IT'S A STICK-UP. YOUR MONEY OR YOUR HEALTH! - SADAG
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EDITORIAL
IT’S A STICK-UP.
YOUR MONEY OR
YOUR HEALTH!
By Mark Heywood
Executive Director Section 27
Braamfontein, Johannesburg.
Heywood@section27.org.za
T
he Health Market In some instances the costs of people in South Africa (16.9% of
Inquiry report has been medical care for catastrophic illness the population) are members of
published at a rare like cancer can bankrupt a family. medical schemes. Many of them
moment of opportunity The Heart of Private Healthcare, a feel resentful. They feel they pay a
for a new dawn in health report compiled by SECTION27 in lot to medical schemes yet have to
reform in South Africa. In the 2014, told the stories of patients pay still more out of pocket when
context of a crisis in the public and who experienced exactly this. In they need care. We “choose” to use
private health systems, it is the time 2014 as a result of widespread private health care in the shadow
for active citizenship – or forever complaints about rising prices and of Africa’s largest public health
hold your peace. declining benefits the Competition system, a system that is staffed by
Commission set up an inquiry into some of the best specialists in the
Every month I pay R9,568 for myself the private health care market, called world, providing some of the best
and my three dependants for the Health Market Inquiry (HMI). health programmes in the world.
medical aid coverage – insurance, A panel of independent experts But we do so because the public
for want of a better word – to cover was appointed, chaired by former health system is mismanaged,
the costs of access to private Chief Justice Sandile Ngcobo, and characterised by long waiting
healthcare services should we need it began a slow, patient process of times, drug-stock outs, poor
them. That amount is almost three compiling and studying the evidence infection control and is stretched
times the government’s annual per about the private health market. beyond the limit. So the truth is
capita expenditure on public health, The inquiry has been a mammoth that we use private health primarily
currently R4,300. It’s my personal task, involving the study of over out of fear and convenience. When
contribution to an ever-widening 43-million individual patient records, you have a health need it needs to
inequality in health, an issue that 11-million admissions, numerous be met. The HMI report confirms
our Constitution has defined as a written submissions and specially that premiums are rising and
human right: everyone’s right of commissioned studies. benefits are falling. As we see the
“access to health care services”. Over the period 2010 – 2014, grandiose and ostentatious new
When I use this insurance the the average expenditure per buildings of medical schemes
medical scheme often only covers private medical scheme member administrators going up in
a portion of by medical bills. In fact increased by 9.2% per annum. Sandton, many wonder aloud
this year, despite being a healthy At the beginning of July 2018 it whether our premiums pay for
person in a healthy family, of claims published its Provisional Findings more than just our health. Similarly,
totaling R17,000 just over 60% have and Recommendations in a 479 as a new private hospital seems
been covered by my medical aid. page report, backed up by lots of to spring up on every well-heeled
I’m relatively lucky. Touch wood, my mini-reports and annexures. It’s a corner, suspicions grow that our
family don’t suffer much ill health – complex, dense and evidence-heavy health insecurities are feeding a
we know this could change within report. The recommendations made highly profitable business that is
a second which is why we pay for by the HMI may be a once-in-a adding to inequality. Judging by
the insurance. Medical aid scheme lifetime possibility to make private who are the top income earners
members who get cancer or a health well again. it’s also making some people
mental illness, will tell you a much According to the Competition very rich.
worse story. Commission nearly nine million The HMI report suggests that this
MHM Issue 5 | 2018 | MENTAL HEALTH MATTERS | 1
EDITORIAL is possible because most medical one way to keep prices low). All country. The national bed population scheme members don’t know what these factors have combined to of the private sector exceeds that of they are paying for. Neither are they create a perfect storm that drives the public sector, despite servicing able to judge the quality of care up costs. The words the HMI approximately 16% of the overall they receive. In fact, they often don’t uses are polite: “Supplier-induced population … [Thus] the capacity know whether the healthcare they demand”, “unexplained expenditure” needed in the public sector to receive really helps them or even if and “over-servicing”. increase accessibility to public health they need it. Economists call this Finally, it’s not only the rich that care is actually available as excess an ‘information asymmetry’ – put benefit from the private health capacity in the private sector”. simply, the inequality of knowledge market. If we count the elite as between me, the user, and my health being the top 5% of earners (and WHAT IS TO BE DONE? care provider (be it a broker, the their dependants) in South Africa, The HMI report has been published scheme itself or a specialist) leaves they number around two million at a rare moment of opportunity me vulnerable to exploitation. But people. That means that the other for a new dawn in health reform it’s not just my personal health or seven million of us who use private in South Africa. In the context of pocket that suffers. The way the health are middle class or on National Health Insurance (NHI), private system is run impacts low incomes; this includes most health systems are getting closer and negatively on public health – members of trade unions, whose more honest scrutiny. President Cyril and vice versa. Expenditure on leaders negotiated medical aid as Ramaphosa admits there’s a crisis private health, where R235-billion an employee benefit many years in the public health system and, in is spent on nine million people, ago. We spend over R200-billion the face of the evidence compiled by overshadows the R201-billion the a year on our health and then the HMI, there’s little point denying government spends on the other another R4-billion on the services the crisis of private health. However, 44-million. Yet the two systems medical aids refuse to cover. now is not the time for blame or are tied at the hip: they have So, given that it covers so many political point scoring – too many overlapping staff, overlapping lives and given the corresponding people are paying the price. Activists regulatory institutions, and of incapacity of the public system to need to force a new consensus on course an overlapping population take us into its arms, it is clear that health reform, not further divisions. for whom healthcare is a right. we need the private for-profit health The HMI contains a raft of important So as we talk about giving real sector if we are to realise “everyone’s recommendations for regulations, meaning to the Constitutional right right of access to health care systems for effective and fair price of access to health care services, services”. control and institutions to oversee it’s important that we address However, that should not make us the market. But unfortunately the the strengths and weaknesses hostage to (mis)fortune or overlook Competition Commission and of both systems and not just the the duty on the government to the Department of Economic easier-to-target public health intervene in private markets to protect Development have done next to system. But before I go there, let and advance human rights. And this nothing to publicise and simplify its me make several points to blow is where the HMI report becomes very findings or to generate debate. some clouds away from this issue. important. Its overall finding is that Consequently there is a For the time being, the private private health care is characterised danger that if we do not pay the sector is an indispensable part of by “market failure”. In response, recommendations proper attention our health system and economy. its recommendations are not a they will get subverted by those It has world class facilities and “private health grab”, but reasonable, parts of the private sector that do specialists, as well as a dedicated well rationalised, well researched benefit from the status quo, the and a mostly ethical workforce recommendations that will benefit the three very profitable hospital groups, of general practitioners, nurses, whole health system. In this respect or that they are just overlooked by specialists, hospital staff and a vital finding of the HMI concerns a faction in government fixated on administrators. Private doctors the lack of co-operation, planning NHI and ideologically wedded to a are feeling picked on and many and sharing of resources between different path of achieving universal are fleeing the country so it’s also the public and private system. A cold health coverage. Scheme members important to stress that the HMI’s war between these two systems is can contact their administrators or findings are not against the health in nobody’s interests. It means that scheme Trustees about the findings professionals; they are against the while hospitals are full to bursting of the report or challenge the Minister systems that have developed in the one side of the road (public), they of Health to accept and implement absence of adequate regulation are half empty on the other (private). the recommendations. The HMI has and oversight of private health care. The public health system turns its done its work. Now is the time for The HMI provides evidence of an demand away, often to die at home; your active citizenship – or forever over concentration in ownership of the private system has to specially hold your peace. private hospitals; they point to the manufacture demand by ensuring that power of for-profit medical scheme its much smaller population over- administrators vis a vis the not- utilises its most expensive services. Full opinion piece was published in for profit schemes they manage; “While there is excess capacity in Daily Maverick the absence of accountability of most provinces in the private sector, https://www.dailymaverick.co.za/ trustees, consumer ignorance and there are widespread shortages in opinionista/2018-09-06-its-a the collapse of price controls (as the public sector throughout the stick-up-your-money-or-your-health/ 2 | MENTAL HEALTH MATTERS | Issue 5 | 2018 MHM
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MHM
EDITOR
Dr Frans Korb
Psychiatrist & Psychologist, Johannesburg
Zane Wilson
Founder SADAG
ADVISORY BOARD MENTAL HEALTH MATTERS
CONTENTS
Neil Amoore, Psychologist, Johannesburg
Dr Jan Chabalala, Psychiatrist, Johannesburg
Dr Lori Eddy, Psychologist, Johannesburg
Prof Crick Lund, Psychiatrist, Cape Town
Dr Rykie Liebenberg, Psychiatrist, Johannesburg
Dr Colinda Linde, Psychologist, Johannesburg VOLUME 5 • ISSUE 5 • 2018
Zamo Mbele, Psychologist, Johannesburg
Nkini Phasha, SADAG Director, Johannesburg
David Rosenstein, Psychologist, Cape Town
EDITORIAL
It’s a stick-up. Your money 01 06
Prof Dan Stein, Psychiatrist, Cape Town or your health!
Prof Bernard van Rensburg, Psychiatrist, Johannesburg M Heywood
Dr Sheldon Zilesnick, Psychiatrist, Johannesburg
COPY EDITOR
Marion Scher Suicide’s aftermath:
Finding calm in the chaos 06 08
EDITORIAL ASSISTANT C Campbell & C Grobler
Tracy Mukute
SADAG
Cassey Chambers What is Schizoaffective
08
SADAG CONTACT DETAILS
Disorder Compared to
Schizophrenia? 13
www.sadag.org T Moodley
Tel: 0800 21 22 23
Tel: 011 234 4837
Email: zane@sadag.org
ADHD – ‘Ritalin’ again?
13
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SUICIDE’S AFTERMATH:
FINDING CALM IN THE CHAOS
Claudia Campbell Prof Christoffel Grobler
Social Science consultant Psychaitrist
Mental Health care user Mental Health care user
Johannesburg Port Elizabeth
claudia@redbench.co.za dr.stof@mweb.co,za
‘Suicide’ – it’s a word, a term, verb, add up and become supportive: For profession to the collective voice of
noun, feeling and a thought. The instance groups where there is open those with mental illness. Mental
voice of suicide has been for the discussion, help.” health care providers tend to talk to
most part a silent voice – mute. individuals or even groups, but rarely
Often we shy away from speaking It’s a hard truth that when you’re find a forum where mental health
about a death which has been self- involved with the mental health care provider and user share the
induced. care system, in whichever capacity, same platform. It’s not uncommon
you will at some stage be exposed for mental health care providers
“Suicide is an unpleasant topic to to suicide - either in discussion, to themselves be mental health
speak about. Feelings of uncertainty debate, or more personally having to care users or visa-versa. Therefore,
usually precede any discussion about handle the suicide of a patient, client, platforms that offer all participants an
suicide” colleague or friend. Even though opportunity for equal expression, one
the authors engage with the mental free of labels, may provide immense
Having open conversations about health care system in different insights and explore territories
suicide is difficult for almost ways and in different capacities, previously deemed taboo to speak
everyone – where does one begin it’s true that all of our lives have felt openly about. Professional identities
to find calm amidst the chaos left in the tremor the effects of suicide aside, all authors of this article are
suicides’ wake? leave, on us personally and on those mental health care users themselves.
around us. As such, although some professional
“Tragedies like suicide leave us in a When discussing the format of perspectives are included, this forum
certain state of mind – sometimes this article there was deliberation has provided a chance for people
the future seems bleak. We find regarding on whose opinions and whose voices are positioned in a
ourselves asking if we can trust experiences it should be based. We manner quite often overlooked to be
ourselves. However, if we all speak referred to the seeming inattention heard – those of the mental health
up, the different perspectives heard amongst the mental health care care user. All contributors to this
6 | MENTAL HEALTH MATTERS | Issue 5 | 2018 MHM
article have experienced suicide be spent delving into why each health care users and professionals
in some manner - patients under individual who chooses to end their alike felt shaken. However, it was this
psychiatric admission, clients who lives do so. Understanding or at least discussion that forms the basis of
were residents of a psychosocial attempting to understand a person’s this article. Due to the nature of their
rehabilitation centre, and fellow choice of suicide can go some way life circumstances many individuals
mental health care users. in helping those left behind make who are residents of a centre that
sense of their own feelings and quiet provides mental health-care services
“Everyone involved in the topic of the toxic, yet permeating whisper have profound insights into suicide
suicide, the consequences of a suicide of guilt. However, when someone as a concept, as well as how suicides
or their own suicidal feelings need to takes their life, no matter the setting, reverberate into the world around
have coping mechanisms ready at it’s not only their family and friends them. These individuals have a wealth
hand. This will assist all of us to deal who are affected by their suicide, but of knowledge about tools that can
with suicides and their consequences.” all who knew the person, including help others manage the aftershocks
fellow mental health care users and of a suicide. The value of the insight
Recently a poignant and important mental health care providers. The and knowledge held by individuals
piece of writing by Professor Lizette result is that these individuals need who engage with mental health care
Rabé was published that provides to engage with the topic of ‘suicide’ in a full-time residential capacity
a wealth of food-for-thought and that has been, and largely remains a should not be underestimated,
reflection. In her open letter to difficult and taboo territory to traverse. and certainly not side-lined by
students after the death of Prof We need to ask those that have been professionals.
Mayosi, dean of the faculty of health personally affected how to approach
sciences at UCT, Prof Rabé, who lost this discourse. This includes asking “Just as we treat guests with kindness,
her son, a medical student in his mental health care providers if they hospitality and generosity, we need
fourth year to depression, suggests are partly to blame for this taboo to try and find ways to ‘be guests to
that suicide be seen as the terminal because they may be blaming ourselves’ – to treat ourselves with
phase of a biological disease themselves in some way for failing those qualities. If we do this, perhaps
that claims its victims seemingly the human being that died by suicide? we won’t chastise ourselves so much
anywhere, any time. if we feel we have had moments of
“When everyone is transparent it helps suicidality.”
“Be alert to those around you and us to develop trust in ourselves. I think
whether you can pick up possible signs that is true for professionals also These residents and co-authors
they may be in trouble”. being willing to be transparent about participated with the specific intent
their own feelings when dealing with of not only passing their insights
Prof Rabé encourages medical the aftermath of suicide. Perhaps we forward, but also adding to a
students to speak openly, as opposed can just help each other as humans process, which will hopefully assist
to keeping quiet on this topic, which during these times, instead of only in opening up conversations about
will only perpetuate the stigma and professionals helping patients.” suicide. Conversations that may
silence around mental illness. This begin to chip away at the power of
advice extends beyond medical “Finding hope within ourselves helps associated stigma and help people
students to the population in general. to understand the dilemma created speak about difficult thoughts before
We’re in complete agreement with around us by a suicide.” those thoughts become a threat to
Professor Rabé. Only by having an their lives.
open and honest discourse about It’s agreed by all those who have
suicide, as equals in the aftermath given input into compiling this “We need to remember that regardless
thereof, can we begin to rethink the article, mental health care users to of our diagnosis we are all human.”
words we use, breaking the taboo, counsellors, psychiatrists to nurses,
closing the divide and finding our that in our studies and experience we Everyone involved has to ask
human connection in the process. have found no manual, no textbook, themselves: what is the reason for
And we can’t help wondering about which provides a fool proof procedure the divide between mental health
what common themes will emerge. to deal with the aftermath of a suicide. care provider/mental health care
user which seemingly hinders public
“Finding a way to cope in the aftermath “We tend to bottle up dangerous debate between the two groups?
of suicide is essential. Sometimes issues, so it is very important to share Ironically, it’s known that doctors are
though it seems overwhelming and it them. By doing this you begin to amongst the professions in the world
helps when we can talk in formalised develop relationships that help you to with the highest suicide rate...
forums, such as support groups or trust ‘somebody is in your corner’.”
with doctors and counsellors. These “The concept of worth seems critical.
discussions prompt us to discover the In the absence of a ‘textbook’, the day The gift of life is valuable. If we all
coping mechanisms that we already after a suicide occurred at one mental work on our ability to notice what is
possess.” health care centre an open discussion happening in the lives of those around
was held with a group of residents. us, we might be able to help them
It’s absolutely true that time should Each person in the room, mental thrive and not just survive.”
Thank you to all Mental Health care users that shared their experiences
MHM Issue 5 | 2018 | MENTAL HEALTH MATTERS | 7
By Dr Thuraisha Moodley
Clinical Psychologist
Morningside, Johannesburg
info@drtmoodley.co.za
WHAT IS
SCHIZOAFFECTIVE
DISORDER COMPARED
TO SCHIZOPHRENIA?
M
ental illness can often with schizoaffective disorder are and both types of symptoms present
feel overwhelming to often incorrectly diagnosed at in the patient at the same time or
those who struggle first with bipolar mood disorder or within two weeks of each other.
to understand the schizophrenia because it shares
signs and symptoms. symptoms of multiple mental health The word schizoaffective has two
General practitioners, psychiatrists, conditions. parts:
clinical psychologists and other Schizoaffective disorder and • ‘schizo–‘ refers to psychotic
mental health professionals are schizophrenia are two different symptoms and
trained to diagnose mental illness, disorders, each with its own • ‘–affective’ refers to mood
so having awareness of the subtle diagnostic criteria and treatment. symptoms.
signs and presentations of the They are both defined as psychiatric
various disorders can help connect disorders in the latest version of the A patient may experience times
your patient with the proper Diagnostic and Statistical Manual of when they struggle to care for
treatment and improve his/her Mental Disorders (DSM V). themselves, from basic grooming to
quality of life. A schizoaffective disorder lacking insight into their behaviour/
Most health practitioners have diagnosis is given if the patient awareness of how they’re feeling
knowledge of schizophrenia and experiences: – this is an indication that they are
can list some of the symptoms. psychotic symptoms, similar between episodes. The episodes
However, schizoaffective disorder to schizophrenia and mood vary in length. Some patients have
is less well known. Many people symptoms of biploar mood disorder repeated episodes but this does not
8 | MENTAL HEALTH MATTERS | Issue 5 | 2018 MHM
necessarily happen and it may not psychotic symptoms may or may
be a lifetime diagnosis. not be present during the times
In essence, schizoaffective disorder when a person is experiencing
is a mental health condition in which depression or mania. That
a person experiences psychotic being said, the diagnosis of
symptoms of schizophrenia, schizoaffective disorder requires
such as delusions, hallucinations, that the psychotic symptoms be
disorganized thinking or flat affect; present for a long enough time (at
along with symptoms of a mood least a few weeks) when a person is
disorder, such as depression and/or not experiencing any serious mood
mania. symptoms.
There are two types of (3) The major differences between
schizoaffective disorder: the symptoms and presentation in
the two disorders:
(1) Bipolar type: characterised Schizophrenia affects roughly 1%
by episodes of mania and major of the population. Men typically
depression. develop schizophrenia in their
(2) Depressive type: characterised early 20s; women typically develop worthlessness
by episodes of major depression it in their late 20s or early 30s. In • difficulty concentrating
without mania. order to receive a clinical diagnosis • thoughts of death or suicide
Subtle differences in symptoms can of schizophrenia, the following
help differentiate between the two symptoms must be experienced for A manic episode requires a period
disorders. For example, a person more than a month: of elevated or irritable mood and
who has schizophrenia can become • Delusions – Beliefs that increased activity or energy for at
depressed or manic however, these have no evidence in reality. least one week and at least three of
mood-disordered symptoms are not • Hallucinations – Seeing, the following symptoms:
generally a prominent or persistent hearing, or sensing things • increased self-esteem or
part of the condition. The time course, that are not real. sense of grandiosity
prognosis and treatment also differ in • Disorganized speech • needing less sleep
minor ways. – Meaningless words or • becoming more talkative
sentences that do not fit • racing thoughts
Important differences between together. • being easily distracted
schizophrenia and schizoaffective • Disorganized or catatonic • more goal-directed activity
disorder include: behaviour – Agitated or (energy)
(1) The duration of mood episodes bizarre behaviour or a lack • engaging in risky behaviours
and psychotic episodes are different. of responsiveness. (i.e., sexual, financial, etc.)
A person who has schizoaffective • General apathy – Neglecting
disorder is likely to experience severe personal hygiene, lack of DIAGNOSIS
mood symptoms accounting for more interest in activities, or a There are no laboratory tests
than half of the total duration of the lack of facial expressions. to specifically diagnose
illness. By contrast, a person who has schizoaffective disorder. Health
schizophrenia may also experience Comparatively, schizoaffective professionals therefore rely on
mood episodes but the total duration disorder affects roughly 0.3% of the a person’s medical history and
of the mood symptoms is brief population. Men typically develop may use various tests such as
compared to the duration of the schizoaffective disorder earlier than brain imaging (e.g., MRI scans)
psychotic symptoms. Furthermore, women. Furthermore, a person with and blood tests to ensure that a
the duration of psychotic symptoms schizoaffective disorder exhibits physical illness is not the reason
of schizophrenia tend to be persistent, the symptoms of schizophrenia for the symptoms.
while in schizoaffective disorder, they (listed above) in addition to a mood If the medical practioner finds
tend to come and go. episode including depression and no physical cause, they may
mania. refer the person to a psychiatrist
(2) In terms of the course of the or clinical psychologist. These
disease, most people who are A depressive episode requires five mental health professionals
diagnosed with schizophrenia have or more of the following symptoms are trained to diagnose and
a chronic and persistent course of during a two-week period: treat mental illnesses. They use
illness. By contrast, most people • depressed mood clinical observation and specific
diagnosed with schizoaffective • lack of pleasure in activities diagnostic assessment tools to
disorder experience episodes of the person used to engage in evaluate a person for a psychiatric
symptoms and are more likely to have • fluctuation in weight or disorder/psychotic disorder.
symptom-free intervals than people appetite In order to diagnose someone
who have schizophrenia. However, • disturbances in sleep pattern with schizoaffective disorder,
this is not a hard and fast rule; in • slowing of movement the person must have periods of
some people, the opposite is true. • lack of energy uninterrupted illness and, at some
In schizoaffective disorder, the • feelings of guilt or point, an episode of mania, major
MHM Issue 5 | 2018 | MENTAL HEALTH MATTERS | 9
We don’t know why someone might
develop schizoaffective symptoms
rather than schizophrenia or bipolar
disorder. It may be that all of these
conditions are on a spectrum
of ways that individuals may be
affected by life events.
TREATMENT
Schizoaffective disorder and
schizophrenia may be treated and
managed in the following ways:
Through medication –
depression or a mix of both – CAUSES including mood stabilizers,
while also having symptoms of The etiology of schizoaffective antipsychotic medications and
schizophrenia. The person must disorder is unknown. Factors that may antidepressants, depending on the
also have had a period of at least contribute to the disorder include: presenting symptoms.
two weeks of psychotic symptoms • Brain structure and function:
without the mood (depression or People with schizophrenia Psychotherapy also assists in
bipolar) symptoms. and mood disorders may creating more self-regulation and
have problems with management of the experienced
Key signs in clinical presentation brain circuits that manage symptoms. Therapy modalities such
for the Medical Practitioner to mood and thinking. as cognitive behavioural therapy
be aware of when evaluating for • Environment: Factors such and/or family-focused therapy have
schizophrenia or schizoaffective as a viral infection, unhealthy proven effective.
disorder: relationships, highly stressful Psychotherapy helps people with
• Personal hygiene - good or situations and /or trauma mental disorders to understand the
poor? may trigger schizoaffective behaviours, emotions and ideas
• Is the person generally disorder in people who are at that contribute to their illness and
cooperative or easily risk for it. learn how to modify them. Also, the
agitated? • Stressful life events or patient has an ability to understand
• Do the facial expressions trauma: This is more likely and identify the life problems or
match the mood? to be a cause if the person events, like a major illness, a death
• Does the patient make eye experienced a stressful or in the family, a loss of a job or a
contact? traumatic event/s when they divorce that has contributed to
• Are the movements slow, were young and didn’t have his or her illness and help him/her
as if the person is moving adequate coping skills to deal understand which aspects of those
through water? with the experience or the problems he/she may be able to
• Do words and sentences person had not been cared solve or improve on. The patient is
follow a normal thought for in a way that helped able to regain a sense of control
process? them to develop coping and pleasure in life. In addition,
• Does the person appear skills. Subsequently, this they are able to learn healthy
depressed or manic? person may be particularly coping techniques and problem-
• Does he or she have a vulnerable to a relapse in solving skills, learn how to form
grandiose sense of self? times of stress. healthy relationships, learn new
• Does the patient know his/ • Genetic influences: A person healthy behaviours and acquire new
her name? Can he/she tell may inherit a tendency to life skills.
you the day of the week? develop schizoaffective Living with schizoaffective
• Does the patient respond disorder from his/her disorder is very much like living
to stimuli that are parents or family members. with schizophrenia, except
imaginary? The psychotic and mood that there is a prominent mood
• Does the patient have symptoms tend to run in component with schizoaffective
paranoid thoughts? families. The person may disorder. It’s debilitating to live
• Does the patient have be more likely to develop with when not treated. While these
suicidal thoughts? the symptoms if a close disorders are serious and interfere
• Has the patient recently relative has a diagnosis of substantially with daily life, they can
used drugs and/or alcohol? bipolar mood disorder or be managed with proper treatment,
schizophrenia. However, which can significantly, positively
The presence of these symptoms there is not much research impact the quality of life for the
typically lasts for at least six evidence for a genetic person living with the disorder
months, unless mitigated by explanation and many with the adequate pharmaceutical,
treatment. They must interfere with people who have this psychotherapeutic and family
self-care, work, or relationships, diagnosis have no family support.
and cannot be caused by drugs or history of mental health
alcohol. problems. References available upon request
10 | MENTAL HEALTH MATTERS | Issue 5 | 2018 MHMS CH I ZOPHRENIA Several faces, one therapy. Indicated for acute forms or phases of schizophrenia psychoses ¹ Psychotic disorders with manic, paranoid or hallucinatory symptoms 1.2 Non psychotic disorders to depress excitation and also psycho-reactive or neurotic symptoms 1 REC OMM E N D E D D O S I N G Initial Treatment Normal Daily Dose: 120 - 160 mg 1 • Orally 3 to 4 tablets in 2-3 divided doses • IM or IV 3 to 4 ampoules in 2-3 divided doses Refrences: 1. Etomine South African Approved Package Insert. Approved 19th September 1995. 2. González CA. Expert Report ons Clotiapine (Etumina®). Department of Pharmacology, Universidad de Alcalá.
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* (Attention Deficit/Hyperactivity Disorder)
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OROS TECHNOLOGY
* OROS® Osmotic controlled - release oral delivery system
S6 Concerta® 18, 27, 36 or 54 mg extended release tablets containing 18 mg, 27 mg, 36 mg or
54 mg of methylphenidate hydrochloride respectively. Reg. Nos. 37/1.2/0322; 42/1.2/0282; 37/1.2/0323 and 37/1.2/0324. For full prescribing information, refer to the latest package
insert (April 2013). JANSSEN PHARMACEUTICA (PTY) LTD, (Reg. No. 1980/011122/07), Building 6, Country Club Estate, 21 Woodlands Drive, Woodmead, 2191. www.janssen.co.za. Medical Info
Line: 0860 11 11 17. PHZA/CONC/1117/0013By Dr Helen Clark
Child & Adolescent
Psychiatrist
Johannesburg
hmclark@mweb.co.za
ADHD – ‘RITALIN’ AGAIN?
I
n a recent radio interview I They’re supported by the popular continue to delay referral of patients
was asked a version of a now press and social media where to appropriate avenues of care.
all too familiar question which information is sustained by regular
went something like “Do you injections from the scientology These are some of my concerns.
still throw ‘Ritalin’ at children for movement. • ‘Ritalin’ is but one preparation
everything, like you did in the old Perhaps of greatest concern of a base drug called
days?” There is still the perception is the number of our colleagues methylphenidate of which
that child psychiatrists, and this there are now a number
question is asked of you as soon of other formulations, e.g
as you identify yourself as such, What is so Concerta, Neucon and
prescribe excessive amounts often lacking is a Contramyl. It’s interesting
of this drug for questionable that many are happy to take
reasons without regard for a host fundamental lack other formulations until they’re
of mythical, yet widely supported, of understanding of informed of its constituents.
side effects. ADHD • Many are reluctant to engage
These concerns are held in the diagnosis of ADHD
significantly by the general public, because of its inevitable link
including parents who present – allied health professionals, to ‘Ritalin’.
to our rooms and teachers at psychologists and even fellow • What is so often lacking
schools who refuse to administer psychiatrists who remain is a fundamental lack of
doses during school time. significantly misinformed and understanding of ADHD or else
MHM Issue 5 | 2018 | MENTAL HEALTH MATTERS | 13an unwillingness to accept
that the child psychiatrist
does know this.
• Many, including the
scientologists, still believe
that ADHD doesn’t exist
and is merely a set of
behaviours which are the
product of bad parenting.
Hence the uncontrolled
child in the supermarket
warrants discipline as well
as an irritated stare at the
already desperate parent in
pursuit. According to this
belief system ADHD as a
biological entity would not
exist so a medication would
not be necessary and in fact
is claimed to have significant bottles of supplements and and don’t want anything bad to
negative effects such as capsules of horrible smelling happen to them.
causing brain damage and fish oils. They are often very • The ‘good parents’ are ones
turning children into zombies. angry children who have who have tried the alternatives
The other interesting theory been labelled as oppositional - the occupational therapy, play
that is proposed against the defiant surviving as they are therapy, neurofeedback - and
use of what has become a on dairy free, gluten free and come to you as a last resort.
‘HATE’ Drug is that ADHD does sugar free diets. Enough to They always have horror stories
in fact exist but is caused make anyone angry. to tell you that they heard
by either deficiencies of • The next problem is even if the from mothers in the parking
certain trace elements in the parent is able to accept the lot outside the school about
child’s diet or the ingestion diagnosis of ADHD they still relatives of theirs, or which they
of certain basic foodstuffs remain totally resistant to the read in the media, of children
to which the child is allergic. use of this potentially ‘toxic’ who sustained brain damage or
It’s always interesting to medication. I always have to became zombies on ‘Ritalin.
me seeing these children in remind myself that these are
my practice (because that’s the good parents. They care I’d like to conclude with one assertive
where they always land up) on very much about their children statement. Methylphenidate is one
of two drugs registered for use in the
treatment of ADHD in South Africa.
Its efficacy and safety has been
demonstrated through extensive
research in children. It does have
side effects which can be carefully
monitored by the child psychiatrist
who is generally very experienced in
making the diagnosis of ADHD and
the use of methylphenidate and can
be trusted in this regard.
There has been a very positive
trend recently in popular press –
magazines, social media, radio and
television - to increase awareness of
mental health issues in children (teen
suicide and anxiety for example).
Isn’t it about time we put ‘Ritalin’
to bed and started educating our
parents, teachers (and of course all
the adults with undiagnosed ADHD)
as well as our colleagues about what
ADHD really is and what the real
efficacy, safety and potential side
effects of the treatments available
are. Treatment of ADHD has the
potential to change the lives of those
affected by ADHD.
14 | MENTAL HEALTH MATTERS | Issue 5 | 2018 MHMPEACE
OF MIND
• ARIZOFY® - the first aripiprazole generic 1,2
• Demonstrated bioequivalence to the
originator 3
• Offering a clear difference in side-effect
profile 4
• Favourable tolerability profile 5
• Promoting treatment adherence 5
3
1
2
References:
1. IMS TPM December 2017. 2. Arizofy Package Insert, MCC approved 29 September 2017. 3. Data on file November 2008. 4. Citrome L. A review of aripiprazole in the treatment of patients
with schizophrenia or bipolar I disorder. Neuropsychiatric Disease and Treatment 2006:2(4) 427–443. 5. Pigott TA, et al. Aripiprazole for the prevention of relapse in stabilized patients with chronic
schizophrenia: A placebo-controlled 26-week study. J Clin Psychiatry 2003; 64(9):1048-1056.
ARIZOFY® 5 mg (tablets). Reg. No.: 46/2.6.5/0874. Each tablet contains 5 mg aripiprazole. ARIZOFY® 10 mg (tablets). Reg. No.: 46/2.6.5/0875. Each tablet contains 10 mg aripiprazole.
S5 ARIZOFY® 15 mg (tablets). Reg. No.: 46/2.6.5/0876. Each tablet contains 15 mg aripiprazole. PHARMACOLOGICAL CLASSIFICATION: A 2.6.5 Tranquilisers – miscellaneous structures.
For full prescribing information refer to the package insert approved by the medicines regulatory authority. Sandoz SA (Pty) Ltd. Reg. No. 1990/001979/07. 72 Steel Road, Spartan, Kempton Park, 1619.
Tel: (011) 929 9000, Fax: (011) 394 7895. Customer Care Line: 0861 726 225/0861 SANCAL. www.sandoz.com SAN.ARI.2018.02.05WHEN PHYSICAL PAIN
MEETS DEPRESSION
By Charity Mkone
Clinical Psychologist
Johannesburg
charitymkone@gmail.com
T
he association between are depressed might struggle • changes in sleep patterns
physical, chronic to improve or maintain physical • changes in appetite
pain and depression health. In turn, chronic pain can • feelings of guilt or despair
is well established. lead to trouble sleeping, increased • lack of energy
Research suggests that stress, or feelings of guilt or • trouble concentrating
approximately 50% of patients who worthlessness associated with • Suicidal thoughts.
suffer from chronic pain suffer depression. These influences can
from some degree of depression. create a cycle that’s hard to break. Some of these symptoms of
The bi-directionality of physical The intricate link between physical depression often coincide with
pain and depression makes it pain and psychiatric illnesses, physical pain in that people
very difficult to know which one such as depression, serve as who are experiencing pain
precedes the other. Answering proof that mental and emotional may have difficulty falling and
the question ‘did pain cause experiences can and do manifest staying asleep due to the pain;
physically. they may have diminished
Pain and depression create functioning in the times when
a vicious cycle in which pain they do feel physical pain, and
worsens symptoms of depression, perhaps as a result, harbour
Pain and depression and the resulting depression feelings of guilt or despair
create a vicious worsens feelings of pain. It about the loss of agility and
cycle in which pain is important to note the most full capacity due to the feeling
common symptoms of depression, of being in pain.
worsens symptoms of which include: With regards to the biological
depression bases of depression, a
• lack of interest in activities useful metaphor is to think
• depressed mood or about the hormones and
irritability neurotransmitters in the body
as a monthly budget.
depression or did depression For instance, if one
cause pain?’ is often an onerous has R100 worth of
task for health practitioners. This neurotransmitters
is because the same chemicals and chemicals,
in the brain that modulate mood R50 of that
are the same ones that affect a could arguably
number of physical systems in the go towards
body, especially pain. adequately and
A noteworthy point is that a
diagnosis of depression itself can
lead to physical pain. Depression
frequently causes unexplained
pain, such as headaches or
back pain, and people who
16 | MENTAL HEALTH MATTERS | Issue 5 | 2018 MHMsuccessfully facing the above symptoms may well They can also work with day, leaving the person with serve as coping mechanisms patients’ families to help about 50% of that capacity that one employs to try to cope them better understand to utilise in high stress and with the physical pain. chronic pain and challenging circumstances To this end, to think depression. they may encounter. When of chronic physical pain • A Physical Therapist. A considering someone who is in conditions and psychiatric physical therapist who physical, chronic pain, the use disorders as two can help improve mobility, of neurotransmitters would manifestations of a singular reduce pain, and increase arguably be R85. The effort process can help doctors low mood by introducing and experience of discomfort effectively treat and take note helpful exercises and evidently requires a great deal of both. Assembling of a muscle relaxation of both mental and physical comprehensive treatment team techniques. resources in order for the and treatment is of utmost Other professionals such as person to achieve importance. Patients benefit nutritionists, acupuncturists, and even the simplest tasks, leaving the most when chronic pain occupational therapists can provide them with a diminished reserve and depression are treated special knowledge to help curb to tackle the more demanding together and utilise a team of chronic pain and depression. and challenging tasks. people. This team of experts Owing to the analogy, may include: References available it’s clearer to see how the • Physician. A physician upon request. experience of physical pain can provide a thorough may masquerade as or lead examination and to symptoms of depression. evaluation, give a An individual who is suffering diagnosis, and, if from chronic pain may lack necessary, prescribe the energy to participate both pain and psychiatric in activities once enjoyed medications. because of the pain that they • Pain specialist. A pain feel, or they may feel irritable specialist can educate and have a low mood due to the patient about the lack of or poor quality sleep relationship between due to being in pain. The lack chronic pain and of energy may also be as a depression and help result of having to manage design a treatment plan. and cope with the pain. Things • A psychologist/ such as withdrawal, sleeping psychotherapist. Regular more (perhaps due to sedation sessions with a therapist from analgesics), over-or-under trained in any form of eating, abusing substances psychotherapy, can etc., may tick all the boxes help address anxious or for a depressive episode or negative thinking patterns disorder, however, it’s worth and teach coping skills noting that if someone is in that reduce symptoms of chronic, physical pain, the both pain and depression. MHM Issue 5 | 2018 | MENTAL HEALTH MATTERS | 17
DEAR ADDICTION, I’M
APPALLED BY YOUR
BEHAVIOUR:
P.S. I STILL LOVE YOU
By Craig M. Traub
Clinical Psychologist & Criminologist
Sandton, Gauteng
www.craigmtraub.com
craigmtraub@gmail.com
Consider defining addiction (Latin: upon health; safety; criminality; and repulsion from the
addicere, meaning, “devotion”, progression in life; and/or, realities of being human
“enslavement”, or “compulsion”,) relations with partners, family or and average, in most ways,
as a kind of excessive relationship, friends. In sum, this excessive is commonly witnessed in a
superseding all others. This relationship to substances or ‘go-big-or-go-home’ attitude,
excessive relationship is processes, to provide a semi- described aptly by family and
dedicated to narcotics (Greek: unconscious state, may exist with friends as ‘Dr Jekyll and Mr
narke, meaning, “numbness”, severe multifaceted outcomes. Hyde’.
“deadness”, or “stupor”,) in order • Emotional Avoidance:
to instil a liveable state of semi- The excessive use of substances The limited feeling-word
unconsciousness. Narcotics, and processes reinforce the vocabulary and conflict
therein, involve both legal and psychodynamic structure of the avoidance approach highlights
illegal substances (e.g. alcohol, person with an addiction, which in the tremendous difficulty in
cocaine) and processes (e.g. turn, propels further misuse. That honest, meaningful, long-
gambling, prostitution). The structure is briefly envisaged as: term relationships, as well as,
problematic nature of this • Dichotomy: The intolerability coping with internal feelings
relationship is reflective of the toward boredom and of loss, rejection, failure, grief,
negative duration and severity stagnation (often ironically) guilt and shame, for example.
18 | MENTAL HEALTH MATTERS | Issue 5 | 2018 MHM• Entitlement (i.e. “I want, what accommodation to others knows triggers me to use!”)
I want, when I want it, which with the expectation of • Minimisation: To fuse denial
is now”): The ‘king baby’ need having one’s own needs met and rationalisation to distort
for short-term, immediate immediately (e.g. “I’m on time the significance of a behaviour
gratification of reward (or even for my appointment and taken (e.g. “I only occasionally drink
punishment) – presenting all my meds… I was wondering to take the edge off, like most
often as a ‘‘know-it-all’ sense if you could book me off people, so could there be
of self-absorption and/ work… or consider temporary another reason for my failing
or apathy toward others – disability…. Why not!?! I do liver?”)
negatively impacts dedication everything you ask! Please!”) • Moralisation: To use
to treatment and other • Tantrums: Intentional injury morality to justify one’s own
meaningfully, long-term to person or property when a inappropriate behaviour (e.g.
positive behaviours and boundary has been set (e.g. “My wife found empty bottles
investments. “Why can’t I use my cellphone under my car seat, after I said
• Omnipotence: The frequent in groups!?! I’m gonna leave, if I quit, but what kind of person
(and self-protective) need you don’t let me! This place is looks there? Trust is vital!”)
to puppeteer the thoughts, so unfair!“) • Perfectionism: To protect
behaviours and emotions of oneself against the pain
others, in conjunction with Cognitive Biases: of making a simple human
initial superficial charm (and • Availability (Heuristic) Bias: mistake (e.g. “I accidently
‘illusory attachment’ on behalf To use a single, overvalued, took a sip – my sobriety was
of the practitioner), often readily available example, done. So, I just drank the rest
prevents the depth required to contradict a multitude of of night”)
in sober, healthy, long-term opposing examples (e.g. “I • Withdrawal: To physically
relationships. knew this one guy who drank avoid or escape situations
• Self-Destruction: In spite of and smoked into his 90s, so I’ll that are experienced as
the paradoxical egocentrism, be fine”) emotionally challenging (e.g.
the capacity to disavowal the • Backfire Effect: To be further “This place is awful – I’m
healthy and good aspects of entrenched into one’s own leaving this facility!”)
assistance (and even that position directly due to a
of themselves), bolsters the challenge to that position (e.g. Argumentation Fallacies:
readily available employment “You keep insisting otherwise, • Ad Hominem: A distracting
of the ‘f#@k-it’ button, often but actually, I’m so much more personal attack rather than
confusingly and frustratingly productive on cocaine”) legitimately defending one’s
sabotaging progression. • Confirmation Bias: To search own position (e.g. “Maybe I
for, interpret and/or recall use sleeping pills, but at least
MECHANISMS TO PROTECT THE information, to confirm one’s I’m not too busy to attend the
ADDICTION pre-existing beliefs (e.g. “I kids’ soccer matches!”)
Persons with an excessive never see an elderly crack- • Appeal to Authority: Insisting
relationship to substances addict walk around, so they one’s own position is valid
and processes, accordingly, must be able to quit it sooner simply by referring to an
may protect the vitality of that or later”) authority or expert connected
relationship by multiple deceitful • Fundamental Attribution to the matter (e.g. “If cocaine
means, such as: Error: To judge others on their is so bad for my mental health,
character or behaviour, but why did Sigmund Freud use it
Actual Behaviours oneself on the situation (e.g. all the time, huh?”)
• Concealment: Intentional “So the drugs made me behave • Appeal to Emotion: Structuring
omission of addiction-related unpredictably – but I’ve been an argument to manipulate
events (e.g. [“I drove away clean for three weeks – why the recipient’s emotions in
from an accident I caused don’t they trust me? What’s order to win that argument
while high”]) wrong with them?”) (e.g. “Alcohol helps me sleep.
• Fabrication: Intentional false • Reactance Bias: To over- It’s torturous being awake all
retelling of events (e.g. “I compensate against a feeling night. I’ll lose my job if I don’t
booked a session with the of restraint by performing get sleep”)
psychologist, that psychiatrist the opposite action of the • Appeal to Nature: Structuring
recommended, mother”) one proposed (e.g. “I hate an argument as that
• Half-Truths: Intentional authority-figures. I do the which is naturally-grown is
exploitation of linguistic opposite of what I’m told, even legitimate, and thus, correct
loopholes to retell events (e.g. if it’s bad for me”) (e.g. “marijuana is natural,
A: “Did you use the money I and people have used it for
gave you for petrol?” B: “Yes, Psychological Defences: thousands of years, so it can’t
I did [technically, but also on • Externalisation: To blame be that bad”)
drugs. You didn’t ask if I used one’s behaviour on outside • Black-or-White: Structuring an
all the money for petrol]”) circumstances (e.g. “My wife argument in a false ‘either/
• Nice-isms: Intentional fought with me, which she or’ situation, when there is at
MHM Issue 5 | 2018 | MENTAL HEALTH MATTERS | 19least one other option (e.g. and losses, highlight routine disorders, various family
“Would you prefer I died in the and socialisation, identify addictions, past (e.g.
streets, or, stayed with you, and emotions that trigger, and, childhood sexual abuse) or
used heroin?”) localise rejection to specific current (e.g. marital discord,
behaviours (versus entire self). financial issues) traumas,
FOR ADDICTION • Enhance Practitioner ‘illusory attachment’, and
PRACTITIONERS Understanding: It will likely patient sensitivity to shame,
For those noble practitioners help to read addiction guilt, rejection and failure in
taking on the challenge of treating literature, visit self-help groups treatment. Additionally, be
persons with addictions, a few (e.g. AA, OA), note secular aware of one’s own feelings
suggestions are: resources (e.g. The Fix), increase of inadequacy, moralisation,
• Approve of Positive rehabilitation training or ask dejectedness, and, martyrdom.
Behaviours: Any attempts a colleague, and, understand Respect the initial protective
at sobriety (e.g. titration, milestone challenges (e.g. “It’s development of addiction
‘cold turkey’, poly- to mono- nearing 6 months, so now I can relationships
abuse), as well as, any definitely moderate”).
constructive and healthy (vs • Limit Practitioner Expectations: Recommended Readings
destructive and unhealthy) One may expect self-defeating Flores, P. J. (2004). Addiction as
activities, reward systems, behaviours and self-sabotage, an Attachment Disorder. Maryland,
non-deceptions, non- inebriated attendance, USA: Jason Aronson.
procrastinations, self-care, boundary violations (e.g. Khantizan, E. J. (2007). Treating
and expressions of positive non-payment), and poor Addiction as a Human Process.
autonomy, are to be directly, prognosis. In addition, one Maryland, USA: Jason Aronson.
or nonchalantly, commended may expect superficial charm, Khantizan, E. J. & Albanese, M. J.
(despite disavowal). distrust, blaming, impatience, (2008). Understanding Addiction
• Enhance Patient frustration intolerance, as Self Medication: Finding Hope
Understanding: It is important deception, and limited Behind the Pain. Maryland, USA:
to normalise mediocrity attention-spans. Rowman & Littlefield.
and boredom, help identify • Retain Practitioner Awareness: Ulman, R. B. & Paul, H. (1995). The
emotions, explore positive Be aware of patient, partner, Self Psychology of Addiction and Its
entertainment, stoically clarify or family boundary-pushing, Treatment: Narcissus in Wonderland.
short- and long-term gains co-occurring Axis I and II Oxfordshire, UK: Routledge.
20 | MENTAL HEALTH MATTERS | Issue 5 | 2018 MHMYou can also read
