South African Psychiatry - February 2019

ISSN 2409-5699 

ABOUT the discipline FOR FOR the the discipline discipline issue 18 • FEBRUARY 2019 

THE GLOBAL 

B U R D E N 

OF DISEASE STUDIES AND 

MENTAL HEALTH IN 

SOUTH AFRICA 

D E A D L Y 

MEDICINE: 

PAYING THE PIPER 

THE CHALLENGES OF 

PERINATAL 

DEPRESSION 

PUBLISHED IN ASSOCIATION WITH THE SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS 

PHARMACOGENOMIC 

T E S T I N G 

IN SOUTH AFRICAN 

PSYCHIATRY 

C E L L U L A R 

NEUROSCIENCE 

OF PSYCHIATRIC DISORDERS 

www.southafricanpsychiatry.co.za

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Features 

THE GLOBAL BURDEN 

7 

OF DISEASE STUDIES AND 

MENTAL HEALTH IN 

SOUTH AFRICA 

DEADLY MEDICINE: 

17 



TESTING 

27 

IN SOUTH AFRICAN PSYCHIATRY 


PERINATAL DEPRESSION 

34 

CELLULAR NEUROSCIENCE 

53 

OF PSYCHIATRIC DISORDERS 

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SOUTH AFRICAN PSYCHIATRY ISSUE 18 2019 * 3

CONTENTS 

CONTENTSFEBRUARY 2019 

5 FROM THE EDITOR 

34 THE CHALLENGES OF PERINATAL DEPRESSION 

38 DEPARTMENTS OF PSYCHIATRY NEWS 

61 THE IMPACT OF CLINICAL EXPOSURE 

63 TWO VINYL CHAIRS, PRISON, AND A PETAL 

68 BOOK REVIEW: SNOEK THE COUCH 

70 CULINARY CORNER 

74 WINE FORUM: HERITAGE, ROMANCE …OR BOTH? 

76 MOVIE REVIEW: THE WIFE 

79 SASOP HEADLINE 

7 THE GLOBAL BURDEN OF DISEASE STUDIES AND MENTAL 

HEALTH IN SOUTH AFRICA 

17 DEADLY MEDICINE: PAYING THE PIPER - THE PERVERSE 

PROTOPSYCHOTIC NATURE OF LIFE ESIDIMENI THROUGH A 

CONTEMPORARY FREUDIAN LENS 

27 PHARMACOGENOMIC TESTING IN SOUTH AFRICAN PSYCHIATRY 

45 SENSORY ROOM CALMING FOR THOSE WITH DEMENTIA WHO 

ARE SUFFERING FROM ANXIETY 

48 THIRD NATIONAL PUBLIC MENTAL HEALTH FORUM (PMHF) 

50 FEEDBACK FROM THE ROYAL COLLEGE OF PSYCHIATRISTS 

INTERNATIONAL CONFERENCE, JUNE 2018: ‘NEW HORIZONS’ 

53 CELLULAR NEUROSCIENCE OF PSYCHIATRIC DISORDERS 

56 MAINTAINING YOUR PATIENCE AND COMPASSION FOR YOUR 

LOVED ONE WITH DEMENTIA 

58 UK BUSINESS LEADERS CALL TO GIVE MENTAL HEALTH ISSUES 

GREATER RECOGNITION 

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

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

4 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 2019

FROM THE EDITOR 

Dear Reader, 

Welcome to our first issue for 2019. The year is well underway. Since the 

last issue I had a response from the Department of Higher Education and 

Training (DoHET) regarding accreditation. The outcome did not surprise – 

not recommended. At one level I can understand the DoHET’s requirement 

for a certain conformity of content - and process - that is recognized as 

scientific, and thus worthy of accreditation. However, the outcome got me 

wondering how much bad science is published in peer reviewed journals, 

accredited by the DoHET, that is subsequently rewarded with subsidy? I 

suppose that depends on one’s definition of bad science. Another way 

of looking at it is how much good science does not see the light of day? 

I suppose the distinction between good and bad rests at the foot of peer review – and editorial 

discretion. Certainly the merits of peer review are not infrequently discussed in the scientific literature. 

Clearly for good reason. The process is an area of contention albeit an accepted requirement for 

acceptance for publication and ultimately deemed an absolute requirement for a publication’s 

scientific credentials. The ability of a peer reviewer to reject or accept publication can have 

significant consequences for researchers. Bias is hard to control for, but I am not sure that we are 

ready for the move to non-peer reviewed content that is subject to the scrutiny of the consumer 

who decides whether an article has utility or not – subject to any such data having been the 

outcome of a valid review of both methodological and ethical components of the study protocol. 

And who controls for that I wonder? Then there is the thorny issue of the relationship with industry. 

Industry adverts are an absolute no-no in scientific publications deemed suitable for inclusion by 

the DoHET, but industry sponsored drug trials are seemingly ok…albeit that inherent bias in reporting 

has been consistently shown in terms of favouring the product of the sponsoring company. Most 

importantly such content must be peer reviewed, and should not be accompanied by an actual 

advert. Maybe so called drug trials should simply appear in a repository and not be published 

in journals? Maybe we should do away with journals altogether, and have repositories of studies 

conducted at universities or institutions freely available in the interests of science to all who would 

seek them out – but contained in a directory of such work that would direct clinicians or researchers 

accordingly. Can you imagine, a world without data driven journals who own the copyright of the 

work of others? No scientific publishing industry – noting that in a 2017 article the industry was worth 

19 billion USD annually https://www.theguardian.com/science/2017/jun/27/profitable-businessscientific-publishing-bad-for-science? 

The article in question went on to highlight the business 

model contributing to such turnover…it is worth a read. The democratization of science. No impact 

factors, no publish or perish and promotion by number of publications in ranked journals? Are these 

such dangerous ideas? To return data ownership to the owners, to make data freely available? 

What would replace these publications? Maybe those that publish articles that require thoughtful 

reflection by experienced clinicians (or researchers) to provide meaningful information and 

sharing of knowledge that truly enhances patient care – interpreting available data and fusing that 

with their lived experience of patient care, in the real world. When was the last time a data driven 

piece actually fundamentally changed the way you practiced? Of course I am being provocative, 

but when I consider the meaningful contributions to South African Psychiatry over the years of its 

existence I find so much of real value – that is both scientifically and, as importantly, experientially 

based. And yet, not scientific enough. Frankly, DoHET accreditation was never a have to have…but 

it would have been nice – for the authors of valuable content...and the subsidy their effort would 

have yielded them…at least a portion of whatever was awarded to their university. Another thorny 

issue…another time. I have been invited to speak at the forthcoming World Psychiatric Association 

Congress in Lisbon (August, 2019) on the topic of… The Future of Publications…I think I have some 

talking points already. Audience response will be interesting. I might start out by simply using the 

word… imagine…and a recurring backing track…cue John Lennon. 

As always, the current issue has a range of content ranging from the psychodynamics of the Life 

Esidimeni Tragedy to pharmacogenomics and psychiatry… with quite a bit in between. Please feel 

free to submit…science is everywhere. Enjoy! 

Louw Roos - Department of Psychiatry, University of Pretoria 

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

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

Headline Editor: Bernard Janse van Rensburg 

Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading 


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FEATURE 

THE GLOBAL 

BURDEN 

OF DISEASE STUDIES 

AND MENTAL HEALTH 

IN SOUTH AFRICA 

Lesley Robertson 

The Feature is based on a lecture at the September 2018 Public Mental Health 

Forum – see Report by Richard J Nichol in this issue 

The global burden of disease (GBD) studies 

have irrevocably changed the perception of 

diseases and injuries in terms of population 

health, epidemiological research, and 

economics and development. 1 The first GBD study, 

commissioned for the 1993 World Bank report, 

estimated mortality and morbidity of 100 diseases 

and injuries by age, sex, and geography for eight 

world regions. The incorporation of morbidity, as 

measured by years lived with disability (YLD) and 

disability-adjusted life years (DALYs), highlighted 

the impact of neuropsychiatric illness, as its chronic 

disabling effects were better quantified than with 

conventional mortality measures. 2 

THE GBD STUDY 2015 REPORTED DALYS 

OF 315 DISEASES AND INJURIES FOR 195 

COUNTRIES 3 AND INTRODUCED ANOTHER 

HEALTH GAP MEASURE, THE HEALTHY 

LIFE EXPECTANCY (HALE), AS WELL AS 

A SOCIO-DEMOGRAPHIC 

INDEX (SDI). 

The SDI, calculated from income 

per capita, average years of 

schooling and total fertility rate, 

provides a measure of a country’s 

development. Thus, the GBD 

studies quantify the burden of Lesley Robertson 

diseases and injuries and enable 

comparisons to be made across time, between 

countries, and against a nation’s own rate of socioeconomic 

development. 

HEALTH GAP MEASURES 

The GBD studies use various health gap measures 

(Table I) rather than mortality measures. These 

capture the difference between a population and 

a normative standard, such as a maximum lifespan 

in full health. 


FEATURE 

Health Gap Measure 

Years lost to life (YLLs) 

Years lived with disability 

(YLDs) 

Disability-adjusted life-years 

(DALYs) 

Healthy life expectancy (HALE) 

Health gap 

quantified 

The difference between 

observed mortality and a 

normative life expectancy 

Years of non-fatal 

health loss according to 

prevalence of conditions 

and the severity of those 

conditions. 

Represent the sum of YLLs 

and YLDs 

Functional health loss 

experienced before death 

Table I 

Health Gap Measures 

YEARS LOST TO LIFE (YLLs) 

A standard reference life table (Table II) is used to 

calculate the expected years of life lost. This has 

varied with the different GBD studies. The 1990 study 

used potential maximum life span in good health 

and drew from life expectancy of the Japanese 

population where the life expectancy of females 

was 82.5 years and of males was 80 years. The GBD 

2010 study used a normative loss of years to life from 

average death rates, giving a figure of 87.1 years for 

both females and males. For the GBD 2015 study, the 

highest projected life expectancy in 2050 was used. 

This is known as a global health estimate (GHE) and 

gives a life expectancy of 91.9 years for females and 

males. Thus, the death of two-year-old translates to 

89.41 YLLs, whereas that of a 65-year-old equates to 

25.59 YLLs. 

Source: WHO methods and data sources for global burden of disease 

estimates 2000-20151 

Table II Standard loss functions used in the Global Burden 

of Disease Studies and for WHO Global Health Estimates 

Table III summarises the distribution of global YLLs 

for the year 2011. The additional two points for 

noncommunicable diseases between the GBD 

2010 and the WHO GHE are accounted for by the 

capturing of a longer life expectancy, and therefore 

more years in which to develop disease, by the WHO 

GHE. In contrast to using a crude death rate (see 

section on mortality below), YLLs capture the burden 

of premature mortality. Thus, it is seen that over 90% 

of this burden is borne by low- and middle- income 

countries (LMICs), related to people dying at a 

younger age in these countries. 

Source: WHO methods and data sources for global burden of disease estimates 2000-20151 

Table III Distribution of global YLLs for 2011 by major cause group, sex, income group, and age 


FEATURE 

YEARS LIVED WITH DISABILITY (YLDs) 

The GBD studies use the term ‘disability’ to refer to a 

loss of optimal health in any of the important health 

domains. YLDs quantify functional health loss utilising 

the prevalence of a disease or injury state and a 

measure of the severity of disability (a disability 

weight) caused by that state (i.e. YLD = prevalence 

of the disease x disability weight for that disease). 

The 1990 GBD study used incidence of disease and 

injury but this was changed to prevalence by 2010, 

as the use of incidence involved calculations of 

prospective average duration of disease. Prevalence 

data capture the loss of health at the age at which 

it occurs rather than the age at which the disease 

is incident. 

ADDITIONALLY, PREVALENCE DATA ARE 

MORE COMMONLY COLLECTED AT 

COUNTRY-LEVEL, AND BETTER ENABLE 

ADJUSTMENTS FOR COMMONLY 

COMORBID CONDITIONS TO PREVENT 

OVERCOUNTING OF DISEASE BURDEN. 

THE HIGH COMORBIDITY BETWEEN 

DEPRESSION, ANXIETY AND SUBSTANCE 

USE DISORDERS IS INCORPORATED BY 

COMBINING THE YLDS CALCULATED FOR 

EACH OF THE CONDITIONS. 

The disability weight is numerical value determined 

by using surveys of the general population, where 0 

= a state of perfect health, and 1 = a state equivalent 

to death (Table IV). It is similar to a Quality Adjusted 

Life-Year (QALY), a measure related to loss or gain 

of quality of life used by health economists. It 

should reflect or quantify the loss of “healthfulness” 

caused by the disease or injury. It should not be 

a value judgement related to quality of life, the 

worth of a person, social undesirability or stigma. 

Nevertheless, there is still uncertainty around the 

weighting of a disability. For example, substance 

dependence, although better defined in the GBD 

2015 study to prevent the influence of social values, 

may still be affected by perception of disability. It 

is possible the more severe weighting for heroin vs 

amphetamine dependence may be related to the 

distressing withdrawal symptoms reported by heroin 

users. However, while amphetamine users may not 

perceive their addiction to be so disabling, it may 

result in greater psychiatric symptomatology, violent 

behaviour, and medical and psychiatric hospital 

admissions, which might not be captured in the 

disability weight. 

Another aspect of the disability weight is the 

adaptation by society to that disease state. Hence, 

it is possible that where there is a high level of 

adaptation to, for example, visual or hearing 

impairment, these states may not be as disabling as 

in societies which offer little or no assistance to blind 

Source: WHO methods and data sources for global burden of disease estimates 2000-2015 1 

Table IV Comparison of GBD2010, GBD2015 and revised GHE disability weights. 


FEATURE 

and deaf. Therefore, it is important to understand the 

context of the disability and the population among 

whom the disability weight is determined. 

THIS CONCEPT COULD ALSO SPEAK TO 

SEVERITY OF PSYCHOSOCIAL DISABILITY 

EXPERIENCED BY PEOPLE WITH MENTAL 

ILLNESS WHERE TREATMENT IS LESS 

ACCESSIBLE, OR IN HIGHLY VERSUS LESS 

STIGMATISING SOCIETIES. 

DISABILITY-ADJUSTED LIFE YEARS (DALYs) 

The DALY combines time lost through premature 

death (YLLs) and time lived in a state of less than 

optimal health (YLDs). The calculation has been 

simplified since the 1990 GBD study, so that in the 

2010 and 2015 GBD studies, a DALY = YLLs + YLDs, 

and YLDs = prevalence x disability weight with 

calculations combined for comorbid conditions. 

HEALTHY LIFE EXPECTANCY (HALE) 

Like DALYs, HALE is a single summary measure of 

population health. It was introduced because of 

the aging population and the need to account 

for health loss before death, as measured against 

a lifespan in optimal health. A problem that 

occurred in this population was the high level 

of independent and dependent comorbidities, 

such that the sum of multiple YLDs resulted in 

more years lost to disability than possible in one 

lifetime. The HALE provides a measure of functional 

health loss at the level of the individual rather 

than at the level of the disease or injury. It weights 

the years lived with a measure of functional 

health loss before death and includes more 

comprehensive adjustments for comorbidity than 

YLDs. These include combining calculations for 

independently occurring comorbid conditions 

and for dependent comorbidities (e.g. a stroke 

secondary to hypertension). 

BURDEN OF DISEASE IN SUB-SAHARAN AFRICA 

AND SOUTH AFRICA 

As a single summary measure of population health 

which combines both YLLs and YLDs, DALYs are 

extremely useful for establishing disease priorities 

for health planning and funding. A comparison 

between high income countries and the different 

regions in sub-Saharan Africa (Table V) reveals 

the extremely high burden of poor obstetric and 

child health in Africa. The high number of YLLs 

outweigh YLDs due to chronic diseases. Notably, 

depression does not feature in sub-Saharan Africa 

when using DALYs. Using all three measures gives a 

more complete understanding of disease burden, 

and the top ten causes in YLLs, YLDs and DALYs for 

South Africa are shown in Table VI. Of note is that 

both depression and anxiety are amongst the top 

ten YLDs, but because of the impact of premature 

mortality by other prevalent conditions, they do not 

account for any of the top ten DALYs. 

Source: Robertson LJ, Szabo CP. Implementing Community Care in Large Cities and Informal Settlements: An African Perspective. 4 Data source: GBD 2015 DALYs and 

Hale Collaborators. 3 

COPD=chronic obstructive pulmonary disease; LRTI=lower respiratory tract infections; PEM=protein energy malnutrition. a due to birth asphyxia/trauma 

Table V Top ten causes of disease burden in DALYs, globally, in high-income countries, and in sub-Saharan Africa (SSA) 

1 2 3 4 5 6 7 8 9 10 

YLLs 

HIV/AIDs 

Interpersonal 

Violence 

LRTIs 

Road 

Injuries 

Tuberculosis 

Ischaemic 

Heart Disease 

Diabetes 

Mellitus 

Stroke 

Diarrhoea 

Neonatal 

preterm delivery 

YLDs 

HIV/AIDs 

Back & neck 

pain 

Sensory 

deficits 

Depression 

Diabetes 

Mellitus 

Skin problems 

Iron 

deficiencies 

Migraine Asthma Anxiety 

DALYs 

HIV/AIDs 

Diabetes 

mellitus 

Interpersonal 

violence 

LRTIs Tuberculosis Road Injuries 

Ischaemic 

Heart Disease 

Back & 

neck pain 

Stroke 

Diarrhoea 

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 

Hale Collaborators. 3 

LRTI=lower respiratory tract infections; DALYs=Disability-Adjusted Life Years; YLDs=Years Lived with Disability; YLLs=Years Lost to Life; 

Table VI Top ten causes of disease burden in South Africa, in YLDs, YLLs, and DALYs 


FEATURE 

FACTORS AFFECTING BURDEN OF DISEASE 

ESTIMATES FOR MENTAL HEALTH 

PRIMARY DATA 

The extent and quality of country-level data is the 

most important factor affecting the GBD estimates. 1 

To be included in the GBD analyses, adherence to 

minimum standards around data transparency and 

methodology and data sharing is needed. While 

clinical data may be incorporated with sophisticated 

epidemiological modelling and statistical inference, 

it cannot fully make up for scarce primary population 

level data. 

CHANGES IN METHODOLOGY TO 

ACCOMMODATE POOR QUALITY DEATH 

CERTIFICATION AND OTHER DEFICITS IN 

DATA WERE MOST MARKED BETWEEN THE 

1990 AND 2010 STUDIES. NEVERTHELESS 

AVAILABLE, HIGH QUALITY DATA LEAD TO 

CONSISTENT HEALTH ESTIMATES BETWEEN 

INSTITUTIONS, WHEREAS SCARCE, LOW 

QUALITY DATA LEAD TO DISCREPANCIES 

BETWEEN INSTITUTIONS. 

A lack of primary data is particularly prominent in 

LMICs and for serious mental illness. Baxter et al. 

(2013) 7 analysed epidemiological data used in the 

2010 GBD study for high prevalence (depression 

and anxiety) and low prevalence (schizophrenia, 

bipolar disorder and eating disorders) mental 

illness. Globally, less than 1% of identified studies 

met inclusion criteria, and even those included had 

methodological limitations. Only North America had 

a 75-100% population coverage for both low and 

high prevalence disorders. Australasia had a 75- 

100% for high prevalence and 50-74% population 

coverage for low prevalence disorders. South 

Africa’s population coverage was 25-49% for high 

prevalence disorders, possibly largely related to 

the South African Stress and Health Study, with no 

coverage for low prevalence disorders. Thus, these 

disorders may be perceived as not contributing to 

the burden of disease in the country. 

the behaviour is directly due to the mental illness is 

not so simple. Similarly, causal directionality is difficult 

to prove with medical causes of death. 

BOX 1. ILLUSTRATIVE EXAMPLE 

The following news report describes an incident in 

Kwa Zulu Natal in which a 20-year-old, on treatment 

for a psychotic disorder, killed his two-year-old niece 

and three year-old-nephew, injured his 57-year-old 

mother, and then was killed as he ran in front of a 

truck. 

https://www.sowetanlive.co.za/news/southafrica/2018-02-19-why-did-he-kill-his-mother-andthe-children-ask-family-of-mental-health-patient/ 

Estimated burden of disease 

Death YLLs Cause of death 

Niece, 2 years 

old 

Nephew, 3 

years old 

Patient, 20 

years old 

Disability 

89.4 + 89.4 = 

178.8 YLLs 

69.7 YLLs 

(Total = 248.5 

YLLs) 

YLDs 

Interpersonal 

violence 

Road injury or 

Suicide (injury 

due to self-harm) 

(Psychotic 

disorder) 

Cause of 

disability 

ATTRIBUTION OF CAUSE OF DEATH 

The cause of death attribution affects understanding 

of disease burden due to mental illness, as the 

immediate cause of death is documented, and 

underlying cause(s) may not be reported. Deaths 

attributed to mental illness are usually due to 

substance use or neurocognitive disorders. Suicide 

is not recorded as being due to a mental illness but 

rather to death by injury due to self-harm. Hence, the 

vulnerability of people with mental illness to premature 

death is not recognised in YLLs estimates. A note is 

made in the 2015 GBD study that mortality related 

to schizophrenia will be explored more closely in 

future studies. However, cause of death might not be 

unequivocally caused by mental illness. For example, 

it is easy to quantify the YLLs in violent behaviour of 

one individual, as illustrated in Box 1, but certainty that 

Mother, 57 

years old 

(depression 

assumed) 

Patient, 20 

years old 

DW=Disability Weight 

Prevalence of 

trauma x DW 

+ Prevalence of 

depression x DW 

(note, HALE 

should count 

these as 

independent 

comorbidity) 

Prevalence of 

psychosis x DW 

(Total DALYs = 

Total YLLs + YLDs) 

Interpersonal 

violence 

Bereavement/ 

depression 

Psychotic disorder 

(Psychotic 

disorder) 


FEATURE 

FOR 2016, STATISTICS SOUTH AFRICA 

FOUND MENTAL ILLNESS TO ACCOUNT 

FOR 0.5% OF DEATHS, 8 USING THE ICD-10 

DEFINITION OF UNDERLYING CAUSE OF 

DEATH AS ‘THE DISEASE OR INJURY THAT 

INITIATED THE SEQUENCE OF EVENTS 

LEADING DIRECTLY TO DEATH’ OR ‘THE 

CIRCUMSTANCES OF THE ACCIDENT OR 

VIOLENCE THAT PRODUCED THE FATAL 

INJURY’. 

However, in their meta-analysis on mortality among 

people with mental illness, Walker et al, 9 calculated 

a pooled relative risk of 2.22 (95% CI, 2.12–2.33) 

compared to the general population, with a median 

of 10 years of potential life lost. Two-thirds of deaths 

were due to natural causes, mainly cardiopulmonary 

disease; 17.5% were of unnatural cause and the 

remainder were unknown. They estimated that 

mental illness could account for 14.3% of the global 

burden of disease through higher rates of premature 

mortality. 

MORTALITY STATISTICS 

IT WAS THE DEATH OF 36 PEOPLE WHICH 

CAUSED THE INVESTIGATION INTO LIFE 

ESIDIMENI. WHEN THE OMBUD RELEASED 

HIS REPORT, 94 PEOPLE HAD DIED. A FEW 

MONTHS LATER, THE MEDIA REPORTED 

OVER 140 DEATHS. ALL THESE FIGURES 

ARE MEANINGLESS WITHOUT CONTEXT 

(THE HUMAN RIGHT TO DIGNITY) AND 

WITHOUT COMPARISON TO THE NUMBER 

OF DEATHS EXPECTED (THE HUMAN 

RIGHT TO LIFE). 

Most mortality analyses among people with mental 

illness are cohort studies where a group of people 

are followed over at least one year, with comparison 

of the cohort death rate to that of the general 

population. 

CRUDE DEATH RATE 

The crude death rate is calculated as the number of 

deaths for a given year per 1000 people. 10 

IN 2016, THE CRUDE DEATH RATE FOR 

SOUTH AFRICA WAS 10/ 1000 PEOPLE, 11 

TWO POINTS HIGHER THAN THE WORLD 

CRUDE DEATH RATE OF 8/ 1000 PEOPLE. 

Other countries with a crude death rate of 10/ 1000 in 

2016 include Belgium, Finland, Italy, Poland, Slovenia, 

the Democratic Republic of the Congo, Cameroon 

and Mozambique. At 9/ 1000 people, the crude 

death rate of high-income countries was greater 

than that of LMICs, which stood at 7/ 1000 people 

for 2016. Context is necessary to give meaning to the 

crude death rate. For example, a country with a low 

birth rate and aging population may have a higher 

crude death rate than a low-income country with a 

high infant and child mortality rate but a growing, 

predominantly young population. 

AGE-ADJUSTED DEATH RATE AND 

STANDARDISED MORTALITY RATIO 

A life-table provides the death rate of the general 

population in age categories for a period of time 

(usually a calendar year). The age-adjusted death 

rate reflects the number of deaths that would have 

occurred if the general population had of died at the 

same rate as the study population within the same 

age categories and over the same time period. The 

Standardised Mortality Ratio (SMR) is the ratio of the 

observed deaths in the study population in each 

age group to the deaths (the expected deaths) in 

the general population in the same age group and 

over the same time period. Thus, in Life Esidimeni, the 

overall SMR was found to be highly significant at 4.9 

(95% confidence interval 3.92 - 5.80). 12 

THIS MEANS THAT, OVERALL THERE WERE 

ALMOST 5 MORE OBSERVED DEATHS 

THAN WHAT WAS EXPECTED FOR EACH 

AGE GROUP. 

However, for those over the age of 80 years, although 

observed deaths were more than double the 

expected deaths, this was not significant (SMR 2.3: 

95% confidence interval 0.32 - 4.28). 

In essence, the emergence of measures to more 

accurately quantify the impact of illness on affected 

individuals has led to a more comprehensive 

understanding of burden of disease. 

REFERENCES 

1. World Health Organisation. WHO methods and 

data sources for global burden of disease 

estimates 2000-2015 Geneva: WHO; 2017 [cited 

2018 20 September]. Available from: http://www. 

who.int/healthinfo/global_burden_disease/ 

GlobalDALYmethods_2000_2015.pdf. 

2. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, 

Ferrari AJ, Erskine HE, et al. Global burden of 

disease attributable to mental and substance 

use disorders: findings from the Global Burden of 

Disease Study 2010. Lancet. 2013;382(9904):1575- 

86.10.1016/S0140-6736(13)61611-6 

3. GBD 2015 DALYs and Hale Collaborators. Global, 

regional, and national disability-adjusted life-years 

(DALYs) for 315 diseases and injuries and healthy 

life expectancy (HALE), 1990-2015: a systematic 

analysis for the Global Burden of Disease Study 

2015. Lancet. 2016;388(10053):1603-58.10.1016/ 

S0140-6736(16)31460-X 

4. Robertson LJ, Szabo CP. Implementing 

Community Care in Large Cities and Informal 

Settlements: An African Perspective. In: Okkels N, 


FEATURE 

Kristiansen CB, Munk-Jorgensen P, editors. Mental 

Health and Illness in the City. Singapore: Springer 

Singapore; 2017. p. 1-24.10.1007/978-981-10- 

0752-1_16-1 

5. GBD 2015 Mortality and causes of death 

collaborators. Global, regional, and national 

life expectancy, all-cause mortality, and 

cause-specific mortality for 249 causes of 

death, 1980-2015: a systematic analysis for the 

Global Burden of Disease Study 2015. Lancet. 

2016;388(10053):1459-544.10.1016/S0140- 

6736(16)31012-1 

6. GBD 2015 Disease and Injury Incidence and 

Prevalence Collaborators. Global, regional, 

and national incidence, prevalence, and 

years lived with disability for 310 diseases and 

injuries, 1990-2015: a systematic analysis for the 

Global Burden of Disease Study 2015. Lancet. 

2016;388(10053):1545-602.10.1016/S0140- 

6736(16)31678-6 

7. Baxter AJ, Patton G, Scott KM, Degenhardt 

L, Whiteford HA. Global epidemiology of 

mental disorders: what are we missing? 

PloS one. 2013;8(6):e65514.10.1371/journal. 

pone.0065514 

8. Statistics South Africa. Mortality and causes 

of death in South Africa, 2016: Findings from 

death notification 2017 [cited 2018 8 October]. 

Available from: http://www.statssa.gov.za/ 

publications/P03093/P030932016.pdf. 

9. Walker ER, McGee RE, Druss BG. Mortality 

in mental disorders and global disease 

burden implications: a systematic review 

and meta-analysis. JAMA psychiatry. 

2015;72(4):334-41.https://doi.org/10.1001/ 

jamapsychiatry.2014.2502 

10. Naing NN. Easy way to learn standardization: 

direct and indirect methods. Malysian Journal of 

Medical Sciences. 2000;7(1):10-5., PMC3406211 

11. The World Bank: Data. Death rate, crude 

(per 1,000 people) [cited 2018 8 October]. 

Available from: https://data.worldbank.org/ 

indicator/SP.DYN.CDRT.IN. 

12. Robertson LJ, Makgoba MW. Mortality analysis 

of people with severe mental illness transferred 

from long-stay hospital to alternative care in the 

Life Esidimeni tragedy. SAMJ. 2018;108(10):813- 

7.https://doi.org/10.7196/SAMJ.2018. 

v108i10.13269 

Lesley Robertson is a community psychiatrist working in the Sedibeng District and is jointly appointed in the Department of 

Psychiatry, University of the Witwatersrand, Johannesburg, South Africa. Correspondence: Lesley.Robertson@wits.ac.za 

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HCL

FEATURE 

DEADLY MEDICINE: 


- THE PERVERSE PROTOPSYCHOTIC 

NATURE OF LIFE ESIDIMENI THROUGH 

A CONTEMPORARY FREUDIAN LENS 

Coralie Trotter 

“ 

Psychoanalysis begins in wonder that the 

unintelligibility of the events that surround 

one do not cause more wonder” writes 

Jonathan Lear (1998, p. 28). This paper is 

about such an event: the Life Esidimeni tragedy in 

South Africa. 

In October 2015 the Gauteng Health Department or, 

as retired Deputy Chief Justice Dikgang Moseneke 

(Moseneke, 2018) put it, ‘an admittedly delinquent 

provincial government’ embarked on an avoidable 

mass relocation of psychiatric patients. This 

Gauteng Mental Health Marathon Project (GMHMP), 

supposedly in line with South Africa’s policy of 

deinstitutionalisation, imploded into a bitter humaninduced 

trauma. Over one and a half thousand 

mental health care users were unlawfully, irrationally, 

and hurriedly dispatched from psychiatric institutions 

mostly without their identity documents, medical files 

and support systems and sometimes with changed 

names. The relocation process left human wreckage 

in its wake. 

THE GAUTENG HEALTH DEPARTMENT 

OR, THE DEPARTMENT, AS THE FAMILIES 

REFERRED TO IT, ALSO CALLED IT 

THE DECANTING. IRONICALLY AND 

TRAGICALLY, ONE MEANING OF THE 

WORD DECANTING IS TO TEMPORARILY 

TRANSFER PEOPLE FROM ONE PLACE 

TO ANOTHER. THIS PROVED TO BE 

PERVERSELY TRUE. 

One hundred and forty four 

patients died silently soon after the 

shambolic and reckless endeavour 

from dehydration, starvation, 

exposure, injury and medical 

neglect rendering their transfers 

truly temporary. Patients were 

moved from place to place: from 

one unlicensed non-governmental 

organisation (NGO) to another or 

Coralie Trotter 

to hospitals or to morgues forcing 

concerned family members to engage in a perverse 

process of ‘hide and seek’ in order to locate their 

loved ones while alive and then their actual bodies 

after death. The whereabouts of some mental health 

care users are still unknown and unidentified bodies 

remain in limbo - or ‘decanted’. The survivors have 

been, again ironically, returned to the original facility. 

The implication of this is sobering: The Department 

used a term to describe a range of temporary 

human transfers before the Marathon Project had 

even been set in motion. 

On 22 nd August 2017 I received an email from a public 

interest law firm, Section27, requesting assistance to 

assess the impact of the Life Esidimeni relocation on 

a group of, at that stage, fifty five families who had 

lost a family member due to the project. The aim 

was to produce a report that could be presented as 

evidence for an Alternative Dispute Resolution (ADR) 

or arbitration process under Justice Moseneke. This 

was done with the assistance of a team (LETEAM) 

of twenty registered mental health professionals 

with diverse clinical qualifications and a range 


FEATURE 

of experience in psychoanalytical work who spoke 

English, Zulu, Sotho, Xhosa, Afrikaans, Swazi, Shona 

and Tswana among them.* The LETEAM committed 

to participate pro bono in the project. I subsequently 

either attended or viewed the forty six-day arbitration 

process. 

I WILL ILLUSTRATE THE ARGUMENT 

PRESENTED IN THIS PAPER CLINICALLY 

WITH INFORMATION DERIVED FROM 

THE CONSULTATIONS WITH THE FAMILY 

MEMBERS (TROTTER ET AL., 2017), 

TRANSCRIBED MATERIAL FROM THE 

ARBITRATION ITSELF AND THE ARBITRATION 

AWARD REPORT PRODUCED BY JUSTICE 

MOSENEKE (2018). 

There is a trail of events in this catastrophe that 

defies comprehension. Vulnerable, dependant, 

poor, impaired people were stripped of their human 

status and essentially tortured to death. For example, 

Deborah Phehla, Maria Phehla’s daughter, was the 

first person to die a few days after being transported. 

She was locked in a filing cabinet and choked on 

her own blood after swallowing plastic and paper. 

The bodies of some individuals were then degraded 

further after death. For example, Solly Mashego’s 

body was found by his sister, Phumzile Motshegwa, 

in the cold storage room of an old butchery piled 

between other naked bodies. Both Phumzile and 

Justice Moseneke could not believe their own eyes 

looking at Solly’s face in death, now without eyes. 

The state of affairs was further compounded by 

treating the families of these patients with contempt 

and disregard for their pain, dignity and humanity. 

These families endured profound, unacknowledged, 

ongoing mental suffering because of the lack of 

disclosure and accountability on the part of The 

Department before and during the arbitration. 

And this took its toll. Two family members whom the 

LETEAM consulted in order to write up the expert 

testimony subsequently died of heart failure during 

the ADR process: Yvonne Mosiane and Shanice 

Machpelah. Shanice had turned twenty one the day 

before she died. 

There is something unbearable and ineffable 

in terms of what motivated and enabled the 

Decanting. For the families and those involved in 

this experience the metaphor of fitting the pieces 

of a jigsaw puzzle together is an apt one. What was 

needed emotionally and psychologically during the 

arbitration was to be presented by The Department 

with the completed jigsaw puzzle. That is, a full 

disclosure and rationale regarding the transfers with 

the gaps filled in. No one, however, took full ownership 

of the atrocity or provided a compelling explanation 

for the harrowing and catastrophic events in spite of 

Justice Moseneke’s repeated and persistent efforts 

with each witness to achieve this. This was particularly 

the case with the leading triumvirate who initiated 

and orchestrated the tragedy: the former Member of 

the Executive Council (MEC) Ms Qedani Mahlangu, 

Dr Tiego “Barney” Selebano and Dr Makgoba 

Manamela. As Counsel Dirk Groenewald said with 

puzzlement during the arbitration: “There is a jigsaw 

puzzle piece missing here.” 

We are thus left with a turgid silence and an 

emptiness in our understanding of the Life Esidimeni 

tragedy. This is not an ordinary break in knowledge 

filled with a necessary uncertainty and curiosity 

which may prove fruitful over time but, rather, a dark, 

heavy, opaque and impenetrable void. It is clear that 

Justice Moseneke carries this burden as this question 

posed twice to Dr Manamela during the arbitration 

indicates: “You know I sat here for weeks and I still 

deeply worry and wonder what was this marathon 

project about. What were you trying to do? Why did 

you go along with that plan that was bound to prove 

murderous?” Many of the family members, however, 

have made up their minds regarding motivation. 

Suzen Phoshoko (Trotter et al., 2017) states: “The 

death was a murder. It was planned, intentional 

murder because they must have known these 

people couldn’t be moved. Was Terence starved to 

death? Was he dehydrated? Was he poisoned? Did 

they give him an injection to kill him?” Sophie and 

Boitumelo Mangena (Trotter et al., 2017) agree: “It is 

one thing to say your mother has passed. It’s another 

to say she was tortured and killed.” 

A FEW SHORT PAPERS WRITTEN BY FREUD 

WILL BE DRAWN ON IN THIS PAPER IN AN 

ATTEMPT TO THINK ABOUT WHAT MADE 

IT POSSIBLE FOR THIS EXTRAORDINARY 

PROCESS TO PLAY ITSELF OUT ACROSS 

GAUTENG IN SEVENTEEN NGOS EVEN 

THOUGH THERE WAS NO FORMAL LINK 

OR COORDINATION BETWEEN THESE 

VARIOUS SITES. 

Neuropsychologically reality itself is unknowable 

as we only have access to a representation of 

it. In addition, the unstoppable play of the work 

of an ‘internal foreign body’ - the unconscious 

- mercilessly interrupts our being. Essentially, 

psychological health implies some emotional 

knowledge that the mind cannot always be 

trusted. Any number of psychological states and 

processes - autistic, neurotic, perverse, psychotic, 

narcissistic - may amplify the illegitimacy of how 

we represent and mediate reality. In Neurosis and 

Psychosis (1924) and The Loss of Reality in Neurosis 

and Psychosis (1924) Freud proposes that the ego 

has to serve more than one master simultaneously. 

The conflict which inevitably emerges is managed 

by the mind using mechanisms which result in 

further distortion and loss of contact with external 

or internal reality. 

* Coralie Trotter, Karen Gubb, Zamakhanya Makhanya, Geordie Pilkington, Junior Manala, Justin Scott, Kelly Bild, Natalie 

Solomon, Lesley Rosenthal, Dana Labe, Rachel Makoni, Vossie Goosen, Zama Radebe, Batetshi Matenge, Johanna Maphosa, 

Nina Lloyd-Geral, Michael Benn, Ntshediseng Tlooko, Kathy Krishnan, Vanessa Gaydon 


FEATURE 

Neurosis, Freud argues, is the result of a fracture in the 

ego’s relationship with its broiling, immoral id while 

psychosis is indicative of a warring faction between 

the ego and the external world. In neurosis, the ego 

avoids the internal pressure exerted by a powerful 

wish through repression. The forbidden desire, 

however, struggles against this fate and a sign to the 

forgotten is created as a compromise. In psychosis, 

we witness not only the refusal of new perceptions 

from external reality but also the decathexis of the 

memory store of lived experience so that it loses its 

significance and can no longer be of use. There 

is a cost both ways says Freud (1924). A neurosis 

contents itself with replacing a piece of reality with 

a fantasy which attaches itself to a current situation 

lending it a hidden meaning, whereas in psychosis 

the ego interrupts its relationship with reality to 

the point where a new imaginary world is created 

in accordance with wishes as a substitute which 

can be patched over the original breach as if it 

originated from the outside. 

NO ONE WHO TOOK THE STAND DURING 

THE ARBITRATION APPEARED TO SUFFER 

FROM A PSYCHOTIC DISORDER IN 

THE WAY DESCRIBED BY FREUD. IT 

IS EQUALLY DIFFICULT TO VIEW THE 

MARATHON PROJECT AS A NEUROTIC 

PROCESS. YET, THE REALITY TESTING AND 

JUDGEMENT OF THOSE IMPLICATED 

IN THE DECANTING ALLOWED NEARLY 

ONE HUNDRED AND FIFTY PEOPLE WHO 

COULD NOT ADEQUATELY TAKE CARE OF 

THEMSELVES TO DIE DAILY AND CRUELLY 

ON THEIR WATCH. HOW CAN WE BEGIN 

TO UNDERSTAND THIS? 

In Negation (1925), Freud argues that the earliest 

developmental process the infant negotiates 

rests on two levels of judgement. The first of these 

relates to a fundamental and spontaneous sensory 

and visceral process of determining whether an 

experience feels good or bad. 

TO PARAPHRASE FREUD, IF WE WERE TO 

EXPRESS THIS IN THE LANGUAGE OF THE 

OLDEST ORAL INSTINCT, THE JUDGEMENT 

WOULD READ AS FOLLOWS: ‘THIS 

TASTES GOOD. IT IS GOOD AND SWEET. 

I WOULD LIKE TO TAKE THIS IN. IT SHALL 

THEN BE INSIDE ME. I WANT TO BE THAT 

THING. I BE THE GOOD THING. IT IS ME.’ 

OR, ALTERNATIVELY: ‘THIS TASTES BAD. IT 

IS BAD AND BITTER. I NEED TO KEEP THIS 

OUT. I WILL SPIT IT OUT. IT SHALL THEN BE 

OUTSIDE ME. I DO NOT WANT TO BE 

THAT THING. IT IS NOT MY BAD. IT IS NOT 

ME.’ 

THIS NEGATION ARGUES MARILIA 

AISENSTEIN (2017) “IS NOT MERELY A 

REFUSAL, BUT THE ROOT OF THE SUBJECT. 

THE INITIAL “NO” IS A REJECTION WHICH 

DISTINGUISHES THE INSIDE AND THE 

OUTSIDE AND BRINGS THE “I” INTO BEING. 

SAYING “NO” IS FIRST AND FOREMOST AN 

AFFIRMATION OF IDENTITY” (P. 204). AN 

INFANT INITIALLY ALLOWED THE PRIVILEGE 

OF SAYING NO IS POTENTIALLY ABLE TO 

INHABIT HIS SKIN AND EMBODY A SENSE 

OF SELF. 

In these early stages of making a mind a ‘purified 

pleasure ego’ is shaped by incorporating that which 

is gratifying, nurturing and exciting and ejecting all 

unpleasure, discomfort and frustration. 

THIS OMNIPOTENCE IS PROTECTIVE 

EMOTIONALLY, PSYCHOLOGICALLY 

AND COGNITIVELY FOR THE NEWBORN. 

IT IS CHARACTERISED BY A STATE OF 

UNDIFFERENTIATION. 

There is a definitive mix up between experiences 

in the form of bits and pieces which belong in 

an interior space and those which originate in 

an external one: a me and a not-me, and, more 

significantly, an illusion of a good me and a bad 

not-me. Judgement of experience is based on what 

feels good or bad regardless of whether external 

events align with the internal landscape. The baby 

may very well be wired to attach to caregivers and 

make sense of the environment neurologically but 

this does not mean that the status quo is being 

represented in the mind accurately in terms of 

objects and reality being separate and distinct. 

THE INFANT TAKES GOOD FROM SUPPLIES 

IN THE WORLD OUTSIDE AND, THROUGH 

IDENTIFICATION, MAKES THESE PART OF 

THE SELF AS IF THE GOOD THING WERE 

NEVER OUTSIDE TO BEGIN WITH. THE 

‘BAD’ IS SPAT OUT AND ALL THAT IS SPAT 

OUT IS PERCEIVED AS BELONGING TO A 

DIFFUSE NOT-ME ENVIRONMENT. “WHAT 

IS BAD, WHAT IS ALIEN TO THE EGO AND 

WHAT IS EXTERNAL ARE, TO BEGIN WITH, 

IDENTICAL” (FREUD, 1925, P. 369). 

It is because the antithesis between subjective 

and objective does not exist initially that our first 

experience of the world is confused and draws 

sustenance from the realm of wishes and affective 

storms. Yet it is essential that the infant is not aware of 

this paradox. Of course, this early forging of mental 

solids is an illusion. The reality is that what is spat out 

begins to assemble as the primitive superego in an 


FEATURE 

unseen corner of the mind. The baby attempts to live 

in a state of bliss and preside over an omnipotent 

objectless ‘imaginary heaven’ but, in truth, has 

constructed a paranoid Kafka-like dominion though 

introjection and projection with the return of the 

projected and dislocation by objects in reality 

imminent. 

OF COURSE, IT IS JUST A MATTER OF TIME 

BEFORE THE BLOW OF THE FALL FROM 

GRACE INTO THE DISILLUSIONMENT 

OF ACTUAL REALITY OCCURS. FAILING 

THIS, THE BABY WILL BE ILL-EQUIPPED TO 

ADAPT TO THE ORDINARY WORLD FROM 

WHICH HE IS, AFTER ALL, NOT EXEMPT. AS 

ESSENTIAL AS IT IS FOR THE INFANT TO 

INITIALLY JUDGE FOR HIMSELF WHETHER 

AN OBJECT OF SATISFACTION POSSESSES 

THE GOOD, DESIRABLE ATTRIBUTE AND SO 

DESERVES TO BE TAKEN INTO HIS EGO, IT 

IS EQUALLY IMPORTANT FOR THE INFANT 

TO REGISTER THAT THE OBJECT IS ‘OUTSIDE 

OVER THERE’ SO THAT IT CAN BE SOUGHT 

OUT WHENEVER IT IS NEEDED (FREUD, 

1925). THE PLEASURE EGO CAN DO 

NOTHING BUT WISH, WORK FOR A YIELD 

OF PLEASURE AND AVOID UNPLEASURE 

(FREUD, 1911). THE BABY HAS TO 

LEARN TO USE HIS APPETITES, IMPULSES, 

DESIRES, WISHES, NEEDS AND FEELINGS 

TO LATCH, TO WORK, TO RETRIEVE THE 

GOOD THAT IS ACTUALLY IN A WORLD 

BEYOND OMNIPOTENT CONTROL. THIS 

ORGANISES THE EGO AND ALLOWS LINKS 

TO BE ESTABLISHED SO THAT THE OBJECTS 

OF THE PSYCHE - REPRESENTATIONS - 

CAN BE PRODUCED AND THE EXTERNAL 

OBJECT CAN BE DISTINGUISHED FROM 

THE PHENOMENOLOGICAL JUDGEMENT 

OF IT. THE REALITY EGO CAN THEN 

STRIVE FOR WHAT IS USEFUL WHILE 

SAFEGUARDING THE EXPERIENCE OF 

PLEASURE (FREUD, 1911). 

How does this first developmental achievement 

occur? “The baby,” writes Donald Winnicott (1945) 

“has instinctual urges and predatory ideas. The 

mother has a breast and the power to produce milk, 

and the idea that she would like to be attacked by 

a hungry baby. These two phenomena do not come 

into relation with each other till the mother and child 

live an experience with each other…I think of the 

process as if two lines came from opposite directions, 

liable to come near each other. If they overlap there 

is a moment of illusion – a bit of experience which the 

infant can take as either his hallucination or a thing 

belonging to external reality” (p. 152). This requires 

a particular type of environment: a caregiver who is 

able to reduce the impingements of internal forces 

and outside demands for the infant and facilitate 

a manageable negotiation of reality and recovery 

from collision with it over time (Winnicott, 1945, 1960, 

1988). Green (1999) elaborates that in order to be 

able to say yes to himself the baby must be able to 

say no to the object. The mother must accept that 

he can say no to her. And not only in the form of ‘you 

are BAD’, but also ‘you don’t exist’. In other words, 

states Green, the object must take the place of the 

undifferentiated space in order to take in what is 

spat out by the baby. 

THE CARETAKER MUST NOT ONLY 

ATTEMPT TO SPARE THE BABY EXCESSIVE 

UNPLEASURE BUT CANNOT HAVE MORE 

BELIEF IN THE BABY’S BADNESS THAN IN HER 

OWN. THE NATURE OF THIS ENVIRONMENT 

IS A SUBJECT DESERVING OF A PAPER 

IN ITS OWN RIGHT PARTICULARLY IN 

THE SOUTH AFRICAN CONTEXT WITH 

THE LEGACY OF COLONIALISM AND 

APARTHEID AND THE DESTRUCTIVE 

IMPACT OF BOTH ON FAMILY BONDS AND 

UNITS AND MATERNAL AND PATERNAL 

FUNCTIONING. 

However, in an ordinary environment the infant is 

allowed the privilege of gradually taking a bit of 

experience as a thing actually belonging to external 

reality, that is, of refinding the object that was always 

there which has already been incorporated by the 

ego and convincing the self that it is still there even 

though it belongs in the real world (Freud, 1925). This 

is a critical emotional and psychological leap for 

the baby as he begins to recognise and ‘re-cognise’ 

his dependence on external provision and objects 

and the necessity of engaging with the unfairness, 

arbitrariness, ordinariness and social contracts of a 

big wide indifferent world. Freud (1925) states: “What 

is not real, what is merely imagined or subjective, is 

only internal; while on the other hand what is real 

is also present externally” (p. 369). Re-discovering 

the object and investing in it essentially equates 

to committing to and engaging with reality in a 

meaningful and relatively constant way with its 

implied disillusionments and losses. This allows a 

‘manageable distaste rather than a bitter hatred’ for 

reality to develop. And, critically, mourning becomes 

an inevitable part of life. 

OF COURSE, AS WITH ALL THINGS 

PSYCHOLOGICAL, THIS IS NOT SIMPLY 

A MATTER OF ONE MOMENT IN TIME. 

RENEGOTIATING A RELATIONSHIP WITH 

REALITY IS AN ONGOING, LIFELONG TASK 

WHICH MAY BE RE-EVOKED WITH EACH 

DEVELOPMENTAL THRUST, CRITICAL 

INCIDENT OR SIGNIFICANT RELATIONSHIP. 


FEATURE 

Nevertheless, failure to initially refind the object 

that was always present in reality implies that at 

a fundamental level the person can essentially 

continue to base judgements of the external world 

on what feels good or bad regardless of whether 

actual events concur with this illusory narrative or 

not. Freud (1925) explains: “All images originate from 

perceptions and are repetitions of them. So that 

originally the mere existence of the image serves 

as a guarantee of the reality of what is imagined... 

The reproduction of a perception as an image is 

not always a faithful one...The process for testing 

the thing’s reality must then investigate the extent of 

these distortions” (pp. 369-370). Failure to interrogate 

these distortions means that the vagaries of thought 

can be equated with external phenomena and the 

tenacity of internal desire with magical fulfilment: 

‘I wish it! Therefore it IS so!’ then dominates the 

relationship with reality and decision making. This 

elevates thinking to an idiosyncratic and concrete 

belief in mind over matter. In the real world, of 

course, things are not absolute and we all revert to 

a problematic relationship with reality intermittently 

and then, hopefully, ‘return to our senses”. 

THIS PSYCHOLOGICAL FLUX IN TERMS OF 

ONGOING ATTEMPTS TO RECOVER AS 

MUCH REALITY AS POSSIBLE IS DIFFERENT 

FROM FORECLOSURE OF THE REALITY 

PRINCIPLE AT A SUBSTANTIVE LEVEL. THE 

LATTER RESULTS IN A DISREGARD FOR 

MEANINGFUL REALITY-TESTING EVEN IF 

COGNITIVE AND INTELLECTUAL ABILITIES 

ARE SUBSEQUENTLY WELL-DEVELOPED 

PRECISELY BECAUSE ESSENTIALLY THE 

PSYCHE IS NOW A CLOSED, REGRESSIVE 

SYSTEM AT ITS CORE. THIS PROCESS 

IS AN UNCONSCIOUS ONE AND SO 

THE INDIVIDUAL AFFECTED HAS LITTLE 

INSIGHT INTO IT. 

This type of thinking is more common than we 

imagine and can appear in many disguises. This 

hallucinatory fulfilment of wishes (wunscherfüllung), 

as noted by Freud (1900) takes place in dreams 

and, unfortunately, in the waking state too. The earth 

is flat and there is no global warming are obvious 

examples. Others follow. Dr Hendrik Verwoerd, the 

architect of Apartheid in South Africa, stated in 1961 

that Apartheid had been much misunderstood and 

that it could just as easily have been described 

as a policy of ‘good neighbourliness’. In 1985 P. W. 

Botha, the Prime Minister who declared the states of 

emergency in South Africa, addressed the National 

Party congress with these words: “I am not prepared 

to lead South Africans and other minority groups 

on a road to abdication and suicide.” After the 

destruction of the twin towers in New York, the 2003 

invasion of Iraq under the presidency of George 

Bush, took place triumphantly in spite of insufficient 

evidence that there were, in fact, weapons of mass 

destruction in Iraq. Thabo Mbeki’s adamant denial 

from 1999 to 2008 that HIV and AIDS were linked 

denied individuals antiretroviral drugs and cost 

nearly half a million South Africans their lives. Donald 

Trump made numerous references to a wall during 

his 2015 to 2016 USA presidential campaign: “I will 

build a great wall - and nobody a builds wall better 

than me, believe me...I will build a great, great wall 

on our Southern border, and I will make Mexicans 

pay for that wall. Mark my words.” Kallie Kriel from 

Afriforum insisted in 2018 that Apartheid was not 

a crime against humanity because the death toll 

was too low and with one fell swoop negated the 

atrocities of Apartheid and the Rome Statute of 1998. 

THUS AN INDIVIDUAL’S LINK WITH 

DECISIONS AND BEHAVIOUR MAY NOT 

BE WELL GROUNDED IN REALITY BECAUSE 

THE SECOND LEVEL OF JUDGEMENT WAS 

NOT SIGNIFICANTLY ESTABLISHED AND 

CONSOLIDATED IN THE FIRST PLACE. 

Perceptions of reality persist but are eclipsed, 

disavowed and denied. Andre Green (1999) 

aptly expresses this: “The subject cannot believe 

his eyes, but it is precisely because he can see 

and not because he is blind” (p. 90). This creates 

a basic internal core upon which the rest of the 

psychic structure has to be put together. The more 

observable layers of psychological scaffolding may 

vary considerably but underneath an essentially 

primitive constellation is used to negotiate living in 

that the sense of self remains inflated, entitled and, 

most importantly, wish laden and oblivious of reality 

which cannot then be negotiated in a complex, 

reasonable, fluid and empathic way. The ideas 

in the mind are then beyond question and desire 

becomes the law for acting rather than judgement 

or emotional thoughtfulness. Moderation of the 

archaic representation of the object through 

learning from experience is inhibited and further 

development of the primitive superego is thwarted. 

THIS IS CLEARLY A FACTOR TO BE 

CONSIDERED IN THE GMHMP WHICH 

WAS SET IN MOTION ACCORDING TO 

INTERNAL PRESSURES IN TERMS OF WHAT 

FELT GOOD AND BAD REGARDLESS 

OF HOW OMNIPOTENT, UNINFORMED 

AND UNREASONABLE THE BASIS FOR 

THE THINKING HAPPENED TO BE. THE 

RATIONALE AND EXECUTION OF 

THE MARATHON PROJECT WAS NOT 

INTERROGATED BUT RATHER DRIVEN BY 

WISHING, FANTASY AND COMPULSION. 

This allowed realistic evidence-based concerns to 

be strenuously negated resulting in a life-threatening 

endeavour - a Decanting. The former MEC, Qedani 

Mahlangu, was able to verbalise exactly this but 

could not see the inherent problem in her thinking. 

When she was asked in an interview (2017) with 

Devi Sankaree Govender for Carte Blanche (MNet 


FEATURE 

TV) why the patients had been transferred against 

all advice from others, her response was: “How 

could they know? Unless they are foretellers” with 

reference to the expert advice given by professional 

bodies. Again during the ADR process Ms Mahlangu 

stated: “If I were a prophet justice, I would have had 

foresight.” 

THIS, IN ESSENCE, IS THE DIFFICULTY: SOME 

FORESIGHT COMES FROM TAKING THE 

DICTATES OF REALITY AND KNOWLEDGE 

SERIOUSLY, LEARNING FROM HARD 

EARNED EXPERIENCE AND LISTENING TO 

OTHERS WITHOUT NECESSARILY ACCEPTING 

RECEIVED WISDOM UNCRITICALLY. 

In the report I wrote that The Decanting turned a 

blind eye to all available psychiatric, psychological 

and sociological research, evidence and theory 

regarding the likely negative impact of relocating 

such a large number of institutionalised patients and 

that it ignored all available expertise and knowledge 

gained from clinical and ordinary experience in the 

manner of relocation (Trotter et al., 2017). There was 

foresight in this case but the subject in question 

could not believe her eyes. 

Ten pages of Justice Moseneke’s award (Moseneke, 

2018) detail how this allowed the statutory substrate of 

social and cooperative living to carry no meaningful 

weight, authority or substance in actual reality: 

“What stands out is the breadth and depth and 

frequency of the arrogant and deeply disgraceful 

disregard of constitutional obligations, other law, 

mental health care norms and ethics by an organ 

of state, its leaders and employees” (p. 72). During 

the arbitration Dr Mvuyiso Talatala said that he knew 

time would tell when asked why further legal action 

had not been taken to halt the Marathon Project. 

And indeed it did as time is beyond omnipotent 

control. 

Once the infant has essentially turned away from 

reality and mourning the premature mind can 

further distort and reshape itself in various ways in 

order to deal with the incessant demand of internal 

forces. A few thoughts regarding this follow. Freud 

(1938) describes how the mind can cleave in two 

in the presence of intense conflict between wishing 

and reality: reality, on the one hand, is rejected and 

prohibitions are refused while, on the other hand, the 

danger of reality is simultaneously recognised. The 

mind both affirms and negates reality and nothing 

is given up. But, as Freud reminds us, we always have 

to pay the piper. The cost here is a rift in the ego 

which never heals. Rather two contrary reactions to 

the conflict persist as the centre-point of a splitting 

of the ego rather than as a dialectical tension 

because things never fit and have to be continually 

manipulated and distorted. 

This results in a double articulation or pivot in the 

mind which allows rotation and oscillation between 

contradictory points of view. Donald Trump refers to 

these as ‘alternative facts’ which can be used to spin 

reality rather than confront it. 

THIS WAY OF DEALING WITH REALITY 

DESERVES TO BE DESCRIBED AS ARTFUL 

AND INGENIOUS SAYS FREUD (1938). THE 

SLIPPERY SLOPE OF FUDGING REALITY 

RENDERS TRUTH OBSOLETE IN SUCH 

SCENARIOS. IF IT IS DISAGREEABLE IT IS 

‘FAKE NEWS’ WHICH ALLOWS AN EVEN 

MORE SPURIOUS VERSION OF EVENTS TO 

BE RELAYED AS HISTORICAL TRUTH. 

We could say that this way of dealing with reality is 

manipulative and perverse. This use of ‘alternative 

facts’ or misinformation was evident throughout 

the GMHMP. The Department perjured itself in court 

at the outset (March 2016) in order to push the 

Marathon Project forward against all opposition. Ms 

Mahlangu did not present the facts accurately to the 

provincial legislature in 2016 and Dr Manamela had 

compiled the response. Ms Mahlangu, Dr Selebano 

and Dr Manamela all pleaded ignorance regarding 

the fact that by August 2016 fifty one people had 

already died. As Justice Moseneke (2018) states: 

“This answer is as improbable as it is untrue.” 

Licensing fraud and unlawful licensing of NGOs 

became the new ethical norm. The families were 

subjected to relentless violations of trust, continual 

stonewalling and incessant deception. 

CROSS-EXAMINATION IS A TOUGH 

PROCESS AND YET THE TRIUMVIRATE 

WERE ABLE TO CONTRADICT THEMSELVES 

ON THE STAND, OBFUSCATE THE FACTS 

AND REMAIN UNTOUCHABLE IN TERMS OF 

AN IMPERATIVE TO TELL THE TRUTH EVEN 

UNDER OATH AND JUSTICE MOSENEKE’S 

WARNINGS: “IT IS JUST A MATTER OF TIME 

BEFORE I DECIDE WHETHER YOU ARE 

TELLING THE TRUTH OR NOT.” 

Essentially reality became plastic and could be 

manoeuvred and morphed at will. In his award Justice 

Moseneke (2018) described parts of the testimony 

of the triumvirate as misleading, improbable and 

inaccurate and finally stated that many of the reasons 

presented were “false, disingenuous, and advanced 

in order to conceal the true reasons for ending 

the contract and moving the patients” (p. 19). Ms 

Mahlangu was actually able to express the operation 

of the pivot in her mind. She said that if she answered 

yes or no it wouldn’t be good for her, a privilege not 

allowed many individuals who took the stand. She 

begged the indulgence of the court continually to 

present, explain and overelaborate a perspective 

of the relocation which was totally detached from 

what had transpired in the real world. And she clung 

tenaciously to discredited reasons for the relocation 

such as cost cutting, deinstitutionalisation and 

promoting community care. 


FEATURE 

IT STRIKES ME THAT WHAT FREUD (1938) 

DESCRIBES AS THE SPLITTING OF THE 

EGO IS AN ORGANISED STATE AND 

THAT THIS MAY NOT BE POSSIBLE FOR 

INDIVIDUALS WHO HAVE LOWER LEVELS 

OF INTERNAL STRUCTURE, INTEGRATION 

AND CONSTANCY AND WHO ARE THUS 

MORE ESSENTIALLY DISORGANISED 

PSYCHOLOGICALLY. 

Perhaps Wilfred Bion (1957) and Andre Green (1999, 

2001, 2003) offer pictures of the ‘psychic poverty’ 

which may ensue in such situations. Green argues 

that it is possible early in life for primary identification 

to be soldered not in relation to an object but, rather, 

in relation to a black hole, a hole nevertheless with 

a potent charge. The original object then only has 

a negative existence. Green (2002) describes how 

thoughts, images, passions and impulses flicker on 

and off, often loaded with terror and dread looking 

for a name and a place, but, finding only a bleak, 

harsh, heavy, silent core. The mental activity which 

gives birth to substitute representations and free 

associative pathways in the mind is under the threat 

of being destroyed as the black hole in the mind 

attracts and destroys thoughts and substance and 

structure are swallowed up. 

THIS IS NEGATIVE NARCISSISM WHICH IS 

PERVERSE AND ALIENATING. THE DRIVES 

ARE THEN EXPRESSED THROUGH ACTION 

AND SOMATIC DISCHARGE RATHER 

THAN IN WORDS. 

Similarly, for Bion (1957) destructive attacks on 

links with feelings, parts of the self, objects and 

reality as a result of a certain set of circumstances 

during the initial developmental stage lead to the 

predominance of associations which appear to 

be logical, almost mathematical, but are seldom 

emotionally reasonable as a result of excessive 

projective identification. In Differentiation of the 

Psychotic from the Non-Psychotic Personalities Bion 

(1957) argues that the thoughts which arise are 

severed, fragmented, isolated and concrete and, yet, 

they are experienced with certainty and are devoid of 

true curiosity. This is actually a highly confused state. 

JUSTICE MOSENEKE TRIED REPEATEDLY 

TO ASSIST DR MANAMELA WITH HER 

DIFFICULTIES IN TERMS OF HER RIGID, 

ILLOGICAL, CIRCULAR THINKING. FOR 

EXAMPLE: “WE WILL NEED SOMEONE TO 

LEAD YOU IF YOU GO ON IN AN OPEN 

ENDED WAY,” AND LATER “I WANT BASIC, 

SIMPLE SENTENCES WITH A SUBJECT 

AND AN OBJECT.” 

This incoherent thinking and confounding of reality 

is clearly illustrated in the following transcript from 

the arbitration. Dr Manamela, appears to have no 

appreciation of cause and effect and thus problems 

cannot be stated let alone solved, as described by 

Bion (1957). 

Dr Manamela: ‘Justice I’m giving you the procedure 

as it happens. That’s what I’m trying to give to these 

proceedings. Because I felt I must tell you what 

events took place before I come to the questions. 

Now it’s two way. I must answer the question and tell 

you what happened. The unfortunate part some of 

the people who came before me some of them who 

didn’t understand the process they told you what 

they told you and it’s like now I come as an accused.’ 

Justice Moseneke: ‘I’m going to ask the question 

again. What did you do?’ 

Dr Manamela: ‘What I just explained is what we did. 

Should I explain again?’ 

There is a sigh from Justice Moseneke: ‘I don’t know 

what you are saying. Yes you would have signed it or 

no I wouldn’t have signed it? What are you saying?’ 

Dr Manamela: ‘Justice what I was saying is how did it 

happen. That’s the truth I know.’ 

Counsel Groenewald: ‘I am putting it to you that you 

are shifting blame...Take responsibility. And say well 

there was a number of issues and I shouldn’t have 

issued these licences and I know it now.’ 

Dr Manamela: ‘Counsel, it was presented to me that 

the NGOs can be able to manage..you don’t deliver 

by yourself all the time...’ 

Justice Moseneke: ‘No, but listen to the question. Do 

you know now according to you what you did not 

know then? But do you know now that you should 

not have issued the licences? That’s what counsel is 

asking you. What is your response to that?’ 

Dr Manamela: ‘I know now but I still saying I didn’t...’ 

Justice: ‘No, no, do you know now that you should 

not have issued the licenses?’ 

Dr Manamela: ‘That is what these proceedings are 

saying but I...’ 

Justice: ‘No! No! No! No!’ 

Dr Manamela: ‘But I..’ 

Justice: ‘Counsel wants your answer. Do you know now?’ 

Dr Manamela: ‘I know now although I don’t agree with 

the now because at the time when I issued the licenses 

the NGO were eligible to take care of the patients.’ 

Justice: ‘No as you sit where you sit now knowing 

your statutory responsibilities... knowing that now do 

you think the right thing in issuing the licences where 

143 died? That is the question.’ 

Dr Manamela: ‘But I said at that time I knew at that 

time it was right. Now I know that you are saying it 

was not right.’ 

Justice: ‘You are saying that?’ 

Dr Manamela: ‘I am saying according to the legal 

document I have I still know there that was no 

request that I be delegated. Last week I was told that 

what I know is not right. That’s what you said to me.’ 


FEATURE 

Retired Deputy Chief Justice Dikgang Moseneke 

bows his head and says ‘Aaah’ and speaks in the 

vernacular, then says: ‘Listen to the...Advocate 

Groenewald says to you do you now know that 

whatever you might have thought then you were 

wrong in issuing the licences? You won’t concede 

even that?’ 

Dr Manamela: ‘That I was wrong in issuing the 

licences?’ 

Justice: ‘Do you know now that was the wrong 

decision?’ 

Dr Manamela: ‘I know now from you but then it was 

not wrong.’ 

Justice with despair: ‘Counsel you go ahead.’ 

ILLUMINATING IN THIS PART OF THE CROSS- 

EXAMINATION IS THAT DR MANAMELA 

STATES THAT SHE DOES NOT AGREE WITH 

THE NOW: NOW CAN BE DIVORCED 

FROM ACTUAL EVENTS THAT TRANSPIRED 

- REALITY - AND JUDGED ACCORDING 

TO THAT WHICH IS ONLY INTERNAL. IT IS 

NOT ONLY THAT THE INDIVIDUAL WITH 

FLAWED REALITY TESTING IS IMPERVIOUS 

TO REALITY AND OTHERS IN THAT REALITY 

WHICH DIMINISHES THE CAPACITY 

TO LEARN FROM EXPERIENCE AND 

RESPOND TO FEEDBACK BUT ALSO THAT 

EMPATHIC FAILURE ALLOWS PEOPLE - 

NOW TRULY OBJECTS - TO BE DEVALUED, 

DEPERSONALISED AND COLONISED. 

Bion (1957) states that the links with objects which 

survive are perverse, cruel, and sterile. This is partly 

because failure to re-discover the external object 

allows the baby to avoid ‘taking its bad property back’. 

JUSTICE MOSENEKE REMINDED DR 

MANAMELA REPEATEDLY TO TREAT 

OTHERS WITH RESPECT: “NO MA’AM! I 

DO INSIST. I INSIST YOU MUST CALL HER 

MRS FRANKS. WE DON’T GO RUNNING 

AROUND USING FIRST NAMES HERE. 

WE DON’T USE YOUR FIRST NAME. LET’S 

ACCORD RESPECT TO EVERYONE WE 

ARE DEALING WITH.’’ 

The following statement by Dr Manamela illustrates 

not just the contempt for others but the conviction 

that there are no problems except those posed 

by the object: “Through you Counsel I think I’m 

answering to your questions. And I sense that there 

is a staring of family members that they should be 

angry continuously towards me and I believe I need 

protection for that. But my worry is that the staring of 

anger towards me might put my life and that of my 

family in danger. That I must record.” The problem 

here is not only the very concrete idea that looks 

could kill but that the source of danger is external. 

In an extraordinary turnaround Dr Manamela 

positioned herself as the victim throughout the 

arbitration to the point where she complained in her 

opening testimony that a drone was following her. 

SIMILARLY, EVEN THOUGH MS MAHLANGU 

WAS THE ARCHITECT OF A TORTUROUS 

AND MURDEROUS PROCESS, SHE ARRIVED 

AT THE ARBITRATION WITH SEVERAL 

BODYGUARDS AS IF SHE TOO WERE THE 

ONE WHO NEEDED PROTECTION. SHE 

PRESENTED HERSELF AS THE AGGRIEVED 

PARTY WHO HAD BEEN LET DOWN BY 

THE HEALTH PROFESSIONALS. HER FINAL 

WORDS WHERE ABOUT HERSELF AND 

NOT THOSE WHO DIED SILENTLY OR 

THOSE WHO SURVIVED OR THE FAMILIES. 

The dehumanisation which took place during this 

project is possible because, as is evident above, 

it is the object that is the problem. A failure to 

discriminate meaningfully between what is internal 

and what is external results in a fundamentally 

paranoid psychological world because every 

attempt is made to evacuate all bad experiences, 

states and parts into the external not-me. As a result 

others are not seen or are seen as threatening in 

spite of their vulnerabilities in reality. This is perverse. 

The tragedy with Life Esidimeni - a microcosm of the 

state of mental health and health in general in South 

Africa and a portal or wormhole into the legacy of 

our history and its implications for the future - is that 

it allowed internal drivers, compulsions and fantasies 

to manifest in a manic project which in all likelihood 

had very little to do with people and their best 

interests from the beginning. Unfortunately, it is then 

the ‘other’ who has to pay the piper. 

Justice Moseneke stated in his final report and 

award on the 19 th March 2018: “This is also a story 

of the searing and public anguish of the families of 

the affected mental health care users and of the 

collective shock and pain of many other caring 

people in our land and elsewhere in the world” (p.2). 

We cannot hope to fully understand such an event 

without taking into account the unconscious forces 

operating in the key individuals implicated in the 

Decanting. 

PERHAPS ONE OF THE REASONS THE 

ADR PROCESS DID NOT HAVE GREATER 

EXPLANATORY POWER IS THAT THE 

ASSUMPTION WAS THAT THE MARATHON 

PROJECT WAS DRIVEN BY MOTIVES 

WHICH WERE REASONABLE RATHER THAN 

IRRATIONAL AND FANTASY BASED AS 

THE LATTER IS SIMPLY TOO UNBEARABLE 

TO CONTEMPLATE. WE TOO COULD NOT 

BELIEVE OUR EYES. 


FEATURE 

THE 2018 OXFORD DICTIONARY 

WORD OF THE YEAR, A WORD JUDGED 

TO REFLECT THE ETHOS, MOOD OR 

PREOCCUPATION OF THE PASSING YEAR 

AND ONE WHICH MAY HAVE LASTING 

IMPACT AS A DESCRIPTOR OF CULTURAL 

SIGNIFICANCE, IS TOXIC. 

And toxic is a good word to describe the impact of 

individuals with sufficient power to determine the 

course of action of a family, group or society who 

appear to operate in a perverse protopsychotic 

manner. 

Justice Moseneke (2018) referred to the ‘toxic 

aftermath’ (p. 80) of the entire Marathon Project 

in his award. As mental health professionals we 

can refuse to collude with toxic practice and use 

our psychoanalytic knowledge to wrestle with the 

impact of unconscious forces which erupt in our 

communities. We can contradict perverse narratives 

which demand that those with less sociopolitical 

currency pay the piper for those who refuse to accept 

responsibility for their own actions. And we, like 

Justice Moseneke (2017), need to carry the weight of 

continuing to wonder about the unintelligibility of this 

event as a way of thinking about the psychological 

state of our society and world. 

REFERENCES 

Aisenstein, M. (2017). An analytic Journey: From the 

art of archery to the art of psychoanalysis. London: 

Karnac Books. 

Bion, W. R. (1957). Differentiation of the psychotic 

from the non-psychotic personalities. International 

Journal of Psychoanalysis, 38:266-275. 

Freud, S. (1900). The interpretation of dreams. The 

Standard Edition of the Complete Psychological 

Works of Sigmund Freud, Volume IV (1900): The 

Interpretation of Dreams (First Part), ix-627 

Freud, S. (1911). Formulations on the two principles 

of mental functioning. The Standard Edition of the 

Complete Psychological Works of Sigmund Freud, 

Volume XII (1911-1913): The Case of Schreber, Papers 

on Technique and Other Works, 213-226. 

Freud, S. (1924). Neurosis and psychosis. The 

Standard Edition of the Complete Psychological 

Works of Sigmund Freud, Volume XIX (1923-1925): The 

Ego and the Id and Other Works, 147-154. 

Freud, S. (1924). The loss of reality in neurosis and 

psychosis. The Standard Edition of the Complete 

Psychological Works of Sigmund Freud, Volume XIX 

(1923-1925): The Ego and the Id and Other Works, 

181-188. 

Freud, S. (1925). Negation. International Journal of 

Psycho-Analysis, 6:367-371. 

Freud, S. (1938). Splitting of the ego in the process 

of defense. The Standard Edition of the Complete 

Psychological Works of Sigmund Freud, Volume 

XXIII (1937-1939): Moses and Monotheism, An 

Outline of Psycho-Analysis and Other Works, 271- 

278. 

Green, A. (1999). The work of the negative. London: 

Free Association Books 

Green, A. (2001). Life narcissism death narcissism. 

London: Free Association Books. 

Green, A. (2002). A dual conception of narcissism: 

Positive and negative organizations. Psychoanalytic 

Quarterly, 71:631-649. 

Green, A. (2003). On private madness. London: 

Karnac. 

Lear, J. (1998). Open minded: Working out the logic 

of the soul. Boston, MA: Harvard University Press. 

Moseneke. D. (2018). Arbitral Report: Families of 

Mental Health Care Users Affected by the Gauteng 

Mental Health Marathon Project and the National 

Minister of Health of the Republic of South Africa. 

Trotter, C. et al., (2017). The mark of the Life Esidimeni 

decanting: Expert Testimony for the Alternative 

Dispute Resolution (ADR) Process with Justice 

Dikgang Moseneke. 

Winnicott, D. W. (1945). Primitive emotional 

development. International Journal of Psycho- 

Analysis, 26:137-143. 

Winnicott, D. W. (1960). The theory of the parent-infant 

relationship. International Journal of Psycho-Analysis, 

41:585-595. 

Winnicott, D. W. (1988). Human nature. Great Britain: 

Taylor and Francis Group. 

Coralie Trotter has an M. A (Clinical Psychology) WITS and is also registered as a Psychoanalyst with The International 

Psychoanalytic Organisation (SAPA/IPA). She has many years of clinical experience in a psychoanalytic private practice 

and supervising mental health professionals. Her supervision experience also includes ten years at both the 702 Crisis 

Centre and the University of the Witwatersrand. In addition, Coralie worked for the Detainees Counselling Service and was 

responsible for debriefing the clinical team at the Trauma Clinic of the Centre for Violence and Reconciliation for many 

years. She has been teaching for over twenty years. 

This includes the formal teaching and professional development of clinicians in various and numerous psychoanalytic 

groups in Johannesburg, most notably Groups for the Reading and Study of Psychoanalysis (GRASP) which is her initiative. 

In 2017 Coralie was asked by Section27 to be an expert witness for the Life Esidimeni Arbitration Hearing. This involved a 

consultation process with the families affected by the Gauteng Mental Health Marathon Project with the help of a professional 

team. The material which emerged was then analysed by Coralie to produce an expert report and oral testimony for the 

Alternative Dispute Resolution Process (2017). Coralie has presented papers at a number of local conferences and coorganised 

The Deadly Medicine - The Mark of the Life Esidimeni Decanting Conference in August 2018. Correspondence: 

coralie@tiscali.co.za 



FEATURE 


T E S T I N G 

IN SOUTH AFRICAN 

PSYCHIATRY 

Aron B. Abera a * and Pierre M. Durand b 

a 

Inqaba Biotechnical Industries, Hatfield, Pretoria, South Africa 

b 

Evolutionary Studies Institute, University of the Witwatersrand, Johannesburg, South Africa 

*Corresponding author: aron.abera@inqababiotec.co.za 

An area of increasing interest in psychiatry 

is the use (and sometimes abuse) of 

pharmacogenomic analyses. Globally, 

pharmacogenomics already play a role 

in psychiatry treatment guidelines in the so-called 

‘developed’ countries. This area of interest is poised 

to grow in South Africa, but there are important 

considerations for the local context that are largely 

unexplored. Perhaps the most pressing question is 

how appropriate the available pharmacogenomic 

analyses are for psychiatrists working in SA. To 

attempt to answer this all-encompassing question, a 

brief review of the aims, scope and methodologies in 

pharmacogenomics is warranted. 

PHARMACOGENOMICS: AIMS 

AND SCOPE 

An individual’s genetic make-up (the genotype) 

affects how their body responds to, and metabolises 

drugs (the phenotype). The term pharmacogenomics 

is a portmanteau of pharmacology and genomics 

and aims to match the individual’s genotype with 

the expected response to the prescribed drug. The 

majority of assays include both pharmacokinetic 

(PK) and pharmacodynamic (PD) genomic 

panels. Pharmacokinetic genes affect the body’s 

absorption, distribution, metabolism, and elimination 

of medications. The cytochrome P450 (CYP) 

enzyme family is the major PK mechanism and the 

genetic information used to assess 

variations in drug metabolism is 

most often based on this gene family. 

Approximately 90% of all drugs are 

metabolized by just seven different 

cytochrome enzymes including 

CYP1A2, CYP3A4, CYP3A5, CYPC19, 

CYP2D6, CYP2C9 and CYP2B69. 

CYP2D6, for example, contributes 

to the metabolism of 25% of most 

commonly prescribed medications 

including psychiatric medications like tricyclic antidepressants, 

opioids and anti-psychotics. 

Aron Berhanie Abera 

CYP2D6 IS A HIGHLY POLYMORPHIC GENE 

WITH OVER 130 SINGLE NUCLEOTIDE 

POLYMORPHISMS (SNPS) AND INCLUDES 

INSERTIONS, DELETIONS, DUPLICATIONS 

AND FRAME SHIFT MUTATIONS. THESE 

GENETIC VARIATIONS LEAD TO DECREASED, 

INCREASED OR NON-FUNCTIONAL 

ENZYMATIC ACTIVITY IN THE INDIVIDUAL. 

Allelic variants are sometimes very broadly 

classified as poor metabolizers (PM), extensive 

metabolizers (EM), intermediate metabolizers (IM) 

and ultra-rapid metabolizers (UM) according to the 

pharmacokinetics. 


FEATURE 

Pharmacodynamic genes affect what the medication 

does to the body and alter the efficacy or side-effect 

profiles. A well-known example is the correlation 

between carbamazepine-induced Stevens–Johnson 

syndrome (SJS) and toxic epidermal necrolysis (TEN), 

and the HLA-B*1502 allele in some Asian populations. 

The correlation in some ethnicities is very high (odds 

ratio for developing carbamazepine-induced SJS/TEN 

if positive for HLA-B*1502 is 2504 in the Han Chinese). 

SJS or TEN conditions are life-threatening, which has 

led to the FDA recommendation that patients of 

Asian ancestry be assessed for this allele prior to the 

initiation of carbamazepine therapy. 

PHARMACOGENOMICS: SOME 

COMMON METHODOLOGIES 

There is an abundance of pharmacogenetic testing 

options. These vary in their validity, costs, positive and 

negative predictive values, turn-around-times and 

the clinical usefulness of the information. Selecting a 

particular methodology depends on what information 

is being sought. It is always advisable to discuss the 

options with the pathologist overseeing the assays, 

because the methodology is matched to the 

information required by the clinician. 

TRADITIONAL SANGER SEQUENCING 

Sanger sequencing is the ‘gold standard’ for 

detecting genetic variants. The method evaluates 

variations in PCR-amplified fragments with optimal 

sensitivity and specificity. While it has an excellent 

accuracy and reasonable read length it is unsuitable 

to study multiple targets. The technique involves 

DNA synthesis in the presence of chain-terminating 

inhibitors followed by capillary electrophoresis, 

hence the throughput can be time-consuming and 

labour intensive. The cost is generally very low and is 

ideal for examining a few genetic variants, especially 

when they are in close proximity to each other. 

REAL TIME PCR 

Real time PCR-based SNP genotyping assays allow 

the detection of single genetic polymorphisms that 

are associated with a particular drug metabolism 

phenotype. The assay is usually a single real time 

PCR reaction that discriminates alleles based on 

sequence-specific oligonucleotide probes that 

carry a fluorescent reporter dye for identification. 

The reaction either occurs or fails depending 

upon the allele being amplified. The assay is rapid 

(a few hours) but does not involve sequencing of 

a particular region. The assay is relatively cheap 

and there are several commercial pre-designed 

SNP genotyping assays from Roche, ThermoFisher, 

Applied Biosystems, and many others. 

NEXT GENERATION SEQUENCING 

(NGS) 

NGS refers to the large-scale DNA sequencing 

technology that follows a ‘sequencing-by-synthesis 

principle’ to generate data from the entire exome 

or genome. The advantage of NGS over sanger 

sequencing or single PCR assays, is the capacity 

for high throughput. NGS can generate millions to 

billions of nucleotide sequence data in a single 

experiment. It may, therefore, identify multiple 

variants in a single individual and is commonly 

used in the discovery of novel genetic variants 

that influence drug response. 

Due to the massive amounts of data generated, 

the skills required for analyses, the infrastructure 

and technology requirements, and the costs 

associated with these analyses can be 

prohibitive). 

THE SHEER SCALE OF THE DATA 

PRODUCED BY NGS IS FAR MORE THAN 

ROUTINE PATHOLOGISTS AND CLINICAL 

SCIENTISTS ARE EQUIPPED TO DEAL WITH. 

These sorts of assays, therefore, are usually more 

appropriate for research institutions. 

MATRIX-ASSISTED LASER DESORPTION/ 

IONIZATION TIME-OF-FLIGHT (MALDI- 

TOF) MASS SPECTROMETRY (MS) 

The MALDI-TOF MS technology is one of the 

methodologies that fills the gap between analyzing 

only a couple of variants by PCR or Sanger 

sequencing, and the huge amounts of data 

generated by NGS. This is clinically helpful, because 

clinicians often wish to have information concerning 

multiple variants (between five and several hundred), 

but not on the scale that NGS provides. Genetic 

variants are identified based on the differences in 

their molecular charge-mass ratios. PCR amplicons 

are generated that differ in their nucleotide 

sequences, which are identified by the time-of-flight 

of the molecules between two poles, rather than the 

sequencing of the fragments. 

The assay is as accurate and has the same positive 

and negative predictive values as the Sanger 

sequencing gold standard. The cost of the analysis 

is also comparable and there is currently at least 

one (Agena BioScience) commercially available 

product (Box 1). 

PHARMACOGENOMIC DATA 

In its most simplistic form, pharmacogenomic data 

are presented as the phenotype with the associated 

phenotype (for example, Table I). 

The patient’s genotype may be the allelic variant 

or a copy number variant and the corresponding 

phenotype listed as either poor, extensive or 

intermediate metabolizer of drugs. This, however, 

is only a very general approach and what is more 

typical is that the data are interpreted by the clinical 

scientist or pathologist with respect to a specific set 

of medications. 


FEATURE 

Table II provides an example of a recommended 

psychiatric drug prescription panel based on 

pharmacogenetic data. 

Phenotype 

Genotype 

Poor metabolizer CYP2D6*3–*8, *11,*16, *18– 

*21, *38, *40, *42, *44, *56, *62 

Extensive 

metabolizer 

Intermediate 

metabolizer 

CYP2D6*2, *17 x 2, *27, *35, *39, *48 

CYP2D6*10, *14, *17, *18, *36, *41, *47, 

*49 – 

*51, *54, *55, *57 

Table I Genotype-based phenotype classifications 

The traditional PGx nomenclature system describes 

each haplotype with a unique label comprising the 

name of the gene followed by the major (*) allele 

assignment based on the genetic variant identified. 

These haplotypes are then linked to a specific 

phenotype and can be categorized in several 

groups such as ‘Poor Metabolizer’ (PM), ‘Extensive 

Metabolizer’ (EM) or ‘Intermediate Metabolizer’ (IM) 

according to the enzyme’s functionality. The table 

illustrates the variant alleles and their classification 

for CYP2D6 variants. 

Used as 

directed 

Citalopram 

(Celexa) 

Desvenlafaxine 

(Pristiq) 

Escitalopram 

(Lexapro) 

Fluvoxamine 

(Luvox) 

Selegiline (Emsam) 

Sertraline (Zoloft) 

Use with 

caution 

Duloxetine 

(Cymbalta) 

Mirtazapine 

(Remeron) 

Trazodone 

(Desyrel) 

Use with great 

increased 

caution and 

with more 

frequent 

monitoring 

Amitriptyline 

(Elavil) 

Bupropion 

(Wellbutrin) 

Clomipramine 

(Anafranil) 

Desipramine 

(Norpramin) 

Fluoxetine (Prozac) 

Imipramine 

(Tofranil) 

Nortriptyline 

(Pamelor) 

Paroxetine (Paxil) 

Venlafaxine 

(Effexor) 

Table II Example of the recommended psychiatric drug usage 

An individual was identified with the genotype 

CYP2D6*4/*4 (poor metabolizer) and CYP2C19 

1/*1 (extensive metabolizer). The recommendations 

associated with this combined genotype are listed. 

ARE THE PHARMACOGENOMIC DATA 

APPLICABLE IN SA, AND ARE THEY 

APPROPRIATE FOR PSYCHIATRISTS 

WORKING IN SA? 

We return to the question posed at the beginning 

of this article. There is no doubt that an individual’s 

genetic makeup is key to creating personalized 

drugs with greater efficacy and safety. The 

pharmacogenomic data published by reputable 

scientists and institutions are, of course, subject 

to the same peer review standards as any other 

scientific analyses. 

THEY ARE APPLICABLE. THE MORE 

IMPORTANT QUESTION, HOWEVER, IS 

HOW APPROPRIATE THEY ARE TO THE 

SOUTH AFRICAN CONTEXT. THIS IS 

THE CRUX OF THE MATTER. AS THINGS 

STAND, THERE IS UNFORTUNATELY NO 

SATISFACTORY ANSWER EXCEPT FOR 

THE ONE: “IT DEPENDS”. 

For example, the environment, diet, age, lifestyle, 

and state of health may all influence a person’s 

response to medicines. These factors are, in many 

instances, not comparable to the regions where 

the data were generated. In addition, even at 

the genetic level, the way a person responds to 

a drug (this includes both positive and negative 

reactions) is a complex trait that is influenced 

by many different genes and not just the typical 

analyses provided by the pharmacogenomic 

data. The complexity of the genotype-phenotype 

map was discussed in a previous issue (“Evolution 

and the molecular basis of psychiatric illness” 

Issue 5, November 2015). A good example of 

this is the association between carbamazepineinduced 

SJS/TEN and the HLA-B*1502 genotype 

alluded to above. In the Han Chinese the 

correlation is extremely strong (OR=2504), but 

the same genotype is not correlated with SJS or 

TEN in other Asian populations. In black South 

Africans, there is a dearth of information, although 

research institutions like the SBIMB (Sydney Brenner 

Institute for Molecular Bioscience, University of the 

Witwatersrand), the Genomics Research Institute 

(University of Pretoria), and others have research 

programmes underway to address this gap in 

knowledge. 

AS WITH SO MANY ASPECTS OF HEALTH 

IN SA, DECISION-MAKING TRENDS DIFFER 

BETWEEN THE PRIVATE AND PUBLIC 

SECTORS. THESE DIFFERENCES MIRROR 

THE EXTREME INEQUALITY AMONG 

DIFFERENT POPULATION GROUPS IN SA. 

IN THE IDEAL SCENARIO, KNOWING THE 

INDIVIDUAL’S GENOTYPE IS SOMETIMES 

HELPFUL, BECAUSE IT MAY PROVIDE AN 

ADDITIONAL LAYER OF INFORMATION TO 

PATIENT MANAGEMENT. 

This is especially true if the individual is not responding 

as expected to a particular drug regimen. In other 

instances, there is simply not enough information 

and knowing an individual’s genotype may 

have no bearing whatsoever on current patient 

management. 


FEATURE 

CONCLUDING REMARKS AND 

RECOMMENDATIONS 

The most sensible path to follow seems that (i) 

where there are sufficient supporting data, (ii) these 

are applicable to the ethnicity of the person in 

question, and (iii) the information will impact patient 

management, then pharmacogenetic testing is 

appropriate. This is, of course, resource permitting. 

IN OTHER SCENARIOS WHERE THERE 

ARE INSUFFICIENT DATA, STANDARD 

CLINICAL JUDGEMENT IS WARRANTED. 

THIS SECOND SCENARIO IS CURRENTLY 

LIKELY TO BE THE PREVAILING ONE IN 

MOST SOUTH AFRICAN PATIENTS. 

PHARMACOGENETICS 

SOLUTIONS IN PSYCHIATRY 

bonosi genomics, a division of Inqaba 

Biotechnical Industries (Pty) Ltd, 

offers several human molecular 

genetic assays. 

BOX 1. The Agena MassARRAY iPLEX platform for SNP 

genotyping 

Following DNA extraction, the sample is subjected 

to targeted PCR amplification of several regions 

of CYP gene family. This is followed by primer 

extension with the iPLEX extension reaction. The 

extension products are desalted and dispensed 

onto a SpectroCHIP Array and detected via mass 

spectrometry using the MassARRAY technology 

(credit: Agena Biosciences). 

Cost-effective solution for 

pharmacogenetics (PGx) testing using 

the Agena MassARRAY system. The 

assay provides simultaneous testing 

of key pharmacogenetics variants and 

copy number variation analysis. 

Aron Berhanie Abera is currently employed as a technical 

support manager at Inqaba Biotechnical Industries (Pty) 

Ltd, Pretoria, South Africa. He runs the MassARRAY SNP 

genotyping platform at Inqaba Biotechnical Industries. 

Originally from Eritrea he completed his undergraduate 

study at University of Asmara, Eritrea, in 2001 and was 

awarded a scholarship to pursue postgraduate studies in 

South Africa. He completed a Master’s degree in Human 

Genetics, a Doctoral degree in Medical Biochemistry and 

five-years of postdoctoral research in the Department of 

Medical Biochemistry all through the University of Cape 

Town. Correspondence: aron.abera@inqababiotec. 

co.za 

Inqaba Biotechnical Industries (Pty) Ltd. 

PO Box 14356, Hatfield 0028 

Pretoria, South Africa 

Tel: +27 12 343 5829 

E-mail: orders@bonosigenomics.co.za 

www.inqababiotec.co.za 

TECHNICAL ENQUIRIES 

Dr AB Abera 

Technical Support Manager 

aron.abera@inqababiotec.co.za 

PATHOLOGY ENQUIRIES 

Dr PM Durand 

Consultant Molecular Pathologist 

pierre.durand@wits.ac.za 


Biological Psychiatry Congress 

2019 

‘The Changing Landscape of Psychiatry, Neuroscience and Technology’ 

FRIDAY 20 SEPTEMBER – MONDAY 23 SEPTEMBER, 

CENTURY CITY CONFERENCE CENTRE, CAPE TOWN, SOUTH AFRICA 

Abstract Submissions: 

http://biopsychsa.co.za/index.php/ 

abstracts-bio/abstract-submission 

The deadline for the submission of abstracts is 

20 April 2019 

Registrars and postgraduate students are specifically invited to present. 

OUTLINE OF PROGRAMME 

Friday 20 September 2019: 

10:00 – 11:00 Registration for morning workshops 

11:00 – 13:30 Workshops 

13:30 – 14:30 Lunch for all workshop delegates 

14:00 – 14:30 Registration for afternoon workshops 

14:30 – 17:00 Workshops 

17:00 – 21:00 Registration for congress opens 

17:15 – 17:45 Official opening of congress 

17:45 – 18:30 Keynote address 

18:30 – 20:30 Welcome Cocktail Function in exhibition area 

Saturday 21 September 2019: 

07:00 – 08:15 Trade sponsored breakfast symposia 

08:30 – 17:00 Scientific Sessions 

17:30 Trade sponsored dinner symposium 

Sunday 22 September 2019: 

07:00 – 08:15 Trade sponsored breakfast symposia 


19:00 Congress Dinner & Awards 

Monday 23 September 2019: 

07:00 – 08:15 Trade sponsored breakfast symposium 


11:00 – 11:15 Closing of congress 

FRIDAY 20 SEPTEMBER – MONDAY 23 SEPTEMBER, 

CENTURY CITY CONFERENCE CENTRE, CAPE TOWN, SOUTH AFRICA 

Register at: http://biopsychsa.co.za/index.php/registration/full-registration

Welcome to Vancouver 

14 th World Congress 

of Biological Psychiatry 

Neuroscience Discoveries and 

Translation to Clinical Practice 

2 – 6 June 2019 

Vancouver, Canada 

Vancouver Convention 

Centre East 

PLENARY SPEAKERS 

a Elizabeth Blackburn, USA 

a Leroy Hood, USA 

a George Koob, USA 

www.wfsbp-congress.org 

Organised by: World Federation of Societies of Biological Psychiatry 

Hosted by the Canadian Network for Mood and 

Anxiety Treatments (CANMAT)

FEATURE 


PERINATAL 

DEPRESSION 

Carina Marsay 

Perinatal depression can be defined as 

depression occurring any time from conception, 

including during pregnancy and into the first 

postpartum year. Rates of perinatal depression 

in high income countries (HIC) are reported at 

about 13% of all perinatal women, but there is a 

significantly higher rate of perinatal depression in 

low and middle income countries (LMICs), ranging 

from approximately 15 to 20% . Studies conducted 

in LMICs report higher prevalence rates as socially 

and economically disadvantaged women are 

more vulnerable to perinatal depression. 1,2 Maternal 

depression has serious consequences, resulting in 

significant morbidity and even mortality for both 

mothers and infants. 

PARTICULARLY IN LMICs, MOTHERS FACE 

PHYSICAL AND LOGISTICAL CHALLENGES, 

INCLUDING CARING FOR AN INFANT 

IN CONTEXTS OF POOR SANITATION, 

OVERCROWDING, FOOD INSECURITY, 

AND POOR SOCIAL SUPPORT. THESE 

DIFFICULTIES ARE COMPOUNDED FOR 

WOMEN WITH DEPRESSION, IN WHOM THE 

SYMPTOMS − INCLUDING ANHEDONIA, 

IMPAIRED COGNITION, LOW MOOD AND 

ENERGY LEVELS − IMPACT ON THEIR 

ABILITY TO CARE FOR THEIR INFANTS’ 

PHYSICAL AND EMOTIONAL NEEDS. 3 

The daily demands of early infant care are more 

difficult to negotiate when functioning is suboptimal 

as a result of depression. 4 As a result, infants and 

children of depressed mothers have poorer physical, 

cognitive and emotional outcomes. In these 

settings, poor maternal mental 

health during the antenatal period 

is a risk factor for low birth weight 

and preterm delivery. 5,6 Postnatally, 

malnutrition, poor infant growth, 

and increased frequency of infant 

diarrheal illness are prevalent, 

which may be related to the 

early cessation of breastfeeding 

in depressed mothers living in 

Carina Marsay 

poverty. 7 This can lead to an increase 

in child mortality. 8 The emotional development of 

infants is compromised because of a disturbed 

mother-infant relationship, where mothers are less 

sensitive towards their infants and infants are less 

responsive towards mothers. 9 This in turn leads to 

poorer quality attachment, resulting in behavioural 

and psychological difficulties that can last into 

adolescence and adulthood. 10 Compromised 

cognitive functioning and delayed development 

also affect infants and children of depressed mothers, 

impacting on their scholastic achievement. 11 In the 

context of chronic social and economic adversity, as 

experienced by poor women in both high and low to 

middle income countries, poor quality parenting as a 

result of maternal depression is especially harmful. 10 

These adverse outcomes further perpetuate social 

and economic inequality. 

Poverty and low-socioeconomic status affect more 

women numerically and as a proportion of a given 

population in low and middle income countries 

as compared to women in high income countries, 

making them vulnerable to depression. This is 

very clear in South Africa, where approximately 

40% of women living in relative poverty will 

experience perinatal depression -- three times the 

rate documented in high income countries. 12-14 

Historically significant racial and wealth disparities 


FEATURE 

in South Africa existed as a result of Apartheid, but 

these have yet to be redressed. The country still faces 

many social, political and economic challenges and 

is one of the most economically unequal countries 

in the world, with a Gini co-efficient of 0.7. 

THE TOP 10% OF THE POPULATION 

CONTRIBUTE (AND BENEFIT FROM) 

58% OF THE INCOME AND THE BOTTOM 

10% ONLY 0.5%. THIS IS RELEVANT AS 

ECONOMIC AND SOCIAL FACTORS 

CONTRIBUTE TO HEALTH EQUITY AND THE 

GENERAL HEALTH OF A SOCIETY. THIS 

IS SIGNIFICANT AS SOCIAL INJUSTICE 

IMPACTS NEGATIVELY ON HEALTH AND 

HEALTH EQUALITY. 15 THE HIGH RATES OF 

PERINATAL DEPRESSION MAY BE RELATED 

TO THE COMPOUNDING NATURE OF 

MULTIPLE ECONOMIC, SOCIAL AND 

PSYCHOSOCIAL STRESSORS. 

These including poverty and unemployment, 

intimate partner violence, lack of partner support, 

unplanned pregnancy, and the high prevalence 

of HIV in pregnant women (39-45%), including 

diagnosis of HIV infection in the course of antenatal 

care. 12,13,16-19 Similar associations have been found in 

other low and middle income countries. 

A SYSTEMATIC REVIEW CONDUCTED IN 

2012, INCLUDING VARIOUS COUNTRIES 

FROM BOTH ASIA AND AFRICA, 

FOUND THAT SOCIOECONOMIC 

DISADVANTAGE COMPRISING OF FOOD 

INSECURITY, FINANCIAL DIFFICULTIES, 

UNEMPLOYED PARTNER AND LOW 

INCOME WERE ASSOCIATED WITH 

PERINATAL DEPRESSION. 

In addition, social disadvantage comprising of 

poor emotional support and lack of empathy 

from partners, having hostile in-laws and having 

insufficient practical and emotional support, 

contributed to the risk of perinatal depression. 1 

From this, it is clear that maternal depression has 

multiple etiologies, and cannot be solely explained 

by women’s biological and psychological 

vulnerability. Rather, social and environmental 

factors are important contributing factors and 

determinants of risk and sociocultural context 

impacts both prevalence and presentation of 

perinatal depression. 20,21 

Recently there has been an increased awareness 

that mental health is a vital part of public health in 

South Africa. About 16.5% of South Africans suffer 

from common mental disorders. 22 In responding 

to this, most provincial health services support 

the integration of mental health in primary health 

care, run by primary health care nurses who have 

undergraduate training in mental health. These 

nurses are able to continue prescriptions while 

primary health care doctors initiate prescriptions 

with drugs available on the essential medicines list. 

Mental illness cannot be viewed in isolation, 

however, as many social, political and economic 

factors, including those elucidated above, play a 

role in epidemiology of the illness. In South Africa, 

the country’s high rate of mental health disorders, 

including perinatal depression, is exacerbated 

by high levels of violence, social and economic 

exclusion and racial discrimination, as existed 

under colonialism and apartheid, and as a result of 

apartheid’s continued legacy. 

ONE OF THE KEY OBJECTIVES OF SOUTH 

AFRICA’S MENTAL HEALTH CARE ACT 

2002 (NO. 17 OF 2002) IS TO INTEGRATE 

THE PROVISION OF MENTAL HEALTH 

CARE SERVICES INTO THE GENERAL 

HEALTH SERVICES ENVIRONMENT. 23 

THIS IS FURTHER SUPPORTED BY THE 

SUBSEQUENT NATIONAL MENTAL HEALTH 

POLICY FRAMEWORK AND STRATEGIC 

PLAN 2013-2020, 24 IN WHICH MATERNAL 

MENTAL HEALTH IS INCORPORATED 

INTO THE GENERAL MENTAL HEALTH 

ENVIRONMENT, INCLUDING THROUGH 

THE TREATMENT OF PERINATAL 

DEPRESSION AND ANXIETY AT ANTENATAL 

AND POSTNATAL CLINICS. 

The policy states: 

• Specified micro and community level mental 

health promotion and prevention intervention 

packages will be included in the core services 

provided, across a range of sectors, to address 

the particular psychosocial challenges and 

vulnerabilities associated with different lifespan 

developmental stages. These will include: 

Motherhood: treatment programmes for maternal 

mental health as part of the routine antenatal 

and postnatal care package; and programmes 

to reduce alcohol and substance use during and 

after pregnancy. Infancy and Early childhood: 

programmes to increase maternal sensitivity and 

infant-mother attachment. 

• Introduce routine indicated assessment and 

management of common mental disorders in 

priority programmes at PHC level, among others, 

antenatal mothers and postnatal care. 

In addition, the South African National Development 

Plan 2030 (2012) 25 makes specific reference to 

early childhood development by emphasizing the 

importance of the first 1000 days of life, describing 

how pregnant women need access to both 

emotional and material support, and explaining 


FEATURE 

that empowered mothers lay a solid foundation for 

healthy children. However, despite these policies, the 

establishment and provision of integrated mental 

health services into antenatal and postnatal clinics 

is non-existent in most areas. The Maternal Care 

Guidelines are also lacking in achieving these 

goals as they have no reference to screening, 

assessing or documenting current mental state nor 

recommendations regarding stepped referral for 

mental health care. 

SOUTH AFRICA HAS AN UNACCEPTABLY 

HIGH MATERNAL MORTALITY RATE OF 

269 PER 100 000 LIVE BIRTHS; OF THESE 

60% ARE AVOIDABLE IF EARLY ANTENATAL 

CARE IS SOUGHT. 26 ANTENATAL CARE IS 

FREE IN SOUTH AFRICA’S PUBLIC HEALTH 

SYSTEM AND 91% OF ALL PREGNANT 

WOMEN ATTEND AN ANTENATAL 

CLINIC AT LEAST ONCE DURING THEIR 

PREGNANCY. 26 ANTENATAL CARE IS AN 

OPPORTUNITY TO PROVIDE VITAL HEALTH 

INFORMATION TO WOMEN ON LIFESTYLE 

RISKS AND TO OFFER SOCIAL SUPPORT 

AND COUNSELING. 

Health promotion and screening can prevent the 

severe adverse effects of depression, including 

loss of quality of life and the risk of suicide and 

neonaticide in extreme cases. Given this, antenatal 

care may provide a good opportunity for health 

workers to intervene and offer screening and 

treatment for antenatal depression. This would be 

in line with the move to incorporate mental health 

services into primary health care. Preliminary 

evidence from a public obstetric facility in Cape 

Town suggests that it is feasible and acceptable 

to incorporate mental health screening and 

depression assessment, with referral, into antenatal 

clinics using a task-sharing approach. In another 

qualitative study conducted in Johannesburg, 

women found the screening process itself, to 

be helpful in building awareness and effecting 

behaviour change. 27 

HEALTH EQUITY SHOULD BE OUR AIM 

IN SOUTH AFRICA IN AN ATTEMPT TO 

ADDRESS HISTORICAL INEQUALITY. THIS 

CAN BE IMPROVED BY IMPLEMENTING 

UNIVERSAL SCREENING ON A NATIONAL 

LEVEL FOR COMMON MENTAL 

DISORDERS IN PERINATAL WOMEN. THE 

WHOOLEY CASE FINDING QUESTIONS 

ARE TWO CASE-FINDING QUESTIONS 

THAT REQUIRE ONLY A YES OR NO 

RESPONSE. THEY CAN IDENTIFY ANXIETY 

AND DEPRESSION WITH REASONABLE 

ACCURACY. 

They are short and do not require literacy, or scoring 

and interpretation like pencil and paper tests, and so 

are more time-effective. They have been validated in 

urban women attending a high-risk antenatal clinic 

in Johannesburg. 28 These two questions address 

symptoms of depression that are necessary but not 

sufficient to make a diagnosis of depression: “During 

the past month, have you often been bothered by 

feeling down, depressed or hopeless?” and “During 

the past month, have you often been bothered by 

little interest or pleasure in doing things?” 

A BRIEF AND VALIDATED SCREENING 

TOOL THAT CAN IDENTIFY DEPRESSION 

AND ANXIETY IN SOUTH AFRICAN 

PERINATAL WOMEN WOULD BE A 

VALUABLE ADDITION TO UPDATE THE 

ADULT PRIMARY CARE GUIDELINE AND 

FOR INCLUSION IN THE MATERNAL CARE 

GUIDELINES AND AMENDMENTS TO THE 

MATERNITY CASE RECORD (ANTENATAL 

CLINIC CARD). 

References 

1. Fisher J, Mello MCd, Patel V, Rahman A, Tran T, 

Holton S, et al. Prevalence and determinants of 

common perinatal mental disorders in women 

in low-and lower-middle-income countries: a 

systematic review. Bulletin of the World Health 

Organization. 2012;90(2):139-49. 

2. Witt WP, DeLeire T, Hagen EW, Wichmann MA, 

Wisk LE, Spear HA, et al. The prevalence and 

determinants of antepartum mental health 

problems among women in the USA: a nationally 

representative population-based study. Archives 

of Women’s Mental Health. 2010;13(5):425-37. 

3. Field T. Postpartum depression effects on early 

interactions, parenting, and safety practices: 

A review. Infant Behavior and Development. 

2010;33(1):1-6. 

4. Parsons CE, Young KS, Rochat TJ, Kringelbach 

ML, Stein A. Postnatal depression and its effects 

on child development: a review of evidence 

from low-and middle-income countries. British 

Medical Bulletin. 2012;101(1):57. 

5. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar 

S, Katon WJ. A meta-analysis of depression 

during pregnancy and the risk of preterm 

birth, low birth weight, and intrauterine growth 

restriction. Archives of General Psychiatry. 

2010;67(10):1012-24. 

6. Field T, Diego M, Hernandez-Reif M. Prenatal 

depression effects on the fetus and newborn: 

a review. Infant Behavior and Development. 

2006;29(3):445-55. 


FEATURE 

7. Stewart RC. Maternal depression and infant 

growth–a review of recent evidence. Maternal & 

child nutrition. 2007;3(2):94-107. 

8. Deyessa N, Berhane Y, Emmelin M, Ellsberg 

MC, Kullgren G, Högberg U. Joint effect of 

maternal depression and intimate partner 

violence on increased risk of child death in 

rural Ethiopia. Archives of Disease in Childhood. 

2010;95(10):771-5. 

9. Cooper PJ, Tomlinson M, Swartz L, Woolgar M, 

Murray L, Molteno C. Post-partum depression 

and the mother-infant relationship in a South 

African peri-urban settlement. The British Journal 

of Psychiatry. 1999;175(6):554-8. 

10. Stein A, Pearson RM, Goodman SH, Rapa E, 

Rahman A, McCallum M, et al. Effects of perinatal 

mental disorders on the fetus and child. The 

Lancet. 2014;384(9956):1800-19. 

11. Murray L, Arteche A, Fearon P, Halligan S, 

Croudace T, Cooper P. The effects of maternal 

postnatal depression and child sex on 

academic performance at age 16 years: a 

developmental approach. Journal of Child 

Psychology and Psychiatry. 2010;51(10):1150-9. 

12. Hartley M, Tomlinson M, Greco E, Comulada WS, 

Stewart J, Le Roux I, et al. Depressed mood in 

pregnancy: prevalence and correlates in two 

Cape Town peri-urban settlements. Reprod 

Health. 2011;8(9). 

13. Manikkam L, Burns JK. Antenatal depression and 

its risk factors: An urban prevalence study in 

KwaZulu-Natal. South African Medical Journal. 

2012;102(12):940-4. 

14. Rochat TJ, Tomlinson M, Bärnighausen T, Newell 

M-L, Stein A. The prevalence and clinical 

presentation of antenatal depression in rural 

South Africa. Journal of affective disorders. 

2011;135(1):362-73. 

15. Marmot M, Friel S, Bell R, Houweling TA, Taylor S, 

Commission on Social Determinants of Health. 

Closing the gap in a generation: health equity 

through action on the social determinants of 

health. The lancet. 2008 Nov 8;372(9650):1661-9. 

16. Health Systems Trust. “ HIV prevalance % 

antenatal.” Health Statistics. 2013 [cited 2016 

June].Available from: http://www.healthlink. 

org.za/healthstats/13/data 

17. Davies TS, M; Nyatsanza, M; Lund, C. “The sun 

has set even though t is morning”: Experiences 

and explanatins of perinatal depression in 

an urban township, Cape Town. Transcultural 

Psychiatry.53(3):286-312. 

18. Kathree T, Selohilwe OM, Bhana A, Petersen I. 

Perceptions of postnatal depression and health 

care needs in a South African sample: the 

“mental” in maternal health care. BMC Women’s 

Health. 2014;14(1):140. 

19. Mathews S, Abrahams N, Martin LJ, Vetten L, 

Van Der Merwe L, Jewkes R. A national study 

of female homicide in South Africa. CiteSeeer. 

2004. 

20. Chen Y-Y, Subramanian S, Acevedo-Garcia 

D, Kawachi I. Women’s status and depressive 

symptoms: a multilevel analysis. Social Science 

& Medicine. 2005;60(1):49-60. 

21. Patel V, Lund C, Hatherill S, Plagerson S, Corrigall 

J, Funk M, et al. Mental disorders: equity and 

social determinants. Equity, social determinants 

and public health programmes. 2010;115. 

22. Herman AA, Stein DJ, Seedat S, Heeringa SG, 

Moomal H, Williams DR. The South African Stress 

and Health (SASH) study: 12-month and lifetime 

prevalence of common mental disorders. SAMJ: 

South African Medical Journal. 2009;99(5):339- 

44. 

23. Mental Health Care Act (No17 of 2002), (2002). 

24. National Department of Health. National 

mental health policy framework and strategic 

plan 2013-2020. Government Printer Pretoria; 

2012 

25. National Planning Commission. National 

Development Plan 2030: Our future–make it 

work. Pretoria: National Planning Commission. 

2012. 

26. Amnesty International. Struggle for maternal 

health: barriers to antenatal care in South Africa. 

London 2014. [cited 2017 November] Avaiable 

from: https://www.health-e.org.za/wp-content/ 

uploads/2014/10/Struggle-for-Maternal-Heath-. 

pdf 

27. Marsay C, Manderson L, Subramaney U. 

Changes in mood after screening for antenatal 

anxiety and depression. Journal of reproductive 

and infant psychology. 2018 Mar 30:1-6. 

28. Marsay C, Manderson L, Subramaney U. 

Validation of the Whooley questions for 

antenatal depression and anxiety among lowincome 

women in urban South Africa. South 

African Journal of Psychiatry. 2017;23(1). 

Carina Marsay is a specialist psychiatrist. She obtained her FC Psych (SA) in 2009 and her MMed (Psych) in 2010. Dr Marsay has a 

PhD from the University of Witwatersrand related to her work in perinatal psychiatry and is an honorary appointee in the Department 

of Psychiatry at Wits. She is a recipient of the MRC Clinician Researcher Programme Scholarship. Dr Marsay has an interest in perinatal 

psychiatry and is a member of the International Marcé Society, an organisation dedicated to perinatal mental health. Correspondence: 

carinamarsay@gmail.com 


NEWS 

VISITING PROFESSOR – SEMINAR 

Christopher Paul Szabo, in his capacity as a 

Visiting Professor at the University of Belgrade’s 

School of Medicine and at the invitation of 

the Serbian Psychiatric Association and the 

Institute for Psychiatry in Belgrade, presented 

a seminar on eating disorders to specialist 

trainees on the 12 th February 2019 

Prof. Szabo – right, front row - with trainees 

Adj Prof. Ugash Subramaney has been 

appointed as the new Academic Head as 

of the 1 st March 2019 (until 28 th February 

2024), succeeding Prof. Christopher Paul 

Szabo who served from 1 st November 2009 

until 28 th February 2019 

GRADUATIONS – PHD / DSc: DECEMBER 

2018 

Carina Marsay was awarded her PhD for her work on 

perinatal mental health and Christopher Paul Szabo a DSc 

for his work related to eating disorders 

ASSISTANT HEAD OF SCHOOL – 

NEW APPOINTMENT 

Ass Prof. Bernard Janse van Rensburg has 

been appointed as an Assistant Head of 

School in the School of Clinical Medicine as 

of the 1 st March 2019 

Carina Marsay, Christopher Paul Szabo 


NEWS 

TRIBUTE TO PROF BONGANI MAYOSI 

The HOD, Prof Dan Stein, paid tribute to the memory of Prof Bongani Mayosi, following his tragic suicide. 

Prof Mayosi represented many values that the Department and University hold dear, including mentorship, 

comradeship, and a true passion for knowledge. 

We owe Prof Mayosi’s family a huge debt of gratitude for immediately speaking about his depression. This has 

raised the awareness of the profession and the country of the importance of common mental disorders, and 

gives us hope for the future. 

Prof Mayosi, amongst his many contributions, advocated for more PhDs in South Africa, as well as increased 

specialty and sub-specialty training, within the context of the primary health care approach. 

WELCOME TO STAFF 

Dr Bhaskaran Charles as a Senior Registrar in Liaison Psychiatry. 

Dr Kokes Moloto as Psychiatrist Consultant in Male Admissions at Lentegeur hospital. 

Dr Nisaar Dawood as Community Psychiatrist at Mitchells Plain hospital 

GOODBYE TO GRAEME HENDRICKS 

The Division of Psychotherapy bade farewell to Clinical 

Psychologist Graeme Hendricks on 4 December. The 

Department thanked him for his invaluable contributions to 

the Addictions diploma and teaching and wished him well on 

his adventures abroad 

CONGRATULATIONS 

Congratulations to Nyameka 

Dyakalashe on passing 

the Certificate in Forensic 

Psychiatry. 

Prof Sean Kaliski is also 

congratulated for initiating 

this degree, a first in Africa 

and a key step forwards for 

the discipline. 

Fleur Howells has been 

Nyameka Dyakalashe 

promoted to Associate 

Professor, reflecting her 

significant contributions to translational 

neuroscience. 

Nastassja Koen has been promoted to Senior 

Lecturer. She has made significant contributions 

in psychiatric genetics with ongoing grants and 

work in epigenetics, particularly as related to 

psychological trauma. 

Simone Honikman has been promoted to 

Associate Professor, reflecting her significant 

contributions to perinatal mental health. 

Prof Dan Stein congratulated the following people 

on their respective academic achievements: 

Goodman Sibeko, John-Joe Dawson-Squibb, 

Tania Swart, Erica Breuer (thesis about theory 

of change in the context of the work of the 

Division of Public Mental Health on PRIME), 

Jean-Paul Fouche (thesis on brain imaging in 

adolescent HIV/AIDS), Stephanie Sieberhagen 

and Memory Munodawafa (thesis on “Filling 

the gap: development and qualitative process 

evaluation of a task sharing psycho-social 

counselling intervention for perinatal depression 

in Khayelitsha, South Africa”) for obtaining their 

PHDs. 

To Aubrey Kumm and Marisa Viljoen for obtaining 

their M Med (Neuroscience) degrees. 

To Judith Boshe, Jessica Stanbridge, John-Randal 

Vermaak Carmen Vlotman, Michelle Barnard, 

Nizaar Dawood, Nada Lagerstrom and Mwanja 

Chundu for passing their FCPsych (SA) Part II 

exams. 

To Deidre Pieterse for obtaining her M Phil in 

Liaison Psychiatry and Lisa Dannatt for obtaining 

her M Phil in Addictions1 Psychiatry. 

To Deirdre Pieterse and all those who contribute 

to the mentoring of interns; the HPCSA visited in 

July, and after speaking with interns about their 

experience in Psychiatry, gave the department a 

5/5 assessment. 

Thanks also to Peter Ashman who long led the 

internship program in the department 


NEWS 

ADDICTION PSYCHIATRY - NEW HEAD 

OF DIVISION 

By Dan Stein 

A vote of thanks is given to key staff members of the 

Division of Addiction Psychiatry, namely Don Wilson 

as the first Head, Sharon Kleintjes as its first SFARS 

lecturer, Henk Temmingh succeeding Don Wilson, 

Graeme Hendricks SFARS, Lisa Dannatt and Bronwyn 

Myers, who have all contributed in strengthening the 

Division. 

CHILD AND ADOLESCENT PSYCHIATRY 

AND MENTAL HEALTH DCAP 

WORKSHOPS ON ODD 

By Willem de Jager 

Goodman Sibeko (SFARS, Director of the Addictions 

Training and Technology Centre), is succeeding 

Henk Temmingh as the new head of the Division, 

while the latter will continue as Deputy Head. 

Goodman and Henk are thanked for taking on their 

important portfolios 

EQUINE-ASSISTED PSYCHOTHERAPY 

The Forensic Unit at Valkenberg Hospital conducted 

an equine-assisted psychotherapy program for state 

patients for the past four years. The unit looks forward 

to continue with this innovative therapy in 2019 and 

beyond 

Two DCAP Psychologists, Jon Yako and Willem de 

Jager, organised a two-part workshop, respectively 

in November 2017 and October 2018, to assist 

clinicians and health workers in addressing the 

increase in referrals to Child and Adolescent Mental 

Health Services (CAMHS) 

GENERAL ADULT PSYCHIATRY - EARLY INTERVENTION, SUPPORT AND HEALTH – EISH! 

By Naaheeda Allie 

“EISH”, an outpatient program run by the Valkenberg Hospital Outpatient Department aims to assist mental 

health service users, and their families, who are in the earlier stages of severe mental illness, to come to terms 

with the condition. 

It shifts the focus of healthcare provision from a traditional biomedical perspective of wellness to a more holistic 

approach to wellness. 

INTELLECTUAL DISABILITY - SYMPOSIUM 

ON CHANGING THE PARADIGM TO 

ENABLE PARTICIPATION AND MEANINGFUL 

LIVES FOR PWID 

By Toni Abrahams 

At a symposium on 2 nd October 2018, the Division of 

Intellectual Disability co-convened a one-day seminar 

with UCT’s Division of Disability Studies, hosting a 

delegation from the American Association of Intellectual 

and Developmental Disabilities (ASIDD). 

The theme “Changing the paradigm: Enabling 

Participation and meaningful lives for people with 

Intellectual Disability” was highlighted through 

presentations from a wide array of stakeholders, 

including self-advocates and caregivers, NGO’s, health 

practitioners, managers and academics. 

Prof Sharon Kleintjes, Judith McKenzie and Colleen 

Adnams chaired the sessions. It was an inspiring 

symposium and one could not end the day without 

feeling re-energised to work towards actualising the 

mantras “leave no one behind” and “nothing about us, 

without us” 


NEWS 

NEUROPSYCHIATRY - TAKING INVENTORY ON 2018, HIV 

MENTAL HEALTH RESEARCH UNIT 

By Sybil Majokweni and Kareema Poggenpoel 

The HIV Mental Health Research Unit (HIVMHRU) achieved its goal in 2018 to 

foster more collaboration and enlarge its footprint in HIV and mental health 

research. 

New members were welcomed to the team while two study start-ups were 

initiated, namely The Inkumbulo study which was started in 2018. The aims are 

to investigate sex differences in HIV-associated neurocognitive impairment and 

the factors contributing to possible sex differences, as well as determining the 

relationship between depression, HIV-associated neurocognitive impairment 

and adherence to anti-retroviral therapy. 

The second study, a Hybrid Effectiveness-Implementation Trial for ART 

Adherence and Substance Use in HIV Care in South Africa, better known as 

Project Khanya, started in August 2018 

EXPANDING OUR FOOTPRINT 

By Sam Nightingale and Kareema Poggenpoel 

Sam Nightingale, a neurologist from the 

UK, joined Prof John Joska in the Division 

of Neuropsychiatry. Sam is expanding his 

footprint in the department as he has recently 

been awarded a large grant from the Newton 

Fund. The venture will run a collaborative South 

Africa – UK project looking at cognition and 

neuropsychiatric symptoms in people living with 

HIV before and after switching from efavirenz to 

dolutegravir 

CPMH COMMEMORATES WORLD 

MENTAL HEALTH DAY WITH 

ROUNDTABLE DISCUSSION 

By Maggie Marx 

To commemorate World Mental Health Day, 

10 October 2018, the Alan J Flisher Centre for 

Public Mental Health (CPMH) and the Social 

Responsiveness Committee of UCT’s Division of 

Public Mental Health, arranged a roundtable 

discussion (event partly sponsored by the latter 

committee). 

PUBLIC AND COMMUNITY MENTAL HEALTH 

PRIME PRESENTS FINDINGS AROUND THE 

WORLD 

By Maggie Marx 

Over the last few months, led from the Alan J Flisher the 

Centre for Public Mental Health (CPMH) at the University of 

Cape Town, the Programme for Improving Mental Health 

Care (PRIME) saw its researchers busily disseminating 

their findings across the globe. 

This is, amongst other events, underscored by the fact 

that PRIME researchers, including UCT’s Prof Crick 

Lund, formed part of the Lancet Global Mental Health 

Commission which recently launched its report on World 

Mental Health Day at the Global Ministerial Mental Health 

Summit 

Three researchers, namely Dr Jason Bantjes, Dr 

Tara Carney and Dr Sarah Skeen, were invited 

to present on their work relating to this year’s 

theme: “Young People Mental Health in a 

Changing World.” 

Ms Bonnie Mbuli concluded the event by 

speaking candidly about her journey with 

clinical depression and anxiety 


NEWS 

THE PERINATAL MENTAL HEALTH PROJECT’S (PMHP) NEW 

OPEN ACCESS RESOURCES 

By Sally Field and Simone Honikman 

The PMHP www.pmhp.za.org, located in the Alan J Flisher Centre for Public 

Mental Health, has been involved in developing three open access resources. 

The PMHP team produced a short training film “Empathic Engagement 

Skills”. Feedback from audience (psychiatrists, psychologists, NGO workers) 

attending the Malawi launch of the African Alliance for Maternal Mental 

Health, demonstrated that the film was relevant and appropriate for the 

Malawian setting. 

Together with Digital Medic South Africa, an initiative of the Stanford University Center for Health Education 

and “Grow Great” at the DG Murray Trust, the PMHP developed an animated film aimed at mothers and 

community level service providers in low-resource settings. All training videos are openly accessible on the 

PMHP YouTube channel 

ARTISTIC MURAL TO CHANGE NEGATIVE PERCEPTION OF MENTAL HEALTH 

By John Parker 

In an exciting collaboration, the Spring Foundation recently partnered with Arting Health For Impact (AFHI), a 

collaborative public engagement project that explores collaboration with artists to improve and engagement 

methods. 

The project involved 25 in- and outpatients from the Child and Adolescent Mental Health Service. It aimed to 

develop a collective understanding of participants experiences during their health journey. 

The mural was completed by experienced and professional muralists during a Mental Health Engagement 

Event and focused on relaying messages of support, recovery and hope. The completed mural would be visible 

by the community via Highlands Drive 


NEWS 

DRIVING THE LEGACY 

By Marina Lawrence (for the DCHS Social 

Responsiveness Team) 

On 18 th July 2018, we celebrated Mandela’s 100th 

birthday, and the Mandela Foundation encouraged us 

to live the legacy. UCT’s Drakenstein Child Health Study 

(DCHS) Social Responsiveness team partnered with 

local and international organizations to facilitate the 

construction of a library at an under-resourced school 

in Mbekweni, Paarl. 

The DCHS also partnered with the Val de Vie Foundation, 

Breadline Africa, Solomon Schechter Day School (USA), 

Biblionef, and West End United Methodist Church (USA) 

to construct and stock a library at Langabuya Primary 

School in Mbekweni. 

Learners now have access to books written in their 

home language, as well as in English, which provides an 

opportunity for reading and literacy skills development 

and potential improvement on long-term educational 

outcomes 

HEALING CHOCOLATES 

By John Parker 

In a beautiful collaboration, Chocolate Time and the Spring Foundation took students to the Peter Clarke Art 

Centre on a journey of self-discovery that involved thinking about mental illness and how this is dealt with in our 

society. Students were then challenged to produce designs for chocolate wrappers that reflected what they 

had learnt. 

The winning designs have been used to produce wrappers for a range of chocolates that will be sold to raise 

funds for the Spring Foundation. The beautiful artworks were exhibited to the public at Lentegeur Hospital’s 

adolescent unit and UCT Faculty of Health Sciences 

THE VOICE PROJECT / SOCIAL 

RESPONSIVENESS 

Valkenberg hosted a Voice Workshop which was 

arranged by the South African Society of Psychiatrists 

Western Cape Subgroup on 24 th July. 

The establishment of the social responsiveness 

committee within the UCT Psychiatry and Mental 

Health Department is a major achievement. 

This forum will be a platform for re-envisioning mental 

health in South Africa and questioning traditional 

methods of mental health service delivery which 

has compromised access. 

The years ahead are likely to be challenging and 

contentious. The question is not so much about 

whether the state has the will to address mental 

health services but rather – do we? And to what 

end? 

Left to right: ,Karessa Govender, John Parker and Mafoko Phomane who facilitated 

The Voice Workshop hosted by Valkenberg and arranged by the South African 

Society of Psychiatrists Western Cape Subgroup on 24 th July. 


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UPDATE 

SENSORY ROOM 

CALMING 

FOR THOSE WITH DEMENTIA WHO 

ARE SUFFERING FROM ANXIETY 

A 

dementia care facility in Johannesburg has 

developed a ‘sensory room’, an innovative 

new international concept in the care of 

people with dementia, where light, textures, 

movement, sound and décor are used to create a 

calming, familiar and comforting environment. 

“THE IDEA BEHIND THE SENSORY 

ROOM IS TO CREATE A SPACE WHERE 

ENVIRONMENTAL FACTORS CAN BE 

CAREFULLY CONTROLLED IN ORDER TO 

ACHIEVE A CALMING EFFECT FOR THE 

INDIVIDUAL WITH DEMENTIA WHO MAY 

BE FEELING ANXIOUS OR OVERWHELMED, 

WHICH IS UNFORTUNATELY A RELATIVELY 

COMMON SYMPTOM OF MORE 

ADVANCED DEMENTIA,” EXPLAINS 

IVAN OOSTHUIZEN, CHIEF EXECUTIVE 

OFFICER OF THE LIVEWELL VILLAGES IN 

BRYANSTON AND SOMERSET WEST. 

“The considerable benefits of sensory rooms for 

people with dementia, which is characterised 

by symptoms such as progressive memory loss, 

have been demonstrated by some of the most 

pioneering dementia care services and practitioners 

internationally,” points out Oosthuizen. 

“Their experience has shown that for those with 

more advanced levels of dementia and Alzheimer’s, 

many of whom can suffer bouts of bewilderment 

and severe anxiety, a sensory room can greatly 

assist in relieving stress and create a sense of 

comfort and well-being. As stress commonly has a 

negative impact on memory, this form of therapeutic 

activity can therefore also often meaningfully assist 

in supporting the individual’s memory.” 

According to Oosthuizen, Livewell Villages is a 

dementia care service that is constantly monitoring 

the latest dementia care approaches and trends 

globally in order to provide leading-edge care 

to residents and those who are making use of its 

respite care services. Impressed by the sensory 

room concept, which was proving of therapeutic 

benefit for many people abroad, the team decided 

to investigate the possibility of developing its own 

sensory room at its Johannesburg care facility. 

“After research and consultations with appropriate 

experts, we were able to develop a sensory room 

that we believe is ideally suited to local conditions, 

as well as completely adaptable to meet the needs 

and varying requirements of each our residents with 

dementia. 

“THE LIVEWELL TEAM IS IMMENSELY 

PROUD OF THE RESULT, WHICH TO THE 

BEST OF OUR KNOWLEDGE IS THE FIRST 

FACILITY OF ITS KIND IN SOUTH AFRICA, 

AND AN EXPRESSION OF OUR HIGHLY 

INNOVATIVE APPROACH TO CARING 

FOR PEOPLE WITH DEMENTIA. WE ARE, 

HOWEVER, PARTICULARLY GRATIFIED TO 

HAVE BEEN ABLE TO CREATE A PLACE 

WHERE THOSE IN OUR CARE CAN SPEND 

MANY TRANQUIL AND HAPPY HOURS.” 


UPDATE 

Corlia Schutte, occupational therapist at the 

Livewell Village in Bryanston, says that it is essential 

in dementia care to ensure that the person is 

adequately stimulated according to their individual 

and constantly evolving needs, but at the same time 

they should not feel overwhelmed by an overload of 

sensory information. 

“THE SENSORY ROOM IS PROVING 

POPULAR FOR THOSE RESIDENTS WHO 

REQUIRE A PEACEFUL RETREAT AFTER AN 

EXCITING DAY OF ACTIVITIES, OR WHO 

ENJOY A RICH SENSORY EXPERIENCE 

THAT PLEASANTLY STIMULATES THEM. IT 

IS ALSO MOST USEFUL IN THOSE CASES 

WHERE THE INDIVIDUAL MAY FEEL 

FRETFUL AND DISORIENTATED, WHICH 

QUITE COMMONLY OCCURS IN PEOPLE 

WITH DEMENTIA.” 

She says the team meticulously records which 

aspects of the room a particular person with 

dementia engages with, and what affects this has 

on their mood and behaviour. “This is enabling us 

to build up a very useful record that helps us to 

enhance the room and the experience it creates for 

our residents. 

WE CAN ALSO USE THIS INFORMATION TO 

TAILOR AND ADAPT THE ENVIRONMENT 

TO SUIT THE INDIVIDUAL’S MOOD AND 

PREFERENCES AT A PARTICULAR TIME.” 

The muted lighting in the room is accented with 

softly glowing coloured lights, and a soundtrack of 

melodious classical music incorporating natural 

sounds of birdsong, ocean waves and running water 

create a sense of serenity in the room. A soothing 

scent of lavender aromatherapy oil permeates the 

air – an aroma that is known for its relaxing qualities 

for many people, according to Schutte. 

Drapery on the ceiling creates the feeling of a 

sheltered, cosy womb-like environment, which is also 

aesthetically pleasing, while comfortable antique 

rocking chairs and ottomans, textiles of various 

textures and cool, pale blue green painted walls 

are familiar and evocative of peace and safety. 

She notes that the sensation of gently rocking in 

a rocking chair is particularly comforting for some 

people with advanced dementia. 

An array of old-fashioned toys, weighted cuddly toys 

and dolls are available in the room for people to 

hold. “The sensation of cradling a weighted doll is 

especially comforting for many of our residents and 

we have noted that it often serves to reduce feelings 

of agitation or stress. It is believed that certain people 

with dementia are drawn to such items because 

they replicate similar feelings to that of a parent 

caring for a baby. 

“Some of our residents are moved to caress and 

hum to a doll as a mother will comfort her infant, and 

this can be a welcome distraction if the person has 

become upset, as it replaces this emotion with more 

positive feelings of love and protective, nurturing 

instincts,” observes Schutte. 

“IN DIFFERENT MOODS, THE SAME 

RESIDENT MAY FIND DIFFERENT ASPECTS 

OF THE EXPERIENCE OF THE SENSORY 

ROOM ENTICING. A CERTAIN RESIDENT 

MAY BE FEELING LOW ONE DAY, AND WE 

BRING THEM TO THE SENSORY ROOM 

AND NOTICE THAT THEY CONCENTRATE 

DEEPLY ON THE MUSIC, BECOME MORE 

SUBDUED, AND LATER APPEAR TO BE 

MORE UPLIFTED AFTER SPENDING TIME 

THERE. IN ANOTHER MOOD, THE SAME 

RESIDENT MAY STROKE THE SOFT FABRICS 

AND HANDLE THE TOYS, AND BE LULLED 

INTO A CALMER MOOD.” 

She says that at other times, the Livewell team may 

find the person is not inclined to spend time in the 

room and may prefer to rather be out and about 

in the garden watching the birds or picking flowers, 

and this is also encouraged. 

“While people with dementia may not always be 

able to express what they feel like doing, we are so 

sensitive to their non-verbal cues that we can usually 

tell whether they are in the mood for a particular 

activity or environment at a given time, and can 

make adjustments for their comfort accordingly.” 

“The Sensory Room at Livewell Villages in Bryanston 

is proving to be an invaluable tool that is not only 

assisting in providing residents with appropriate 

levels of stimulation, but is also helping many to deal 

with their feelings of agitation and promoting an 

improved sense of wellbeing. While these benefits 

may seem somewhat intangible, we as carers can 

observe the very real difference this facility is making 

to the lives of many of our residents,” concludes 

Schutte. 

For more information about the Livewell Villages and the 

services available, please visit: https://livewell.care/ 

Issued by Martina Nicholson Associates (MNA) on behalf of Livewell Villages Correspondence:martina@mnapr.co.za 


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REPORT 

T H I R D 

NATIONAL PUBLIC 

MENTAL HEALTH 

F O R U M 

( P M H F ) 

Richard J. Nichol 

This forum took place on the 21 st of September 

2018 at the conference venue of the Council 

of Scientific and Industrial Research (CSIR) in 

Pretoria. It was organized by the Department 

of Psychiatry, School of Health Sciences, of the 

University of the Free State (UFS) in collaboration 

with the Psychiatry Department of the School of 

Health Sciences of the University of Pretoria (UP). 

MORE THAN TWENTY PSYCHIATRY 

REGISTRARS IN THEIR THIRD YEAR FROM 

ALL THE MEDICAL SCHOOLS IN SOUTH 

AFRICA, WERE INVITED TO ATTEND THE 

FORUM WHICH INTERFACED WITH THE 

19 TH NATIONAL CONGRESS OF THE SOUTH 

AFRICAN SOCIETY OF PSYCHIATRISTS 

HELD AT THE SAME VENUE. A NUMBER 

OF HIGHLIGHTS OF THIS FORUM ARE 

PRESENTED. 

During his opening address Prof Christopher 

Paul Szabo (Academic Head – University of the 

Witwatersrand) alluded to the theme of the forum: 

Public Mental Health; Here, there and everywhere. 

He thanked the sponsors of the forum, Mr. Greg 

Sinovich on behalf of Sanofi Pharmaceuticals, 

SASOP and the Colleges of Medicine of South 

Africa (Psychiatry). Prof Szabo continued with a 

presentation ‘Introduction to Public Mental Health’. 

He related how the first PMHF came 

into being in 2015 after he realised 

that most psychiatric curricula 

of the various medical schools 

in South Africa lacked adequate 

teaching on Public Mental Health. 

Subsequently the second PMHF 

took place in 2017 in Stellenbosch. 

Dr Andre Rose, a consultant in Richard J. Nichol 

Community Medicine and currently 

the Chairman of the Public Health Association of 

South Africa (PHASA), discussed Mental Health 

Economics. (The world population was estimated to 

be 7,7 billion people in December 2018). Quoting 

WHO statistics, published in 2018 he informed 

the audience of the numbers of people affected 

globally (Table I). 

Table I: Burden of mental illness: 

Disease 

Depression 

Anxiety Disorders 

Bipolar affective disorders 

Dementia 

Schizophrenia and other 

psychoses 

Source: WHO, 2018 

Number of people 

affected globally 

300 million 

275 million 

60 million 

50 million 

23 million 


REPORT 

THIRD NATIONAL PMHF 

The 2016 Institute for Health Metrics and Evaluation, 

(IHME) statistics concerning ‘the prevalence by 

mental and substance use disorder’ internationally, 

are noted in Table II. 

Table II: Share of the population with a given mental 

health or substance use disorder in 2016 

Disorder 

Prevalence 

Anxiety Disorders 3.83 % 

Depression 3.77% 

Alcohol Use Disorders 1.37% 

Drug Use Disorders 0,85% 

Bipolar Disorder 0.61% 

Schizophrenia 0.29 % 

Eating Disorders 0.14% 

Source: http://ghdx.healthdata.org/gbd-results-tool. 

THE FIGURES ATTEMPT TO PROVIDE 

A TRUE ESTIMATE OF THE FINDINGS, 

GOING BEYOND REPORTED DIAGNOSIS, 

OF DISORDER BASED ON MEDICAL, 

EPIDEMIOLOGICAL DATA SURVEYS 

AND MET-REGRESSION MODELLING. 

DR. ROSE WENT ON TO EXPLAIN THAT IN 

2014 A PERSON HAVING DEPRESSION 

AND ANXIETY FACED A REDUCTION 

OF PERSONAL INCOME OF $ 4798, 

(PER ADULT ANNUALLY) RESULTING IN 

A $3.6 BILLION ANNUAL NATIONAL 

LOSS IN SOUTH AFRICA. IN CONTRAST 

A NIGERIAN STUDY ESTIMATED THE 

NATIONAL LOSS TO BE $166.2 MILLION 

ANNUALLY. THE ANNUAL PRODUCTIVITY 

LOSS IN KENYA WAS $453 MILLION. IN 

GHANA PSYCHOLOGICAL STRESS WAS 

ASSOCIATED WITH A 6.8% LOSS IN GDP. 

A consultant in Psychiatry at the University of Pretoria, 

Dr Funeka Sokudela, discussed the role of stigma in 

mental health. She highlighted the fact that many 

Mental Health Care Users are still being discriminated 

against for a number of reasons including their 

mental illnesses, gender, ethnic background and 

sexual orientation. She stressed the importance of 

psychiatrists taking responsibility for combating this 

stigma. 

Dr Lesley Robertson, a community psychiatrist 

affiliated to the University of the Witwatersrand, 

discussed studies related to the Global Burden of 

Disease and their relevance to mental health in 

South Africa (see Feature article in this issue). 

Dr Michelle Nel of the Department of Psychiatry at 

the University of the Free State addressed the topic 

“The Mental Health of Refugees”. The population of 

our world is over 7,7 billion people of which tens of 

millions have been forced to flee their homes due to 

violent conflict. 

THE OFFICE OF THE UNITED NATIONS HIGH 

COMMISSIONER FOR REFUGEES (UNHC) 

CLAIMS THE WORLD IS CURRENTLY 

FACING ONE OF THE HIGHEST LEVELS 

OF DISPLACEMENT EVER IN HISTORY. 

ACCORDING TO UN STATISTICS, AN 

UNPRECEDENTED 65.3 MILLION PEOPLE 

HAVE BEEN FORCED FROM THEIR HOMES 

BY WAR, INTERNAL CONFLICTS, DROUGHT 

OR POOR ECONOMICS. AMONG THESE 

ARE 21.3 MILLION REFUGEES, OVER HALF 

OF WHOM ARE UNDER THE AGE OF 18; 

THE REST ARE ECONOMIC MIGRANTS 

AND INTERNALLY DISPLACED PERSONS. 

THE MENTAL CONDITIONS FACING 

REFUGEES INCLUDE MAJOR DEPRESSION, 

POST-TRAUMATIC STRESS DISORDER, 

ADJUSTMENT DISORDERS, ANXIETY 

DISORDERS, PSYCHOTIC DISORDERS 

AND GRIEF AND BEREAVEMENT. THERE 

IS COMPELLING EVIDENCE THAT 

SCHIZOPHRENIA AND OTHER PSYCHOTIC 

DISORDERS ARE MORE PREVALENT 

AMONGST REFUGEES RESETTLED IN 

HIGH-INCOME COUNTRIES, COMPARED 

TO OTHER IMMIGRANTS AND HOST 

POPULATIONS. 

Dr Carla Kotze, consultant in Psychiatry at the 

University of Pretoria concluded the forum by 

thanking all the speakers and everyone who made 

it possible. It is anticipated that the Public Mental 

Health Forum for senior registrars will continue 

annually or at least bi-annually in future. 

Richard J. Nichol is an Associate Professor and a Principal Specialist (Head: Childand Adolescent Psychiatry) in the Department 

of Psychiatry, University of the Free State, Bloemfontein, South Africa.Correspondence: NicholR@fshealth.gov.za 


REPORT 

FEEDBACK FROM 

THE ROYAL COLLEGE 

OF PSYCHIATRISTS 

INTERNATIONAL CONFERENCE, 

JUNE 2018: 

‘NEW HORIZONS’ 

Lesley Robertson 

I 

represented the South African Society of 

Psychiatrists (SASOP) at the Royal College 

of Psychiatrists (RCPsych) 2018 international 

conference. A “tripartite” agreement exists 

between the South African College of Psychiatrists, 

the SASOP, and the RCPsych. Unlike South Africa, 

where the College is responsible for conducting 

national examinations and the SASOP furthers other 

objectives of the profession, the RCPsych combines 

both functions in one organisation. 

WITH ITS MISSION STATEMENT OF 

“IMPROVING THE LIVES OF PEOPLE 

WITH MENTAL ILLNESS”, THE RCPSYCH 

IS GOVERNED BY A BOARD OF TEN 

TRUSTEES, WHICH INCLUDES THREE LAY 

PEOPLE. AT PRESENT THE LAY TRUSTEES 

INCLUDE A RETIRED BUSINESSMAN, A 

LAWYER AND A PERSON WITH EXPERIENCE 

AS A NON-EXECUTIVE DIRECTOR AND IN 

STRATEGIC MANAGEMENT. 

The Board is supported and advised by the Council, 

which has overall responsibility for education and 

training, policy, professional practice, professional 

standards, public engagement, quality improvement 

and research. A far larger body, the Council includes 

a patient and a carer representative as well as four 

members of the Board, academic and divisional 

representatives. 

The theme of the congress was 

“New Horizons”, and the first 

new horizon discussed was the 

prospect of a new Mental Health 

Act, to be aligned with the United 

Nations Convention on the Rights 

of Persons with Disabilities (CRPD). 

Baroness Hale, the president of 

the supreme court, outlined the 

complexities around the comment Lesley Robertson 

on article 12 of the CRPD, legal 

capacity, involuntary mental health care and 

insanity defence. The difficulties she raised were like 

those raised by Freeman et al (2015), 1 and are highly 

relevant to South Africa, also signatory to the CRPD. 

I BELIEVE WE COULD GAIN BY CLOSELY 

WATCHING THE PROCESSES FOLLOWED 

BY THE UK IN DRAFTING THEIR NEW 

LEGISLATION. 

In view of the Essential Medicines List, I opted to 

attend presentations by the British Association 

of Psychopharmacology (BAP), which publishes 

evidence-informed treatment guidelines. They 

presented on the management of the aggressive 

patient, on schizophrenia, and on the use of valproate. 

Their approach differs from the NICE guidelines 

in their inclusion of observational studies. Of note, 

RCTs may not recruit severely ill people, leading to 

small effect sizes and a lack of generalisability. So, to 

inform the BAP guidelines, observational studies with 


REPORT 

hard, patient-oriented outcomes (e.g. readmission 

or repeat offending) may be upgraded, and RCTs 

downgraded, for strength of evidence. Their updated 

schizophrenia guidelines should be published soon. 

I ATTENDED AN NHS TRUST AUDIT OF 

PSYCHIATRIC CARE, SOMETHING 

WHICH, IN THEORY AT LEAST, NHI WOULD 

INTRODUCE IN SOUTH AFRICA. THE AUDIT 

WAS MAINLY AROUND PRESCRIBING 

PATTERNS; REFLECTING ON THE VARYING 

PROPORTIONS OF MEDICINES USED AND 

CHANGES OVER TIME. THERE WAS SOME 

DISCUSSION AROUND THE PRESENCE 

OF AND PRESCRIBING FOR PHYSICAL 

COMORBIDITIES. HOWEVER, THERE 

WAS LITTLE RELATION OF PRESCRIBING 

PATTERNS TO CARE OUTCOMES. THIS I 

THINK MAY BE RELATED TO A GLOBAL 

UNCERTAINTY REGARDING OUTCOME 

MEASURES IN PSYCHIATRIC CARE, BUT 

NEVERTHELESS IT RENDERS A CLINICAL 

AUDIT SOMEWHAT LACKING IN MEANING. 

PHYSICAL HEALTH IN PEOPLE WITH 

SEVERE MENTAL ILLNESS ALSO FEATURED 

IN A SESSION IN WHICH RESULTS OF THE 

HOME, STEPWISE AND PRIMROSE TRIALS 

WERE PRESENTED. THESE TRIALS ARE 

WELL WORTH LOOKING OUT FOR AND 

WILL PROBABLY REINFORCE THE NEED 

FOR HEALTH SYSTEMS WHICH PROMOTE 

COLLABORATIVE AND INTEGRATED 

CARE. 

Deinstitutionalisation also featured, with symposiums 

on residential facilities and community-based 

mental health care. Although highly pertinent to 

South Africa, I was unfortunately unable to attend 

these. I did however speak to members of the 

National Collaborating Centre for Mental Health, the 

organisation presenting on community psychiatry. 

Interestingly, they are having to re-examine their 

mental health system as those with severe illness 

are falling through the cracks. This was evident in the 

numbers of homeless people in both London and 

Birmingham, some of whom were clearly unwell. With 

a comprehensive welfare system and ample shelters 

in the cities, it’s possible that mental illness and 

personality factors perpetuate the homelessness. 

One of the plenary sessions was given by a journalist, 

Sathnam Sanghera, author of “The Boy with the Top 

Knot and Marriage Material”. He spoke of how, in his 

early twenties, he realised his father and sister had 

schizophrenia. 

HE TERMED SCHIZOPHRENIA AS THE 

LEPROSY OF TODAY AND DESCRIBED 

GREAT DIFFICULTY IN ACCESSING 

APPROPRIATE CARE FOR HIS FATHER 

WITHIN THE NATIONAL HEALTH SYSTEM, 

WHICH HE FELT NEGLECTED SEVERE 

MENTAL ILLNESS EXCEPT DURING 

PERIODS OF AGGRESSION. 

His words of wisdom conveyed caution regarding: 

• awareness campaigns which have inadvertently 

led to the prioritisation of mild to moderate 

common mental illness; 

• a recovery orientated approach which may 

cause false expectations and a sense of 

personal failure among people with severe 

illness and their carers; 

• the reluctance to use the risk of violence as a 

lobbying tool for better mental health services 

and preventative care. 

A meeting of the RCPsych Africa Division included 

representatives from Kenya and Ghana. Discussion 

revolved mainly around UK training opportunities 

for psychiatry registrars. At the gala dinner, I had the 

pleasure of meeting Dr Altha Stewart, the APA chair, 

who remembered all the South Africans she had 

met at the APA congress in May. 

I SAT WITH THE RCPSYCH TREASURER AND 

ONE OF THE LAY TRUSTEES, AND LEARNT 

MORE ABOUT THE RCPSYCH, AND OF THE 

GAPS IN MENTAL HEALTH CARE IN THE 

UK, WHICH ARE VERY SIMILAR TO MANY 

OF OUR ISSUES. 

Overall, the congress was excellent and very 

enlightening. I am grateful to my SASOP colleagues 

for the sponsorship. Among all the lessons I learnt is 

the certainty that we will also become, in the words 

of Professor Sir Simon Wessely of the RCPsych for 

the UK, the “calm, trusted, and authoritative voice in 

mental health” for South Africa. 

REFERENCE: 

1. Freeman MC, Kolappa K, de Almeida JM, 

Kleinman A, Makhashvili N, Phakathi S, et al. 

Reversing hard won victories in the name 

of human rights: a critique of the General 

Comment on Article 12 of the UN Convention 

on the Rights of Persons with Disabilities. Lancet 

Psychiatry. 2015;2(9):844-50. 

Lesley Robertson is a community psychiatrist working in the Sedibeng District and is jointly appointed in the Department of 

Psychiatry, University of the Witwatersrand, Johannesburg, South Africa. Correspondence: Lesley.Robertson@wits.ac.za 


REPORT 

CELLULAR 

NEUROSCIENCE 

OF PSYCHIATRIC 

DISORDERS 

Tanya Calvey 

On the 23 rd of November, 2018, the Wits 

Cortex Club hosted two prominent 

neuroscientists (Profs. Harry Steinbusch 

and Marie-Ève Tremblay) to address 

the Wits Faculty of Health Sciences on cellular 

mechanisms involved in various psychiatric 

disorders. The lunch time seminar took place in 

the Adler Museum of Medicine and was funded 

by the National Research Foundation and the Wits 

Department of Psychiatry. 

Marie-Ève Tremblay is an Associate Professor of 

Molecular Medicine at Université Laval, Québec, 

Canada. Her research focuses on elucidating the 

roles of microglia in the loss of synapses, which 

is one of the best pathological correlates of 

cognitive decline across chronic stress, aging, and 

neurodegenerative diseases. 

Her seminar ‘Dark microglia across contexts of health 

and disease’ uncovered the recent characterization 

by her laboratory of an ultra-structurally distinct 

microglial subtype that is predominantly associated 

with pathological states. These cells are rare in 

steady state conditions, but become prevalent 

upon chronic stress, aging, and Alzheimer’s disease 

pathology, where they account for two-thirds of the 

normal microglial population. They exhibit several 

signs of cellular stress including a condensed, 

electron-dense cytoplasm and nucleoplasm giving 

them a ‘dark’ appearance in electron microscopy, 

accompanied by endoplasmic reticulum dilation, 

mitochondrial alterations, and a loss of nuclear 

heterochromatin pattern. The physiological 

significance of these dark 

microglia has yet to be elucidated 

but they appear extremely active, 

frequently reaching for synaptic 

clefts, while extensively encircling 

axon terminals, dendritic spines, 

and excitatory synapses with their 

highly ramified and extremely thin 

processes. In addition, her recent 

work revealed the occurrence 

Tanya Calvey 

of these dark microglia in a 

schizophrenia mouse model induced by a prenatal 

immunological challenge, as well as in early 

postnatal brain development, two conditions where 

synaptic pruning is exacerbated. 

THESE FINDINGS INDICATE THAT DARK 

MICROGLIA COULD REPRESENT A SUBSET 

OF CELLS THAT BECOME STRESSED 

AS A RESULT OF THEIR HYPERACTIVE 

INVOLVEMENT WITH THE REMODELING 

OF NEURONAL CIRCUITS ACROSS 

DEVELOPMENT, PLASTICITY, AND DISEASE. 

Prof. Harry Steinbusch is appointed as Professor in 

Cellular Neuroscience, chairman of the Department 

of Translational Neuroscience, past-director of the 

School for Mental Health and Neuroscience, current 

Director of the European Graduate School for 

Neuroscience at Maastricht University and President 

of the Neurotoxicity Society. He is the founding editor of 

the Journal of Chemical Neuroanatomy. His research 


REPORT 

is focused on neurodevelopmental influences 

towards depression and neurodegenerative 

diseases studied in animal models. 

His seminar was on ‘Brainstem Dysfunction in 

Neuropsychiatric Disorders’ such as Alzheimer’s 

Disease, Parkinson’s Disease and depression. 

Despite the fundamental role of the brainstem in 

regulating vital functional abilities such as arousal, 

breathing, autonomic nervous system activity as 

well as regulating all higher cerebral functions via 

neurotransmitter projection systems originating in 

the brainstem, the role of the brainstem has received 

relatively little attention in most neuropsychiatric 

disorders. His seminar reviewed the neuroanatomy 

of the brainstem as well as the current status on 

findings, derived from a wide range of studies using 

molecular, cellular and imaging technologies, of 

brainstem involvement in neurodevelopmental (i.e. 

autism, schizophrenia) and neurodegenerative 

disorders (Alzheimer’s and Parkinson’s disease). 

Besides the dorsal and median raphe nuclei 

complexes comprising mainly of serotoninproducing 

neurons, the brainstem also contains 

noradrenalin, dopamine and histamine-producing 

nuclei, i.e. the locus coeruleus, the substantia 

nigra and the mamillary bodies respectively. The 

brainstem is furthermore the relay station of afferent 

and efferent projections between the autonomic 

nervous system in the peripheral body and higher 

cerebral brain regions. 

Over the past decades, the incidence of agerelated, 

neurological and psychiatric disorders such 

as Alzheimer’s disease, Parkinson’s disease, but 

also depression has increased considerably. Mood 

disorders are strongly related to exposure to stress. 

THE HIPPOCAMPUS AND OTHER 

FOREBRAIN STRUCTURES ARE THE 

APEX OF STRESS HORMONE CONTROL 

MECHANISMS AND DAMAGE TO THEM 

MAY BE ONE WAY IN WHICH STRESS 

HORMONE SECRETION ESCAPES FROM 

INHIBITORY CONTROL IN DEPRESSION. 

In turn, stress, probably through toxic effects of 

glucocorticoids, decreases neurogenesis and 

cell survival while antidepressants enhance these 

processes in experimental animals. Therefore, 

since treatment strategies are not yet available, 

primary prevention in these age-related and stressrelated 

neurological disorders is of importance. 

As mentioned before most of the focus on 

neurobiological questions on the above mentioned 

diseases are related to forebrain structures since 

they are often associated with cognitive dysfunction. 

The brainstem is a highly neglected brain area in 

neurodegenerative diseases, including Alzheimer’s 

and Parkinson’s disease and frontotemporal lobar 

degeneration. Likewise, despite a long-standing 

recognition of brainstem involvement, relatively few 

studies have addressed the exact mechanisms that 

underlie brainstem autonomic dysfunction. Improved 

insight in the cellular and molecular characteristics of 

brainstem function is pivotal to study developmental 

origins. In the area of depression, several observations 

have been made in relation to changes in one 

particular brain structure: the dorsal raphe nucleus. 

In addition, dysfunction of the cerebellum is also 

observed in Alzheimer’s disease and associated with 

pulmonary deregulation. The dorsal raphe nucleus 

is also involved in the circuit of stress regulated 

processes and cognitive events. In order to gain 

more information about the underlying mechanisms 

that may govern neurodegeneration, e.g. amyloid 

plaques, neurofibrillary tangles, and impaired 

synaptic transmission in Alzheimer’s disease, a rat 

dissociation culture model was established by Prof 

Steinbusch and his colleagues that allows mimicking 

of certain aspects of autopsy findings. They observed 

a similar phenomenon in brains from patients 

suffering from neurodegenerative disease since this 

also related to changes in brain derived neurotropic 

factor (BDNF) levels. The ascending projections and 

multi-transmitter nature of the dorsal raphe nucleus 

in particular and the brainstem in general stress its 

role as a key target for research into Alzheimer’s and 

Parkinson’s disease and autonomic dysfunction. 

It also points towards the increased importance 

and focus of the brainstem as a key area in various 

neurodevelopmental and age-related diseases. 

Prof Steinbusch taking questions from the audience. 

Profs. Steinbusch and Tremblay with Wits Cortex Club members, students and staff 

members. 

Tanya Calvey has a background in evolutionary neurobiology and lectures morphological anatomy in the Faculty of Health 

Sciences, University of the Witwatersrand. Tanya studies the neuropsychopharmacology of SUDs in humans and animals. 

Her research team is multidisciplinary and her research is funded by the South African Medical Research Council, the 

National Research Foundation and the International Society for Neurochemistry. Tanya is also actively involved in developing 

neuroscience research in Africa. She is the Secretary of the Southern African Neuroscience Society and the co-founder of the 

Wits Cortex Club. Correspondence: Tanya.Calvey@wits.ac.za 


10 

“How beautifully 

leaves grow old. 

How full of light 

and colour are 

their last days.”

UPDATE 

MAINTAINING YOUR PATIENCE 

AND COMPASSION 

FOR YOUR LOVED ONE 

WITH DEMENTIA 

People with more advanced dementia, 

which is associated with symptoms such as 

progressive memory loss, may lack the ‘social 

filters’ that keep most of us from honestly 

expressing what we really think out of politeness for 

other people. 

This was noted by Corlia Schutte, an occupational 

therapist who works with residents at Livewell Villages 

in Bryanston, Johannesburg, which places a focus 

on providing the highest levels of care to people 

with dementia. She points out that many people 

with advanced dementia become less inhibited, 

lose a sense of social norms and may consequently 

express themselves rather more candidly than is 

generally considered acceptable. 

“There is certainly no intention to be hurtful to others, 

this is just one of the effects that can be associated 

with more advanced dementia and cognitive 

decline. Nevertheless, this kind of behaviour may 

be challenging to families who care for people 

with dementia and Alzheimer’s within the home 

environment,” adds Schutte. 

She says that the experienced and trained staff 

at Livewell Villages, a pioneer in dementia care in 

South Africa with care facilities in Bryanston and 

Somerset West in Cape Town, understand and 

have learned not to take offence at some of their 

residents’ eccentricities or idiosyncrasies, and often 

very forthright observations. 

THESE CAN, HOWEVER, SOMETIMES BE 

HURTFUL FOR FAMILY MEMBERS AND 

CAREGIVERS WHO ARE LOOKING AFTER 

PEOPLE WITH DEMENTIA, AND WHO MAY 

NOT UNDERSTAND THE CHANGES THAT ARE 

OCCURRING IN THEIR LOVED ONE. 

“It can be easy for anyone who is taking care of a 

person with dementia to forget that their loved one 

is suffering from memory loss and other cognitive 

problems, and assume that they are just being 

difficult. After all it can be extremely challenging 

to come to terms with the fact that their parent or 

grandparent may now be saying hurtful things that 

they would never have said before the onset of 

dementia. 

“If you can stay aware of the fact that they may be 

having problems associated with dementia, and 

keep in mind that their behaviour does not have the 

purpose of being insensitive and hurtful, however, it 

can assist you to avoid losing your patience with the 

individual concerned.” 

DEMENTIA IS A GROUP OF SYMPTOMS 

THAT CAN OCCUR DUE TO A VARIETY 

OF POSSIBLE UNDERLYING MEDICAL 

CONDITIONS AND, BESIDES MEMORY 

LOSS, MAY RESULT IN A NUMBER OF OTHER 

SYMPTOMS SUCH AS IMPAIRMENTS IN 

REASONING, COMMUNICATION, AND 

FOCUS. 

Schutte says that if a loved one with advanced 

dementia starts to behave inappropriately or 

say insensitive things, it can be useful to try to 

establish what may be causing the behaviour. It 

may, for example, be that something within their 

environment, such as loud music; a noisy, busy 

environment; hunger; tiredness; or even a need 

for the toilet may be causing the reaction. It may 

even be that the person is in pain or is experiencing 

some form of discomfort. By understanding the 

reasons for the behaviour, it can be meaningfully 

addressed. 


UPDATE 

“ALSO REMEMBER THAT IF YOU ARE GOING 

ON AN EXCURSION, OR TAKING A FEW DAYS 

HOLIDAY, THAT WHILE YOU AND THE FAMILY 

MAY BE EXCITED ABOUT IT, THE PERSON 

WITH DEMENTIA CAN EASILY BECOME 

BEWILDERED AND ANXIOUS WHEN THEY 

ARE OUT OF THEIR ROUTINE AND FAMILIAR 

ENVIRONMENT,” SHE ADVISES. 

According to Schutte, it can also be helpful to honestly 

explain the causes of any unusual behaviour in their 

loved one to other family members, particularly 

younger ones, so that they can understand it and 

be better equipped to deal with it. 

Beatrice Masiiwa, office supervisor: administration 

at the Livewell Village in Bryanston says that before 

joining Livewell Villages, she worked in the hospitality 

industry and didn’t know much about dementia at 

first. 

“However, we all receive on the job training and 

have ongoing formal monthly training sessions. It 

was challenging at first, but with some experience 

I got to know the particular requirements of our 

residents,” she adds. 

BEATRICE AND A RESIDENT, MRS L, SHARE A 

PASSION FOR FASHION. MRS L IS EXTREMELY, 

SOME MIGHT SAY ‘BRUTALLY’, HONEST, 

ACCORDING TO MASIIWA. “IF SHE DOESN’T 

LIKE YOUR NEW HAIRSTYLE, SHE WILL TELL YOU 

SO IN NO UNCERTAIN TERMS. I FIND THIS A 

REFRESHING CHANGE, HOWEVER, BECAUSE 

MOST PEOPLE WILL BE LESS HONEST OUT 

OF POLITENESS, BUT WHEN MRS L SAYS SHE 

LIKES SOMETHING YOU CAN BE SURE THAT 

SHE SINCERELY APPROVES,” SHE EXPLAINS. 

“Working with people with dementia is very rewarding, 

although you need to have a heart and a sense of 

humour. You need to learn not to take offence or you 

can easily have your feelings bruised. We spend so 

much time with the residents that we become like 

family, and we have the same understanding for 

them that we have for our own grandparents.” 

Schutte says that loneliness and boredom are 

common problems affecting elderly people in 

society, and the sense of isolation this creates is often 

strongly associated with depression. “This is why we 

place particular importance on ensuring that at 

Livewell, every resident has company, whether they 

are spontaneously drawn to participate, or whether 

they prefer spending time with their companions 

and carers. 

As for Mrs L, Masiiwa says she cannot help but be 

in awe of this woman who has a seemingly innate 

sense of style and elegance. “Other than our shared 

love of fashion, we have a strong human connection 

that I find very meaningful. Although she may not 

express it in so many words, I have a good idea that 

she feels the same.” 

Leaders in dementia care in South Africa, Livewell 

Villages in Bryanston and Somerset West host free 

monthly support groups where people can get 

advice and assistance from its teams, as well as 

obtain the support of others who are facing similar 

challenges. Those who may in some or other way be 

impacted by the condition are invited to join them at 

one of these sessions. 

“Caring for a loved one with dementia or Alzheimer’s 

can be immensely trying but also most rewarding. 

It can help if you can try to keep in mind that their 

memory loss is not their fault and try to understand 

their experience. If you can do this, it can assist you 

to be more patient with them and treat them with 

the compassion they need. By showing your care 

and love for them, you are able to make them feel 

safer,” concludes Schutte. 

Issued by Martina Nicholson Associates (MNA) on behalf of Livewell Villages Correspondence:martina@mnapr.co.za 


UPDATE 

SOUTH AFRICA WOULD DO WELL TO FOLLOW 

UK BUSINESS 

LEADERS CALL 

TO GIVE MENTAL HEALTH ISSUES 

GREATER RECOGNITION 

With the growing awareness of mental 

health issues, and increasing 

acceptance of their impact on 

individuals, their families and employers, 

Oxford Healthcare Retreat believes South Africa 

should follow a recent appeal made by some of 

the UK’s biggest employers, who are calling for 

changes in the law to give mental health the same 

status as physical health at work. 

According to Julia Halstead-Cleak, a clinical 

psychologist and founder of the retreat, a wellness 

guesthouse offering integrated stress relief and 

health management, while there has been a definite 

increase in the acceptance of mental health 

issues, there remains a very strong stigma about 

recognising and addressing mental health issues in 

the workplace. 

“THERE IS A HUGE NEED FOR MENTAL 

HEALTH TREATMENT, ESPECIALLY AT 

EXECUTIVE LEVEL, WHICH IS OUR 

FOCUS. WE LIVE IN AN INCREASINGLY 

PRESSURED ENVIRONMENT, WHERE 

THE COMBINATION OF SECURITY 

ISSUES, POLITICAL AND ECONOMIC 

UNCERTAINTIES, GENERAL STABILITY, 

FINANCIAL PRESSURES, RETRENCHMENTS 

AND THE INCREASING DEMANDS FOR 

PROFITS ARE CREATING THE PERFECT 

STORM RESULTING IN PEOPLE HOLDING 

A LOT OF STRESS,” SHE SAYS. 

“It is concerning that so many people still find 

themselves unable to speak to their colleagues or 

bosses about the impact that work is having on their 

wellbeing and even more worrying that they feel 

unable to ask for time off when they need it.” 

Oxford Healthcare Centre, the sister facility to Oxford 

Healthcare Retreat, has seen a definite increase in 

executives seeking holistic treatment which was a 

key factor in the establishment of the retreat earlier 

this year. 

“Even though there is a decline in the stigma of 

mental illness, more and more high-functioning 

individuals are feeling overwhelmed, stressed and 

fatigued by the demands of everyday life,” says 


UPDATE 

Theresa Partington, a clinical psychologist based 

at Oxford Healthcare Retreat who has specialised 

in the business sector providing group facilitation 

and counsel for difficulties such as psychological 

stress and burnout, change management and 

interpersonal dynamics. She says this is further 

exacerbated by people often dismissing their own 

self-care and health maintenance until they can no 

longer cope and reach burnout. 

This was the primary reason for the establishment of 

Oxford Healthcare Retreat which places emphasis 

on seeking help before the onset of mental illness. 

STRESS, AS AN EXAMPLE, LEADS TO 

ANXIETY AND EXHAUSTION WHICH 

IF UNTREATED, CAN PROGRESS TO 

PHYSICAL ILL HEALTH WHERE INDIVIDUALS 

EXPERIENCE DROPS IN ENERGY LEVELS, 

LACK OF SLEEP, A DECREASE IN SOCIAL 

ENGAGEMENT, A NEGATIVE IMPACT ON 

HOME AND PERSONAL RELATIONSHIPS 

AND COGNITIVE IMPAIRMENT SYMPTOMS 

SUCH AS A DECLINE IN THINKING AND THE 

ABILITY TO FOCUS OR CONCENTRATE, 

ALL OF WHICH CAN ULTIMATELY LEAD TO 

A BREAKDOWN. 

“This is when we see most people seeking treatment, 

but the ideal is to recognise the symptoms and 

address them sooner rather than later. Greater 

acceptance of mental health issues may see a 

reversal of this – the more corporates recognise it as 

a valid and real health issue, so will employees feel 

less stigmatised about seeking treatment,” Halstead- 

Cleak says. 

A SURVEY CONDUCTED IN 2017 BY 

THE SOUTH AFRICAN DEPRESSION AND 

ANXIETY GROUP (SADAG) REVEALED 

THAT ONLY ONE IN SIX EMPLOYEES WITH 

MENTAL ILLNESS FELT COMFORTABLE 

DISCLOSING THEIR CONDITION TO THEIR 

MANAGER. IN THE SAME YEAR, FINANCIAL 

MAIL REPORTED THAT MENTAL HEALTH 

PROBLEMS COST THE SOUTH AFRICAN 

ECONOMY BILLIONS PER YEAR, WITH 

LOSS OF EARNINGS DUE TO MAJOR 

DEPRESSION AND ANXIETY DISORDERS 

ESTIMATED AT R54,121 PER AFFECTED 

ADULT PER YEAR AND AMOUNTING TO 

OVER R40 BILLION IN TOTAL ANNUAL 

COST TO OUR ECONOMY. 

Further, mental health problems cost the economy 

two to six times the cost of its treatment, yet the 

government spends only 5% of its health budget on 

mental health. 

“While early identification of mental issues is key, 

there are effective and proven strategies to minimise 

and manage stress and its impact, especially at 

executive level. Within the workplace, managers 

should be better trained to deal with these issues 

and should be given the tools to support staff who 

are suffering. Businesses should prioritise overall wellbeing, 

defined as a combination of physical, mental, 

and spiritual health and should encourage staff at 

all levels to reduce stigma by speaking out about 

the risks of mental illness,” Halstead-Cleak concludes. 

Julia Halstead-Cleak 

ABOUT OXFORD HEALTHCARE RETREAT 

Johannesburg-based Oxford Healthcare Retreat 

is a new, exclusive boutique wellness guesthouse 

which focuses on stress relief and management. It 

holistically treats burnout and the implications of 

chronic, unmanaged stress. The retreat has been 

developed by a team of accredited medical 

professionals to provide meaningful and effective 

strategies to enhance the overall sense of wellbeing. 

The experienced team of psychologists, 

physiotherapists, medical doctors, yoga and 

mindfulness practitioners work collectively to address 

the intertwined relationship between psychological 

and physical health. Find out more at https://www. 

oxfordhealthcareretreat.co.za/ 

It is the sister facility to the Oxford Healthcare 

Centre, founded in 2015 and based in Saxonwold, 

Johannesburg, which is a facility dedicated to mental 

wellness. It houses several psychiatrists, clinical 

psychologists, a dietician and an occupational 

therapist together with a day clinic that offers day 

programmes for adolescents and adults. 

Issued by Kalsey Windsor Correspondence: kalsey@ggisa.com 


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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 

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PERSPECTIVE 

THE IMPACT 

OF CLINICAL EXPOSURE 

Kajal Patel 

Tara is a public sector specialized psychiatric 

hospital that renders inpatient as well as 

outpatient services to adults and children 

with serious mental illnesses. The hospital 

is home to an Eating Disorders and Adolescent 

Unit (wards 1 & 2), a Psychotherapy Unit (wards 4 

& 5), Biological wards (6-8), a Child Unit (ward 9), 

outpatient services, Lufuno Neuropsychiatric Centre 

and HIV Clinic. The learning opportunities in this type 

of specialized hospital are endless. Each ward has 

a unique experience to offer, with patients from all 

walks of life. 

PSYCHIATRY HAS ALWAYS BEEN AN 

EXTREMELY INTERESTING FIELD FOR ME. 

IT’S VERY DIFFERENT FROM ALL OTHER 

SPHERES OF MEDICINE. IT DEALS WITH THE 

MIND INSTEAD OF THE BRAIN. OUR MINDS 

ARE INCREDIBLY COMPLEX, AS ARE OUR 

SOCIAL AND CULTURAL INTERACTIONS. 

In medicine, doctors can usually treat cases of 

asthma, chest pain or pulmonary oedema. Surgeons 

might do one knee replacement after the other 

until they, themselves retire or collapse. In Psychiatry, 

however, there can be no factory line, no standard 

procedure and no mindless protocol: each patient 

has something unique to return to the psychiatrist. 

Mental illnesses in our society, generally, are bagged 

with stigma and non-acceptance as well as 

indifference and alienation. Patients diagnosed with 

schizophrenia are pariahs and patients with Major 

Depression are weak or lazy. No one really takes 

the time to educate themselves about what these 

illnesses are and how they affect the patients’ lives. 

I chose psychiatry because I wanted to know more 

about mental illnesses, how people are affected 

and what is being done to help these people. I 

can now correct and change people’s unjustified, 

preconceived ideas about what they perceive as 

mental illness. 

The Life Healthcare Esidimeni scandal crushed my 

heart. 143 deaths later, I realized how important it is 

to protect these patients and take care of them. It 

should never have taken such a tragedy to awaken 

South Africa. A special Sunday Times investigation 1 

revealed that a third of all South Africans have 

mental illnesses and 75% of them 

will not get any type of help. Despite 

this high number, the Department 

of Health annually spends 4% or 

R9.3 billion of its budget to address 

the crisis. It still makes me curious 

as to why people don’t take mental 

illness seriously. 

A mental illness is defined as a 

Kajal Patel 

condition which causes serious 

disorder in a person’s behaviour or thinking. Being 

at Tara, I discovered that it means different things to 

different people: 

• For a patient in ward 1 & 2, it means body 

dysmorphia and an unhealthy relationship with 

food. Patients in this ward need a large multidisciplinary 

team to treat them including nurses, 

a psychologist, a dietitian and a psychiatrist. 

• For a patient in ward 4 & 5, it means they’ve 

had developmental difficulties which has illequipped 

them with dysfunctional coping skills 

in adulthood. I learnt about psychotherapy and 

its importance in treating personality disorders. 

• For a patient in ward 6, it means an altered reality. 

These patients are especially vulnerable as their 

families cannot understand them and find their 

behaviour and grooming habits strange. They 

need medication, and extreme care. 

• For a patient coming into the neuropsychiatric 

clinic, it means a major life event has altered their 

anatomy which causes psychiatric sequalae. 

It doesn’t matter what the illness is, it changes 

these patient’s lives completely. 

A skill that I really improved during my elective at Tara 

was history taking. In other disciplines, investigations 

can provide you with so much information. In 

psychiatry, talking to a patient provides you with most, 

if not all, the information you need. It’s important to 

ask the right questions and to make the patient feel 

safe enough to talk about their experiences. During 

the elective period, I was placed in Ward 6 which is 

an open adult ward. I interviewed a patient which 

had just come in. Our interview lasted an hour 

because of the intricate details and past history I 

had to extract from him. 


PERSPECTIVE 

IT WAS CAPTIVATING FOR ME TO 

IDENTIFY THE SYMPTOMS OF PSYCHOSIS 

AND THOUGHT FORM DISORDER IN 

THE PATIENT. HE WAS RESERVED IN THE 

BEGINNING OF THE CONVERSATION BUT 

AFTER ESTABLISHING A GOOD RAPPORT, 

HE OPENED UP MORE. 

I wrote up and gave a case presentation for this 

patient in the ward round as well. It was great to 

have been able to integrate all the information, 

come up with differential diagnoses and feedback 

on the Mental State Exam of the patient. 

I also learnt compassion. Learning people’s stories 

and their backgrounds teaches you to become 

empathetic. This experience taught me to think and 

feel, and to relate to others and to the world in a 

genuine and meaningful way. A colleague and I 

clerked a patient in the closed women’s ward. It 

was extremely sad to hear her story and to touch 

on aspects of her life that hurt her the most. She 

was alone and hardly any of her family members 

would visit, let alone speak to her. Interviewing her 

was very tricky as she was on edge nearly the entire 

conversation. But after seeing her, I certainly started 

looking at other patients differently. Instead of just 

seeing a person to interview, I began respecting their 

stories more. 

Interacting with many patients, I noticed a 

correlation between xenophobia and mental illness. 

Many patients I saw were from surrounding countries 

who came to South Africa to make something of 

themselves but ended up institutionalized. A patient 

I remember mentioned to me that he could not get 

a job for around 6 months because he was from 

Malawi and once he did, he was not paid as well 

as the other employees and was an outcast among 

the employees. Another patient from Lesotho was 

found roaming the streets of Braamfontein and 

was diagnosed with dementia caused by extreme 

trauma. People come to this country with high hopes 

but end up sick because of the many stressors they 

encounter in this country. 

Another important lesson I learnt was professionalism 

and self-respect. During a ward round in the closed 

ward, a patient screamed at the doctor and accused 

her of keeping her in the ward despite trying her 

best to get better and of treating her as merely a 

case file. The doctor in charge handled the situation 

calmly, responding respectfully to all her concerns 

and validating her emotions. This interaction was 

powerful, and I was amazed at her expertise. 

An experience that ‘popped my patella’ was that of 

Electroconvulsive Therapy (ECT). ECT, I learnt, is used 

to treat patients with treatment-resistant depression 

(TRD) 2 and as an adjunct to non-clozapine 

antipsychotic medication for treatment resistant 

schizophrenia 3 . Inducing therapeutic seizures in 

patients to give symptomatic relief of symptoms 

seemed unethical to me. Witnessing the process is 

heart wrenching. The long-term effects are, however, 

promising. This made me realize that some aspects 

of psychiatry are hard to digest, but what is important 

is the wellbeing of the patient. 

A story with a happy ending came from the Lufuno 

Neuropsychiatric clinic. I sat in on an outpatient 

group therapy session which made me extremely 

happy. The patients have mild neuropsychiatric 

symptoms but manage to live ordinary lives with the 

help of therapy and medication. They share their 

victories and failures in group which uplifts them and 

inspires others in the group. 

In conclusion, my visit to Tara was an incredible one, 

with lots of learning involved. I learnt many lessons 

which can’t be taught in a lecture room and my 

appreciation for psychiatry and its aspects has 

quadrupled. 

REFERENCES 

1. Tromp, B., Dolley, C., Laganparsad, M. & Govender, 

S., 2014. SA’s sick state of mental health. Sunday 

Times, 8 July, pp. 1,4. 

2. Magnezi, R. et al., 2016. Comparison between 

neurostimulation techniques repetitive transcranial 

magnetic stimulation vs electroconvulsive therapy 

for the treatment of resistant depression: patient 

preference and cost effectiveness. Dovepress, pp. 

1481-1487. 

3. Zheng, W., Coa, X.-L. & Ungvari, G. S., 2016. 

Electroconvulsive therapy added to Non- 

Clozapine Anti-psychotic medication for 

Treatment Resistant Schizophrenia: Metaanalysis 

of Ramdomized controlled Trials. 

PLOS one, Volume 10. 

ANTIDEPRESSANTS – ANOTHER PERSPECTIVE 

Shall I compare you to a modern plague? 

Thou art more insidious and more craved 

You calm the rough winds for today 

But ultimately make me sign a lease on the 

summers I see 

Sometimes too devious for the eye of another to 

clutch 

The storm that simmers inside this form 

As every blossoming flower you turn into a crusted 

frame 

You are changing nature’s way to claim 

But thy eternal summer shall not fade 

As pharmaceutics hold you in high care 

Death brags that you are its new associate 

Eternal exhaustion is the only thing that grows 

In this garden of despair 

Of which the seeds you have sown 

Written by Kajal Patel 

Kaja Patel undertook an elective at Tara Hospital as a GEMP 2 student - 2018 Correspondence: 862101@students.wits.ac.za 


PERSPECTIVE 

TWO VINYL CHAIRS, 

PRISON, AND 

A 

PETAL. 

Claudia Campbell and Mark Booth (a pseudonym) 

CLAUDIA 

Ordinarily, I am not a fan of anything covered 

in vinyl. Childhood memories of feeling 

my legs sticking to the synthetic plastic 

polymer covering the bench chairs at our 

local ice-cream shop, halted any future cravings for 

frozen dairy products. 

However, in more recent years some other chairs 

were given a second chance when they received 

new covers of bright, bright blue vinyl. These chairs 

exist in a room with a greenish carpet, where ambient 

temperatures are either frigid or sweltering. That said, 

there is a huge picture window, which offers endless 

amounts of natural light. But, the most redeeming 

feature of this room is that it is where I am able to 

listen to extraordinary stories of life and survival. I 

am privileged to occupy that room and a blue vinyl 

chair as stories previously saturated with hurt, pain, 

and illness begin to be retold in healthier ways, ways 

accentuated with hope rather than despair. I am 

not a psychiatrist, nor a psychologist. It is not my 

responsibility to attempt to ‘fix’ or ‘cure’ anyone. But, 

I do listen with the hope that perhaps the process of 

being heard might be helpful in some way. 

FOR THE LAST WHILE, MARK HAS 

OCCUPIED THE BLUE CHAIR ACROSS 

FROM ME. HIS IS A STORY YOU WANT 

TO LEARN ABOUT. THIS JUNCTURE IS A 

GOOD ONE FOR MARK TO INTRODUCE 

HIMSELF. 

MARK 

I am a very ordinary South African 

man. I am the youngest of three 

siblings. From an early age, nothing 

would have appeared irregular 

or abnormal about my life to the 

average outsider. I had a good 

upbringing by parents who both 

loved me. After matric, I began to 

Claudia Campbell 

study for a B. Com degree. I found the 

university environment difficult and concentration 

was a constant struggle. I felt like a failure and so I 

chose military training over my degree. However, over 

the next 10 years I managed to enter the working 

world, complete my accounting degree, and build 

my own successful real estate business. I was at the 

top of my game! 

IN 2008 THE PROPERTY MARKET CRASHED, 

AND I WAS CRUSHED AND ON THE BRINK 

OF FINANCIAL RUIN. I COULD NOT SHAKE 

THE FEELING OF THE “DARK BLACK HOLE”. 

MY LIFE WAS BECOMING A SPIRALING, 

TRAUMATIC DISASTER. 

I just wanted to feel “normal”, but I didn’t know where 

to turn. At 35 I dissolved into depression, riddled with 

anxiety and panic attacks. A good friend saw what I 

couldn’t. She persuaded and sponsored a visit to a 

psychiatrist. He prescribed a cocktail of medication, 

which included Ritalin. Although it made some 

difference I still had off-the-chart stress levels. Any 

suggestion of hospitalization was dismissed. After 


PERSPECTIVE 

all I was simply dealing with financial stress and a 

hectic business. I did not have a mental illness, right? 

Things went from bad to worse, almost overnight. I 

had lost hope in everything including my ability to 

solve my own problems. I felt like I was going to have 

a stroke or die of a heart attack. It was at this point I 

started to use illegal substances. 

CLAUDIA 

As I listened to Mark’s story I began to hear some 

of the distress his ‘whirlwind’ mind had caused 

him. However, I knew he was not sitting in the blue 

vinyl chair across from me because of a lack of 

concentration and a busy work schedule. 

I WAS AWARE MARK HAD A HISTORY 

OF SUBSTANCE ABUSE AND HAD SPENT 

SOME TIME IN PRISON. I ALSO NOTICED 

HE ALWAYS ALSO SPOKE WITH HUMILITY 

AND CONCERN FOR THE WORLD 

AROUND HIM. I WAS STRUGGLING TO 

HEAR ONE COHERENT STORY. 

At the beginning Mark tended to speak at superspeed, 

sometimes cluttered super-speed. I wanted to 

ask a question, which would assist me to understand 

what was fundamentally meaningful to him. Perhaps 

then I could listen in a more helpful way. I chose 

the question: “what was it that you wished for most 

when you were in prison?” I didn’t ask this question 

based on a hunch of what Mark’s reply could be, 

but when it came, his answer took me by surprise. 

Without hesitation, Mark said: “to hold a petal and a 

book”. I found the clarity, honesty and depth of that 

simple answer quite astounding. At that point Mark 

began to tell his story in a paced and clear manner. 

Something in his approach to his story shifted that 

day. 

MARK 

FROM THE OUTSET, I NEVER HAD A 

STARTING POINT AS TO WHAT MY 

PRIMARY PROBLEMS ACTUALLY WERE 

(AND THERE WERE MANY). 

However, Claudia was able to contain the content 

of our discussions by slowly giving me perspective 

on one point or another - by initially listening, and 

then reflecting back to me in point form. Similar to 

painting by numbers, Claudia guided me from 1 

to number 50. I did not feel Claudia was trying to 

control my content, but rather helping me steer the 

pains of my heart. 

CLAUDIA 

Whilst listening to Mark, substance abuse stood out 

as something quite incompatible with the principles 

Mark lives his life by. Principles clearly as important to 

him prior to substance abuse as they are today. I felt 

the part of Mark’s story about his hiatus into the world 

of substance abuse was discordant, in comparison 

to an otherwise consistent character. Why did Mark 

really start using drugs? 

MARK 

On reflection today, I see I chose drugs to help me 

cope with the very things my friend had recognized 

I needed psychiatric help and hospitalization for. 

Except one 30 minute consultation had not allowed 

for a full diagnosis, formulation of a treatment plan, 

as well as a complete explanation of all the whats 

and whys. During that first appointment I had not 

been made aware of the crucial importance of 

showing up for follow-up consultations. Despite my 

friend’s constant encouragement, I didn’t show up. 

I DID NOT UNDERSTAND ‘THE PRESSURE’ 

WOULD HAVE BEEN DEALT WITH BETTER 

TOGETHER WITH A PSYCHIATRIST THAN 

WITH ILLEGAL SUBSTANCES. AFTER ALL I 

NEEDED HELP DEALING WITH ‘LIFE’ NOT 

WITH MENTAL ILLNESS, RIGHT? 

CLAUDIA 

What exactly was ‘the pressure’ though? Was Mark 

referring to pressures of a hectic business, anxiety 

and panic attacks? Hadn’t he seen a psychiatrist 

for that? 

MARK 

I HAD BEEN PERSUADED TO TRY DRUGS 

‘JUST ONCE’ MONTHS BEFORE MY LIFE 

WOULD BECOME AN UNCONTROLLABLE 

ROLLERCOASTER RIDE. ALTHOUGH 

THE DRUGS HAD NOT LEFT ME FEELING 

AN IMMEDIATE ‘AWAKENING WITHIN 

MY SENSES’, IN THE BACK OF MY MIND 

THAT EXPERIENCE LEFT ME WITH THE 

PROMISE OF ‘ESCAPE’, SHOULD I NEED 

IT IN THE FUTURE. MY LIFE FELL APART 

- I REMEMBERED THAT ‘PROMISE OF 

ESCAPE’. ILLEGAL SUBSTANCES STARTED 

OFF AS A MECHANISM TO COPE WITH 

PRESSURE AND ENDED UP AS DRUG 

ADDICTION. 

CLAUDIA 

Although I have never taken illegal substances, I 

found common ground in this part of Mark’s story. 

Psychiatrists treat ‘crazy’ people – or that is what I 

thought years ago. I bristled against the notion that 

I needed follow-up appointments, because I was not 

‘crazy’. It took years of medical, mental and physical 

frustration until a psychiatrist took the time to gently 

draw me out and listen to my complete story, and 

then explain his role. I realized he was there to help 


PERSPECTIVE 

reduce distress caused by too many thoughts going 

too fast. He wasn’t there to erase ‘the crazy’, but rather 

to help me function better. It would be a long, long 

time before we found the right prescription for me. 

Therefore, I go so far as to say initially it was the time 

he took to really hear me which saved my life, not 

the prescription he wrote out. To me there is a deep 

sadness that, to Mark, illegal drugs seemed a more 

logical option than psychiatric care. But, I digress… 

MARK 

My drug addiction gave birth to further bad 

decisions. I found myself incarcerated for 2 years in 

a Brazilian prison for drug muling. Trust me; if anything 

changes your perspective on mental health try 

being locked away in a Brazilian prison for a single 

day. You secretly cry yourself to sleep and pray you 

never wake up. In Brazil suicide seemed to be the 

only way out. I vowed that if I ever made it back to 

South Africa alive I would seek help and treatment – I 

would become the master of my brain, understand 

its quirks and intricate network of wiring failures. 

Miraculously, I returned to South Africa. I was 

undernourished, emaciated and very sick. My family 

did not recognize me. A few days later I found 

myself across from a neuropsychiatrist and various 

psychologists, in what was to be my entry interview 

into a psychiatric hospital. 

NO JOURNEY OF A THOUSAND MILES 

CAN BE COMPLETED IF ONE PREDICTS 

THE OUTCOME IS GOING TO BE 

NEGATIVE. THE JOURNEY BEGINS WITH 

THE EXPECTATION THAT AT THE END OF 

THE PROCESS ONE WILL BE A BETTER AND 

MORE FULFILLED INDIVIDUAL. 

Although I felt suicidal, I still knew I wanted to get 

better. I needed to conceptualize my problems 

without sounding like a nutcase. I had no words to 

verbalize the misconceptions I had about myself. I 

felt hopeless. I was perspiring from anxiety, depressed 

for feeling the way I did and very nervous. My 

biggest concern was whether the psychiatrist would 

understand what I was feeling on the inside, without 

judging the way I looked on the outside. 

MY GREATEST CHALLENGE WOULD BE TO 

ARTICULATE WHAT WAS HAPPENING IN 

MY BRAIN. WHEN I USED THE METAPHOR 

OF MY BRAIN FEELING LIKE ‘RICE 

KRISPIES’ ‘SNAP, CRACKLE AND POP’ I 

SAW HIS REACTION. I REALIZED HE WAS 

MORE INTERESTED IN WHAT WAS GOING 

ON WITHIN MY BRAIN THAN WITH THE 

TOUCHY-FEELY KIND OF STUFF. HE WAS 

INTERESTED IN THE HOWS AND WHYS OF 

THE WAY MY NEURONS AND DENDRITES 

WERE FIRING. 

I think this is fundamentally the problem. We as 

patients don’t understand (or initially understand) 

how billions of neurons should all fit together like a 

glove. I did eventually begin to trust my psychiatrist’s 

ability to help me and understand his role in my 

recovery. My journey of mental health discovery 

had begun. Despite this progress toward chemical 

stability, I felt unable to tell my authentic story. 

CLAUDIA 

An immense part of one’s psychiatric diagnosis and 

treatment is based on verbal accounts of feelings 

and experiences. There seems to be professional 

agreement that the more detailed knowledge a 

practitioner has of his patient’s story, the better the 

prospect for correct diagnosis. However, I have 

learned that telling one’s authentic, un-censored 

story is impossible without trust. 

THE THING IS, TRUST IS NOT A GIVEN 

BYPRODUCT OF A HIGHLY SKILLED 

PROFESSIONAL. TRUST IS AN INNATELY 

HUMAN QUALITY, SOMETHING EACH ONE 

OF US HAS TO EARN. THE ASSUMPTION 

THAT BY VIRTUE OF ONE’S PROFESSION A 

PERSON SHOULD AUTOMATICALLY TRUST 

YOU IS DEEPLY FLAWED, AND AT TIMES 

DISASTROUS. 

I don’t believe inordinate amounts of time are 

needed to start earning trust. I believe it starts by 

meeting as equal humans whilst still acknowledging 

the different roles patient and practitioner play. 

Patients need to trust their doctors in order for 

doctors to trust their patients. 

MARK 

I agree with Claudia’s reflection. Presumptions have 

been the ultimate breaking point in my experience 

with some psychiatrists and therapists. A lack of 

trust has left me feeling emptier and worse for wear, 

convinced no amount of medication or therapy 

would make me feel complete or normal. 

RECENT TREATMENTS HAVE BEEN MOST 

EFFECTIVE WHEN, IN MOMENTS OF 

VULNERABILITY, MY PSYCHIATRIST HAS 

SHOWN ME HE TOO IS HUMAN. BY 

LISTENING HE HAS COME TO OPEN 

UP AN EASY DIALOGUE, ALLOWING 

ME TO ENGAGE FREELY WITH HIM, 

AND TOGETHER CONSIDER THE BEST 

MEDICATIONS FOR MY TREATMENT. 

CLAUDIA 

Paying heed to clinical and academic perspectives 

is a necessity. However, as this account shows, 

my own experience as a patient can sometimes 

underpin the responses or questions I pose to the 


PERSPECTIVE 

person across from me. My first therapist allowed me 

small, appropriate glimpses into his experience of 

being human. It was this, not his technical prowess, 

which truly helped me trust him. The choice to 

bring in a sliver of my own story is always carefully 

considered on the sole basis of ‘will this be helpful to 

the person sitting with me?’ 

MARK 

Claudia’s own experiences have been significant 

for me. I remember the first time Claudia told me 

her own ADHD diagnosis is treated with Ritalin. I 

immediately felt at ease with her – she was human, 

just like me. It is one thing to try to build trust with a 

practitioner, but when in the back of my mind the 

person is purely theoretical it keeps my own story 

within the confines of a textbook. This has always 

been incredibly difficult when seeking help. 

KNOWING CLAUDIA HAS BEEN IN THE 

TRENCHES (SO TO SPEAK) WITH THE 

REST OF US IS AN IMMENSE HELP. IT 

CREATES AN ATMOSPHERE THAT ALLOWS 

ME TO TUNE IN TO HER REMARKS AND 

QUESTIONS AND BUILDS TRUST. 

CLAUDIA 

Practitioners write up patient files. These files contain 

medical and prescription information, consultation 

notes, progress reports and even a ‘patient history’ 

section. By virtue of a patient file’s authorship, they 

in some way document practitioners’ stories about 

working with a patient, rather than their patient’s 

own story told in their own words. ‘Holding a petal 

and a book’ is not a symptom, it is not part of a 

practitioner’s story, but it is a fundamental statement 

which birthed insight. ‘I have a dream…’ were the 

opening words of a speech, which changed history. 

The words are simple, but their meaning is immensely 

deep. So ask yourself: how important are the words 

‘to hold a petal and a book’? 

MARK 

I REPLIED: ‘TO HOLD A PETAL AND A BOOK’. 

SUDDENLY I WAS ABLE TO UNCOVER THE 

HORROR THAT LAY AT THE EPICENTER OF 

MY STORY. 

Today, many miles into my journey, I find myself in a 

wonderful NGO psycho-social rehabilitation center. 

It is here where I am being nurtured and cared for 

by amazing humans. I have time to heal and reprogram 

my brain’s faulty wiring. In the process, I 

found myself in a blue vinyl chair…. 

CLAUDIA 

I DON’T BELIEVE I WILL EVER CRAVE 

FROZEN DAIRY PRODUCTS. HOWEVER, 

OCCUPYING A BRIGHT BLUE VINYL CHAIR 

IS AN HONOUR I NOW DEEPLY VALUE. AS 

HUMANS, OUR STORIES SHAPE MUCH OF 

WHO WE ARE. BUT, IT CAN BE SCARY TO 

TELL ONE’S COMPLETE, UNCENSORED 

STORY FEARING OF JUDGMENT, BECAUSE 

ORDINARILY ONE DOES NOT TRUST A 

JUDGMENTAL PERSON. UNFORTUNATELY 

DIAGNOSIS AND JUDGMENT CAN 

MISTAKENLY FEEL THE SAME. 

Although listening to stories without the expectation 

to diagnose or ‘treat’ is a privilege, it’s not a necessity. 

After all the person I trusted enough to listen without 

judgment was the very same person whose ‘job’ it 

was to diagnose me. 

Place: 

Brazil 

Date: 12 July 2015 

Incarceration: Day 19 

Time without drugs: 20 days 

PRECISION 

I look outside but nothing 

Only Grey and White 

Precision as if anyone cares 

For when gates open and mind circles 

Inner courtyard tightened by Iron bars 

And the sense of hopelessness 

One can only wonder how do my thoughts differ 

From the treadmill of rats circling around and 

around 

Conversations into the realms of nowhere 

CONCLUSION 

by Mark Booth 

Life fails when hope ends. Today there is hope and 

so there is life. 

Claudia Campbell holds a post-graduate degree in psychology and has 10 years experience in the field of corporate 

transformation strategy. Claudia works in a voluntary capacity as a psychosocial facilitator, public speaker, and strategic 

consultant. Claudia is currently undertaking a psychology research master’s degree focused on the implementation of the 

National Mental Health Policy Framework 2013-2020 and the role of registered counsellor, through Stellenbosch University. Due 

to various health concerns, Claudia’s personal life includes many experiences from the patient’s side of the consultation table. 

Correspondence: claudia@redbench.co.za 


in Mental Health

BOOK REVIEW 

SNOEK 

ON THE COUCH 

BY ROBIN EMSLEY 

Sue Hawkridge 

this book I would obviously have 

found a reason not to review it, and 

the only thing this review can now 

be about is how much I like it, and 

why. 

FIRST A WORD ABOUT WHAT 

SORT OF BOOK THIS IS: IT 

DOES NOT EASILY LEND 

Sue Hawkridge 

ITSELF TO CLASSIFICATION. 

IT HAS ELEMENTS OF AN ESSAY 

COLLECTION, OF A MEDITATION, OF A 

SCIENTIFIC SYNTHESIS AND A PERSONAL 

MEMOIR, NOT TO MENTION A WILDLIFE 

GUIDE. IT’S ALSO VERY FUNNY IN PARTS. 

Title: Snoek on the Couch 

Publisher: Print Matters Heritage 

Author: Professor Robin Emsley 

There is a certain apprehension in reviewing 

a book written by someone I know well, and 

I wondered, as I began, whether a review 

by someone known to be a friend of the 

author has any credibility at all. After a little selfinterrogation, 

I concluded that I had actually 

agreed to do this review because I like the book, 

rather than because I like the author. I do, of course, 

like the author – he has been my mentor and friend 

for over a quarter of a century. What would have 

made me say no? Well, if I hadn’t liked the book. Do I 

never review books I don’t like? Apparently not, given 

my publication record. So far so good, but can I 

really be objective? Alarmingly for my literary friends, 

yes, I can, as evidenced by the very colourful trackchanges 

edits with which I routinely provide them 

when they are rash enough to ask. So if I hadn’t liked 

I suppose we all spend more time musing as the 

years accumulate, and official retirement offers 

an ideal opportunity to consolidate our thoughts. 

Sometimes the result is a set of rules for the young, 

sometimes a Jeremiad about humankind’s state of 

incivility, but sometimes, as with this book, the author 

is simply sharing a journey through things and 

places that have puzzled or fascinated him or her 

over the years. It’s a generous impulse and there’s 

often something of the late, great Oliver Sacks about 

this kind of writing – if you like Uncle Tungsten, I think 

you will enjoy the “Snoek boek”. 

On first reading, Snoek on the Couch is a quirky 

meander through the fish species and its odd 

(disgusting) ailments, the snoek industry of the West 

Coast and the people who work in it, the complexities 

of language, the mysteries of schizophrenia, the 

possibility of self-awareness in non-human animals, 

and a contemplation of the possible subjective 

experience of animals. 


BOOK REVIEW 

POIGNANTLY, EMSLEY FORCES US TO 

PONDER OUR OFTEN DUBIOUS ETHICS 

OF EATING, AND THE SAD INEVITABILITY 

OF THE FOOD CHAIN. 

We then move on through the roots of evolutionary 

social psychology and the science of facial 

expressions and what they may mean (or not). 

While this may suggest anthropomorphism to the 

uninitiated, there appears to be a sound scientific 

basis for the attribution of personality traits to fish. 

In one study, some unfortunate guppies were 

placed in stressful situations and their responses 

measured and compared, and apparently “some 

attempt to hide, others try to escape, (and) some 

explore cautiously,” according to Dr Tom Houslay, 

an evolutionary ecologist then working at Exeter 

University, now at Cambridge University. “The 

differences between them were consistent over time 

and in different situations. So, while the behaviour 

of all the guppies changed depending on the 

situation - for example, all becoming more cautious 

in more stressful situations - the relative differences 

between individuals remained intact.” The presence 

of predators had an effect on ‘average’ behaviour, 

making all the guppies more cautious. But individuals 

still retained their distinct personalities. 

Professor Alastair Wilson, another member of the 

team, explained, ‘We want to know how personality 

relates to other facets of life, and to what extent 

this is driven by genetic, rather than environmental, 

influences. The goal is really gaining insight into 

evolutionary processes, how different behavioural 

strategies might persist as species evolve.” 

In fact, group dynamics among fish appear not to 

be too different from those among humans. Kyriacos 

Kareklas and his colleagues “tested zebrafish shoals 

to examine whether groups exhibit collective 

spatial learning and whether this relates to the 

personality of group members... There were strong 

indications of collective learning and collective 

reorienting … but these processes were unrelated 

to personality differences within shoals. However, 

there was evidence that group decisions require 

agreement between differing personalities. Notably, 

shoals with more boldness variation were more 

likely to split during training trials and took longer 

to reach a collective decision. Thus cognitive tasks, 

such as learning and cue memorisation, may 

be exhibited collectively, but the ability to reach 

collective decisions is affected by the personality 

composition of the group. A likely outcome of the 

splitting of groups with very disparate personalities is 

the formation of groups with members more similar 

in their personality.” It may be a far stretch from there 

to political parties, but the idea is intriguing. 

Well then, the idea of a depressed snoek may not be 

as far out as might at first glance appear. And so the 

unsettling starts: If facial expression has meaning, it 

may induce empathy, and being empathic towards 

your food is a delicate balancing act, although 

one perhaps pioneered by the first peoples of our 

country. And what if appearance does indeed say 

something about character or mental state, even in 

non-human animals? Can one speculate about the 

emotional aspects of a particular species’ capacity 

to adapt without having direct knowledge of those 

emotions? 

As Randolph Nesse wrote in 2009, “… Darwin clearly 

recognized that evolution shaped not only the 

physical characteristics of an organism but also its 

mental processes and behavioural repertoires. The 

knowledge that natural selection shaped the brain 

mechanisms that mediate motivation and emotions 

offers a solid foundation on which a modern theory 

of emotions is being built.” So Darwin did it all the 

time. He even wrote a book about it (The Expression 

of the Emotions in Man and Animals: Charles Darwin, 

1872). 

But adding the possibility of consciousness to 

evolutionary adaptation in animals takes us beyond 

the descriptive and into the experiential, and makes 

us ponder the complexities of our own transitions, 

especially over the last 30 odd years. Emsley tells 

the story of an unsuccessful adapter, and the 

psychopathology that preceded and followed 

his failure, and wonders how the personality traits 

of snoek might affect their ability to survive the 

changing environment (no, Donald, this is no longer 

an argument). In the long run, says Emsley, it’s about 

balance. And so it is. 

I loved this book, and would recommend it to anyone 

looking for some fresh thinking on some of life’s really 

hard questions. Emsley cuts through shibboleths 

and jargon, and gives us an eloquent, undistorted 

account of what life looks like from where he sits. In 

an age of universal deceit, to borrow a phrase from 

George Orwell, it’s rare. It’s also thought-provoking 

and destabilising. As I reach guiltily for a seed 

cracker smothered in snoek pate… 

REFERENCES 

1. https://www.timeslive.co.za/sunday-times/ 

lifestyle/2017-09-26-hidden-depths-scientistsconfirm-fish-have-different-personalities/ 

2. Kareklas, K., Elwood, R. W., & Holland, R. A. Fish 

learn collectively, but groups with differing 

personalities are slower to decide and more 

likely to split. Biology Open, (2018) 7(5), https:// 

doi.org/10.1242/bio.033613 

3. Nesse, RM and Ellsworth PC. Evolution, Emotions, 

and Emotional Disorders. American Psychologist 

(2009) 64, No. 2 (February–March), 129–139 DOI: 

10.1037/a0013503 

Sue Hawkridge is Clinical Head of the Child and Adolescent Psychiatry Unit of of Tygerberg Hospital in the Western Cape. 

She is a senior lecturer in the Department of Psychiatry, Stellenbosch University and a visiting lecturer in the Department of 

Psychology at Rhodes University. Reading, writing, reviewing and editing are how she maintains a semblance of balance. 

Correspondence: smh@sun.ac.za 


CULINARY CORNER 

A MEANINGFUL MEAL 

OF PSYCHIATRIC AND 

PSYCHOLOGICAL 

INFORMATION 

If you are interested in acrophobia, our menu 

today starts with a study regarding the most 

therapeutic way of dealing with a fear of heights. 

Then we go on to the medication used to help 

a patient tormented by ghostly insects; the use 

of mirror therapy in those tortured by phantom 

limb pain; and the influence of alexithymia on 

symptom over-reporting. The refresher comes from 

a study which explores the impact of social group 

membership on the recognition of creative work, 

and dessert provides an answer to the question as to 

whether the expressive arts can alleviate symptoms 

of trauma or not. Coffee is accompanied by a review 

study of optimism’s association with good physical 

health. 

STARTER 

USING VIRTUAL REALITY AS A 

THERAPEUTIC MEANS 

Do you often listen in awe as others 

boast about aeroplane or bungee 

jumping? It sounds magical - but 

also anxiety-provoking, particularly 

if standing on a second-floor 

balcony is about as high as you 

will go. It turns out there’s a good 

way of helping those of us with a 

fear of heights to get in touch with 

our adventurous selves. A group 

of researchers (Freeman et al, 2018) carried out a 

randomised trial of automated reality in the treatment 

of a fear of heights. They divided up one hundred 

acrophobic individuals into an experimental group 

(forty-nine members) and a control group (fifty-one 

participants). The members of the control group 

were linked to a virtual reality program (VR) and their 

levels of improvement were compared to those of 

the control group. 

PARTICIPANTS OF BOTH GROUPS WERE 

OLDER THAN EIGHTEEN YEARS AND 

SCORED MORE THAN 29 ON THE HEIGHTS 

INTERPRETATION QUESTIONNAIRE (HIQ). 

THIS QUESTIONNAIRE WAS CHOSEN 

BECAUSE IT HAS BEEN FOUND TO BE 

PREDICTIVE OF DISTRESS, ANXIETY, 

AND AVOIDANCE OF REAL HEIGHTS. 

FREEMAN ET AL (2018) NOTED THAT IT 

HAS HIGH INTERNAL CONSISTENCY AND 

CONVERGENT VALIDITY WITH OTHER 

FEAR OF HEIGHTS MEASURES. 

The experimental group interacted with a virtual 

coach in a virtual office. He started off by presenting 

ways of dealing with this fear from a cognitive 

perspective. Participants were then “taken” to the 



atrium of a large ten storey building where they chose 

the floor that they wished to tackle first. Tasks were 

graded from easier to more difficult and an attempt 

was made for each challenge to be engaging and 

entertaining. For example, one of them was: playing 

a xylophone near the edge of a floor. 

As expected, the researchers found the virtual reality 

treatment to be associated with significant changes 

in scores on the HIQ (mean change score: -24.5; SD: 

13.1) as against the scores of those in the control 

group (mean change score: -1.2; SD: 7.3). Treatment 

uptake was high and levels of discomfort after a VR 

session were very low. 

The authors point out that the strength of VR treatment 

is that patients are willing to go into situations that 

trouble them and to try different ways of responding 

because it is a simulation. The learning achieved in 

this way has been found to transfer to the real world. 

Use of VR can also offer one of the most powerful 

aspects of a direct therapeutic intervention - namely 

direct coaching in everyday situations that trouble 

people. 

MAIN MEAL 

TREATING PARASITOSIS 

The feeling of insects crawling on one’s skin is not in 

itself unpleasant. However, it is irritating and most of 

us will look quickly to see where the creature is and 

swiftly flick or blow it away. How awful it must be if 

the cause of the tickling sensation on one’s body 

remains hidden - like a ghostly bug. This is a case of 

a patient with parasitosis, reported on by Rathi and 

Bhatia (2018) in the Indian Journal of Psychiatry. 

THE INDIVIDUAL CONCERNED WAS A 

THIRTY-FOUR-YEAR-OLD HINDU MALE 

WHO WORKED IN AN ELECTRONICS 

SHOP. HE WAS INITIALLY REFERRED TO A 

DERMATOLOGIST ON ACCOUNT OF A 

YEAR-LONG HISTORY OF FEELING THAT 

AN INSECT WAS CRAWLING OVER HIS 

LEGS AT NIGHT. PREOCCUPIED WITH 

WORRY REGARDING THIS NOCTURNAL 

PEST, HE SUSPECTED THAT HIS BEDDING 

MIGHT BE INFESTED, DESPITE HAVING 

WASHED IT OUT SEVERAL TIMES. 

As might be expected, he was then directed to the 

psychiatrists. The authors reported that they started 

him on 4mg of blonanserin per day. After two weeks 

they increased the dosage to 8mg per day. He was 

also given 2mg of lorazepam at night to help him 

with sleep (on an SOS basis). There was complete 

remission of his symptoms at six weeks and on followup, 

at three months, he continued to be well. 

MIRROR THERAPY 

From ghostly insects to ghostly limbs - it’s bad enough 

when the existing parts of a person’s body produce 

discomfort and suffering, but how disconcerting to 

have one’s amputated body parts evoking pain too. 

Phantom limb pain (PLP) happens when there is a 

visual-proprioception dissociation in the brain. Mirror 

therapy has been used to relieve PLP by resolving 

this dissociation. However previous studies into this 

treatment modality have been based on small 

sample sizes. 

Ramadugu et al (2017) carried out a randomized 

single crossover study of mirror therapy in the 

treatment of PLP in a sample of 64 amputees. The 

participants (between the ages of 15 and 75 years) 

were randomly distributed into test and control 

groups. The test group were made to carry out a 

standardized set of exercises for 15 minutes a day in 

front of a mirror for 4 weeks. The control group carried 

out these tests in front of a covered mirror. 

A significant reduction in PLP was revealed in the test 

group by means of the visual analog scale and the 

short-form Mc Gill Pain Questionnaire (P


researchers therefore concluded that mirror therapy 

is effective in relieving the intensity, duration and 

frequency of PLP. 

ALEXITHYMIA OR MALINGERING 

It is embarrassing and discouraging to go to one’s 

physician with a list of complaints that he or she 

cannot find any reason for. Merckelbach et al (2018) 

note that doctors often suspect such patients of being 

malingerers or - one might add - attention-seekers. 

However, these researchers questioned whether an 

over-reporting of eccentric symptoms might not be 

associated with alexithymia, which refers to a deficit 

in reading one’s internal experiences. Alexithymia 

has also been linked to sleep problems and fatigue. 

In their exploratory study, Merckelbach et al (2018) 

therefore administered measures of alexithymia, 

symptom-over-reporting and sleep quality to 

both forensic psychiatric outpatients and nonforensic 

participants. They found that overreporting 

correlated positively and significantly with 

alexithymia. While sleep problems were also found to 

be associated with over-reporting, the link between 

alexithymia and over-reporting was stronger. They 

concluded that alexithymia as a potential source of 

over-reporting should therefore be explored further. 

REFRESHER 

GENIUS BEGINS AT HOME 

For those of us who understand the intense suffering 

engendered by not having one’s genius recognised, 

the following study offers a small comfort. 

STEFFENS ET AL (2017) EXPLORED THE 

EXTENT TO WHICH THE RECOGNITION OF 

CREATIVE WORK IS AFFECTED BY SOCIAL 

GROUP MEMBERSHIP. THEY DID THIS BY 

ANALYSING THE AWARD OF MERIT PRIZES 

FOR THE BEST ACTOR OR ACTRESS IN A 

LEADING ROLE IN THE UNITED STATES- 

BASED OSCARS AND THE BRITISH BAFTAS, 

GOING BACK TO 1968. 

They found that US actors won a significantly greater 

proportion of the Oscars (odds ratio: 2.10), while 

British artists won a greater proportion of BAFTAs 

(odds ratio: 2.26). They concluded that, among 

other things, a creative performance is more likely to 

be viewed as outstanding when the artist involved is 

perceived to be “one of us”. 

DESSERT 

CAN EXPRESSIVE ARTS ALLEVIATE 

SYMPTOMS OF TRAUMA? 

Demott et al (2017) carried out a study of an expressive 

arts group intervention with unaccompanied 

minor asylum children in Norway. The goal was to 

determine whether such an intervention alleviated 

symptoms of trauma and enhanced life satisfaction 

and hope. 

One hundred and forty-five unaccompanied 

refugee boys between the ages of 15 and 18 years 

were allocated into either a ten-session expressive 

arts intervention group (EXIT) where participants 

worked through a manual of creative tasks, or a 

life as usual group (LAU). The participants were 

assessed at onset and four times over a period of 

25 months on instruments measuring post-traumatic 

stress, general psychological distress, current life 

satisfaction and expected life satisfaction. 



As expected, the EXIT group intervention had a 

significant beneficial effect on helping the boys 

cope with symptoms of trauma, strengthening their 

life satisfaction and developing hope for the future. 

COFFEE 

OPTIMISM AND PHYSICAL HEALTH 

In conclusion the authors note that the literature 

strongly suggests that dispositional optimism is a 

robust predictor of diverse physical health outcomes. 

More work, however, still needs to be done on this 

relationship. 

In the meantime, if you can, try to be positive. 

INGREDIENTS 

Finally, for all of you for whom the glass is always 

half empty rather than half full, Scheier and Carver 

(2018) carried out a thirty year review of research 

on dispositional optimism and physical wellbeing. 

Their review encompassed initial research 

suggesting a connection between physical wellbeing 

and optimism as well as later, large-scale, 

epidemiological studies that linked the two factors 

more emphatically. 

The reasons for this association are three-fold. On the 

one hand it may be because optimists have better 

coping strategies than pessimists. It is hypothesised 

that the former are more likely to take constructive 

action to improve matters and solve problems. 

On the other hand, there is some indication that 

pessimists tend to make use of avoidant strategies 

such as denial or mental disengagement. 

A POSSIBLE SECOND WAY IN WHICH 

OPTIMISM MIGHT AFFECT PHYSICAL 

HEALTH IS THROUGH ITS INFLUENCE 

ON STRESS. THE COPING STRATEGIES 

OF OPTIMISTS MAY ENSURE THAT THEY 

SUFFER LESS STRESS WHEN LIFE BECOMES 

CHALLENGING. 

Thirdly, the researchers found a complex relationship 

between optimism and the immune system. The 

most consistent finding, however, was that there is 

an association between optimism and components 

of the immune system that reflect systemic 

inflammation. 

Demott, M.A.M., Jakobsen, M., Wentzel-Larsen, I., 

Heir, T. (2017). A controlled early group intervention 

study for unaccompanied minors: Can expressive 

arts alleviate symptoms of trauma and enhance life 

satisfaction? Scandinavian Journal of Psychology, 

58, 510-518. 

Freeman, D., Haselton, P., Freeman, J., Spanlang, 

B., Kishore, S et al. (August 2018). Automated 

psychological therapy using immersive virtual reality 

for treatment of fear of heights: a single-blind, 

parallel-group, randomised controlled trial, Lancet 

Psychiatry, 5, 625-623. 

Merckelbach, H., Prins, C., Boskovic, I., Niesten, I., A 

Campo, J. (2018). Alexithymia as a potential source 

of symptom over-reporting: An exploratory study in 

forensic patients and non-forensic participants, 

Scandinavian Journal of Psychology, 59(2), 192-197. 

Ramadugu, S., Nagabusham, S.C., Katuwal, N., 

Chatterjee, K. (2017). Intervention for phantom limb 

pain: A randomized single crossover study of mirror 

therapy, Indian Journal of Psychiatry, 59(4), 457-464. 

Rathi, A., Bhatia, M.S. (2018). A case of delusional 

parasitosis responded to Blonanserin, Indian Journal 

of Psychiatry, 60, 254-5 

Scheier, M.F., & Carver, C.S. (2018). Dispositional 

Optimism and Physical Health: A Long Look Back, A 

Quick Look Forward, American Psychologist, 73(9), 

1082-1094. 

Steffens, N.K., Haslam, S.A., Ryan, M.K., & Millard, K. 

(2017). Genius begins at home: shared social identity 

enhances the recognition of creative performance, 

British Journal of Psychology,108, 721-736. 

Ethelwyn Rebelo (PhD) is a clinical psychologist working in private practice. She has spent a good part of her 

professional life working in psychiatric wards and psychiatric clinics. Correspondence: ee.vajdakova@outlook.com 


WINE FORUM 

HERITAGE, 

ROMANCE … 

OR BOTH? 

When Bruwer Raats accepted Platter’s 

2018 Winery of The Year accolade, he 

had a tilt at the old vine debate. Five of 

seven wines in the Raats Family portfolio 

garnered coveted Five Star awards and, like their 

cellar siblings, the celebrity duo of Eden High Density 

Single Vineyard chenin blanc and cabernet franc 

were from vines barely six years old. Top end wines 

didn’t only come from old vines he suggested, a dig 

at some of his illustrious peers… 

Fast forward to the launch of Platter’s 2019, which 

introduced the Certified Heritage Vineyards icon 

(and bottle decal) for wines made from grapes off 

vines older than 35 years as certified by the Old Vine 

Project. Old vines are now officially hip; OVP 1 Raats 

0? 

ROSA KRUGER IS THE CURRENT DOYENNE 

OF THE CAPE VINEYARD AND HAS A 

FOLLOWING OF YOUNG, VIBRANT AND 

EDGY WINEMAKERS – THE YOUNG GUNS 

– THAT VERGES ON CULT STATUS. SHE WAS 

VINEYARD MANAGER AT L’ORMARINS 

WHEN HER CURIOSITY ABOUT REALLY 

MATURE VINEYARDS STARTED HER 

SEARCH FOR THEM IN 2002. 

in the matter swelled and Johann 

Rupert provided seed capital to 

establish The Old Vine Project in 

2016. It aims to create awareness 

of the heritage of older wines 

and to preserve those more than 

35 years old. With Ms Kruger at 

its helm, Andre Morgenthal is the 

hyperkinetic Project Manager. 

There are 1377 vineyard blocks over 3197 hectares 

of vines older than 35 years, in the context of a 

national vineyard of 95 000 ha (down 5% over the 

last ten years). Ten parcels are over 100 years old; 

Franschhoek’s La Colline semillon, planted in 1936, 

still provides fruit for rock star Chris Alheit’s eponymous 

bottling, amongst others. 

The old vine parcels – mostly in Stellenbosch, Paarl 

and Swartland – are generally small (around 1 

ha) and reflect what was favoured by the farmer 

of the day: workhorse chenin, ubiquitous muscat 

d’Alexandrie, and colombar, palomino, crouchen 

blanc (“Paarl Riesling”) & clairette blanche destined 

for brandy. The Young Guns are now coaxing decent 

wine out of these less fashionable varieties and 

creating formidable Cape white blends. Cinsaut – 

also enjoying a renaissance – pinotage and tinta 

barocca are common old black grape plants. 

This voyage took her to forgotten grenache in the 

Piekenierskloof and venerable chenin and semillon 

at Skurfkop. Add Eben Sadie – in the vanguard of 

The Young Guns – and his Old Vine Series, and the 

momentum grew. 

The problem was that, while the old vineyards 

were documented, their existence couldn’t be 

made public at the time. Kruger eventually coaxed 

custodian of these matters, South African Wine 

Information & Systems, to release the list subject to 

her personal undertakings in 2012. Foreign interest 

Rosa Kruger 


WINE FORUM 

Rewind Raats; does it make a difference? It’s a field 

thick with romance. ‘Old vines often reflect the lives 

and the culture of the people – the fishermen on the 

coast, the sheep farmers inland, the wheat farmers of 

the Swartland and the fruit farmers of Piekenierskloof 

– and are often preserved by sentiment rather than 

budgets,’ avers Kruger. ‘Old vines and the wines they 

make are a monument to the farmer’s love of his land.’ 

Marco Ventrella, head viticulturist at KWV, offers a 

scientific perspective. It’s akin to human ageing. As 

the vine matures it stores more carbohydrate, making 

it more resistant to adverse (especially drought) 

conditions due to accumulated reserves. The grapes 

reach ‘phenolic ripeness’ – when flavour compounds 

are fully developed – earlier. Fruity exuberance and 

obvious varietal character may be the preserve of 

youth, but wine from more venerable stock has fuller 

texture, is better structured, with greater intensity, 

palate-weight, and complexity. 

BUT IS IT WORTH IT? THE LIFE CYCLE OF 

A VINE IS SUCH THAT ITS FRUIT DON’T 

CONVERT TO POTABLE WINE FOR THE 

FIRST FEW YEARS, THEY GROW INTO 

QUALITY PRODUCTION BY ABOUT 10 TO 

15 YEARS, AND THEN, ON THE OTHER SIDE 

OF 20 TO 30 YEARS OF AGE PRODUCTION 

FALLS OFF. 

Selling grapes by the ton, a farmer will need to double 

prices when yields halve. Or grub up the old vines 

for new ones or alternative crops to stay financially 

afloat. It’s the OVP’s aim to keep these 20-something 

wines in the ground: ‘Encouraging “planting to grow 

old”,’ as Morgenthal puts it. 

In a University of Cape Town and Stellenbosch 

collaboration, Jonathan Steyn and David Priilaid 

constructed a hedonic pricing model to investigate 

how wine price-setters in the supply chain prioritise 

old vine cues, relative to more conventional cues of 

worth. ‘In addition to the contribution of established 

cues such as aggregate ratings, exemplar brands, 

prototypical varieties, and origin, our study confirmed 

that vine age contributes significantly to wine price.’ 

Steyn added that, ‘The introduction of the certified 

heritage vineyard seal is an important step and is 

likely to sharpen and further shape the category 

boundaries globally.’ 

VinPro, the local wine research body, reports 37% of 

wine growers are operating at a loss, 2% break even, 

47% make a low profit; only 14% are profitable. A 

wine farm needs to generate R40-60 000/ha to be 

sustainable, which means making wine that can sell 

at R300 a bottle. With 80% of all old vines within the 

cooperative system, the OVP is a potential leg up for 

that sector into the premium wine market. 

The L’Ormarins Old Bush Vine Chenin Blanc was first planted in 1964 on the 

Paardeberg Mountain between Malmesbury and Paarl. In 2007/8 these old 

bush vines were replanted on the north facing decomposed granite slopes 

of L’Ormarins in Franschhoek, where they now produce a single varietal wine. 

Photo: Gideon Nel 

La Colline, Franschhoek. Semillon planted in 1936 

Bellevue Wine Estate Pinotage, 1953 

Anthonij Rupert Wines Henk Laing Vineyard, Semillon, Planted 1956 

www.oldvineproject.co.za 

Andre Morgenthal 

Project Manager 

andre@oldvineproject.co.za 

0826583883 

David Swingler is a writer and taster for Platter’s South African Wine Guide over 21 years to 

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

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

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

Correspondence: swingler@telkomsa.net 


MOVIE REVIEW 

THE WIFE 

a review by Franco P. Visser 

A Silver Reel Presentation 

An Anonymous Content / 

Meta Film London / Tempo 

Productions Limited Production 

Directed by Björn Runge 

Screenplay by Jane Anderson 

Let me start this review by wishing you a happy 

and prosperous 2019. May this year for you be 

filled with endless wonder and joy. Last year 

was my year of music – this year I shall have 

beauty in all its forms! 

THIS YEAR MARKS THE 118 TH YEAR THAT 

THE NOBEL PRIZE FOR LITERATURE WILL 

BE AWARDED TO A DESERVING AUTHOR 

WHO ‘PRODUCED IN THE FIELD OF 

LITERATURE THE MOST OUTSTANDING 

WORK IN AN IDEAL DIRECTION’. ALONG 

WITH THE PULITZER PRIZE, THE NOBEL 

PRIZE FOR LITERATURE IS THE MOST 

PRESTIGIOUS AND COVETED AWARD 

ANY WRITER CAN DREAM OF RECEIVING 

IN HIS OR HER CAREER. 

Imagine getting a telephone call one morning, very 

early, from an individual with a distinctly Scandinavian 

accent informing you that you have been chosen 

as that particular year’s recipient of the Nobel Prize. 

Then imagine being treated like royalty and having 

every whim catered for by the Nobel Prize committee 

for your trip to Stockholm and for the duration of 

your stay there, not to mention your name being 


MOVIE REVIEW 

THE WIFE 

broadcast the world over. Imagine a sumptuous 

and very regal award ceremony, followed by an 

even more sumptuous gala dinner… all ‘white tie 

and ball gown’. 

IF THE VIVID IMAGERY GETS YOUR TOES 

CURLING AND YOU THINK THAT THIS 

MIGHT BE YOUR THING, START WRITING, 

IT IS NEVER TOO LATE! 

Achieving this realm of excellence often comes 

with problems of its own. The Wife, based on the 

novel by the same name written by American writer 

Meg Wolitzer deals with the exact same scenario 

as imagined above, this time round as it applies 

to the lives of Joe and Joan Castleman (played 

by Jonathan Pryce and Glenn Close respectively). 

Joe, a celebrated and respected author in the 

graying years of his life, receives ‘the call’ early one 

morning from the Nobel Prize committee informing 

him that he will be awarded the Literature prize for 

1992. Joe is beyond ecstatic, and it is clear that his 

world rather revolves around himself and his writing, 

and that his wife Joan plays her part as the silent, 

supportive and caring wife of a husband with a 

very important career. Though adamantly by her 

husband’s side, hers is a life outside the limelight, 

and she shies away from any form of recognition 

or praise for her role in Joe’s success. Not only has 

Joan had to give up her own dreams, but she also 

has had to turn a blind eye to Joe’s numerous 

infidelities over the course of their 40-somewhatyear 

marriage. 

FROM THE START OF THE FILM ONE GETS 

A VERY STRONG SENSE THAT JOAN’S 

LIFE HAS BEEN MORE THAN SACRIFICED 

IN HELPING BUILD THE EXTRAORDINARY 

CAREER OF HER HUSBAND. 

It is as the couple is making their way to Stockholm 

for the award ceremony that things start to unravel 

in their relationship. Joe and Joan share a secret, 

and the secret is beginning to exact a heavy toll 

on Joan’s conscience. When confronted by Joe’s 

narcissistic and adulterous behaviour even on the 

eve of a major achievement in a foreign country, 

Joan comes to the realization that she can no 

longer proceed with her life as she had known it 

up to that point. 

On the trip to Stockholm the Castlemans are 

escorted by their son David (played by Max Irons), 

a budding writer craving his father’s recognition 

and positive feedback. It goes without saying 

that Joe and David share very difficult fatherson 

relationship dynamics, especially in light of 

Joe’s self-centeredness and brash manner. No 

household is big enough for the egos of more than 

one successful writer, right? Add to this that on the 

very same trip to Sweden is a wannabe biographer 

of Joe’s out to get any piece of juicy gossip that he 

can. The scene is truly set for a bumpy ride (no pun 

intended!). 

It is in Stockholm too that Joe and David’s 

relationship comes to a head, and things turn out 

quite unexpectedly for the Castleman family. A 

lot more happens in the film which I will leave for 

you to discover as I might just be giving away too 

much here. 

ALTHOUGH THE WIFE IS NOT THE BEST 

FILM THAT I HAVE EVER SEEN, IT COMES 

HIGHLY RECOMMENDED AS IT IS 

SUCCESSFUL IN DELIVERING STELLAR 

PERFORMANCES BY TWO VERY 

STRONG ACTORS (PRYCE AND CLOSE) 

ON A DIFFICULT SUBJECT MATTER. 

The roles of husband and wife caught up in such 

a precarious relationship demands actors of their 

caliber. Get your hands on a copy of this late 2017 

release, you will not be disappointed. Until next 

time, enjoy the viewing! 

Franco Visser is a psychologist and former lecturer in 

Neuro- & Forensic Psychology at UNISA, Pretoria, South 

Africa and currently in private practice Correspondence: 

francopierrevisser@gmail.com 


EPILIZINE 

® 

CR 

Sodium valproate I Valproic acid 

EPILIZINE INTRAVENOUS 400 

Sodium valproate 

Choose Control. Choose Life. 

Valproate derivatives should never be prescribed to female children, female adolescents, pregnant women and women of 

childbearing potential for any indication other than epilepsy which is not effectively controlled by other available medicines 

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 

tolerated. Such patients and/or their relatives should be fully informed of the risks to unborn children. 

Summary: 

• Children exposed in utero to valproate are at a high risk of serious developmental disorders (in up to 30 - 40 %) and/or 

congenital malformations (in approximately 10 % of cases). 

• Valproate should not be prescribed to female children, female adolescents and pregnant women or women of 

childbearing potential with epilepsy unless other treatments with a lower risk of causing congenital abnormalities 

or developmental defects are ineffective or not tolerated. 

Recommendations 1 

• Valproate treatment must be started and supervised by a doctor experienced in managing epilepsy or bipolar disorder. 

• Carefully balance the benefits of valproate treatment against the risks of congenital malformations and 

developmental abnormalities. This assessment should be made when prescribing valproate for the first time, 

at routine treatment reviews, when a female child reaches puberty and when a woman plans a pregnancy or 

becomes pregnant. 

• You must ensure that all female patients are fully informed of and understand: 

- the risks associated with valproate during pregnancy; 

- the need to use effective contraception; 

- the need for regular review of treatment; 

- the need to rapidly consult her prescribing physician if she 

is planning a pregnancy or becomes pregnant. 

Reference: 1. DHCP Letter. December 2015. 

For full prescribing information refer to the professional information approved by the Medicines Regulatory Authority. 

13485 

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: 

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 

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 South Africa (Pty) Ltd, a sanofi 

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. 

1, Midrand, 1685. Tel: (011) 256 3700. Fax: (011) 256 3707. www.sanofi.com. SAZA.GVPA.19.01.0007

SASOP HEADLINE 

FEBRUARY 2019 

EDITORIAL 

Best wishes for 2019 to all, 

hoping that all had a good start 

of the annual new beginnings. 

This is the first Headline edition 

for 2019, reporting on some of 

the activities identified by the 

new SASOP Board and with Prof 

Bonga Chiliza, SASOP President, 

having set out the three-fold 

objectives for the 2018-2020 

Prof Bernard Janse van 

term of office, all is set to engage Rensburg 

with the known, but also new and 

different anticipated challenges and experiences. 

A HAPPY AND PRODUCTIVE 2019 TO ALL 

SASOP MEMBERS, FRIENDS AND OTHER 

COLLEAGUES AND PARTNERS. 

Best regards 

Prof Bernard Janse van Rensburg 

HEADLINE Editor 

January 2019 

1. SASOP BOARD AND GOVERNANCE 

– 2018-2020 

The new SASOP Board of Directors met for the first 

time on the 17 th November 2018. 

1.1 SASOP DIVISIONS 

The first task of the new Board was to confirm 

and identify the new advisory committees and 

convenors for the new term of office, which include 

the following: 

SASOP Divisions 

1. Subgroups Dr Lachman 

2. Academic 

3. Publications 

4. Scientific meeting 

and CPD 

5. Early Career TBC 

Convenors 

Prof Seedat, Prof Chiliza; 

Prof S Seedat (CPSYCH 

President, Ex Officio) 

Prof Chiliza; Prof J/van 

Rensburg 

Dr Talatala 

6. Communications Dr Lachman 

7. Ethics peer review 

and disability 

8. Special Interest 

Group 

9. Advocacy 

Dr Chetty; Prof J/van 

Rensburg; Dr Seape 

Dr Lachman 

Dr Maaroganye; Dr 

Seape 

10. African psychiatry Prof Chiliza 

11. Financing Dr Talatala; Dr Roux 

1.2 SASOP PUBSEC EXCO 

Back: Kobus Roux (Chair Private Sector Group), Kagisho Maaroganye 

(Chair Public Sector Group), Anusha Lachman (Hon Secretary), 

Indhrin Chetty (Hon Treasurer) 

Front: Bernard Janse van Rensburg (Past-President), Bonga Chiliza 

(President), Sebolelo Seape (President-Elect) 

In addition, a SASOP Public Sector Group (PUBSEC) 

Executive Committee has been established to 

strengthen the executive and operational capacity 

of the PUBSEC, consisting of: Dr Kagisho Maaroganye 

(Chair), Dr Pete Milligan, Dr Suvira Ramlall, Prof Rita 

Thom, Dr Kathleen Mawson, Prof Bernard Janse van 



Rensburg, Dr Anusha Lachman and Prof Bongo 

Chiliza (Ex-Officio). This national executive committee 

will continue to work closely with the different regional 

PUBSEC representatives of the Subgroups, including 

Dr John Parker (Western Cape), Dr Thupana Seshoka 

(Eastern Cape), Prof Richard Nichol (Free State), Dr 

Janine Brooker (KZN), Dr Monica Ndala (Limpopo) 

and Dr Thuli Mdaka (Southern Gauteng). 

• They have arranged a “meet and greet” event 

with cheese and wine in appreciation of the 

support for the Subgroup, at Akeso Crescent 

Clinic, Randburg, on Thursday 31 st January 2019 

(from 16h00 to 18h00). 

THE SASOP EXECUTIVE COMMITTEE 

(PUBSECEXCO) WILL BE ACTING AS THE 

SASOP’S PUBLIC SECTOR VOCATIONAL 

GROUP’S “MANAGEMENT GROUP” AND 

WILL FUNCTION AS AN EXECUTIVE 

OPERATIONAL ENTITY DEDICATED TO 

SPECIFICALLY SERVE THE SASOP IN 

ACHIEVING ITS MAIN OBJECTIVES WITH 

RESPECT TO THE PUBLIC SECTOR IN THE 

FOLLOWING WAYS: 

• PubSecExCo will ensure psychiatrists in public 

practice on regional and national level of direct 

representation in the South African public health 

care sector 

• PubSecExCo and SASOP will be entering into 

cooperation agreements acknowledging that 

PubSecExCo will act as SASOPs official agent 

regarding matters that affect the collective 

interests of psychiatrists in public practice, 

also through PubSecExCo’s membership and 

through its affiliation with the South African 

Medical Association’s (SAMA) Employed 

Doctors’ Committee (eDC) 

• As such, the PubSecExCo also operates within the 

vision/mission and objectives of the SAMA eDC 

At its first constituting meeting on the 16th November 

2018, the following projects were identified for the 

current term of office: (1) Human resources and 

training; (2) Advocacy and working with others; 

(3) Public-private psychiatrists’ partnership; and (4) 

projects related to the national strategic process. 

Rita Thom will be leading a working group on 

Public-private partnership, consisting of Kagisho 

Maaroganye, Mvuyiso Talatala, Kobus Roux, Sebo 

Seape, Eugene Allers, Bernard Janse van Rensburg 

and Gerhard Grobler. This group will report regularly 

to the SASOP Board and to the PsychMG Board. 

1.3 SASOP SOUTHERN GAUTENG SUBGROUP 

The Southern Gauteng Subgroup has elected 

a new management committee for 2018- 

2020, including the Chair - Pevashnee Naicker, 

Secretary - Thriya Ramasar, Treasurer - Anusha 

Rama, Registrar representative – Tejil Morar, 

Public Sector/Early Career - Thuli Mdaka and 

PsychMG - Laila Paruk. 

• They also organized a “night-at-the-movies” 

event, with the screening of the popular 

Bohemian Rhapsody, starring Rami Malek, on 

Thursday 7 th February 2019, 18h30 at Nu Metro 

Hyde Park. 

• Registrar update seminar on sleep disorders, 

PTSD and cannabis related issues by, amongst 

other, Dr Alison Bentley, on Saturday 16 th March 

2019 - detail to be confirmed. 

2. MEDIA REPORTS AND STATEMENTS 

2.1 SASOP PRESIDENT 

MENTAL HEALTH CARE IN SA NEEDS STRONGER 

LEADERSHIP AND INCREASED BUDGETS 

The Life Esidimeni tragedy, patient abuse and 

health professionals’ suicides all point to the need 

for better management of public sector psychiatry 

says incoming South African Society of Psychiatrists 

president, Prof Bonga Chiliza 

The psychiatric profession should play a greater 

role in advocating for patients’ rights and improving 

management of mental health in the public sector 

after a series of recent tragedies that highlighted 

the neglect of mental health care in South Africa. 

Newly-elected president of the South African Society 

of Psychiatrists (SASOP) Prof Bonga Chiliza said the 

deaths of 144 patients in the now-notorious Life 



Esidimeni tragedy; allegations of abuse and human 

rights violations at the Tower Psychiatric Hospital in 

the Eastern Cape; and the suicide of UCT Health 

Sciences Dean Prof Bongani Mayosi following his 

battle with depression, all pointed to the need for 

the organisation to “rise and answer the call for 

advocating on behalf of mental health care users 

and our profession”. 

Prof Chiliza, who heads the Psychiatry Department 

of the University of KwaZulu-Natal (UKZN) Medical 

School and will serve as SASOP President to 

2020, said the organisation would ramp up its 

lobbying for mental health care to be allocated 

an equitable share of the national health budget. 

HE SAID SASOP WOULD ALSO BE DOING 

MORE TO ENCOURAGE MEDICAL 

STUDENTS TO SPECIALISE IN PSYCHIATRY, 

IN ORDER TO GROW THE NUMBERS OF 

QUALIFIED PROFESSIONALS ABLE TO 

SERVE PUBLIC MENTAL HEALTH CARE 

NEEDS. 

“Mental health conditions are often misunderstood, 

mis-managed and stigmatised, particularly for those 

who rely on the public health system for treatment. 

They are extremely vulnerable to abuse and SASOP 

as the professional body for psychiatrists must take 

the lead in ensuring better services to our people. 

We will live out the promise we made to society 

when we engaged in a social contract with our 

community as practising, professional psychiatrists,” 

he said. 

Prof Chiliza said SASOP was establishing a “robust 

Public Sector Executive Committee of senior 

psychiatrists in academia and government 

services” to guide its efforts to strengthen 

psychiatric care in the public health sector. 

HE SAID SASOP WOULD CONTINUE 

ITS LEADING ROLE IN THE NATIONAL 

MENTAL HEALTH ALLIANCE OF NGOS IN 

THE MENTAL HEALTH CARE SECTOR AS 

A VEHICLE FOR ADVOCACY ON POLICY 

AND BUDGET ISSUES AFFECTING MENTAL 

HEALTH CARE AND THE PROVISION OF 

PROFESSIONAL PSYCHIATRY SERVICES 

IN THE PUBLIC SECTOR. 

Outlining his vision for SASOP and its contribution 

to the profession of psychiatry, Prof Chiliza said 

the organisation would also focus on renewing its 

leadership transformation efforts, strengthening 

the relationship between public and private sector 

psychiatry, and supporting early-career psychiatrists. 

“We will re-energise our efforts to transform the 

leadership of SASOP and psychiatry in general. 

The leadership of SASOP will continue to transform 

until it is aligned with the demographics of 

South Africa and is able to fully engage with 

issues that plague our country such as racism, 

sexism and other forms of discrimination. 

We will thus embark on a strategic drive towards 

succession planning for all key positions of 

leadership in psychiatry,” he said. 

Prof Chiliza said that as a scarce resource, 

psychiatrists in the public and private sectors 

needed to work together, especially in preparing for 

the reorganisation of the health care system with 

implementation of National Health Insurance (NHI). 

“We are already piloting value-based care models 

in the private sector. There is no reason why these 

pilots cannot be performed in both private and 

state sectors,” he said. 

On early-career psychiatry, he said he aimed to 

grow SASOP by focusing on young psychiatrists, 

registrars and medical officers, ensuring that young 

doctors had ample opportunity to do internships in 

the discipline and “fall in love with psychiatry”. 

“We need to push harder for psychiatry to be truly 

recognised as a major discipline in undergraduate 

medical education,” he said. 

PROF CHILIZA SAID SASOP WOULD 

LOOK TO INCREASE THE SUPPORT 

IT ALREADY OFFERS TO MEDICAL 

REGISTRARS IN ORDER TO “FACILITATE A 

MORE EQUITABLE TRAINING PLATFORM 

FOR ALL REGISTRARS REGARDLESS OF 

THE UNIVERSITY AT WHICH THEY ARE 

TRAINING”. 

Support for early-career psychiatrists would also 

extend to assistance in dealing with professional 

practice issues such as billing, and mentorship for 

young psychiatrists and future academics. 

In addition to his position at UKZN, where he is 

Associate Professor/Chief Specialist and head of the 

Department of Psychiatry, Prof Chiliza is a founding 

director of Harambee Medical Consulting and the 

African Global Mental Health Institute, and serves on 

a number of NGO Boards including the SA YMCA 

and Life Choices. 

He has authored over 50 peer reviewed articles 

and book chapters and won awards including the 

Hamilton Naki Clinical Research Fellowship and the 

CINP Rafaelsen Young Investigators Award. 



He completed his medical degree and psychiatry 

specialization at the University of KwaZulu-Natal 

and his PhD at Stellenbosch University. His research 

interests include schizophrenia, consultation-liaison 

psychiatry, health services and medical education. 

He is the Deputy Editor of the South African Journal 

of Psychiatry. 

2.2 MEDICAL PRACTITIONERS AND EMPLOYEE 

WELLNESS 

Wellness, in particular mental wellness, of medical 

practitioners and students has attracted much 

media and other attention during the past year 

following, for example, successful and public 

suicides by prominent professionals and students 

on several campuses. Statistics are quoted which 

rate the suicide figure at 10,7 per 100 000 people 

for the South African general population as the 6 th 

highest in Africa. 1 

AS FAR AS SUICIDE AND MEDICAL 

PRACTITIONERS ARE CONCERNED, A 

SYSTEMATIC REVIEW OF PUBLISHED 

STUDIES ON SUICIDE AMONG PHYSICIANS 

SHOWED THAT THESE PROFESSIONALS 

HAVE A 2.5 TIMES HIGHER CHANCE 

OF COMMITTING SUICIDE THAN THE 

GENERAL POPULATION (DAMASCENO, 

2017). 2 

Similarly, another meta-analysis on the topic 

reported elevated physician’s suicide ratios (higher 

for women) compared with the general population 

(Schernhammer, ES, 2004). 3 Details on suicide 

among US physicians in seven states included that 

having a known mental health disorder, or a job 

problem, contributed significantly to the increased 

risk of physicians successfully committing suicide 

(Gold et al., 2013). 4 In a cohort of about 20,000 

doctors employed by the National Health Service of 

the UK who died between 1962 and 1979, the death 

rate from accidental poisoning involving prescription 

drugs (overdose) were significantly raised among 

male consultants (most apparent in obstetricians 

and gynaecologists), while the death rate from 

(self) injury and poisoning for female consultants, 

were largely a twofold excess of suicide (significantly 

raised for anaesthetists), Carpenter et al. (1997). 5 

Sheikhmoonesi and Zarghami (2014) noted that 

some studies identified certain specialties such as 

psychiatry, anaesthesiology and dentistry as higher 

risk for physician suicide. 6 They also reported on 

risk factors/attributes in women physicians who 

had attempted suicide to include the history of 

depression, alcohol abuse or dependence, sexual 

abuse, domestic violence, poor current mental 

health and family history of psychiatric disorder. 8 

Furthermore, those who suffer from obesity, chronic 

fatigue syndrome, worsening health, eating 

disorders, overworking, career displeasure, and 

job stressors have also been reported as high 

risk physicians. 8 Kõlves and De Leo reported on 

suicide in medical doctors and nurses compared 

to educational professionals in Queensland, 

Australia, and found that female medical doctors 

in this study had significantly higher suicide rates 

than educational professionals, similarly for nurse 

of both sexes. 7 Studies included in the mentioned 

systematic reviews also reported expressive levels 

of psychic suffering while concluding that suicide 

among physicians is associated with the exercise on 

their professional role in the society and workplace 

(Damasceno et al., 2017) and were calling for 

more information about suicide among health 

professionals. 

IN TERMS OF DEPRESSION, MAJOR 

DEPRESSIVE DISORDER AND OTHER 

MENTAL DISORDERS, SHEIKHMOONESI 

AND ZARGHAMI (2014) OBSERVED 

THAT THE LITERATURE ALSO SUGGESTS 

THAT PHYSICIANS WHO KILL THEMSELVES 

ARE MORE CRITICAL OF OTHERS AND 

OF THEMSELVES AND MORE LIKELY TO 

BLAME THEMSELVES FOR THEIR OWN 

ILLNESSES. 

Furthermore, there is some evidence that physicians 

do not welcome the idea of approaching colleagues 

for help, and instead utilize alcohol or drugs, while 

resorting to isolation. 8 Some of the “ten facts” about 

physician suicide and mental health listed by the 

American Foundation for Suicide Prevention (www. 

afsp.org) include that: (1) suicide is generally 

caused by the convergence of multiple risk factors, 

the most common being untreated or inadequately 

managed mental health conditions; (2) in cases 

where physicians died by suicide, depression is 

found to be a significant risk factor leading to their 

death at approximately the same rate as among 

non-physician suicide deaths; and (3) drivers of 

burnout include work load, work inefficiency, lack 

of autonomy and meaning in work, and work-home 

conflict 

Burnout per se, consisting of the three dimensions 

of emotional exhaustion, depersonalization and 

reduced professional accomplishment (Maslach 

et al., 2001), 8 does not constitute a clinical medical 

diagnosis, but nevertheless has a significant impact 

on sufferers, their work environment and productivity. 

Collier 10 and Dr Sandra Roman, advisor to the Quebec 

Physicians Health Program, both cited a 2012 study 10 

which found that 45.8% of physicians in the US over 

time reported at least one symptom of burnout. 

Furthermore, burnout is a leading cause of medical 



errors, as well as affecting the prescribing habits, 

test ordering and professionalism of doctors. 11 Selfawareness, 

is being identified by these authors, as 

an important factor to address the problem, referring 

to a useful tool in this regard, the Maslach Burnout 

Inventory, a self-administered questionnaire. 11, 12 In 

addition to the individual practitioners, who have 

to recognize their own vulnerabilities and possible 

risky coping mechanisms, strategies to intervene 

and alleviate the effects of burnout, include, on an 

organizational level, to acknowledge the existence 

of the problem, to develop targeted interventions 

and to promote resilience and self-care. 

ON A LEADERSHIP/MANAGERIAL LEVEL, 

IT INCLUDES TO REVIEW LEADERSHIP 

STYLES, TO RESPECT OPINIONS AND 

TO EMPOWER TEAM MEMBERS TO DO 

THEIR WORK AND ADVANCE IN THEIR 

CAREERS. 11 

While, per regulations, cases of impaired physicians, 

medical interns and students have to be reported 

to the Health Committee of the local Health 

Professional Council of South Africa, this Committee 

clearly states its objectives with assistance to 

such professionals, including to: (1) establish 

mechanisms for the early detection of impairment; 

(2) undertake informal assessment of reports; (3) 

oversee the implementation of treatment programs 

of impaired professionals. In other words, to facilitate 

recovery, rehabilitation and reintegration of sufferers 

of mental and substance related conditions. 11 Dhai 

et al., and Knapp van Bogaert and Ogunbanjo 

earlier identified the scope of the problem and 

ethical challenges of the South African impaired 

physician. 12, 13 They alluded to the potential dilemma 

that fellow physicians may experience to report an 

impaired colleague and to weigh up the privacy 

of the practitioner and the safety of patients, while 

suggesting that early on during training, medical 

education should put more emphasis on doctors 

realizing their limitations and recognizing their 

humanity and fallibility. 

In the meantime the discussion on how to 

support colleagues in terms of peer review and 

relations have been started by some professional 

associations, for example, by the South African 

Medical Association (SAMA) and the South African 

Society of Psychiatrists (SASOP). This includes raising 

the awareness amongst medical practitioners that 

vigilance is required, while stigma (including self 

and professional stigma) should not be allowed to 

delay appropriate interventions when needed. The 

SAMA has started to address the issue by a series 

of articles in its “INSIDER” publication for members, 

where medical practitioners have spoken out on 

their own experience with depression and suicidal 

ideation and its impact on them as people and 

professionals. 14 The SAMA and SASOP are also 

considering the best strategies to de-stigmatise 

mental illness in the health care profession, to 

assist healthcare professionals dealing with mental 

illness and occupational, professional and personal 

difficulties, and to create an environment conducive 

to professional exchange and debate, networking 

and support. An important resource in this regard, 

seems to be a publication edited by Brower and 

Riba on this important topic of mental health and 

related problems among physicians, including 

trainees. The book, according to a review, “addresses 

the all-too-common human response of ‘suffering in 

silence’ and refusing to seek help for professional, 

(as well as) personal issues that have ramifications 

for physicians who work in safety-sensitive positions 

where clear-headed judgment and proper action 

can save lives”. 15 

REFERENCES 

1. https://www.iol.co.za/thepost/sas-suicide-rate- 

6th-highest-in-africa-17065768; 

https://africacheck.org/reports/5facts-sadextent-suicide-south-africa/; 

http://www.702.co.za/articles/318667/onesuicide-every-hour-in-south-africa 

2. Damasceno KS, de Sousa Barbosa E, Pimentel 

JVC, et al. Suicide among Physicians and 

Methodological Similarities of MEDLINE/ 

PubMED and BVS/BIREME Open Access 

Bibliographic Databases: A Systematic Review 

with Metanalysis. Health, 2017; 9: 352-375; DOI: 

10.4236/health.2017.92025 February 23, 2017 

3. Schernhammer ES & Colditz, GA. Suicide 

Rates Among Physicians: A Quantitative and 

Gender Assessment (Meta-Analysis). American 

Journal of Psychiatry. 2004; 161(12):@295-2302; 

Published Online: 1 Dec 2004; https://doi. 

org/10.1176/appi.ajp.161.12.2295 

4. Gold KJ, Sen A, Schwenk TL. Details on suicide 

among US physicians: data from the National 

Violent Death Reporting System. Gen Hosp 

Psychiatry. 2013 Jan-Feb;35(1):45-9. doi: 

10.1016/j.genhosppsych.2012.08.005. Epub 

2012 Nov 2. 

5. Carpenter LM, Swerdlow AJ, Fear NT. Mortality 

of doctors in different specialties: findings from 

a cohort of 20000 NHS hospital consultants. 

Occup Environ Med. 1997 Jun;54(6):388-95. 

6. Sheikhmoonesi F, Zarghami M. Prevention of 

Physicians’ Suicide. Iran J Psychiatry Behav Sci. 

2014 Summer; 8(2): 1–3. 

7. Kõlves K, De Leo D. Suicide in medical doctors and 

nurses: an analysis of the Queensland Suicide 

Register. J Nerv Ment Dis. 2013 Nov;201(11):987- 

90. doi: 10.1097/NMD.0000000000000047. 



8. Maslach C 1 , Schaufeli WB, Leiter MP. Job burnout. 

Annu Rev Psychol. 2001;52:397-422. 

9. Collier R. Physician burnout a major concern. 

CMAJ. 2017 Oct 2; 189(39): E1236–E1237. 

doi: 10.1503/cmaj.1095496 

10. Shanafelt TD, Sonja Boone S, Tan, L et al. Burnout 

and Satisfaction With Work-Life Balance Among 

US Physicians Relative to the General US 

Population. Arch Intern Med. 2012;172(18):1377- 

1385. doi:10.1001/archinternmed.2012.3199 

11. http://www.hpcsa-blogs.co.za/assistance-forimpaired-professionals/ 

12. Dhai A 1 , Szabo CP, McQuoid-Mason DJ. The 

impaired practitioner - scope of the problem 

and ethical challenges. S Afr Med J. 2006 

Oct;96(10):1069-72. 

THEY WERE ALSO INTRODUCED TO SASOP 

AND PSYCHMG AS ORGANIZATIONS TO 

ENCOURAGE INVOLVEMENT AT AN EARLY 

STAGE OF THEIR CAREERS. A HIGHLIGHT 

CERTAINLY WAS THE PRESENTATION AT 

THE RFS DINNER ON FRIDAY EVENING 

WHEN DR KIM DOMINGO SHARED HER 

TALK ON THE “MEANING OF WORDS”. 

We had a very lively group this year who engaged 

fully with the process, making it all the more 

enjoyable for both mentors and mentees! 

Dr Ian Westmore 

Convenor 

13. Knapp van Bogaert D, Ogunbanjo G. Ethics 

in health care: “Physician, heal thyself” South 

African Family Practice. 2014; 56(1)(Supplement 

1): S14-S16 

14. SAMA INSIDER. Nov 2017, p8 Depression does 

not discriminate – even doctors suffer from it; 

Jul 2018, pp5-6 Depression: Don’t wait until it’s 

too late; Jul 2018, pp7-8 Take care of your own 

mental health – it’s vitally important; Sep 2018 

Editorial – Gone but not forgotten: Let’s talk 

about mental health; pp6-8 Death by profession 

has a voice: “I am a doctor; I am human too”; 

Oct 2018 (15-17) When the good doctor burns 

out. http://www.samainsider.org.za/index. 

php/SAMAInsider/issue/archive 

Left to right: Dr Eugene Allers, Mvuyiso Talatala and Dr Ian Westmore 

15. Brower, KJ and Michelle B. Riba MB (Eds). 

Physician Mental Health and Well-Being: 

Research and Practice. 1 st Ed, 2017: Springer 

Prof Bernard Janse van Rensburg WITS Department of 

Psychiatry and SASOP Board of Directors. 

3. REPORT ON REGISTRAR FINISHING 

SCHOOL 2018 

Dr Lavinia Lumu 

The Registrar Finishing School (RFS) was held for the 

6 th year running during November 2018 in Sandton, 

Johannesburg, and has become an important fixture 

on the SA Psychiatry calendar. The workshop was 

generously sponsored again by Lundbeck, Adcock- 

Ingram and SASOP/PsychMg. This time around saw 

a record number of attendees (36) comprising 

registrars in their final year of study or those who have 

recently qualified from all over South Africa. 

There were thirteen speakers drawn from both 

the public and the private sector who acted as 

“mentors” to our younger colleagues – the idea was 

to give registrars an idea of what to expect when 

entering private practice, or when remaining in the 

public sector as consultants. 

Dr Ian Westmore 


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

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

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

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

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

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

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

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

South African Psychiatry - February 2019

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