may now be saying hurtful things that<br />
they would never have said before the onset of<br />
dementia.<br />
“If you can stay aware of the fact that they may be<br />
having problems associated with dementia, and<br />
keep in mind that their behaviour does not have the<br />
purpose of being insensitive and hurtful, however, it<br />
can assist you to avoid losing your patience with the<br />
individual concerned.”<br />
DEMENTIA IS A GROUP OF SYMPTOMS<br />
THAT CAN OCCUR DUE TO A VARIETY<br />
OF POSSIBLE UNDERLYING MEDICAL<br />
CONDITIONS AND, BESIDES MEMORY<br />
LOSS, MAY RESULT IN A NUMBER OF OTHER<br />
SYMPTOMS SUCH AS IMPAIRMENTS IN<br />
REASONING, COMMUNICATION, AND<br />
FOCUS.<br />
Schutte says that if a loved one with advanced<br />
dementia starts to behave inappropriately or<br />
say insensitive things, it can be useful to try to<br />
establish what may be causing the behaviour. It<br />
may, for example, be that something within their<br />
environment, such as loud music; a noisy, busy<br />
environment; hunger; tiredness; or even a need<br />
for the toilet may be causing the reaction. It may<br />
even be that the person is in pain or is experiencing<br />
some form of discomfort. By understanding the<br />
reasons for the behaviour, it can be meaningfully<br />
addressed.<br />
56 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
UPDATE<br />
“ALSO REMEMBER THAT IF YOU ARE GOING<br />
ON AN EXCURSION, OR TAKING A FEW DAYS<br />
HOLIDAY, THAT WHILE YOU AND THE FAMILY<br />
MAY BE EXCITED ABOUT IT, THE PERSON<br />
WITH DEMENTIA CAN EASILY BECOME<br />
BEWILDERED AND ANXIOUS WHEN THEY<br />
ARE OUT OF THEIR ROUTINE AND FAMILIAR<br />
ENVIRONMENT,” SHE ADVISES.<br />
According to Schutte, it can also be helpful to honestly<br />
explain the causes of any unusual behaviour in their<br />
loved one to other family members, particularly<br />
younger ones, so that they can understand it and<br />
be better equipped to deal with it.<br />
Beatrice Masiiwa, office supervisor: administration<br />
at the Livewell Village in Bryanston says that before<br />
joining Livewell Villages, she worked in the hospitality<br />
industry and didn’t know much about dementia at<br />
first.<br />
“However, we all receive on the job training and<br />
have ongoing formal monthly training sessions. It<br />
was challenging at first, but with some experience<br />
I got to know the particular requirements of our<br />
residents,” she adds.<br />
BEATRICE AND A RESIDENT, MRS L, SHARE A<br />
PASSION FOR FASHION. MRS L IS EXTREMELY,<br />
SOME MIGHT SAY ‘BRUTALLY’, HONEST,<br />
ACCORDING TO MASIIWA. “IF SHE DOESN’T<br />
LIKE YOUR NEW HAIRSTYLE, SHE WILL TELL YOU<br />
SO IN NO UNCERTAIN TERMS. I FIND THIS A<br />
REFRESHING CHANGE, HOWEVER, BECAUSE<br />
MOST PEOPLE WILL BE LESS HONEST OUT<br />
OF POLITENESS, BUT WHEN MRS L SAYS SHE<br />
LIKES SOMETHING YOU CAN BE SURE THAT<br />
SHE SINCERELY APPROVES,” SHE EXPLAINS.<br />
“Working with people with dementia is very rewarding,<br />
although you need to have a heart and a sense of<br />
humour. You need to learn not to take offence or you<br />
can easily have your feelings bruised. We spend so<br />
much time with the residents that we become like<br />
family, and we have the same understanding for<br />
them that we have for our own grandparents.”<br />
Schutte says that loneliness and boredom are<br />
common problems affecting elderly people in<br />
society, and the sense of isolation this creates is often<br />
strongly associated with depression. “This is why we<br />
place particular importance on ensuring that at<br />
Livewell, every resident has company, whether they<br />
are spontaneously drawn to participate, or whether<br />
they prefer spending time with their companions<br />
and carers.<br />
As for Mrs L, Masiiwa says she cannot help but be<br />
in awe of this woman who has a seemingly innate<br />
sense of style and elegance. “Other than our shared<br />
love of fashion, we have a strong human connection<br />
that I find very meaningful. Although she may not<br />
express it in so many words, I have a good idea that<br />
she feels the same.”<br />
Leaders in dementia care in <strong>South</strong> Africa, Livewell<br />
Villages in Bryanston and Somerset West host free<br />
monthly support groups where people can get<br />
advice and assistance from its teams, as well as<br />
obtain the support of others who are facing similar<br />
challenges. Those who may in some or other way be<br />
impacted by the condition are invited to join them at<br />
one of these sessions.<br />
“Caring for a loved one with dementia or Alzheimer’s<br />
can be immensely trying but also most rewarding.<br />
It can help if you can try to keep in mind that their<br />
memory loss is not their fault and try to understand<br />
their experience. If you can do this, it can assist you<br />
to be more patient with them and treat them with<br />
the compassion they need. By showing your care<br />
and love for them, you are able to make them feel<br />
safer,” concludes Schutte.<br />
Issued by Martina Nicholson Associates (MNA) on behalf of Livewell Villages Correspondence:martina@mnapr.co.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 57
UPDATE<br />
SOUTH AFRICA WOULD DO WELL TO FOLLOW<br />
UK BUSINESS<br />
LEADERS CALL<br />
TO GIVE MENTAL HEALTH ISSUES<br />
GREATER RECOGNITION<br />
With the growing awareness of mental<br />
health issues, and increasing<br />
acceptance of their impact on<br />
individuals, their families and employers,<br />
Oxford Healthcare Retreat believes <strong>South</strong> Africa<br />
should follow a recent appeal made by some of<br />
the UK’s biggest employers, who are calling for<br />
changes in the law to give mental health the same<br />
status as physical health at work.<br />
According to Julia Halstead-Cleak, a clinical<br />
psychologist and founder of the retreat, a wellness<br />
guesthouse offering integrated stress relief and<br />
health management, while there has been a definite<br />
increase in the acceptance of mental health<br />
issues, there remains a very strong stigma about<br />
recognising and addressing mental health issues in<br />
the workplace.<br />
“THERE IS A HUGE NEED FOR MENTAL<br />
HEALTH TREATMENT, ESPECIALLY AT<br />
EXECUTIVE LEVEL, WHICH IS OUR<br />
FOCUS. WE LIVE IN AN INCREASINGLY<br />
PRESSURED ENVIRONMENT, WHERE<br />
THE COMBINATION OF SECURITY<br />
ISSUES, POLITICAL AND ECONOMIC<br />
UNCERTAINTIES, GENERAL STABILITY,<br />
FINANCIAL PRESSURES, RETRENCHMENTS<br />
AND THE INCREASING DEMANDS FOR<br />
PROFITS ARE CREATING THE PERFECT<br />
STORM RESULTING IN PEOPLE HOLDING<br />
A LOT OF STRESS,” SHE SAYS.<br />
“It is concerning that so many people still find<br />
themselves unable to speak to their colleagues or<br />
bosses about the impact that work is having on their<br />
wellbeing and even more worrying that they feel<br />
unable to ask for time off when they need it.”<br />
Oxford Healthcare Centre, the sister facility to Oxford<br />
Healthcare Retreat, has seen a definite increase in<br />
executives seeking holistic treatment which was a<br />
key factor in the establishment of the retreat earlier<br />
this year.<br />
“Even though there is a decline in the stigma of<br />
mental illness, more and more high-functioning<br />
individuals are feeling overwhelmed, stressed and<br />
fatigued by the demands of everyday life,” says<br />
58 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
UPDATE<br />
Theresa Partington, a clinical psychologist based<br />
at Oxford Healthcare Retreat who has specialised<br />
in the business sector providing group facilitation<br />
and counsel for difficulties such as psychological<br />
stress and burnout, change management and<br />
interpersonal dynamics. She says this is further<br />
exacerbated by people often dismissing their own<br />
self-care and health maintenance until they can no<br />
longer cope and reach burnout.<br />
This was the primary reason for the establishment of<br />
Oxford Healthcare Retreat which places emphasis<br />
on seeking help before the onset of mental illness.<br />
STRESS, AS AN EXAMPLE, LEADS TO<br />
ANXIETY AND EXHAUSTION WHICH<br />
IF UNTREATED, CAN PROGRESS TO<br />
PHYSICAL ILL HEALTH WHERE INDIVIDUALS<br />
EXPERIENCE DROPS IN ENERGY LEVELS,<br />
LACK OF SLEEP, A DECREASE IN SOCIAL<br />
ENGAGEMENT, A NEGATIVE IMPACT ON<br />
HOME AND PERSONAL RELATIONSHIPS<br />
AND COGNITIVE IMPAIRMENT SYMPTOMS<br />
SUCH AS A DECLINE IN THINKING AND THE<br />
ABILITY TO FOCUS OR CONCENTRATE,<br />
ALL OF WHICH CAN ULTIMATELY LEAD TO<br />
A BREAKDOWN.<br />
“This is when we see most people seeking treatment,<br />
but the ideal is to recognise the symptoms and<br />
address them sooner rather than later. Greater<br />
acceptance of mental health issues may see a<br />
reversal of this – the more corporates recognise it as<br />
a valid and real health issue, so will employees feel<br />
less stigmatised about seeking treatment,” Halstead-<br />
Cleak says.<br />
A SURVEY CONDUCTED IN 2017 BY<br />
THE SOUTH AFRICAN DEPRESSION AND<br />
ANXIETY GROUP (SADAG) REVEALED<br />
THAT ONLY ONE IN SIX EMPLOYEES WITH<br />
MENTAL ILLNESS FELT COMFORTABLE<br />
DISCLOSING THEIR CONDITION TO THEIR<br />
MANAGER. IN THE SAME YEAR, FINANCIAL<br />
MAIL REPORTED THAT MENTAL HEALTH<br />
PROBLEMS COST THE SOUTH AFRICAN<br />
ECONOMY BILLIONS PER YEAR, WITH<br />
LOSS OF EARNINGS DUE TO MAJOR<br />
DEPRESSION AND ANXIETY DISORDERS<br />
ESTIMATED AT R54,121 PER AFFECTED<br />
ADULT PER YEAR AND AMOUNTING TO<br />
OVER R40 BILLION IN TOTAL ANNUAL<br />
COST TO OUR ECONOMY.<br />
Further, mental health problems cost the economy<br />
two to six times the cost of its treatment, yet the<br />
government spends only 5% of its health budget on<br />
mental health.<br />
“While early identification of mental issues is key,<br />
there are effective and proven strategies to minimise<br />
and manage stress and its impact, especially at<br />
executive level. Within the workplace, managers<br />
should be better trained to deal with these issues<br />
and should be given the tools to support staff who<br />
are suffering. Businesses should prioritise overall wellbeing,<br />
defined as a combination of physical, mental,<br />
and spiritual health and should encourage staff at<br />
all levels to reduce stigma by speaking out about<br />
the risks of mental illness,” Halstead-Cleak concludes.<br />
Julia Halstead-Cleak<br />
ABOUT OXFORD HEALTHCARE RETREAT<br />
Johannesburg-based Oxford Healthcare Retreat<br />
is a new, exclusive boutique wellness guesthouse<br />
which focuses on stress relief and management. It<br />
holistically treats burnout and the implications of<br />
chronic, unmanaged stress. The retreat has been<br />
developed by a team of accredited medical<br />
professionals to provide meaningful and effective<br />
strategies to enhance the overall sense of wellbeing.<br />
The experienced team of psychologists,<br />
physiotherapists, medical doctors, yoga and<br />
mindfulness practitioners work collectively to address<br />
the intertwined relationship between psychological<br />
and physical health. Find out more at https://www.<br />
oxfordhealthcareretreat.co.za/<br />
It is the sister facility to the Oxford Healthcare<br />
Centre, founded in 2015 and based in Saxonwold,<br />
Johannesburg, which is a facility dedicated to mental<br />
wellness. It houses several psychiatrists, clinical<br />
psychologists, a dietician and an occupational<br />
therapist together with a day clinic that offers day<br />
programmes for adolescents and adults.<br />
Issued by Kalsey Windsor Correspondence: kalsey@ggisa.com<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 59
Make XEPLION ®<br />
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for long-acting<br />
treatment.<br />
Once-per-month XEPLION® is well placed to help patients achieve long-term treatment<br />
continuation together with the associated life benefits. 1, 2<br />
References:<br />
1. Taipale H, Mittendorfer–Rutz E, Alexanderson K, et al. Antipsychotics and mortality in nationwide cohort of 29 823 patiens with schizophrenia. Schizophrenia Research 2017. Available from: http://doi.org/10.1016/<br />
jschres.2017.12.010. 2. Decuypere F, Serman J, Geerts P, et al. Treatment continuation of four long-acting antipsychotics medications in the Netherlands and Belgium: A retrospective database study. PLoS ONE<br />
2017;12(6):e0179049. https://doi.org/10.1371/journal.pone.0179049.<br />
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PERSPECTIVE<br />
THE IMPACT<br />
OF CLINICAL EXPOSURE<br />
Kajal Patel<br />
Tara is a public sector specialized psychiatric<br />
hospital that renders inpatient as well as<br />
outpatient services to adults and children<br />
with serious mental illnesses. The hospital<br />
is home to an Eating Disorders and Adolescent<br />
Unit (wards 1 & 2), a Psychotherapy Unit (wards 4<br />
& 5), Biological wards (6-8), a Child Unit (ward 9),<br />
outpatient services, Lufuno Neuropsychiatric Centre<br />
and HIV Clinic. The learning opportunities in this type<br />
of specialized hospital are endless. Each ward has<br />
a unique experience to offer, with patients from all<br />
walks of life.<br />
PSYCHIATRY HAS ALWAYS BEEN AN<br />
EXTREMELY INTERESTING FIELD FOR ME.<br />
IT’S VERY DIFFERENT FROM ALL OTHER<br />
SPHERES OF MEDICINE. IT DEALS WITH THE<br />
MIND INSTEAD OF THE BRAIN. OUR MINDS<br />
ARE INCREDIBLY COMPLEX, AS ARE OUR<br />
SOCIAL AND CULTURAL INTERACTIONS.<br />
In medicine, doctors can usually treat cases of<br />
asthma, chest pain or pulmonary oedema. Surgeons<br />
might do one knee replacement after the other<br />
until they, themselves retire or collapse. In <strong>Psychiatry</strong>,<br />
however, there can be no factory line, no standard<br />
procedure and no mindless protocol: each patient<br />
has something unique to return to the psychiatrist.<br />
Mental illnesses in our society, generally, are bagged<br />
with stigma and non-acceptance as well as<br />
indifference and alienation. Patients diagnosed with<br />
schizophrenia are pariahs and patients with Major<br />
Depression are weak or lazy. No one really takes<br />
the time to educate themselves about what these<br />
illnesses are and how they affect the patients’ lives.<br />
I chose psychiatry because I wanted to know more<br />
about mental illnesses, how people are affected<br />
and what is being done to help these people. I<br />
can now correct and change people’s unjustified,<br />
preconceived ideas about what they perceive as<br />
mental illness.<br />
The Life Healthcare Esidimeni scandal crushed my<br />
heart. 143 deaths later, I realized how important it is<br />
to protect these patients and take care of them. It<br />
should never have taken such a tragedy to awaken<br />
<strong>South</strong> Africa. A special Sunday Times investigation 1<br />
revealed that a third of all <strong>South</strong> <strong>African</strong>s have<br />
mental illnesses and 75% of them<br />
will not get any type of help. Despite<br />
this high number, the Department<br />
of Health annually spends 4% or<br />
R9.3 billion of its budget to address<br />
the crisis. It still makes me curious<br />
as to why people don’t take mental<br />
illness seriously.<br />
A mental illness is defined as a<br />
Kajal Patel<br />
condition which causes serious<br />
disorder in a person’s behaviour or thinking. Being<br />
at Tara, I discovered that it means different things to<br />
different people:<br />
• For a patient in ward 1 & 2, it means body<br />
dysmorphia and an unhealthy relationship with<br />
food. Patients in this ward need a large multidisciplinary<br />
team to treat them including nurses,<br />
a psychologist, a dietitian and a psychiatrist.<br />
• For a patient in ward 4 & 5, it means they’ve<br />
had developmental difficulties which has illequipped<br />
them with dysfunctional coping skills<br />
in adulthood. I learnt about psychotherapy and<br />
its importance in treating personality disorders.<br />
• For a patient in ward 6, it means an altered reality.<br />
These patients are especially vulnerable as their<br />
families cannot understand them and find their<br />
behaviour and grooming habits strange. They<br />
need medication, and extreme care.<br />
• For a patient coming into the neuropsychiatric<br />
clinic, it means a major life event has altered their<br />
anatomy which causes psychiatric sequalae.<br />
It doesn’t matter what the illness is, it changes<br />
these patient’s lives completely.<br />
A skill that I really improved during my elective at Tara<br />
was history taking. In other disciplines, investigations<br />
can provide you with so much information. In<br />
psychiatry, talking to a patient provides you with most,<br />
if not all, the information you need. It’s important to<br />
ask the right questions and to make the patient feel<br />
safe enough to talk about their experiences. During<br />
the elective period, I was placed in Ward 6 which is<br />
an open adult ward. I interviewed a patient which<br />
had just come in. Our interview lasted an hour<br />
because of the intricate details and past history I<br />
had to extract from him.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 61
PERSPECTIVE<br />
IT WAS CAPTIVATING FOR ME TO<br />
IDENTIFY THE SYMPTOMS OF PSYCHOSIS<br />
AND THOUGHT FORM DISORDER IN<br />
THE PATIENT. HE WAS RESERVED IN THE<br />
BEGINNING OF THE CONVERSATION BUT<br />
AFTER ESTABLISHING A GOOD RAPPORT,<br />
HE OPENED UP MORE.<br />
I wrote up and gave a case presentation for this<br />
patient in the ward round as well. It was great to<br />
have been able to integrate all the information,<br />
come up with differential diagnoses and feedback<br />
on the Mental State Exam of the patient.<br />
I also learnt compassion. Learning people’s stories<br />
and their backgrounds teaches you to become<br />
empathetic. This experience taught me to think and<br />
feel, and to relate to others and to the world in a<br />
genuine and meaningful way. A colleague and I<br />
clerked a patient in the closed women’s ward. It<br />
was extremely sad to hear her story and to touch<br />
on aspects of her life that hurt her the most. She<br />
was alone and hardly any of her family members<br />
would visit, let alone speak to her. Interviewing her<br />
was very tricky as she was on edge nearly the entire<br />
conversation. But after seeing her, I certainly started<br />
looking at other patients differently. Instead of just<br />
seeing a person to interview, I began respecting their<br />
stories more.<br />
Interacting with many patients, I noticed a<br />
correlation between xenophobia and mental illness.<br />
Many patients I saw were from surrounding countries<br />
who came to <strong>South</strong> Africa to make something of<br />
themselves but ended up institutionalized. A patient<br />
I remember mentioned to me that he could not get<br />
a job for around 6 months because he was from<br />
Malawi and once he did, he was not paid as well<br />
as the other employees and was an outcast among<br />
the employees. Another patient from Lesotho was<br />
found roaming the streets of Braamfontein and<br />
was diagnosed with dementia caused by extreme<br />
trauma. People come to this country with high hopes<br />
but end up sick because of the many stressors they<br />
encounter in this country.<br />
Another important lesson I learnt was professionalism<br />
and self-respect. During a ward round in the closed<br />
ward, a patient screamed at the doctor and accused<br />
her of keeping her in the ward despite trying her<br />
best to get better and of treating her as merely a<br />
case file. The doctor in charge handled the situation<br />
calmly, responding respectfully to all her concerns<br />
and validating her emotions. This interaction was<br />
powerful, and I was amazed at her expertise.<br />
An experience that ‘popped my patella’ was that of<br />
Electroconvulsive Therapy (ECT). ECT, I learnt, is used<br />
to treat patients with treatment-resistant depression<br />
(TRD) 2 and as an adjunct to non-clozapine<br />
antipsychotic medication for treatment resistant<br />
schizophrenia 3 . Inducing therapeutic seizures in<br />
patients to give symptomatic relief of symptoms<br />
seemed unethical to me. Witnessing the process is<br />
heart wrenching. The long-term effects are, however,<br />
promising. This made me realize that some aspects<br />
of psychiatry are hard to digest, but what is important<br />
is the wellbeing of the patient.<br />
A story with a happy ending came from the Lufuno<br />
Neuropsychiatric clinic. I sat in on an outpatient<br />
group therapy session which made me extremely<br />
happy. The patients have mild neuropsychiatric<br />
symptoms but manage to live ordinary lives with the<br />
help of therapy and medication. They share their<br />
victories and failures in group which uplifts them and<br />
inspires others in the group.<br />
In conclusion, my visit to Tara was an incredible one,<br />
with lots of learning involved. I learnt many lessons<br />
which can’t be taught in a lecture room and my<br />
appreciation for psychiatry and its aspects has<br />
quadrupled.<br />
REFERENCES<br />
1. Tromp, B., Dolley, C., Laganparsad, M. & Govender,<br />
S., 2014. SA’s sick state of mental health. Sunday<br />
Times, 8 July, pp. 1,4.<br />
2. Magnezi, R. et al., 2016. Comparison between<br />
neurostimulation techniques repetitive transcranial<br />
magnetic stimulation vs electroconvulsive therapy<br />
for the treatment of resistant depression: patient<br />
preference and cost effectiveness. Dovepress, pp.<br />
1481-1487.<br />
3. Zheng, W., Coa, X.-L. & Ungvari, G. S., 2016.<br />
Electroconvulsive therapy added to Non-<br />
Clozapine Anti-psychotic medication for<br />
Treatment Resistant Schizophrenia: Metaanalysis<br />
of Ramdomized controlled Trials.<br />
PLOS one, Volume 10.<br />
ANTIDEPRESSANTS – ANOTHER PERSPECTIVE<br />
Shall I compare you to a modern plague?<br />
Thou art more insidious and more craved<br />
You calm the rough winds for today<br />
But ultimately make me sign a lease on the<br />
summers I see<br />
Sometimes too devious for the eye of another to<br />
clutch<br />
The storm that simmers inside this form<br />
As every blossoming flower you turn into a crusted<br />
frame<br />
You are changing nature’s way to claim<br />
But thy eternal summer shall not fade<br />
As pharmaceutics hold you in high care<br />
Death brags that you are its new associate<br />
Eternal exhaustion is the only thing that grows<br />
In this garden of despair<br />
Of which the seeds you have sown<br />
Written by Kajal Patel<br />
Kaja Patel undertook an elective at Tara Hospital as a GEMP 2 student - 2018 Correspondence: 862101@students.wits.ac.za<br />
62 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
PERSPECTIVE<br />
TWO VINYL CHAIRS,<br />
PRISON, AND<br />
A<br />
PETAL.<br />
Claudia Campbell and Mark Booth (a pseudonym)<br />
CLAUDIA<br />
Ordinarily, I am not a fan of anything covered<br />
in vinyl. Childhood memories of feeling<br />
my legs sticking to the synthetic plastic<br />
polymer covering the bench chairs at our<br />
local ice-cream shop, halted any future cravings for<br />
frozen dairy products.<br />
However, in more recent years some other chairs<br />
were given a second chance when they received<br />
new covers of bright, bright blue vinyl. These chairs<br />
exist in a room with a greenish carpet, where ambient<br />
temperatures are either frigid or sweltering. That said,<br />
there is a huge picture window, which offers endless<br />
amounts of natural light. But, the most redeeming<br />
feature of this room is that it is where I am able to<br />
listen to extraordinary stories of life and survival. I<br />
am privileged to occupy that room and a blue vinyl<br />
chair as stories previously saturated with hurt, pain,<br />
and illness begin to be retold in healthier ways, ways<br />
accentuated with hope rather than despair. I am<br />
not a psychiatrist, nor a psychologist. It is not my<br />
responsibility to attempt to ‘fix’ or ‘cure’ anyone. But,<br />
I do listen with the hope that perhaps the process of<br />
being heard might be helpful in some way.<br />
FOR THE LAST WHILE, MARK HAS<br />
OCCUPIED THE BLUE CHAIR ACROSS<br />
FROM ME. HIS IS A STORY YOU WANT<br />
TO LEARN ABOUT. THIS JUNCTURE IS A<br />
GOOD ONE FOR MARK TO INTRODUCE<br />
HIMSELF.<br />
MARK<br />
I am a very ordinary <strong>South</strong> <strong>African</strong><br />
man. I am the youngest of three<br />
siblings. From an early age, nothing<br />
would have appeared irregular<br />
or abnormal about my life to the<br />
average outsider. I had a good<br />
upbringing by parents who both<br />
loved me. After matric, I began to<br />
Claudia Campbell<br />
study for a B. Com degree. I found the<br />
university environment difficult and concentration<br />
was a constant struggle. I felt like a failure and so I<br />
chose military training over my degree. However, over<br />
the next 10 years I managed to enter the working<br />
world, complete my accounting degree, and build<br />
my own successful real estate business. I was at the<br />
top of my game!<br />
IN 2008 THE PROPERTY MARKET CRASHED,<br />
AND I WAS CRUSHED AND ON THE BRINK<br />
OF FINANCIAL RUIN. I COULD NOT SHAKE<br />
THE FEELING OF THE “DARK BLACK HOLE”.<br />
MY LIFE WAS BECOMING A SPIRALING,<br />
TRAUMATIC DISASTER.<br />
I just wanted to feel “normal”, but I didn’t know where<br />
to turn. At 35 I dissolved into depression, riddled with<br />
anxiety and panic attacks. A good friend saw what I<br />
couldn’t. She persuaded and sponsored a visit to a<br />
psychiatrist. He prescribed a cocktail of medication,<br />
which included Ritalin. Although it made some<br />
difference I still had off-the-chart stress levels. Any<br />
suggestion of hospitalization was dismissed. After<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 63
PERSPECTIVE<br />
all I was simply dealing with financial stress and a<br />
hectic business. I did not have a mental illness, right?<br />
Things went from bad to worse, almost overnight. I<br />
had lost hope in everything including my ability to<br />
solve my own problems. I felt like I was going to have<br />
a stroke or die of a heart attack. It was at this point I<br />
started to use illegal substances.<br />
CLAUDIA<br />
As I listened to Mark’s story I began to hear some<br />
of the distress his ‘whirlwind’ mind had caused<br />
him. However, I knew he was not sitting in the blue<br />
vinyl chair across from me because of a lack of<br />
concentration and a busy work schedule.<br />
I WAS AWARE MARK HAD A HISTORY<br />
OF SUBSTANCE ABUSE AND HAD SPENT<br />
SOME TIME IN PRISON. I ALSO NOTICED<br />
HE ALWAYS ALSO SPOKE WITH HUMILITY<br />
AND CONCERN FOR THE WORLD<br />
AROUND HIM. I WAS STRUGGLING TO<br />
HEAR ONE COHERENT STORY.<br />
At the beginning Mark tended to speak at superspeed,<br />
sometimes cluttered super-speed. I wanted to<br />
ask a question, which would assist me to understand<br />
what was fundamentally meaningful to him. Perhaps<br />
then I could listen in a more helpful way. I chose<br />
the question: “what was it that you wished for most<br />
when you were in prison?” I didn’t ask this question<br />
based on a hunch of what Mark’s reply could be,<br />
but when it came, his answer took me by surprise.<br />
Without hesitation, Mark said: “to hold a petal and a<br />
book”. I found the clarity, honesty and depth of that<br />
simple answer quite astounding. At that point Mark<br />
began to tell his story in a paced and clear manner.<br />
Something in his approach to his story shifted that<br />
day.<br />
MARK<br />
FROM THE OUTSET, I NEVER HAD A<br />
STARTING POINT AS TO WHAT MY<br />
PRIMARY PROBLEMS ACTUALLY WERE<br />
(AND THERE WERE MANY).<br />
However, Claudia was able to contain the content<br />
of our discussions by slowly giving me perspective<br />
on one point or another - by initially listening, and<br />
then reflecting back to me in point form. Similar to<br />
painting by numbers, Claudia guided me from 1<br />
to number 50. I did not feel Claudia was trying to<br />
control my content, but rather helping me steer the<br />
pains of my heart.<br />
CLAUDIA<br />
Whilst listening to Mark, substance abuse stood out<br />
as something quite incompatible with the principles<br />
Mark lives his life by. Principles clearly as important to<br />
him prior to substance abuse as they are today. I felt<br />
the part of Mark’s story about his hiatus into the world<br />
of substance abuse was discordant, in comparison<br />
to an otherwise consistent character. Why did Mark<br />
really start using drugs?<br />
MARK<br />
On reflection today, I see I chose drugs to help me<br />
cope with the very things my friend had recognized<br />
I needed psychiatric help and hospitalization for.<br />
Except one 30 minute consultation had not allowed<br />
for a full diagnosis, formulation of a treatment plan,<br />
as well as a complete explanation of all the whats<br />
and whys. During that first appointment I had not<br />
been made aware of the crucial importance of<br />
showing up for follow-up consultations. Despite my<br />
friend’s constant encouragement, I didn’t show up.<br />
I DID NOT UNDERSTAND ‘THE PRESSURE’<br />
WOULD HAVE BEEN DEALT WITH BETTER<br />
TOGETHER WITH A PSYCHIATRIST THAN<br />
WITH ILLEGAL SUBSTANCES. AFTER ALL I<br />
NEEDED HELP DEALING WITH ‘LIFE’ NOT<br />
WITH MENTAL ILLNESS, RIGHT?<br />
CLAUDIA<br />
What exactly was ‘the pressure’ though? Was Mark<br />
referring to pressures of a hectic business, anxiety<br />
and panic attacks? Hadn’t he seen a psychiatrist<br />
for that?<br />
MARK<br />
I HAD BEEN PERSUADED TO TRY DRUGS<br />
‘JUST ONCE’ MONTHS BEFORE MY LIFE<br />
WOULD BECOME AN UNCONTROLLABLE<br />
ROLLERCOASTER RIDE. ALTHOUGH<br />
THE DRUGS HAD NOT LEFT ME FEELING<br />
AN IMMEDIATE ‘AWAKENING WITHIN<br />
MY SENSES’, IN THE BACK OF MY MIND<br />
THAT EXPERIENCE LEFT ME WITH THE<br />
PROMISE OF ‘ESCAPE’, SHOULD I NEED<br />
IT IN THE FUTURE. MY LIFE FELL APART<br />
- I REMEMBERED THAT ‘PROMISE OF<br />
ESCAPE’. ILLEGAL SUBSTANCES STARTED<br />
OFF AS A MECHANISM TO COPE WITH<br />
PRESSURE AND ENDED UP AS DRUG<br />
ADDICTION.<br />
CLAUDIA<br />
Although I have never taken illegal substances, I<br />
found common ground in this part of Mark’s story.<br />
Psychiatrists treat ‘crazy’ people – or that is what I<br />
thought years ago. I bristled against the notion that<br />
I needed follow-up appointments, because I was not<br />
‘crazy’. It took years of medical, mental and physical<br />
frustration until a psychiatrist took the time to gently<br />
draw me out and listen to my complete story, and<br />
then explain his role. I realized he was there to help<br />
64 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
PERSPECTIVE<br />
reduce distress caused by too many thoughts going<br />
too fast. He wasn’t there to erase ‘the crazy’, but rather<br />
to help me function better. It would be a long, long<br />
time before we found the right prescription for me.<br />
Therefore, I go so far as to say initially it was the time<br />
he took to really hear me which saved my life, not<br />
the prescription he wrote out. To me there is a deep<br />
sadness that, to Mark, illegal drugs seemed a more<br />
logical option than psychiatric care. But, I digress…<br />
MARK<br />
My drug addiction gave birth to further bad<br />
decisions. I found myself incarcerated for 2 years in<br />
a Brazilian prison for drug muling. Trust me; if anything<br />
changes your perspective on mental health try<br />
being locked away in a Brazilian prison for a single<br />
day. You secretly cry yourself to sleep and pray you<br />
never wake up. In Brazil suicide seemed to be the<br />
only way out. I vowed that if I ever made it back to<br />
<strong>South</strong> Africa alive I would seek help and treatment – I<br />
would become the master of my brain, understand<br />
its quirks and intricate network of wiring failures.<br />
Miraculously, I returned to <strong>South</strong> Africa. I was<br />
undernourished, emaciated and very sick. My family<br />
did not recognize me. A few days later I found<br />
myself across from a neuropsychiatrist and various<br />
psychologists, in what was to be my entry interview<br />
into a psychiatric hospital.<br />
NO JOURNEY OF A THOUSAND MILES<br />
CAN BE COMPLETED IF ONE PREDICTS<br />
THE OUTCOME IS GOING TO BE<br />
NEGATIVE. THE JOURNEY BEGINS WITH<br />
THE EXPECTATION THAT AT THE END OF<br />
THE PROCESS ONE WILL BE A BETTER AND<br />
MORE FULFILLED INDIVIDUAL.<br />
Although I felt suicidal, I still knew I wanted to get<br />
better. I needed to conceptualize my problems<br />
without sounding like a nutcase. I had no words to<br />
verbalize the misconceptions I had about myself. I<br />
felt hopeless. I was perspiring from anxiety, depressed<br />
for feeling the way I did and very nervous. My<br />
biggest concern was whether the psychiatrist would<br />
understand what I was feeling on the inside, without<br />
judging the way I looked on the outside.<br />
MY GREATEST CHALLENGE WOULD BE TO<br />
ARTICULATE WHAT WAS HAPPENING IN<br />
MY BRAIN. WHEN I USED THE METAPHOR<br />
OF MY BRAIN FEELING LIKE ‘RICE<br />
KRISPIES’ ‘SNAP, CRACKLE AND POP’ I<br />
SAW HIS REACTION. I REALIZED HE WAS<br />
MORE INTERESTED IN WHAT WAS GOING<br />
ON WITHIN MY BRAIN THAN WITH THE<br />
TOUCHY-FEELY KIND OF STUFF. HE WAS<br />
INTERESTED IN THE HOWS AND WHYS OF<br />
THE WAY MY NEURONS AND DENDRITES<br />
WERE FIRING.<br />
I think this is fundamentally the problem. We as<br />
patients don’t understand (or initially understand)<br />
how billions of neurons should all fit together like a<br />
glove. I did eventually begin to trust my psychiatrist’s<br />
ability to help me and understand his role in my<br />
recovery. My journey of mental health discovery<br />
had begun. Despite this progress toward chemical<br />
stability, I felt unable to tell my authentic story.<br />
CLAUDIA<br />
An immense part of one’s psychiatric diagnosis and<br />
treatment is based on verbal accounts of feelings<br />
and experiences. There seems to be professional<br />
agreement that the more detailed knowledge a<br />
practitioner has of his patient’s story, the better the<br />
prospect for correct diagnosis. However, I have<br />
learned that telling one’s authentic, un-censored<br />
story is impossible without trust.<br />
THE THING IS, TRUST IS NOT A GIVEN<br />
BYPRODUCT OF A HIGHLY SKILLED<br />
PROFESSIONAL. TRUST IS AN INNATELY<br />
HUMAN QUALITY, SOMETHING EACH ONE<br />
OF US HAS TO EARN. THE ASSUMPTION<br />
THAT BY VIRTUE OF ONE’S PROFESSION A<br />
PERSON SHOULD AUTOMATICALLY TRUST<br />
YOU IS DEEPLY FLAWED, AND AT TIMES<br />
DISASTROUS.<br />
I don’t believe inordinate amounts of time are<br />
needed to start earning trust. I believe it starts by<br />
meeting as equal humans whilst still acknowledging<br />
the different roles patient and practitioner play.<br />
Patients need to trust their doctors in order for<br />
doctors to trust their patients.<br />
MARK<br />
I agree with Claudia’s reflection. Presumptions have<br />
been the ultimate breaking point in my experience<br />
with some psychiatrists and therapists. A lack of<br />
trust has left me feeling emptier and worse for wear,<br />
convinced no amount of medication or therapy<br />
would make me feel complete or normal.<br />
RECENT TREATMENTS HAVE BEEN MOST<br />
EFFECTIVE WHEN, IN MOMENTS OF<br />
VULNERABILITY, MY PSYCHIATRIST HAS<br />
SHOWN ME HE TOO IS HUMAN. BY<br />
LISTENING HE HAS COME TO OPEN<br />
UP AN EASY DIALOGUE, ALLOWING<br />
ME TO ENGAGE FREELY WITH HIM,<br />
AND TOGETHER CONSIDER THE BEST<br />
MEDICATIONS FOR MY TREATMENT.<br />
CLAUDIA<br />
Paying heed to clinical and academic perspectives<br />
is a necessity. However, as this account shows,<br />
my own experience as a patient can sometimes<br />
underpin the responses or questions I pose to the<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 65
PERSPECTIVE<br />
person across from me. My first therapist allowed me<br />
small, appropriate glimpses into his experience of<br />
being human. It was this, not his technical prowess,<br />
which truly helped me trust him. The choice to<br />
bring in a sliver of my own story is always carefully<br />
considered on the sole basis of ‘will this be helpful to<br />
the person sitting with me?’<br />
MARK<br />
Claudia’s own experiences have been significant<br />
for me. I remember the first time Claudia told me<br />
her own ADHD diagnosis is treated with Ritalin. I<br />
immediately felt at ease with her – she was human,<br />
just like me. It is one thing to try to build trust with a<br />
practitioner, but when in the back of my mind the<br />
person is purely theoretical it keeps my own story<br />
within the confines of a textbook. This has always<br />
been incredibly difficult when seeking help.<br />
KNOWING CLAUDIA HAS BEEN IN THE<br />
TRENCHES (SO TO SPEAK) WITH THE<br />
REST OF US IS AN IMMENSE HELP. IT<br />
CREATES AN ATMOSPHERE THAT ALLOWS<br />
ME TO TUNE IN TO HER REMARKS AND<br />
QUESTIONS AND BUILDS TRUST.<br />
CLAUDIA<br />
Practitioners write up patient files. These files contain<br />
medical and prescription information, consultation<br />
notes, progress reports and even a ‘patient history’<br />
section. By virtue of a patient file’s authorship, they<br />
in some way document practitioners’ stories about<br />
working with a patient, rather than their patient’s<br />
own story told in their own words. ‘Holding a petal<br />
and a book’ is not a symptom, it is not part of a<br />
practitioner’s story, but it is a fundamental statement<br />
which birthed insight. ‘I have a dream…’ were the<br />
opening words of a speech, which changed history.<br />
The words are simple, but their meaning is immensely<br />
deep. So ask yourself: how important are the words<br />
‘to hold a petal and a book’?<br />
MARK<br />
I REPLIED: ‘TO HOLD A PETAL AND A BOOK’.<br />
SUDDENLY I WAS ABLE TO UNCOVER THE<br />
HORROR THAT LAY AT THE EPICENTER OF<br />
MY STORY.<br />
Today, many miles into my journey, I find myself in a<br />
wonderful NGO psycho-social rehabilitation center.<br />
It is here where I am being nurtured and cared for<br />
by amazing humans. I have time to heal and reprogram<br />
my brain’s faulty wiring. In the process, I<br />
found myself in a blue vinyl chair….<br />
CLAUDIA<br />
I DON’T BELIEVE I WILL EVER CRAVE<br />
FROZEN DAIRY PRODUCTS. HOWEVER,<br />
OCCUPYING A BRIGHT BLUE VINYL CHAIR<br />
IS AN HONOUR I NOW DEEPLY VALUE. AS<br />
HUMANS, OUR STORIES SHAPE MUCH OF<br />
WHO WE ARE. BUT, IT CAN BE SCARY TO<br />
TELL ONE’S COMPLETE, UNCENSORED<br />
STORY FEARING OF JUDGMENT, BECAUSE<br />
ORDINARILY ONE DOES NOT TRUST A<br />
JUDGMENTAL PERSON. UNFORTUNATELY<br />
DIAGNOSIS AND JUDGMENT CAN<br />
MISTAKENLY FEEL THE SAME.<br />
Although listening to stories without the expectation<br />
to diagnose or ‘treat’ is a privilege, it’s not a necessity.<br />
After all the person I trusted enough to listen without<br />
judgment was the very same person whose ‘job’ it<br />
was to diagnose me.<br />
Place:<br />
Brazil<br />
Date: 12 July 2015<br />
Incarceration: Day 19<br />
Time without drugs: 20 days<br />
PRECISION<br />
I look outside but nothing<br />
Only Grey and White<br />
Precision as if anyone cares<br />
For when gates open and mind circles<br />
Inner courtyard tightened by Iron bars<br />
And the sense of hopelessness<br />
One can only wonder how do my thoughts differ<br />
From the treadmill of rats circling around and<br />
around<br />
Conversations into the realms of nowhere<br />
CONCLUSION<br />
by Mark Booth<br />
Life fails when hope ends. Today there is hope and<br />
so there is life.<br />
Claudia Campbell holds a post-graduate degree in psychology and has 10 years experience in the field of corporate<br />
transformation strategy. Claudia works in a voluntary capacity as a psychosocial facilitator, public speaker, and strategic<br />
consultant. Claudia is currently undertaking a psychology research master’s degree focused on the implementation of the<br />
National Mental Health Policy Framework 2013-2020 and the role of registered counsellor, through Stellenbosch University. Due<br />
to various health concerns, Claudia’s personal life includes many experiences from the patient’s side of the consultation table.<br />
Correspondence: claudia@redbench.co.za<br />
66 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
in Mental Health
BOOK REVIEW<br />
SNOEK<br />
ON THE COUCH<br />
BY ROBIN EMSLEY<br />
Sue Hawkridge<br />
this book I would obviously have<br />
found a reason not to review it, and<br />
the only thing this review can now<br />
be about is how much I like it, and<br />
why.<br />
FIRST A WORD ABOUT WHAT<br />
SORT OF BOOK THIS IS: IT<br />
DOES NOT EASILY LEND<br />
Sue Hawkridge<br />
ITSELF TO CLASSIFICATION.<br />
IT HAS ELEMENTS OF AN ESSAY<br />
COLLECTION, OF A MEDITATION, OF A<br />
SCIENTIFIC SYNTHESIS AND A PERSONAL<br />
MEMOIR, NOT TO MENTION A WILDLIFE<br />
GUIDE. IT’S ALSO VERY FUNNY IN PARTS.<br />
Title: Snoek on the Couch<br />
Publisher: Print Matters Heritage<br />
Author: Professor Robin Emsley<br />
There is a certain apprehension in reviewing<br />
a book written by someone I know well, and<br />
I wondered, as I began, whether a review<br />
by someone known to be a friend of the<br />
author has any credibility at all. After a little selfinterrogation,<br />
I concluded that I had actually<br />
agreed to do this review because I like the book,<br />
rather than because I like the author. I do, of course,<br />
like the author – he has been my mentor and friend<br />
for over a quarter of a century. What would have<br />
made me say no? Well, if I hadn’t liked the book. Do I<br />
never review books I don’t like? Apparently not, given<br />
my publication record. So far so good, but can I<br />
really be objective? Alarmingly for my literary friends,<br />
yes, I can, as evidenced by the very colourful trackchanges<br />
edits with which I routinely provide them<br />
when they are rash enough to ask. So if I hadn’t liked<br />
I suppose we all spend more time musing as the<br />
years accumulate, and official retirement offers<br />
an ideal opportunity to consolidate our thoughts.<br />
Sometimes the result is a set of rules for the young,<br />
sometimes a Jeremiad about humankind’s state of<br />
incivility, but sometimes, as with this book, the author<br />
is simply sharing a journey through things and<br />
places that have puzzled or fascinated him or her<br />
over the years. It’s a generous impulse and there’s<br />
often something of the late, great Oliver Sacks about<br />
this kind of writing – if you like Uncle Tungsten, I think<br />
you will enjoy the “Snoek boek”.<br />
On first reading, Snoek on the Couch is a quirky<br />
meander through the fish species and its odd<br />
(disgusting) ailments, the snoek industry of the West<br />
Coast and the people who work in it, the complexities<br />
of language, the mysteries of schizophrenia, the<br />
possibility of self-awareness in non-human animals,<br />
and a contemplation of the possible subjective<br />
experience of animals.<br />
68 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
BOOK REVIEW<br />
POIGNANTLY, EMSLEY FORCES US TO<br />
PONDER OUR OFTEN DUBIOUS ETHICS<br />
OF EATING, AND THE SAD INEVITABILITY<br />
OF THE FOOD CHAIN.<br />
We then move on through the roots of evolutionary<br />
social psychology and the science of facial<br />
expressions and what they may mean (or not).<br />
While this may suggest anthropomorphism to the<br />
uninitiated, there appears to be a sound scientific<br />
basis for the attribution of personality traits to fish.<br />
In one study, some unfortunate guppies were<br />
placed in stressful situations and their responses<br />
measured and compared, and apparently “some<br />
attempt to hide, others try to escape, (and) some<br />
explore cautiously,” according to Dr Tom Houslay,<br />
an evolutionary ecologist then working at Exeter<br />
University, now at Cambridge University. “The<br />
differences between them were consistent over time<br />
and in different situations. So, while the behaviour<br />
of all the guppies changed depending on the<br />
situation - for example, all becoming more cautious<br />
in more stressful situations - the relative differences<br />
between individuals remained intact.” The presence<br />
of predators had an effect on ‘average’ behaviour,<br />
making all the guppies more cautious. But individuals<br />
still retained their distinct personalities.<br />
Professor Alastair Wilson, another member of the<br />
team, explained, ‘We want to know how personality<br />
relates to other facets of life, and to what extent<br />
this is driven by genetic, rather than environmental,<br />
influences. The goal is really gaining insight into<br />
evolutionary processes, how different behavioural<br />
strategies might persist as species evolve.”<br />
In fact, group dynamics among fish appear not to<br />
be too different from those among humans. Kyriacos<br />
Kareklas and his colleagues “tested zebrafish shoals<br />
to examine whether groups exhibit collective<br />
spatial learning and whether this relates to the<br />
personality of group members... There were strong<br />
indications of collective learning and collective<br />
reorienting … but these processes were unrelated<br />
to personality differences within shoals. However,<br />
there was evidence that group decisions require<br />
agreement between differing personalities. Notably,<br />
shoals with more boldness variation were more<br />
likely to split during training trials and took longer<br />
to reach a collective decision. Thus cognitive tasks,<br />
such as learning and cue memorisation, may<br />
be exhibited collectively, but the ability to reach<br />
collective decisions is affected by the personality<br />
composition of the group. A likely outcome of the<br />
splitting of groups with very disparate personalities is<br />
the formation of groups with members more similar<br />
in their personality.” It may be a far stretch from there<br />
to political parties, but the idea is intriguing.<br />
Well then, the idea of a depressed snoek may not be<br />
as far out as might at first glance appear. And so the<br />
unsettling starts: If facial expression has meaning, it<br />
may induce empathy, and being empathic towards<br />
your food is a delicate balancing act, although<br />
one perhaps pioneered by the first peoples of our<br />
country. And what if appearance does indeed say<br />
something about character or mental state, even in<br />
non-human animals? Can one speculate about the<br />
emotional aspects of a particular species’ capacity<br />
to adapt without having direct knowledge of those<br />
emotions?<br />
As Randolph Nesse wrote in 2009, “… Darwin clearly<br />
recognized that evolution shaped not only the<br />
physical characteristics of an organism but also its<br />
mental processes and behavioural repertoires. The<br />
knowledge that natural selection shaped the brain<br />
mechanisms that mediate motivation and emotions<br />
offers a solid foundation on which a modern theory<br />
of emotions is being built.” So Darwin did it all the<br />
time. He even wrote a book about it (The Expression<br />
of the Emotions in Man and Animals: Charles Darwin,<br />
1872).<br />
But adding the possibility of consciousness to<br />
evolutionary adaptation in animals takes us beyond<br />
the descriptive and into the experiential, and makes<br />
us ponder the complexities of our own transitions,<br />
especially over the last 30 odd years. Emsley tells<br />
the story of an unsuccessful adapter, and the<br />
psychopathology that preceded and followed<br />
his failure, and wonders how the personality traits<br />
of snoek might affect their ability to survive the<br />
changing environment (no, Donald, this is no longer<br />
an argument). In the long run, says Emsley, it’s about<br />
balance. And so it is.<br />
I loved this book, and would recommend it to anyone<br />
looking for some fresh thinking on some of life’s really<br />
hard questions. Emsley cuts through shibboleths<br />
and jargon, and gives us an eloquent, undistorted<br />
account of what life looks like from where he sits. In<br />
an age of universal deceit, to borrow a phrase from<br />
George Orwell, it’s rare. It’s also thought-provoking<br />
and destabilising. As I reach guiltily for a seed<br />
cracker smothered in snoek pate…<br />
REFERENCES<br />
1. https://www.timeslive.co.za/sunday-times/<br />
lifestyle/2017-09-26-hidden-depths-scientistsconfirm-fish-have-different-personalities/<br />
2. Kareklas, K., Elwood, R. W., & Holland, R. A. Fish<br />
learn collectively, but groups with differing<br />
personalities are slower to decide and more<br />
likely to split. Biology Open, (2018) 7(5), https://<br />
doi.org/10.1242/bio.033613<br />
3. Nesse, RM and Ellsworth PC. Evolution, Emotions,<br />
and Emotional Disorders. American Psychologist<br />
(2009) 64, No. 2 (<strong>February</strong>–March), 129–139 DOI:<br />
10.1037/a0013503<br />
Sue Hawkridge is Clinical Head of the Child and Adolescent <strong>Psychiatry</strong> Unit of of Tygerberg Hospital in the Western Cape.<br />
She is a senior lecturer in the Department of <strong>Psychiatry</strong>, Stellenbosch University and a visiting lecturer in the Department of<br />
Psychology at Rhodes University. Reading, writing, reviewing and editing are how she maintains a semblance of balance.<br />
Correspondence: smh@sun.ac.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 69
CULINARY CORNER<br />
A MEANINGFUL MEAL<br />
OF PSYCHIATRIC AND<br />
PSYCHOLOGICAL<br />
INFORMATION<br />
If you are interested in acrophobia, our menu<br />
today starts with a study regarding the most<br />
therapeutic way of dealing with a fear of heights.<br />
Then we go on to the medication used to help<br />
a patient tormented by ghostly insects; the use<br />
of mirror therapy in those tortured by phantom<br />
limb pain; and the influence of alexithymia on<br />
symptom over-reporting. The refresher comes from<br />
a study which explores the impact of social group<br />
membership on the recognition of creative work,<br />
and dessert provides an answer to the question as to<br />
whether the expressive arts can alleviate symptoms<br />
of trauma or not. Coffee is accompanied by a review<br />
study of optimism’s association with good physical<br />
health.<br />
STARTER<br />
USING VIRTUAL REALITY AS A<br />
THERAPEUTIC MEANS<br />
Do you often listen in awe as others<br />
boast about aeroplane or bungee<br />
jumping? It sounds magical - but<br />
also anxiety-provoking, particularly<br />
if standing on a second-floor<br />
balcony is about as high as you<br />
will go. It turns out there’s a good<br />
way of helping those of us with a<br />
fear of heights to get in touch with<br />
our adventurous selves. A group<br />
of researchers (Freeman et al, 2018) carried out a<br />
randomised trial of automated reality in the treatment<br />
of a fear of heights. They divided up one hundred<br />
acrophobic individuals into an experimental group<br />
(forty-nine members) and a control group (fifty-one<br />
participants). The members of the control group<br />
were linked to a virtual reality program (VR) and their<br />
levels of improvement were compared to those of<br />
the control group.<br />
PARTICIPANTS OF BOTH GROUPS WERE<br />
OLDER THAN EIGHTEEN YEARS AND<br />
SCORED MORE THAN 29 ON THE HEIGHTS<br />
INTERPRETATION QUESTIONNAIRE (HIQ).<br />
THIS QUESTIONNAIRE WAS CHOSEN<br />
BECAUSE IT HAS BEEN FOUND TO BE<br />
PREDICTIVE OF DISTRESS, ANXIETY,<br />
AND AVOIDANCE OF REAL HEIGHTS.<br />
FREEMAN ET AL (2018) NOTED THAT IT<br />
HAS HIGH INTERNAL CONSISTENCY AND<br />
CONVERGENT VALIDITY WITH OTHER<br />
FEAR OF HEIGHTS MEASURES.<br />
The experimental group interacted with a virtual<br />
coach in a virtual office. He started off by presenting<br />
ways of dealing with this fear from a cognitive<br />
perspective. Participants were then “taken” to the<br />
70 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
CULINARY CORNER<br />
atrium of a large ten storey building where they chose<br />
the floor that they wished to tackle first. Tasks were<br />
graded from easier to more difficult and an attempt<br />
was made for each challenge to be engaging and<br />
entertaining. For example, one of them was: playing<br />
a xylophone near the edge of a floor.<br />
As expected, the researchers found the virtual reality<br />
treatment to be associated with significant changes<br />
in scores on the HIQ (mean change score: -24.5; SD:<br />
13.1) as against the scores of those in the control<br />
group (mean change score: -1.2; SD: 7.3). Treatment<br />
uptake was high and levels of discomfort after a VR<br />
session were very low.<br />
The authors point out that the strength of VR treatment<br />
is that patients are willing to go into situations that<br />
trouble them and to try different ways of responding<br />
because it is a simulation. The learning achieved in<br />
this way has been found to transfer to the real world.<br />
Use of VR can also offer one of the most powerful<br />
aspects of a direct therapeutic intervention - namely<br />
direct coaching in everyday situations that trouble<br />
people.<br />
MAIN MEAL<br />
TREATING PARASITOSIS<br />
The feeling of insects crawling on one’s skin is not in<br />
itself unpleasant. However, it is irritating and most of<br />
us will look quickly to see where the creature is and<br />
swiftly flick or blow it away. How awful it must be if<br />
the cause of the tickling sensation on one’s body<br />
remains hidden - like a ghostly bug. This is a case of<br />
a patient with parasitosis, reported on by Rathi and<br />
Bhatia (2018) in the Indian Journal of <strong>Psychiatry</strong>.<br />
THE INDIVIDUAL CONCERNED WAS A<br />
THIRTY-FOUR-YEAR-OLD HINDU MALE<br />
WHO WORKED IN AN ELECTRONICS<br />
SHOP. HE WAS INITIALLY REFERRED TO A<br />
DERMATOLOGIST ON ACCOUNT OF A<br />
YEAR-LONG HISTORY OF FEELING THAT<br />
AN INSECT WAS CRAWLING OVER HIS<br />
LEGS AT NIGHT. PREOCCUPIED WITH<br />
WORRY REGARDING THIS NOCTURNAL<br />
PEST, HE SUSPECTED THAT HIS BEDDING<br />
MIGHT BE INFESTED, DESPITE HAVING<br />
WASHED IT OUT SEVERAL TIMES.<br />
As might be expected, he was then directed to the<br />
psychiatrists. The authors reported that they started<br />
him on 4mg of blonanserin per day. After two weeks<br />
they increased the dosage to 8mg per day. He was<br />
also given 2mg of lorazepam at night to help him<br />
with sleep (on an SOS basis). There was complete<br />
remission of his symptoms at six weeks and on followup,<br />
at three months, he continued to be well.<br />
MIRROR THERAPY<br />
From ghostly insects to ghostly limbs - it’s bad enough<br />
when the existing parts of a person’s body produce<br />
discomfort and suffering, but how disconcerting to<br />
have one’s amputated body parts evoking pain too.<br />
Phantom limb pain (PLP) happens when there is a<br />
visual-proprioception dissociation in the brain. Mirror<br />
therapy has been used to relieve PLP by resolving<br />
this dissociation. However previous studies into this<br />
treatment modality have been based on small<br />
sample sizes.<br />
Ramadugu et al (2017) carried out a randomized<br />
single crossover study of mirror therapy in the<br />
treatment of PLP in a sample of 64 amputees. The<br />
participants (between the ages of 15 and 75 years)<br />
were randomly distributed into test and control<br />
groups. The test group were made to carry out a<br />
standardized set of exercises for 15 minutes a day in<br />
front of a mirror for 4 weeks. The control group carried<br />
out these tests in front of a covered mirror.<br />
A significant reduction in PLP was revealed in the test<br />
group by means of the visual analog scale and the<br />
short-form Mc Gill Pain Questionnaire (P
CULINARY CORNER<br />
researchers therefore concluded that mirror therapy<br />
is effective in relieving the intensity, duration and<br />
frequency of PLP.<br />
ALEXITHYMIA OR MALINGERING<br />
It is embarrassing and discouraging to go to one’s<br />
physician with a list of complaints that he or she<br />
cannot find any reason for. Merckelbach et al (2018)<br />
note that doctors often suspect such patients of being<br />
malingerers or - one might add - attention-seekers.<br />
However, these researchers questioned whether an<br />
over-reporting of eccentric symptoms might not be<br />
associated with alexithymia, which refers to a deficit<br />
in reading one’s internal experiences. Alexithymia<br />
has also been linked to sleep problems and fatigue.<br />
In their exploratory study, Merckelbach et al (2018)<br />
therefore administered measures of alexithymia,<br />
symptom-over-reporting and sleep quality to<br />
both forensic psychiatric outpatients and nonforensic<br />
participants. They found that overreporting<br />
correlated positively and significantly with<br />
alexithymia. While sleep problems were also found to<br />
be associated with over-reporting, the link between<br />
alexithymia and over-reporting was stronger. They<br />
concluded that alexithymia as a potential source of<br />
over-reporting should therefore be explored further.<br />
REFRESHER<br />
GENIUS BEGINS AT HOME<br />
For those of us who understand the intense suffering<br />
engendered by not having one’s genius recognised,<br />
the following study offers a small comfort.<br />
STEFFENS ET AL (2017) EXPLORED THE<br />
EXTENT TO WHICH THE RECOGNITION OF<br />
CREATIVE WORK IS AFFECTED BY SOCIAL<br />
GROUP MEMBERSHIP. THEY DID THIS BY<br />
ANALYSING THE AWARD OF MERIT PRIZES<br />
FOR THE BEST ACTOR OR ACTRESS IN A<br />
LEADING ROLE IN THE UNITED STATES-<br />
BASED OSCARS AND THE BRITISH BAFTAS,<br />
GOING BACK TO 1968.<br />
They found that US actors won a significantly greater<br />
proportion of the Oscars (odds ratio: 2.10), while<br />
British artists won a greater proportion of BAFTAs<br />
(odds ratio: 2.26). They concluded that, among<br />
other things, a creative performance is more likely to<br />
be viewed as outstanding when the artist involved is<br />
perceived to be “one of us”.<br />
DESSERT<br />
CAN EXPRESSIVE ARTS ALLEVIATE<br />
SYMPTOMS OF TRAUMA?<br />
Demott et al (2017) carried out a study of an expressive<br />
arts group intervention with unaccompanied<br />
minor asylum children in Norway. The goal was to<br />
determine whether such an intervention alleviated<br />
symptoms of trauma and enhanced life satisfaction<br />
and hope.<br />
One hundred and forty-five unaccompanied<br />
refugee boys between the ages of 15 and 18 years<br />
were allocated into either a ten-session expressive<br />
arts intervention group (EXIT) where participants<br />
worked through a manual of creative tasks, or a<br />
life as usual group (LAU). The participants were<br />
assessed at onset and four times over a period of<br />
25 months on instruments measuring post-traumatic<br />
stress, general psychological distress, current life<br />
satisfaction and expected life satisfaction.<br />
72 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
CULINARY CORNER<br />
As expected, the EXIT group intervention had a<br />
significant beneficial effect on helping the boys<br />
cope with symptoms of trauma, strengthening their<br />
life satisfaction and developing hope for the future.<br />
COFFEE<br />
OPTIMISM AND PHYSICAL HEALTH<br />
In conclusion the authors note that the literature<br />
strongly suggests that dispositional optimism is a<br />
robust predictor of diverse physical health outcomes.<br />
More work, however, still needs to be done on this<br />
relationship.<br />
In the meantime, if you can, try to be positive.<br />
INGREDIENTS<br />
Finally, for all of you for whom the glass is always<br />
half empty rather than half full, Scheier and Carver<br />
(2018) carried out a thirty year review of research<br />
on dispositional optimism and physical wellbeing.<br />
Their review encompassed initial research<br />
suggesting a connection between physical wellbeing<br />
and optimism as well as later, large-scale,<br />
epidemiological studies that linked the two factors<br />
more emphatically.<br />
The reasons for this association are three-fold. On the<br />
one hand it may be because optimists have better<br />
coping strategies than pessimists. It is hypothesised<br />
that the former are more likely to take constructive<br />
action to improve matters and solve problems.<br />
On the other hand, there is some indication that<br />
pessimists tend to make use of avoidant strategies<br />
such as denial or mental disengagement.<br />
A POSSIBLE SECOND WAY IN WHICH<br />
OPTIMISM MIGHT AFFECT PHYSICAL<br />
HEALTH IS THROUGH ITS INFLUENCE<br />
ON STRESS. THE COPING STRATEGIES<br />
OF OPTIMISTS MAY ENSURE THAT THEY<br />
SUFFER LESS STRESS WHEN LIFE BECOMES<br />
CHALLENGING.<br />
Thirdly, the researchers found a complex relationship<br />
between optimism and the immune system. The<br />
most consistent finding, however, was that there is<br />
an association between optimism and components<br />
of the immune system that reflect systemic<br />
inflammation.<br />
Demott, M.A.M., Jakobsen, M., Wentzel-Larsen, I.,<br />
Heir, T. (2017). A controlled early group intervention<br />
study for unaccompanied minors: Can expressive<br />
arts alleviate symptoms of trauma and enhance life<br />
satisfaction? Scandinavian Journal of Psychology,<br />
58, 510-518.<br />
Freeman, D., Haselton, P., Freeman, J., Spanlang,<br />
B., Kishore, S et al. (August 2018). Automated<br />
psychological therapy using immersive virtual reality<br />
for treatment of fear of heights: a single-blind,<br />
parallel-group, randomised controlled trial, Lancet<br />
<strong>Psychiatry</strong>, 5, 625-623.<br />
Merckelbach, H., Prins, C., Boskovic, I., Niesten, I., A<br />
Campo, J. (2018). Alexithymia as a potential source<br />
of symptom over-reporting: An exploratory study in<br />
forensic patients and non-forensic participants,<br />
Scandinavian Journal of Psychology, 59(2), 192-197.<br />
Ramadugu, S., Nagabusham, S.C., Katuwal, N.,<br />
Chatterjee, K. (2017). Intervention for phantom limb<br />
pain: A randomized single crossover study of mirror<br />
therapy, Indian Journal of <strong>Psychiatry</strong>, 59(4), 457-464.<br />
Rathi, A., Bhatia, M.S. (2018). A case of delusional<br />
parasitosis responded to Blonanserin, Indian Journal<br />
of <strong>Psychiatry</strong>, 60, 254-5<br />
Scheier, M.F., & Carver, C.S. (2018). Dispositional<br />
Optimism and Physical Health: A Long Look Back, A<br />
Quick Look Forward, American Psychologist, 73(9),<br />
1082-1094.<br />
Steffens, N.K., Haslam, S.A., Ryan, M.K., & Millard, K.<br />
(2017). Genius begins at home: shared social identity<br />
enhances the recognition of creative performance,<br />
British Journal of Psychology,108, 721-736.<br />
Ethelwyn Rebelo (PhD) is a clinical psychologist working in private practice. She has spent a good part of her<br />
professional life working in psychiatric wards and psychiatric clinics. Correspondence: ee.vajdakova@outlook.com<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 73
WINE FORUM<br />
HERITAGE,<br />
ROMANCE …<br />
OR BOTH?<br />
When Bruwer Raats accepted Platter’s<br />
2018 Winery of The Year accolade, he<br />
had a tilt at the old vine debate. Five of<br />
seven wines in the Raats Family portfolio<br />
garnered coveted Five Star awards and, like their<br />
cellar siblings, the celebrity duo of Eden High Density<br />
Single Vineyard chenin blanc and cabernet franc<br />
were from vines barely six years old. Top end wines<br />
didn’t only come from old vines he suggested, a dig<br />
at some of his illustrious peers…<br />
Fast forward to the launch of Platter’s <strong>2019</strong>, which<br />
introduced the Certified Heritage Vineyards icon<br />
(and bottle decal) for wines made from grapes off<br />
vines older than 35 years as certified by the Old Vine<br />
Project. Old vines are now officially hip; OVP 1 Raats<br />
0?<br />
ROSA KRUGER IS THE CURRENT DOYENNE<br />
OF THE CAPE VINEYARD AND HAS A<br />
FOLLOWING OF YOUNG, VIBRANT AND<br />
EDGY WINEMAKERS – THE YOUNG GUNS<br />
– THAT VERGES ON CULT STATUS. SHE WAS<br />
VINEYARD MANAGER AT L’ORMARINS<br />
WHEN HER CURIOSITY ABOUT REALLY<br />
MATURE VINEYARDS STARTED HER<br />
SEARCH FOR THEM IN 2002.<br />
in the matter swelled and Johann<br />
Rupert provided seed capital to<br />
establish The Old Vine Project in<br />
2016. It aims to create awareness<br />
of the heritage of older wines<br />
and to preserve those more than<br />
35 years old. With Ms Kruger at<br />
its helm, Andre Morgenthal is the<br />
hyperkinetic Project Manager.<br />
There are 1377 vineyard blocks over 3197 hectares<br />
of vines older than 35 years, in the context of a<br />
national vineyard of 95 000 ha (down 5% over the<br />
last ten years). Ten parcels are over 100 years old;<br />
Franschhoek’s La Colline semillon, planted in 1936,<br />
still provides fruit for rock star Chris Alheit’s eponymous<br />
bottling, amongst others.<br />
The old vine parcels – mostly in Stellenbosch, Paarl<br />
and Swartland – are generally small (around 1<br />
ha) and reflect what was favoured by the farmer<br />
of the day: workhorse chenin, ubiquitous muscat<br />
d’Alexandrie, and colombar, palomino, crouchen<br />
blanc (“Paarl Riesling”) & clairette blanche destined<br />
for brandy. The Young Guns are now coaxing decent<br />
wine out of these less fashionable varieties and<br />
creating formidable Cape white blends. Cinsaut –<br />
also enjoying a renaissance – pinotage and tinta<br />
barocca are common old black grape plants.<br />
This voyage took her to forgotten grenache in the<br />
Piekenierskloof and venerable chenin and semillon<br />
at Skurfkop. Add Eben Sadie – in the vanguard of<br />
The Young Guns – and his Old Vine Series, and the<br />
momentum grew.<br />
The problem was that, while the old vineyards<br />
were documented, their existence couldn’t be<br />
made public at the time. Kruger eventually coaxed<br />
custodian of these matters, <strong>South</strong> <strong>African</strong> Wine<br />
Information & Systems, to release the list subject to<br />
her personal undertakings in 2012. Foreign interest<br />
Rosa Kruger<br />
74 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
WINE FORUM<br />
Rewind Raats; does it make a difference? It’s a field<br />
thick with romance. ‘Old vines often reflect the lives<br />
and the culture of the people – the fishermen on the<br />
coast, the sheep farmers inland, the wheat farmers of<br />
the Swartland and the fruit farmers of Piekenierskloof<br />
– and are often preserved by sentiment rather than<br />
budgets,’ avers Kruger. ‘Old vines and the wines they<br />
make are a monument to the farmer’s love of his land.’<br />
Marco Ventrella, head viticulturist at KWV, offers a<br />
scientific perspective. It’s akin to human ageing. As<br />
the vine matures it stores more carbohydrate, making<br />
it more resistant to adverse (especially drought)<br />
conditions due to accumulated reserves. The grapes<br />
reach ‘phenolic ripeness’ – when flavour compounds<br />
are fully developed – earlier. Fruity exuberance and<br />
obvious varietal character may be the preserve of<br />
youth, but wine from more venerable stock has fuller<br />
texture, is better structured, with greater intensity,<br />
palate-weight, and complexity.<br />
BUT IS IT WORTH IT? THE LIFE CYCLE OF<br />
A VINE IS SUCH THAT ITS FRUIT DON’T<br />
CONVERT TO POTABLE WINE FOR THE<br />
FIRST FEW YEARS, THEY GROW INTO<br />
QUALITY PRODUCTION BY ABOUT 10 TO<br />
15 YEARS, AND THEN, ON THE OTHER SIDE<br />
OF 20 TO 30 YEARS OF AGE PRODUCTION<br />
FALLS OFF.<br />
Selling grapes by the ton, a farmer will need to double<br />
prices when yields halve. Or grub up the old vines<br />
for new ones or alternative crops to stay financially<br />
afloat. It’s the OVP’s aim to keep these 20-something<br />
wines in the ground: ‘Encouraging “planting to grow<br />
old”,’ as Morgenthal puts it.<br />
In a University of Cape Town and Stellenbosch<br />
collaboration, Jonathan Steyn and David Priilaid<br />
constructed a hedonic pricing model to investigate<br />
how wine price-setters in the supply chain prioritise<br />
old vine cues, relative to more conventional cues of<br />
worth. ‘In addition to the contribution of established<br />
cues such as aggregate ratings, exemplar brands,<br />
prototypical varieties, and origin, our study confirmed<br />
that vine age contributes significantly to wine price.’<br />
Steyn added that, ‘The introduction of the certified<br />
heritage vineyard seal is an important step and is<br />
likely to sharpen and further shape the category<br />
boundaries globally.’<br />
VinPro, the local wine research body, reports 37% of<br />
wine growers are operating at a loss, 2% break even,<br />
47% make a low profit; only 14% are profitable. A<br />
wine farm needs to generate R40-60 000/ha to be<br />
sustainable, which means making wine that can sell<br />
at R300 a bottle. With 80% of all old vines within the<br />
cooperative system, the OVP is a potential leg up for<br />
that sector into the premium wine market.<br />
The L’Ormarins Old Bush Vine Chenin Blanc was first planted in 1964 on the<br />
Paardeberg Mountain between Malmesbury and Paarl. In 2007/8 these old<br />
bush vines were replanted on the north facing decomposed granite slopes<br />
of L’Ormarins in Franschhoek, where they now produce a single varietal wine.<br />
Photo: Gideon Nel<br />
La Colline, Franschhoek. Semillon planted in 1936<br />
Bellevue Wine Estate Pinotage, 1953<br />
Anthonij Rupert Wines Henk Laing Vineyard, Semillon, Planted 1956<br />
www.oldvineproject.co.za<br />
Andre Morgenthal<br />
Project Manager<br />
andre@oldvineproject.co.za<br />
0826583883<br />
David Swingler is a writer and taster for Platter’s <strong>South</strong> <strong>African</strong> Wine Guide over 21 years to<br />
date. Dave Swingler has over the years consulted to restaurants, game lodges and convention<br />
centres, taught wine courses and contributed to radio, print and other media. A psychiatrist<br />
by day, he’s intrigued by language in general, and its application to wine in particular.<br />
Correspondence: swingler@telkomsa.net<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 75
MOVIE REVIEW<br />
THE WIFE<br />
a review by Franco P. Visser<br />
A Silver Reel Presentation<br />
An Anonymous Content /<br />
Meta Film London / Tempo<br />
Productions Limited Production<br />
Directed by Björn Runge<br />
Screenplay by Jane Anderson<br />
Let me start this review by wishing you a happy<br />
and prosperous <strong>2019</strong>. May this year for you be<br />
filled with endless wonder and joy. Last year<br />
was my year of music – this year I shall have<br />
beauty in all its forms!<br />
THIS YEAR MARKS THE 118 TH YEAR THAT<br />
THE NOBEL PRIZE FOR LITERATURE WILL<br />
BE AWARDED TO A DESERVING AUTHOR<br />
WHO ‘PRODUCED IN THE FIELD OF<br />
LITERATURE THE MOST OUTSTANDING<br />
WORK IN AN IDEAL DIRECTION’. ALONG<br />
WITH THE PULITZER PRIZE, THE NOBEL<br />
PRIZE FOR LITERATURE IS THE MOST<br />
PRESTIGIOUS AND COVETED AWARD<br />
ANY WRITER CAN DREAM OF RECEIVING<br />
IN HIS OR HER CAREER.<br />
Imagine getting a telephone call one morning, very<br />
early, from an individual with a distinctly Scandinavian<br />
accent informing you that you have been chosen<br />
as that particular year’s recipient of the Nobel Prize.<br />
Then imagine being treated like royalty and having<br />
every whim catered for by the Nobel Prize committee<br />
for your trip to Stockholm and for the duration of<br />
your stay there, not to mention your name being<br />
76 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
MOVIE REVIEW<br />
THE WIFE<br />
broadcast the world over. Imagine a sumptuous<br />
and very regal award ceremony, followed by an<br />
even more sumptuous gala dinner… all ‘white tie<br />
and ball gown’.<br />
IF THE VIVID IMAGERY GETS YOUR TOES<br />
CURLING AND YOU THINK THAT THIS<br />
MIGHT BE YOUR THING, START WRITING,<br />
IT IS NEVER TOO LATE!<br />
Achieving this realm of excellence often comes<br />
with problems of its own. The Wife, based on the<br />
novel by the same name written by American writer<br />
Meg Wolitzer deals with the exact same scenario<br />
as imagined above, this time round as it applies<br />
to the lives of Joe and Joan Castleman (played<br />
by Jonathan Pryce and Glenn Close respectively).<br />
Joe, a celebrated and respected author in the<br />
graying years of his life, receives ‘the call’ early one<br />
morning from the Nobel Prize committee informing<br />
him that he will be awarded the Literature prize for<br />
1992. Joe is beyond ecstatic, and it is clear that his<br />
world rather revolves around himself and his writing,<br />
and that his wife Joan plays her part as the silent,<br />
supportive and caring wife of a husband with a<br />
very important career. Though adamantly by her<br />
husband’s side, hers is a life outside the limelight,<br />
and she shies away from any form of recognition<br />
or praise for her role in Joe’s success. Not only has<br />
Joan had to give up her own dreams, but she also<br />
has had to turn a blind eye to Joe’s numerous<br />
infidelities over the course of their 40-somewhatyear<br />
marriage.<br />
FROM THE START OF THE FILM ONE GETS<br />
A VERY STRONG SENSE THAT JOAN’S<br />
LIFE HAS BEEN MORE THAN SACRIFICED<br />
IN HELPING BUILD THE EXTRAORDINARY<br />
CAREER OF HER HUSBAND.<br />
It is as the couple is making their way to Stockholm<br />
for the award ceremony that things start to unravel<br />
in their relationship. Joe and Joan share a secret,<br />
and the secret is beginning to exact a heavy toll<br />
on Joan’s conscience. When confronted by Joe’s<br />
narcissistic and adulterous behaviour even on the<br />
eve of a major achievement in a foreign country,<br />
Joan comes to the realization that she can no<br />
longer proceed with her life as she had known it<br />
up to that point.<br />
On the trip to Stockholm the Castlemans are<br />
escorted by their son David (played by Max Irons),<br />
a budding writer craving his father’s recognition<br />
and positive feedback. It goes without saying<br />
that Joe and David share very difficult fatherson<br />
relationship dynamics, especially in light of<br />
Joe’s self-centeredness and brash manner. No<br />
household is big enough for the egos of more than<br />
one successful writer, right? Add to this that on the<br />
very same trip to Sweden is a wannabe biographer<br />
of Joe’s out to get any piece of juicy gossip that he<br />
can. The scene is truly set for a bumpy ride (no pun<br />
intended!).<br />
It is in Stockholm too that Joe and David’s<br />
relationship comes to a head, and things turn out<br />
quite unexpectedly for the Castleman family. A<br />
lot more happens in the film which I will leave for<br />
you to discover as I might just be giving away too<br />
much here.<br />
ALTHOUGH THE WIFE IS NOT THE BEST<br />
FILM THAT I HAVE EVER SEEN, IT COMES<br />
HIGHLY RECOMMENDED AS IT IS<br />
SUCCESSFUL IN DELIVERING STELLAR<br />
PERFORMANCES BY TWO VERY<br />
STRONG ACTORS (PRYCE AND CLOSE)<br />
ON A DIFFICULT SUBJECT MATTER.<br />
The roles of husband and wife caught up in such<br />
a precarious relationship demands actors of their<br />
caliber. Get your hands on a copy of this late 2017<br />
release, you will not be disappointed. Until next<br />
time, enjoy the viewing!<br />
Franco Visser is a psychologist and former lecturer in<br />
Neuro- & Forensic Psychology at UNISA, Pretoria, <strong>South</strong><br />
Africa and currently in private practice Correspondence:<br />
francopierrevisser@gmail.com<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 77
EPILIZINE<br />
®<br />
CR<br />
Sodium valproate I Valproic acid<br />
EPILIZINE INTRAVENOUS 400<br />
Sodium valproate<br />
Choose Control. Choose Life.<br />
Valproate derivatives should never be prescribed to female children, female adolescents, pregnant women and women of<br />
childbearing potential for any indication other than epilepsy which is not effectively controlled by other available medicines<br />
with less risk of toxicity to an unborn child, or if these other medicines with less risk of toxicity to an unborn child are not<br />
tolerated. Such patients and/or their relatives should be fully informed of the risks to unborn children.<br />
Summary:<br />
• Children exposed in utero to valproate are at a high risk of serious developmental disorders (in up to 30 - 40 %) and/or<br />
congenital malformations (in approximately 10 % of cases).<br />
• Valproate should not be prescribed to female children, female adolescents and pregnant women or women of<br />
childbearing potential with epilepsy unless other treatments with a lower risk of causing congenital abnormalities<br />
or developmental defects are ineffective or not tolerated.<br />
Recommendations 1<br />
• Valproate treatment must be started and supervised by a doctor experienced in managing epilepsy or bipolar disorder.<br />
• Carefully balance the benefits of valproate treatment against the risks of congenital malformations and<br />
developmental abnormalities. This assessment should be made when prescribing valproate for the first time,<br />
at routine treatment reviews, when a female child reaches puberty and when a woman plans a pregnancy or<br />
becomes pregnant.<br />
• You must ensure that all female patients are fully informed of and understand:<br />
- the risks associated with valproate during pregnancy;<br />
- the need to use effective contraception;<br />
- the need for regular review of treatment;<br />
- the need to rapidly consult her prescribing physician if she<br />
is planning a pregnancy or becomes pregnant.<br />
Reference: 1. DHCP Letter. December 2015.<br />
For full prescribing information refer to the professional information approved by the Medicines Regulatory Authority.<br />
13485<br />
S3 Epilizine® CR 200/300/500 (Tablets) COMPOSITION: Each CR tablet contains 133,2/199,8/333,0 mg sodium valproate and 58,0/87,0/145,0 mg valproic acid equivalent to 200/300/500 mg sodium valproate respectively. REGISTRATION NUMBERS:<br />
A39/2.5/0038; A39/2.5/0039; A39/2.5/0040. S3 Epilizine Intravenous 400 (Powder for intravenous injection) with Solvent for Epilizine Intravenous (Solvent for intravenous injection). COMPOSITION: Each vial contains 400 mg freeze-dried sodium valproate<br />
and each ampoule contains 4 ml sterile water for injection. REGISTRATION NUMBERS: A40/2.5/0699; A40/34/0781. NAME AND BUSINESS ADDRESS OF THE HOLDER OF THE CERTIFICATE OF REGISTRATION: Zentiva <strong>South</strong> Africa (Pty) Ltd, a sanofi<br />
company. Reg. no.: 1931/002901/07. Sanofi House, 2 Bond Street, Grand Central Ext. 1, Midrand, 1685. Tel: (011) 256 3700. Fax: (011) 256 3707. Marketed by: sanofi-aventis south africa (pty) ltd., Reg. no.: 1996/010381/07, 2 Bond Street, Grand Central Ext.<br />
1, Midrand, 1685. Tel: (011) 256 3700. Fax: (011) 256 3707. www.sanofi.com. SAZA.GVPA.19.01.0007
SASOP HEADLINE<br />
FEBRUARY <strong>2019</strong><br />
EDITORIAL<br />
Best wishes for <strong>2019</strong> to all,<br />
hoping that all had a good start<br />
of the annual new beginnings.<br />
This is the first Headline edition<br />
for <strong>2019</strong>, reporting on some of<br />
the activities identified by the<br />
new SASOP Board and with Prof<br />
Bonga Chiliza, SASOP President,<br />
having set out the three-fold<br />
objectives for the 2018-2020<br />
Prof Bernard Janse van<br />
term of office, all is set to engage Rensburg<br />
with the known, but also new and<br />
different anticipated challenges and experiences.<br />
A HAPPY AND PRODUCTIVE <strong>2019</strong> TO ALL<br />
SASOP MEMBERS, FRIENDS AND OTHER<br />
COLLEAGUES AND PARTNERS.<br />
Best regards<br />
Prof Bernard Janse van Rensburg<br />
HEADLINE Editor<br />
January <strong>2019</strong><br />
1. SASOP BOARD AND GOVERNANCE<br />
– 2018-2020<br />
The new SASOP Board of Directors met for the first<br />
time on the 17 th November 2018.<br />
1.1 SASOP DIVISIONS<br />
The first task of the new Board was to confirm<br />
and identify the new advisory committees and<br />
convenors for the new term of office, which include<br />
the following:<br />
SASOP Divisions<br />
1. Subgroups Dr Lachman<br />
2. Academic<br />
3. Publications<br />
4. Scientific meeting<br />
and CPD<br />
5. Early Career TBC<br />
Convenors<br />
Prof Seedat, Prof Chiliza;<br />
Prof S Seedat (CPSYCH<br />
President, Ex Officio)<br />
Prof Chiliza; Prof J/van<br />
Rensburg<br />
Dr Talatala<br />
6. Communications Dr Lachman<br />
7. Ethics peer review<br />
and disability<br />
8. Special Interest<br />
Group<br />
9. Advocacy<br />
Dr Chetty; Prof J/van<br />
Rensburg; Dr Seape<br />
Dr Lachman<br />
Dr Maaroganye; Dr<br />
Seape<br />
10. <strong>African</strong> psychiatry Prof Chiliza<br />
11. Financing Dr Talatala; Dr Roux<br />
1.2 SASOP PUBSEC EXCO<br />
Back: Kobus Roux (Chair Private Sector Group), Kagisho Maaroganye<br />
(Chair Public Sector Group), Anusha Lachman (Hon Secretary),<br />
Indhrin Chetty (Hon Treasurer)<br />
Front: Bernard Janse van Rensburg (Past-President), Bonga Chiliza<br />
(President), Sebolelo Seape (President-Elect)<br />
In addition, a SASOP Public Sector Group (PUBSEC)<br />
Executive Committee has been established to<br />
strengthen the executive and operational capacity<br />
of the PUBSEC, consisting of: Dr Kagisho Maaroganye<br />
(Chair), Dr Pete Milligan, Dr Suvira Ramlall, Prof Rita<br />
Thom, Dr Kathleen Mawson, Prof Bernard Janse van<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 79
SASOP HEADLINE<br />
Rensburg, Dr Anusha Lachman and Prof Bongo<br />
Chiliza (Ex-Officio). This national executive committee<br />
will continue to work closely with the different regional<br />
PUBSEC representatives of the Subgroups, including<br />
Dr John Parker (Western Cape), Dr Thupana Seshoka<br />
(Eastern Cape), Prof Richard Nichol (Free State), Dr<br />
Janine Brooker (KZN), Dr Monica Ndala (Limpopo)<br />
and Dr Thuli Mdaka (<strong>South</strong>ern Gauteng).<br />
• They have arranged a “meet and greet” event<br />
with cheese and wine in appreciation of the<br />
support for the Subgroup, at Akeso Crescent<br />
Clinic, Randburg, on Thursday 31 st January <strong>2019</strong><br />
(from 16h00 to 18h00).<br />
THE SASOP EXECUTIVE COMMITTEE<br />
(PUBSECEXCO) WILL BE ACTING AS THE<br />
SASOP’S PUBLIC SECTOR VOCATIONAL<br />
GROUP’S “MANAGEMENT GROUP” AND<br />
WILL FUNCTION AS AN EXECUTIVE<br />
OPERATIONAL ENTITY DEDICATED TO<br />
SPECIFICALLY SERVE THE SASOP IN<br />
ACHIEVING ITS MAIN OBJECTIVES WITH<br />
RESPECT TO THE PUBLIC SECTOR IN THE<br />
FOLLOWING WAYS:<br />
• PubSecExCo will ensure psychiatrists in public<br />
practice on regional and national level of direct<br />
representation in the <strong>South</strong> <strong>African</strong> public health<br />
care sector<br />
• PubSecExCo and SASOP will be entering into<br />
cooperation agreements acknowledging that<br />
PubSecExCo will act as SASOPs official agent<br />
regarding matters that affect the collective<br />
interests of psychiatrists in public practice,<br />
also through PubSecExCo’s membership and<br />
through its affiliation with the <strong>South</strong> <strong>African</strong><br />
Medical Association’s (SAMA) Employed<br />
Doctors’ Committee (eDC)<br />
• As such, the PubSecExCo also operates within the<br />
vision/mission and objectives of the SAMA eDC<br />
At its first constituting meeting on the 16th November<br />
2018, the following projects were identified for the<br />
current term of office: (1) Human resources and<br />
training; (2) Advocacy and working with others;<br />
(3) Public-private psychiatrists’ partnership; and (4)<br />
projects related to the national strategic process.<br />
Rita Thom will be leading a working group on<br />
Public-private partnership, consisting of Kagisho<br />
Maaroganye, Mvuyiso Talatala, Kobus Roux, Sebo<br />
Seape, Eugene Allers, Bernard Janse van Rensburg<br />
and Gerhard Grobler. This group will report regularly<br />
to the SASOP Board and to the PsychMG Board.<br />
1.3 SASOP SOUTHERN GAUTENG SUBGROUP<br />
The <strong>South</strong>ern Gauteng Subgroup has elected<br />
a new management committee for 2018-<br />
2020, including the Chair - Pevashnee Naicker,<br />
Secretary - Thriya Ramasar, Treasurer - Anusha<br />
Rama, Registrar representative – Tejil Morar,<br />
Public Sector/Early Career - Thuli Mdaka and<br />
PsychMG - Laila Paruk.<br />
• They also organized a “night-at-the-movies”<br />
event, with the screening of the popular<br />
Bohemian Rhapsody, starring Rami Malek, on<br />
Thursday 7 th <strong>February</strong> <strong>2019</strong>, 18h30 at Nu Metro<br />
Hyde Park.<br />
• Registrar update seminar on sleep disorders,<br />
PTSD and cannabis related issues by, amongst<br />
other, Dr Alison Bentley, on Saturday 16 th March<br />
<strong>2019</strong> - detail to be confirmed.<br />
2. MEDIA REPORTS AND STATEMENTS<br />
2.1 SASOP PRESIDENT<br />
MENTAL HEALTH CARE IN SA NEEDS STRONGER<br />
LEADERSHIP AND INCREASED BUDGETS<br />
The Life Esidimeni tragedy, patient abuse and<br />
health professionals’ suicides all point to the need<br />
for better management of public sector psychiatry<br />
says incoming <strong>South</strong> <strong>African</strong> Society of Psychiatrists<br />
president, Prof Bonga Chiliza<br />
The psychiatric profession should play a greater<br />
role in advocating for patients’ rights and improving<br />
management of mental health in the public sector<br />
after a series of recent tragedies that highlighted<br />
the neglect of mental health care in <strong>South</strong> Africa.<br />
Newly-elected president of the <strong>South</strong> <strong>African</strong> Society<br />
of Psychiatrists (SASOP) Prof Bonga Chiliza said the<br />
deaths of 144 patients in the now-notorious Life<br />
80 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
SASOP HEADLINE<br />
Esidimeni tragedy; allegations of abuse and human<br />
rights violations at the Tower Psychiatric Hospital in<br />
the Eastern Cape; and the suicide of UCT Health<br />
Sciences Dean Prof Bongani Mayosi following his<br />
battle with depression, all pointed to the need for<br />
the organisation to “rise and answer the call for<br />
advocating on behalf of mental health care users<br />
and our profession”.<br />
Prof Chiliza, who heads the <strong>Psychiatry</strong> Department<br />
of the University of KwaZulu-Natal (UKZN) Medical<br />
School and will serve as SASOP President to<br />
2020, said the organisation would ramp up its<br />
lobbying for mental health care to be allocated<br />
an equitable share of the national health budget.<br />
HE SAID SASOP WOULD ALSO BE DOING<br />
MORE TO ENCOURAGE MEDICAL<br />
STUDENTS TO SPECIALISE IN PSYCHIATRY,<br />
IN ORDER TO GROW THE NUMBERS OF<br />
QUALIFIED PROFESSIONALS ABLE TO<br />
SERVE PUBLIC MENTAL HEALTH CARE<br />
NEEDS.<br />
“Mental health conditions are often misunderstood,<br />
mis-managed and stigmatised, particularly for those<br />
who rely on the public health system for treatment.<br />
They are extremely vulnerable to abuse and SASOP<br />
as the professional body for psychiatrists must take<br />
the lead in ensuring better services to our people.<br />
We will live out the promise we made to society<br />
when we engaged in a social contract with our<br />
community as practising, professional psychiatrists,”<br />
he said.<br />
Prof Chiliza said SASOP was establishing a “robust<br />
Public Sector Executive Committee of senior<br />
psychiatrists in academia and government<br />
services” to guide its efforts to strengthen<br />
psychiatric care in the public health sector.<br />
HE SAID SASOP WOULD CONTINUE<br />
ITS LEADING ROLE IN THE NATIONAL<br />
MENTAL HEALTH ALLIANCE OF NGOS IN<br />
THE MENTAL HEALTH CARE SECTOR AS<br />
A VEHICLE FOR ADVOCACY ON POLICY<br />
AND BUDGET ISSUES AFFECTING MENTAL<br />
HEALTH CARE AND THE PROVISION OF<br />
PROFESSIONAL PSYCHIATRY SERVICES<br />
IN THE PUBLIC SECTOR.<br />
Outlining his vision for SASOP and its contribution<br />
to the profession of psychiatry, Prof Chiliza said<br />
the organisation would also focus on renewing its<br />
leadership transformation efforts, strengthening<br />
the relationship between public and private sector<br />
psychiatry, and supporting early-career psychiatrists.<br />
“We will re-energise our efforts to transform the<br />
leadership of SASOP and psychiatry in general.<br />
The leadership of SASOP will continue to transform<br />
until it is aligned with the demographics of<br />
<strong>South</strong> Africa and is able to fully engage with<br />
issues that plague our country such as racism,<br />
sexism and other forms of discrimination.<br />
We will thus embark on a strategic drive towards<br />
succession planning for all key positions of<br />
leadership in psychiatry,” he said.<br />
Prof Chiliza said that as a scarce resource,<br />
psychiatrists in the public and private sectors<br />
needed to work together, especially in preparing for<br />
the reorganisation of the health care system with<br />
implementation of National Health Insurance (NHI).<br />
“We are already piloting value-based care models<br />
in the private sector. There is no reason why these<br />
pilots cannot be performed in both private and<br />
state sectors,” he said.<br />
On early-career psychiatry, he said he aimed to<br />
grow SASOP by focusing on young psychiatrists,<br />
registrars and medical officers, ensuring that young<br />
doctors had ample opportunity to do internships in<br />
the discipline and “fall in love with psychiatry”.<br />
“We need to push harder for psychiatry to be truly<br />
recognised as a major discipline in undergraduate<br />
medical education,” he said.<br />
PROF CHILIZA SAID SASOP WOULD<br />
LOOK TO INCREASE THE SUPPORT<br />
IT ALREADY OFFERS TO MEDICAL<br />
REGISTRARS IN ORDER TO “FACILITATE A<br />
MORE EQUITABLE TRAINING PLATFORM<br />
FOR ALL REGISTRARS REGARDLESS OF<br />
THE UNIVERSITY AT WHICH THEY ARE<br />
TRAINING”.<br />
Support for early-career psychiatrists would also<br />
extend to assistance in dealing with professional<br />
practice issues such as billing, and mentorship for<br />
young psychiatrists and future academics.<br />
In addition to his position at UKZN, where he is<br />
Associate Professor/Chief Specialist and head of the<br />
Department of <strong>Psychiatry</strong>, Prof Chiliza is a founding<br />
director of Harambee Medical Consulting and the<br />
<strong>African</strong> Global Mental Health Institute, and serves on<br />
a number of NGO Boards including the SA YMCA<br />
and Life Choices.<br />
He has authored over 50 peer reviewed articles<br />
and book chapters and won awards including the<br />
Hamilton Naki Clinical Research Fellowship and the<br />
CINP Rafaelsen Young Investigators Award.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 81
SASOP HEADLINE<br />
He completed his medical degree and psychiatry<br />
specialization at the University of KwaZulu-Natal<br />
and his PhD at Stellenbosch University. His research<br />
interests include schizophrenia, consultation-liaison<br />
psychiatry, health services and medical education.<br />
He is the Deputy Editor of the <strong>South</strong> <strong>African</strong> Journal<br />
of <strong>Psychiatry</strong>.<br />
2.2 MEDICAL PRACTITIONERS AND EMPLOYEE<br />
WELLNESS<br />
Wellness, in particular mental wellness, of medical<br />
practitioners and students has attracted much<br />
media and other attention during the past year<br />
following, for example, successful and public<br />
suicides by prominent professionals and students<br />
on several campuses. Statistics are quoted which<br />
rate the suicide figure at 10,7 per 100 000 people<br />
for the <strong>South</strong> <strong>African</strong> general population as the 6 th<br />
highest in Africa. 1<br />
AS FAR AS SUICIDE AND MEDICAL<br />
PRACTITIONERS ARE CONCERNED, A<br />
SYSTEMATIC REVIEW OF PUBLISHED<br />
STUDIES ON SUICIDE AMONG PHYSICIANS<br />
SHOWED THAT THESE PROFESSIONALS<br />
HAVE A 2.5 TIMES HIGHER CHANCE<br />
OF COMMITTING SUICIDE THAN THE<br />
GENERAL POPULATION (DAMASCENO,<br />
2017). 2<br />
Similarly, another meta-analysis on the topic<br />
reported elevated physician’s suicide ratios (higher<br />
for women) compared with the general population<br />
(Schernhammer, ES, 2004). 3 Details on suicide<br />
among US physicians in seven states included that<br />
having a known mental health disorder, or a job<br />
problem, contributed significantly to the increased<br />
risk of physicians successfully committing suicide<br />
(Gold et al., 2013). 4 In a cohort of about 20,000<br />
doctors employed by the National Health Service of<br />
the UK who died between 1962 and 1979, the death<br />
rate from accidental poisoning involving prescription<br />
drugs (overdose) were significantly raised among<br />
male consultants (most apparent in obstetricians<br />
and gynaecologists), while the death rate from<br />
(self) injury and poisoning for female consultants,<br />
were largely a twofold excess of suicide (significantly<br />
raised for anaesthetists), Carpenter et al. (1997). 5<br />
Sheikhmoonesi and Zarghami (2014) noted that<br />
some studies identified certain specialties such as<br />
psychiatry, anaesthesiology and dentistry as higher<br />
risk for physician suicide. 6 They also reported on<br />
risk factors/attributes in women physicians who<br />
had attempted suicide to include the history of<br />
depression, alcohol abuse or dependence, sexual<br />
abuse, domestic violence, poor current mental<br />
health and family history of psychiatric disorder. 8<br />
Furthermore, those who suffer from obesity, chronic<br />
fatigue syndrome, worsening health, eating<br />
disorders, overworking, career displeasure, and<br />
job stressors have also been reported as high<br />
risk physicians. 8 Kõlves and De Leo reported on<br />
suicide in medical doctors and nurses compared<br />
to educational professionals in Queensland,<br />
Australia, and found that female medical doctors<br />
in this study had significantly higher suicide rates<br />
than educational professionals, similarly for nurse<br />
of both sexes. 7 Studies included in the mentioned<br />
systematic reviews also reported expressive levels<br />
of psychic suffering while concluding that suicide<br />
among physicians is associated with the exercise on<br />
their professional role in the society and workplace<br />
(Damasceno et al., 2017) and were calling for<br />
more information about suicide among health<br />
professionals.<br />
IN TERMS OF DEPRESSION, MAJOR<br />
DEPRESSIVE DISORDER AND OTHER<br />
MENTAL DISORDERS, SHEIKHMOONESI<br />
AND ZARGHAMI (2014) OBSERVED<br />
THAT THE LITERATURE ALSO SUGGESTS<br />
THAT PHYSICIANS WHO KILL THEMSELVES<br />
ARE MORE CRITICAL OF OTHERS AND<br />
OF THEMSELVES AND MORE LIKELY TO<br />
BLAME THEMSELVES FOR THEIR OWN<br />
ILLNESSES.<br />
Furthermore, there is some evidence that physicians<br />
do not welcome the idea of approaching colleagues<br />
for help, and instead utilize alcohol or drugs, while<br />
resorting to isolation. 8 Some of the “ten facts” about<br />
physician suicide and mental health listed by the<br />
American Foundation for Suicide Prevention (www.<br />
afsp.org) include that: (1) suicide is generally<br />
caused by the convergence of multiple risk factors,<br />
the most common being untreated or inadequately<br />
managed mental health conditions; (2) in cases<br />
where physicians died by suicide, depression is<br />
found to be a significant risk factor leading to their<br />
death at approximately the same rate as among<br />
non-physician suicide deaths; and (3) drivers of<br />
burnout include work load, work inefficiency, lack<br />
of autonomy and meaning in work, and work-home<br />
conflict<br />
Burnout per se, consisting of the three dimensions<br />
of emotional exhaustion, depersonalization and<br />
reduced professional accomplishment (Maslach<br />
et al., 2001), 8 does not constitute a clinical medical<br />
diagnosis, but nevertheless has a significant impact<br />
on sufferers, their work environment and productivity.<br />
Collier 10 and Dr Sandra Roman, advisor to the Quebec<br />
Physicians Health Program, both cited a 2012 study 10<br />
which found that 45.8% of physicians in the US over<br />
time reported at least one symptom of burnout.<br />
Furthermore, burnout is a leading cause of medical<br />
82 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
SASOP HEADLINE<br />
errors, as well as affecting the prescribing habits,<br />
test ordering and professionalism of doctors. 11 Selfawareness,<br />
is being identified by these authors, as<br />
an important factor to address the problem, referring<br />
to a useful tool in this regard, the Maslach Burnout<br />
Inventory, a self-administered questionnaire. 11, 12 In<br />
addition to the individual practitioners, who have<br />
to recognize their own vulnerabilities and possible<br />
risky coping mechanisms, strategies to intervene<br />
and alleviate the effects of burnout, include, on an<br />
organizational level, to acknowledge the existence<br />
of the problem, to develop targeted interventions<br />
and to promote resilience and self-care.<br />
ON A LEADERSHIP/MANAGERIAL LEVEL,<br />
IT INCLUDES TO REVIEW LEADERSHIP<br />
STYLES, TO RESPECT OPINIONS AND<br />
TO EMPOWER TEAM MEMBERS TO DO<br />
THEIR WORK AND ADVANCE IN THEIR<br />
CAREERS. 11<br />
While, per regulations, cases of impaired physicians,<br />
medical interns and students have to be reported<br />
to the Health Committee of the local Health<br />
Professional Council of <strong>South</strong> Africa, this Committee<br />
clearly states its objectives with assistance to<br />
such professionals, including to: (1) establish<br />
mechanisms for the early detection of impairment;<br />
(2) undertake informal assessment of reports; (3)<br />
oversee the implementation of treatment programs<br />
of impaired professionals. In other words, to facilitate<br />
recovery, rehabilitation and reintegration of sufferers<br />
of mental and substance related conditions. 11 Dhai<br />
et al., and Knapp van Bogaert and Ogunbanjo<br />
earlier identified the scope of the problem and<br />
ethical challenges of the <strong>South</strong> <strong>African</strong> impaired<br />
physician. 12, 13 They alluded to the potential dilemma<br />
that fellow physicians may experience to report an<br />
impaired colleague and to weigh up the privacy<br />
of the practitioner and the safety of patients, while<br />
suggesting that early on during training, medical<br />
education should put more emphasis on doctors<br />
realizing their limitations and recognizing their<br />
humanity and fallibility.<br />
In the meantime the discussion on how to<br />
support colleagues in terms of peer review and<br />
relations have been started by some professional<br />
associations, for example, by the <strong>South</strong> <strong>African</strong><br />
Medical Association (SAMA) and the <strong>South</strong> <strong>African</strong><br />
Society of Psychiatrists (SASOP). This includes raising<br />
the awareness amongst medical practitioners that<br />
vigilance is required, while stigma (including self<br />
and professional stigma) should not be allowed to<br />
delay appropriate interventions when needed. The<br />
SAMA has started to address the issue by a series<br />
of articles in its “INSIDER” publication for members,<br />
where medical practitioners have spoken out on<br />
their own experience with depression and suicidal<br />
ideation and its impact on them as people and<br />
professionals. 14 The SAMA and SASOP are also<br />
considering the best strategies to de-stigmatise<br />
mental illness in the health care profession, to<br />
assist healthcare professionals dealing with mental<br />
illness and occupational, professional and personal<br />
difficulties, and to create an environment conducive<br />
to professional exchange and debate, networking<br />
and support. An important resource in this regard,<br />
seems to be a publication edited by Brower and<br />
Riba on this important topic of mental health and<br />
related problems among physicians, including<br />
trainees. The book, according to a review, “addresses<br />
the all-too-common human response of ‘suffering in<br />
silence’ and refusing to seek help for professional,<br />
(as well as) personal issues that have ramifications<br />
for physicians who work in safety-sensitive positions<br />
where clear-headed judgment and proper action<br />
can save lives”. 15<br />
REFERENCES<br />
1. https://www.iol.co.za/thepost/sas-suicide-rate-<br />
6th-highest-in-africa-17065768;<br />
https://africacheck.org/reports/5facts-sadextent-suicide-south-africa/;<br />
http://www.702.co.za/articles/318667/onesuicide-every-hour-in-south-africa<br />
2. Damasceno KS, de Sousa Barbosa E, Pimentel<br />
JVC, et al. Suicide among Physicians and<br />
Methodological Similarities of MEDLINE/<br />
PubMED and BVS/BIREME Open Access<br />
Bibliographic Databases: A Systematic Review<br />
with Metanalysis. Health, 2017; 9: 352-375; DOI:<br />
10.4236/health.2017.92025 <strong>February</strong> 23, 2017<br />
3. Schernhammer ES & Colditz, GA. Suicide<br />
Rates Among Physicians: A Quantitative and<br />
Gender Assessment (Meta-Analysis). American<br />
Journal of <strong>Psychiatry</strong>. 2004; 161(12):@295-2302;<br />
Published Online: 1 Dec 2004; https://doi.<br />
org/10.1176/appi.ajp.161.12.2295<br />
4. Gold KJ, Sen A, Schwenk TL. Details on suicide<br />
among US physicians: data from the National<br />
Violent Death Reporting System. Gen Hosp<br />
<strong>Psychiatry</strong>. 2013 Jan-Feb;35(1):45-9. doi:<br />
10.1016/j.genhosppsych.2012.08.005. Epub<br />
2012 Nov 2.<br />
5. Carpenter LM, Swerdlow AJ, Fear NT. Mortality<br />
of doctors in different specialties: findings from<br />
a cohort of 20000 NHS hospital consultants.<br />
Occup Environ Med. 1997 Jun;54(6):388-95.<br />
6. Sheikhmoonesi F, Zarghami M. Prevention of<br />
Physicians’ Suicide. Iran J <strong>Psychiatry</strong> Behav Sci.<br />
2014 Summer; 8(2): 1–3.<br />
7. Kõlves K, De Leo D. Suicide in medical doctors and<br />
nurses: an analysis of the Queensland Suicide<br />
Register. J Nerv Ment Dis. 2013 Nov;201(11):987-<br />
90. doi: 10.1097/NMD.0000000000000047.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong> * 83
SASOP HEADLINE<br />
8. Maslach C 1 , Schaufeli WB, Leiter MP. Job burnout.<br />
Annu Rev Psychol. 2001;52:397-422.<br />
9. Collier R. Physician burnout a major concern.<br />
CMAJ. 2017 Oct 2; 189(39): E1236–E1237.<br />
doi: 10.1503/cmaj.1095496<br />
10. Shanafelt TD, Sonja Boone S, Tan, L et al. Burnout<br />
and Satisfaction With Work-Life Balance Among<br />
US Physicians Relative to the General US<br />
Population. Arch Intern Med. 2012;172(18):1377-<br />
1385. doi:10.1001/archinternmed.2012.3199<br />
11. http://www.hpcsa-blogs.co.za/assistance-forimpaired-professionals/<br />
12. Dhai A 1 , Szabo CP, McQuoid-Mason DJ. The<br />
impaired practitioner - scope of the problem<br />
and ethical challenges. S Afr Med J. 2006<br />
Oct;96(10):1069-72.<br />
THEY WERE ALSO INTRODUCED TO SASOP<br />
AND PSYCHMG AS ORGANIZATIONS TO<br />
ENCOURAGE INVOLVEMENT AT AN EARLY<br />
STAGE OF THEIR CAREERS. A HIGHLIGHT<br />
CERTAINLY WAS THE PRESENTATION AT<br />
THE RFS DINNER ON FRIDAY EVENING<br />
WHEN DR KIM DOMINGO SHARED HER<br />
TALK ON THE “MEANING OF WORDS”.<br />
We had a very lively group this year who engaged<br />
fully with the process, making it all the more<br />
enjoyable for both mentors and mentees!<br />
Dr Ian Westmore<br />
Convenor<br />
13. Knapp van Bogaert D, Ogunbanjo G. Ethics<br />
in health care: “Physician, heal thyself” <strong>South</strong><br />
<strong>African</strong> Family Practice. 2014; 56(1)(Supplement<br />
1): S14-S16<br />
14. SAMA INSIDER. Nov 2017, p8 Depression does<br />
not discriminate – even doctors suffer from it;<br />
Jul 2018, pp5-6 Depression: Don’t wait until it’s<br />
too late; Jul 2018, pp7-8 Take care of your own<br />
mental health – it’s vitally important; Sep 2018<br />
Editorial – Gone but not forgotten: Let’s talk<br />
about mental health; pp6-8 Death by profession<br />
has a voice: “I am a doctor; I am human too”;<br />
Oct 2018 (15-17) When the good doctor burns<br />
out. http://www.samainsider.org.za/index.<br />
php/SAMAInsider/issue/archive<br />
Left to right: Dr Eugene Allers, Mvuyiso Talatala and Dr Ian Westmore<br />
15. Brower, KJ and Michelle B. Riba MB (Eds).<br />
Physician Mental Health and Well-Being:<br />
Research and Practice. 1 st Ed, 2017: Springer<br />
Prof Bernard Janse van Rensburg WITS Department of<br />
<strong>Psychiatry</strong> and SASOP Board of Directors.<br />
3. REPORT ON REGISTRAR FINISHING<br />
SCHOOL 2018<br />
Dr Lavinia Lumu<br />
The Registrar Finishing School (RFS) was held for the<br />
6 th year running during November 2018 in Sandton,<br />
Johannesburg, and has become an important fixture<br />
on the SA <strong>Psychiatry</strong> calendar. The workshop was<br />
generously sponsored again by Lundbeck, Adcock-<br />
Ingram and SASOP/PsychMg. This time around saw<br />
a record number of attendees (36) comprising<br />
registrars in their final year of study or those who have<br />
recently qualified from all over <strong>South</strong> Africa.<br />
There were thirteen speakers drawn from both<br />
the public and the private sector who acted as<br />
“mentors” to our younger colleagues – the idea was<br />
to give registrars an idea of what to expect when<br />
entering private practice, or when remaining in the<br />
public sector as consultants.<br />
Dr Ian Westmore<br />
84 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 <strong>2019</strong>
INSTRUCTIONS TO AUTHORS<br />
<strong>South</strong> <strong>African</strong> <strong>Psychiatry</strong> publishes original contributions that relate to <strong>South</strong> <strong>African</strong> <strong>Psychiatry</strong>. The aim of the<br />
publication is to inform the discipline about the discipline and in so doing, connect and promote cohesion.<br />
The following types of content are published, noting that the list is not prescriptive or limited and potential<br />
contributors are welcome to submit content that they think might be relevant but does not broadly conform to<br />
the categories noted:<br />
LETTERS TO THE EDITOR<br />
* Novel experiences<br />
* Response to published content<br />
* Issues<br />
FEATURES<br />
* Related to a specific area of interest<br />
* Related to service development<br />
* Related to a specific project<br />
* A detailed opinion piece<br />
REPORTS<br />
* Related to events e.g. conferences, symposia, workshops<br />
PERSPECTIVES<br />
* Personal opinions written by non-medical contributors<br />
NEWS<br />
* Departments of <strong>Psychiatry</strong> e.g. graduations, promotions, appointments,<br />
events, publications<br />
ANNOUNCEMENTS<br />
* Congresses, symposia, workshops<br />
* Publications, especially books<br />
The format of the abovementioned contributions does not conform to typical scientific papers. Contributors<br />
are encouraged to write in a style that is best suited to the content. There is no required word count<br />
and authors are not restricted, but content will be subject to editing for publication. Referencing should<br />
conform to the Vancouver style i.e. superscript numeral in text (outside the full stop with the following<br />
illustration for the reference section: Other AN, Person CD. Title of article. Name of Journal, Year of publication;<br />
Volume (Issue): page number/s. doi number (if available). All content should be accompanied by a relevant photo<br />
(preferably high resolution – to ensure quality reproduction) of the author/authors as well as the event or with<br />
the necessary graphic content. A brief biography of the author/authors should accompany content, including<br />
discipline, current position, notable/relevant interests and an email address. Contributions are encouraged and<br />
welcome from the broader mental health professional community i.e. all related professionals, including industry. All<br />
submitted content will be subject to review by the editor-in-chief, and where necessary the advisory board.<br />
REVIEW / ORIGINAL ARTICLES<br />
Such content will specifically comprise the literature review or data of the final version of a research report<br />
towards the MMed - or equivalent degree - as a 5000 word article<br />
* A 300 word abstract that succinctly summarizes the content will be required.<br />
* Referencing should conform to the Vancouver style i.e. superscript numeral in text (outside the full stop with<br />
the following illustration for the reference section: Other AN, Person CD. Title of article. Name of Journal, Year of<br />
publication; Volume (Issue): page number/s. doi number (if available)<br />
* The submission should be accompanied by the University/Faculty letter noting successful completion of the<br />
research report.<br />
Acceptance of submitted material will be subject to editorial discretion<br />
All submitted content will be subject to review by the editor-in-chief, and where necessary the advisory board.<br />
All content should be forwarded to the editor-in-chief, Christopher P. Szabo - Christopher.szabo@wits.ac.za
PROUD PUBLISHERS OF:<br />
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The fine art of mental health treatment<br />
S5 Adco-Talomil 20 mg. Each tablet contains citalopram hydrobromide 24,99 mg equivalent to citalopram 20 mg. Reg. No. 35/1.2/0272. S5 Adco-Paroxetine 20 mg. Each tablet contains paroxetine mesylate<br />
equivalent to 20 mg paroxetine. Reg. No. 36/1.2/0096. S5 Adco-Mirteron 15. Each film-coated tablet contains mirtazapine 15 mg. Reg. No. 39/1.2/0217. S5 Adco-Mirteron 30. Each film-coated tablet contains<br />
mirtazapine 30 mg. Reg. No. 39/1.2/0218. S5 Venlafaxine XR 37,5 Adco. Each extended release capsule contains venlafaxine HCl equivalent to venlafaxine 37,5 mg. Reg. No: 43/1.2/0577. S5 Venlafaxine XR 75<br />
Adco. Each extended release capsule contains venlafaxine HCl equivalent to venlafaxine 75 mg. Reg. No: 43/1.2/0578. S5 Venlafaxine XR 150 Adco. Each extended release capsule contains venlafaxine HCl<br />
equivalent to venlafaxine 150 mg. Reg. No: 43/1.2/0579. S5 Adco-Alzam 0,25 mg. Each tablet contains alprazolam 0,25 mg. Reg. No. 30/2.6/0212. S5 Adco-Alzam 0,5 mg. Each tablet contains alprazolam<br />
0,5 mg. Reg. No. 30/2.6/0211. S5 Adco-Alzam 1,0 mg. Each tablet contains alprazolam 1,0 mg. Reg. No. 30/2.6/0213. S5 Serez 25. Each film-coated tablet contains quetiapine fumarate, equivalent to quetiapine<br />
free base 25 mg. Reg. No. 43/2.6.5/0796. S5 Serez 100. Each film-coated tablet contains quetiapine fumarate, equivalent to quetiapine free base 100 mg. Reg. No. 43/2.6.5/0797. S5 Serez 200. Each film-coated<br />
tablet contains quetiapine fumarate, equivalent to quetiapine free base 200 mg. Reg. No. 43/2.6.5/0798. S5 Serez 300. Each film-coated tablet contains quetiapine fumarate, equivalent to quetiapine free base<br />
300 mg. Reg. No. 43/2.6.5/0799. S3 Valeptic CR 300. Each controlled release tablet contains sodium valproate 300 mg. Reg. No. 44/2.5/0067. S3 Valeptic CR 500. Each controlled release tablet contains<br />
sodium valproate 500 mg. Reg. No. 44/2.5/0068. S5 Adco-Zolpidem Hemitartrate 10 mg. Each tablet contains zolpidem hemitartrate 10 mg. Reg. No. 36/2.2/0132. S5 Adco-Zopimed. Each film-coated tablet<br />
contains 7,5 mg zopiclone. Reg. No. 33/2.2/0450. S4 Ebitine 10 mg. Each film-coated tablet contains memantine hydrochloride 10 mg. Reg. No. 45/32.16/0496.<br />
For full prescribing information, refer to the package insert approved by the medicines regulatory authority.<br />
2018092810100780<br />
Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021.<br />
Tel. +27 11 635 0000 www.adcock.com
Restored Sleep<br />
The<br />
• An effective hypnotic 1<br />
• ‘Intermediate’ half-life (6 - 8 hours) 1,2<br />
• Unaltered REM sleep 1,3<br />
• Rapid sleep onset and maintenance of sleep 1,2<br />
• Refreshed morning awakening 1<br />
Definition:<br />
• Helps reduce anxiety symptoms associated<br />
with insomnia 1,4,5<br />
- Caution should be exercised in patients suffering from anxiety<br />
accompanied by an underlying depressive disorder<br />
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 ®<br />
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,<br />
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:<br />
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.<br />
For full prescribing information refer to the package insert approved by the medicines regulatory authority.<br />
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.<br />
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:<br />
sanofi-aventis south africa (pty) ltd., Reg. No. 1996/010381/07, 2 Bond Street, Midrand, 1685, <strong>South</strong> Africa. Tel + 27 (0)11 256 3700, Fax +27 (0)11 256 3707. www.sanofi-aventis.com SAZA.LOME.16.11.0952