LAUNCHING THE SA NATIONAL MENTAL HEALTH ALLIANCE PARTNERS (SA NMHAP) - The Psychology Couch
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EDITORIAL
LAUNCHING THE SA NATIONAL
MENTAL HEALTH ALLIANCE
PARTNERS (SA NMHAP)
Prof Bernard Janse Van Rensburg
President of SASOP
Psychiatrist at Helen Joseph Hospital
bernard.sasop@mweb.co.za
And
Ms Bharti Patel
National Executive Director for the SA Federation of
Mental Health
bharti@safmh.org
I
n recent years, mental health Partners (SA NMHAP). Current
has received much publicity confirmed advocacy partner
and scrutiny in South Africa members include the South African
due to the Life Esidimeni Society of Psychiatrists (SASOP),
tragedy. While the individuals SA Depression and Anxiety Group
responsible for this shameful (SADAG), SA Federation for Mental
violation of the rights of persons Health (SAFMH), SECTION27, the
with mental disability are yet Rural Health Advocacy Project
to be held accountable, there (RHAP) and its Rural Mental Health
have been many promises and Campaign (RMHC), the Steve
plans developed to address the Biko Centre for Bioethics (SBCB),
poor access to mental health Allan Flisher Centre for Public
care in communities, access to Mental Health), MHLP (Mental
medication, assessment and Health Law Project) and the SAPC
support. Very little however has (South African Psychoanalytic
transpired in terms of actual Confederation). The NMHAP will
services on the ground. be inclusive of all prospective
There is a realisation that partners who can support its
legislation, policy and guidelines terms of reference, purpose and
are merely tools that guide duty objectives, such as other advocacy Prof Bernard Janse Van Rensburg
bearers to develop action plans groups focusing on regions, or President of SASOP
to ensure services are provided to other professional groups who are Psychiatrist at Helen Joseph Hospital
the rights holders. However, the part of the multi-disciplinary team
real struggle is to make sure that in mental health.
duty bearers have the will, capacity The purpose of the SA NMHAP
and dedicated resources to ensure is to provide advocacy and
that persons with mental health oversight towards realising access
issues are able to adequately to mental health care in line with
access mental health care within a the Bill of Rights of South Africa,
recovery model. with the premise that health care
In keeping the mental health can’t be obtained separated from
flame alive we need to join forces the right to dignity and the right
to strengthen the mental health to health. The SA NMHAP will
system by identifying the gaps, continue to be inclusive of all
blockages and obstacles that prospective partners who can
prevent the full recovery of mental support its terms of reference,
health care users. purpose and objectives, such as
A meeting was held recently on other advocacy groups focusing
Saturday, the 9th June 2018, at on regions, or other professional
the SA Mental Health Federation’s groups who are part of the multi-
(SAFMH) offices in Randburg, disciplinary team in mental health. Ms Bharti Patel
to formally constitute the At the official launch meeting, National Executive Director for the
collaboration of the South African the programme included an SA Federation of Mental Health
National Mental Health Alliance overview of the advocacy
MHM Issue 4 | 2018 | MENTAL HEALTH MATTERS | 1
EDITORIAL
partnership that existed since
August 2015, alluding to lessons
learnt from Life Esidimeni and
the Eastern Cape, as well as a
discussion of the components of
a proposed strategic advocacy
plan. The provisional scheduling of
2018/19 activities was discussed,
including an endorsement of
SASOP’s programme for “Human
Rights For People Living With
Mental Illness”. This programme
consists of a poster exhibition
by the German Association of
Psychiatry, Psychotherapy and
Neurology (DGPPN), as well as a
speakers programme, in several
cities in the country, including
Johannesburg, at the WITS Adler
Museum and Pretoria, at the UP
Faculty of Medicine.
One of the first tasks of the
SA NMHAP was to coordinate a
response to the proposed policy
guidelines published in March 2018,
for the licencing of residential and/
or day care facilities for persons
with mental illness and/or severe or
profound intellectual disability. If you Back: Mafoko Phomane (RHAP), Cassey Chambers (SADAG), Rita Thom (SASOP) Ames
would like a copy of the response, Dhai (SBCB), Lesley Robertson (SASOP), Bernard Janse van Rensburg (SASOP)
please contact Front: Sebastian Mansfield-Barry (MHLP), Kate Sherry (RMHC), Lauren Gower (SAPC),
bernard.sasop@mweb.co.za. Bharti Patel (SAFMH)
MHM
MENTAL HEALTH MATTERS
Making Mental Health Matter
2 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHM
HCL
YELATE
(DULOXETINE)
INDICATIONS1
Yelate is indicated for the
treatment of:
• Depression as defined by
DSM-IV Criteria
• Diabetic peripheral
neuropathic pain (DPNP)
in Mental Health
HELPLINE
Dr. Reddy’s
Dr. Reddy’s 0800 21 22 23 www.sadag.co.za
1. Yelate Package Insert.
S5 Yelate 30/60. Each capsule contains duloxetine hydrochloride equivalent to duloxetine 30/60 mg. Reg
No’s 44/1.2/0114;0115. Dr. Reddy’s Laboratories (Pty) Ltd. Reg no. 2002/014163/07. Third Floor, The Place, 1
Sandton Drive, Sandton 2196, South Africa. Tel: +27 11 324 2100, Fax: +27 11 388 1262, www.drreddys.co.za.
N E U R O P S Y C H I AT R Y
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For full prescribing information refer to the package inserts approved by the medicines regulatory authority.
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 4 • 2018
Zamo Mbele, Psychologist, Johannesburg
Nkini Phasha, SADAG Director, Johannesburg
David Rosenstein, Psychologist, Cape Town
EDITORIAL
Launching the SA National 01 06
Prof Dan Stein, Psychiatrist, Cape Town Mental Health Alliance Partners
Prof Bernard van Rensburg, Psychiatrist, Johannesburg (SA NMHAP)
Dr Sheldon Zilesnick, Psychiatrist, Johannesburg B Janse Van Rensburg & B Patel
COPY EDITOR
Marion Scher The multiple colours of
depression: it’s not simply 06 10
EDITORIAL ASSISTANT experiencing the “blues”
Tracy Makute K Laxton
SADAG
Cassey Chambers ADHD and Substance
Use Disorders 10 15
SADAG CONTACT DETAILS D Eliasov
www.sadag.org
Tel: 0800 21 22 23
Tel:
Email:
011 234 4837
zane@sadag.org
Essentials in the
Management of Insomnia 15
F A Korb
MENTAL HEALTH MATTERS 20
is published by In House Publications,
P.O. Box 412748, Craighall, 2024.
Johannesburg, South Africa
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Burnout
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Explaining Narcissism
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MENTAL HEALTH MATTERS
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The views expressed in individual articles are the
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shared by the Editors, the Advertisers or the Publisher.
Living with the loss of
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No articles may be reproduced in any way without the overcome it
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By Dr Kim Laxton
Psychiatrist
Parktown North,
Johannesburg
drkimlaxton@gmail.com
THE MULTIPLE COLOURS OF
DEPRESSION: IT’S NOT SIMPLY
EXPERIENCING THE “BLUES”
T
he Depression Celebrities are speaking openly
Conversation has about their struggles with ‘Burnout’ is the word
become something of a depression, anxiety, eating
fashion topic. disorders and the like. For some,
most often used by
enduring extended hours in the a person who simply
Long gone are the days of pushing office, pushing through emotional cannot face yet
through emotional pain and hiding difficulties, limiting sleep to another day of the
the tears. The workplace and complete tasks and replying to components of his or
family home were expected to emails may be worn as badges her expected life
represent an example of emotional of success. ‘Burnout’ is the word
stability and control. Sad talk most often used by a person who
was not encouraged. Discussions simply cannot face yet another day
of being overwhelmed, lost and of the components of his or her wellbeing in the workplace and
emotional were bound tightly into expected life. prioritising the improvement of
journals and wedged beneath The World Health Organisation organisational structures to benefit
books of self-help, taking control claims that Depression will be the human in the business are
and being your own master. the leading cause of disability gaining important traction.
However, has the pendulum worldwide by 2020. Occupational However little has changed in
swung in the opposite direction? Psychiatry, emotional and mental the new edition of the Diagnostic
6 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHM
and Statistical Manual of Mental Disorders (DSM-5) to describe and elaborate upon the individual symptoms of the diagnosis: Major Depressive Disorder. A low mood, poor motivation, sleeping, appetite and psychomotor changes, fatigue with ruminative thoughts of suicide, worthlessness and guilt still form the cornerstone symptoms of the disorder. Therefore, amidst this global health priority, the changing tone of mental health advocacy, the ongoing need to better the holistic and pharmacological management of depression, the seemingly outdated and simplistic diagnostic description of the illness, where is the human in this story? Depression is essentially a deeply personal journey through which a person meditates in darkness, praying for the faintest twinkle of light, wishing for but subconsciously detesting the thought of stepping out from the shadows. Depression is most often silent in its experience. The words used by the depressed are a feint pencil-sketch of the world they are enduring. And most will say the noise of insomnia is the loudest. Visual experiences become colourless. Food lacks flavour. The music of excitement and anticipation is muffled, an echo with no clear origin. And like a cracked record, repeating itself over-and-over, the person’s own voice creates a dialogue, an array of mental mantras, revisiting and re-emphasising self-worthlessness, guilt and hopelessness. If one’s eyes attempt to take in the external world, there is no separation from the darkness within. Concentration and attention are unsustained and the ability to remember, especially the richness of life, is impossible. As this person starts to “accept” this experience as the new status quo, the knock of suicide might be heard. The key to “ending it all” and breaking free from the jail of a Depression Life Sentence, is grasped, manipulated, prioritised, justified and may finally be inserted into the door. As a health care provider we need to insightfully acknowledge the lived experience of a person with Depression. MHM Issue 4 | 2018 | MENTAL HEALTH MATTERS | 7
Firstly, we must gain their
confidence and trust. As
the patient starts describing
their symptoms lean forward,
open yourself to holding their
pain, whilst keeping quiet and
acknowledging their vulnerability.
Patients will not list the
diagnostic criteria mapped out
in the manual. Instead, they
will provide you with images,
desires and emotions (including
frustration, anger and regret).
They will describe the loss of
friendships, work confrontation
and absenteeism, increased
alcohol consumption and
relational conflict. They will wish
for a “change”, to be able to “just
sleep and forget about life” and
“to simply enjoy living again.” And
on occasion they will describe
how suicide often appears along
this journey as an intrusive but
potentially liberating “off- ramp”.
Depression is a conundrum
in that the disease takes away
desires and motivation except that
wish to “want to want”. Patients them a mental colour: As health care providers we
desperately long for the warmth are called to care. This means
of human touch, yet cannot bring One might select red for phrases of the person before you can feel
themselves to step out of the cold. anger and rage, blue for sadness your desire to hold, protect and
Patients describe themselves and despair, black for loneliness and understand. This person is afraid
as “failures”, to their children, suicidality, grey for self-depreciation and has come to you vulnerable
partners, friends and family. and flashing pink for the noise and desperate. You can choose to
However sadness might not be of insomnia. remain as an educated and clinical
the overwhelming emotional professional or reach deeper
expression, and patients often Look at the person in front of you. into the complex mind of the
describe their low frustration Are they appropriately groomed patient, reframing their cognitive
tolerance, “flying off the handle” to show a level of motivation distortions of themselves and
and an inability to remain calm and self-appreciation? Is the eye their worth and securely holding
with fluctuating “rage and tears”. contact adequately maintained their outward expression of
Work is inevitably compromised or does the downcast expression emotion with a soft, gentle and
with patient’s “not performing reveal evidence of self-loathing reassuring voice.
at my full potential”. They have and shame. What’s the person’s By being both professional and
difficulty attending to tasks display of external emotion? Are human with a patient who is a
and prioritising deadlines. there overt tears or the constant victim of Depression, you’ll not
Concentrating and actively internal attempt to prevent the only become their clinical advisor
participating in work requirements outflow of sadness? Is there but also form part of their journey
is compromised. A single day is anxiety? How quickly does the toward recovery. Listen, watch
“made up of dots of time with person speak? Does the person and hold the patient sitting before
no clear sequence or pattern, regularly shift and change position you. Empathetically acknowledge
forgotten from one moment to as if controlled by an internal force the emotional pain the person has
the next”. of self-doubt? and continues to experience. Look
Some days are better spent for subtle facial expressions and
in bed. A box of dry, crunchy, And wait for those words that language cues that direct you to
sugar-coated cereal becomes a strike that dangerous chord. Ask, your clinical diagnosis. Allow
staple diet, feeding the desire for if you feel you need clarity. But be for the person to feel vulnerable,
sweetness. Fatigue wraps itself cognisant of your tone, the words yet safe.
around the person like a thick, you use and the need to continue And finally prioritise a sense of
grey mist… damp, disorientating to therapeutically hold the person hope for that individual, who has
and paralysing. sitting in front of you. now allowed for a small window to
be opened.
Listen intuitively to the words the “Have you ever, or perhaps recently,
person chooses to use and assign thought about stopping the pain?” References available on request
8 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHM
2
AND SUBSTANCE
USE DISORDERS
By Dr Danella Eliasov
Psychiatrist
Parktown, Johannesburg
deliasov@mac.com
10 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHMA
DHD is a disorder
commonly seen in
clinical practice.
Myth and controversy
surrounds the disorder,
posing challenges to the treating
healthcare professional.
ADHD is essentially a disorder
of inattention, hyperactivity and
impulsivity. According to the DSM-5,
symptoms must have been present
prior to the age of 12 years of age,
must be present in 2 or more settings,
and must cause social, academic
or occupational dysfunction for the
diagnosis to be made.
Thus, a comprehensive history is
essential in all patients. In the case
of children, a collateral history
from parents and/or teachers
is also necessary to make an
accurate diagnosis.
3 subtypes of ADHD are
recognised:
1. Combined presentation (where
inattention, hyperactivity and
impulsivity are present).
2. Predominantly inattentive questions and uncertainties by are particularly common in
presentation adult patients and parents of these patients. Symptom overlap
3. Predominantly hyperactive/ children for whom the medication between various disorders can
impulsive presentation has been prescribed. pose a diagnostic challenge. For
The documentary ‘Take your Pills’ example, a patient may report
ADHD was previously viewed explores the use of stimulants as struggling with poor memory and
as a disorder of childhood and ‘performance enhancing drugs in concentration leading to academic
adolescence, however, ADHD is highly competitive and pressured problems which could result
now increasingly recognised as a academic environments.
disorder of adulthood too. ADHD Adolescents and young adults
symptoms have been shown to using stimulants to cope with
persist into adulthood in as much (what may be unrealistic) A thorough history
as 50% of cases. Furthermore, academic demands is a common
theme and a challenge faced in
and assessment is
adults are now presenting with
symptoms undiagnosed while clinical practice. essential in making
they were children but which In my practice, I have seen and the correct diagnosis
cause significant distress and assessed adolescents brought and identifying any
impairment. In these cases, by a parent (quite frequently as comorbidities
a retrospective diagnosis is an ‘emergency’) who is under the
sometimes made. impression that methylphenidate
During the course of the illness, would enable their child to
symptom presentation may achieve top marks. Often the
change. For example, patients child in question does not suffer from a mood or anxiety disorder
who present with prominent from ADHD at all and is simply rather than ADHD. Impulsivity and
hyperactivity as children may not realistically able to achieve restlessness seen in a hypomanic
present with less hyperactivity but straight A’s. Conversely, a common patient may be confused with
more inattentive symptoms as they scenario occurs where a child, symptoms of ADHD.
approach adulthood. who clearly suffers from ADHD, is Thus, a thorough history and
ADHD is a treatable illness. prevented from being treated by assessment is essential in
Effective pharmacological agents parents who have bought into the making the correct diagnosis and
are available. These include myths and misconceptions around identifying any comorbidities.
stimulants (methylphenidate) and the treatment of ADHD and the One of the controversies
atomoxetine as first line agents. evils of ‘Big Pharma’. surrounding stimulant treatment
These medications have been the Co-morbidities are frequently for ADHD is the issue of substance
subject of much controversy in the seen in patients with ADHD. abuse. Common concerns
media. Healthcare professionals Mood and anxiety disorders as from parents include: “Can my
are inevitably confronted with well as substance use disorders child become addicted to this
MHM Issue 4 | 2018 | MENTAL HEALTH MATTERS | 11medication?”, “I have heard that increased likelihood of impulsive, addiction/abuse as seen with Ritalin can increase the risk of risk-taking behaviour and poor high dose amphetamines, someone becoming a drug addict decision-making, which in turn methamphetamine and cocaine. when they are older...” may result in experimenting with • The faster the effect/uptake, the ADHD itself has been shown to illicit substances. Furthermore, greater the abuse potential. increase the risk of developing individuals may ‘self-medicate’ • Methylphenidate takes an a substance use disorder. These with illicit substances. hour to raise dopamine levels illnesses are frequently co- Healthcare practitioners are whereas cocaine takes seconds. morbid. Furthermore, a family sometimes reluctant to prescribe • Slow dose tonic drug delivery history of ADHD has been shown methylphenidate in a patient with produces beneficial effects to be a risk factor for substance ADHD and a history of substance on ADHD symptom control via abuse. Patients who present abuse, particularly where the dopamine and noradrenaline. with substance use disorders patient has a history of addiction often have a history of current or to stimulants. Ironically, sometimes Thus, slow-release previously untreated ADHD. Thus, these patients would benefit greatly methylphenidate (such as rather than causing an addictive from effective treatment for their Concerta) would have less abuse disorder, ADHD treatment can be co-morbid ADHD. potential than faster acting considered protective in this regard. In such cases, atomoxetine (a formulations. Furthermore, there is Studies have shown that stimulant non-stimulant) may be considered less chance of diversion. therapy doesn’t increase the risk of as an alternative. However, Thus, a thorough history and future substance use/abuse. Methylphenidate can still be clinical assessment together with ADHD symptoms result from prescribed with caution in these frequent follow-up and monitoring abnormalities of frontal cortex cases. Some important factors to would hopefully ensure the right circuitry. Both deficient and bear in mind: medication is prescribed for the excessive arousal are thought correct indication. to play a role in the presenting • High dose, pulsatile delivery of Furthermore, the choice of symptoms. One of the core short acting stimulants exerts pharmacological agent can reduce symptoms of ADHD is impulsivity. effects via dopamine and results the risk of abuse or diversion of This may play a role via an in euphoria and reinforcement, stimulant medications. 12 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHM
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2 Bond Street, MIDRAND, 1685, South Africa. Tel + 27 (0)11 256 3700, Fax +27 (0)11 256 3707. www.sanofi-aventis.com. SAZA.GZOL.17.12.0909ESSENTIALS IN THE MANAGEMENT OF INSOMNIA By Dr Frans A Korb Psychiatrist & Psychologist Johannesburg fakorb@telkomsa.net MHM Issue 4 | 2018 | MENTAL HEALTH MATTERS | 15
S
leep problems must be
one of the most reported
problems in general
medical practice. For
this reason it’s important
that insomnia be understood and
adequately assessed as well as
managed. This article will deal
with some of the practical aspects
of insomnia and give the general
practitioner easy to use tools and
references. For further study of
insomnia the Colleges of Medicine
of South Africa has an accredited
diploma course in Sleep Medicine.
WHAT IS NORMAL SLEEP?
During the night normal sleep goes
into cycles. Five cycles have been
identified:
• Stage 1 - Sleep is light and a
person can easily drift in and out
and be easily awakened.
• Stage 2 - A person moves into
a medium sleep area. Eye
movements stop and brain
waves becomes slower.
• Stage 3 - Delta brain waves
begin to appear which is
extremely slow. A person should
now be fast asleep. and impairment in psychomotor (especially of the brain). School-
• Stage 4 - The brain produces performance. Chronic insomnia age children and teens on average
only sluggish delta waves. This in adults has been reported to be need about 9.5 hours of sleep per
is known as deep sleep which between 20%-30% with at least one night. Most adults need 7-9 hours
is the valuable, restorative third being severely affected with of sleep a night, but after age 60,
type of sleep. These first four absenteeism, frequent accidents, night time sleep tends to be shorter,
stages are referred to as Non- memory impairment, greater lighter, and interrupted by multiple
REM Sleep. health care utilisation and a high awakenings. Elderly people are also
• Stage 5 – Is known as REM risk of major depression and other more likely to take medications that
(Rapid eye movement sleep). In psychiatric illness. interfere with sleep.
this stage breathing becomes Several CNS Neurotransmitters
more irregular and shallow, eyes are involved in sleep. These are WHAT IS INSOMNIA?
moves rapidly and the heart rate for promoting wakefulness/ The DSM-5 describes criteria for
and blood pressure increase. arousal: Acetylcholine (cholinergic), Insomnia Disorder.
This is also the stage where a Noradrenalin (adrenergic),
person dreams. REM sleep also Histamine, Glutamate (excitatory 1) Difficulty initiating sleep
stimulates the brain regions amino acid NT), Dopamine 2) Difficulty maintaining sleep
used for learning and memory. (catecholamine), Serotonin 3) Early-morning awakening with
As the night progresses, REM (indolamine), Hypocretin (Orexin) inability to return to sleep
sleep increases and deep (peptide NTs). The sleep promoting
sleep decreases. CNS Neurotransmitters are GABA WHAT CAUSES INSOMNIA?
(inhibitory amino acid) & Galanin Some of the common causes of
Sleep serves an essential (peptide) as well as Melatonin short-term insomnia are conditions
physiological homeostatic function (hormone of darkness). like illness and pain, adjustment to
in the body including restoration and Often the GP will be asked: how a new time zone or work schedule,
recovery reversing and/or restoring much sleep do I need? As we age specific life stress, a new sleeping
biochemical and/or physiological our sleep patterns and needs environment and medications.
processes, energy conservation, change. There is no magic ‘number’ The management of short-term
memory consolidation, that works for everyone of the insomnia usually doesn’t involve
thermoregulation and homeostasis. same age. According to the sleep any medication.
According to the American data from the National Institute of There are numerous
Sleep Association, in the western Neurological Disorders and Stroke medications that can affect
world transient insomnia has babies initially sleep as much as sleep. Examples of these are
been reported by 48%-73% of 16 to 18 hours per day, which may the antidepressants (including
adults producing sleepiness boost growth and development the SSRI’s), Antihypertensives,
16 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHMSympathomimetics (e.g. Insomnia Severity Index (ISI) (see the longer-term they should be
bronchodilators and Appendix 1) might be the most used intermittently and ideally
decongestants), Anticonvulsants practical for general practice. coupled with behavioural therapy/
and Antineoplastics. Not to forget sleep hygiene.
caffeine, energy drinks, chocolate, MEDICAL TREATMENTS
alcohol and nicotine. Several pharmacological agents PSYCHOLOGICAL TREATMENTS
have been available in South Africa In recent years cognitive behavioural
HOW CAN INSOMNIA BE for the management of insomnia for therapy (CBT) has been found to be
TREATED? many years. The original hypnotics an effective alternative in individuals
The evaluation of sleep disorders were part of the benzodiazepine with insomnia. CBT for insomnia
in a patient is important. Some of group e.g. triazolam, midazolam, (CBTi) has been shown to be a safe
the issues to look at are: nitrazepam, temazepam, and effective therapy in the hands
flurazepam, and loprazolam. The of a trained psychologist.
• Is the sleep disturbance a non-benzodiazepine (Z-Drugs) CBTi follows a structured
symptom of something else or hypnotics available are zolpidem treatment programme which
is it a primary sleep disorder? and zopiclone. The off-label use includes sleep hygiene (behavioural
• Interviewing the bed-partner of drugs such as antidepressants, interventions designed to educate
often gives further invaluable antihistamines and antipsychotics patients about health and
information (e.g. snoring, has become popular due to the environmental factors they can
movements and behaviours non-addictive properties of these change to improve sleep), stimulus
during sleep). agents. Over the counter and control (behavioural intervention
• A thorough sleep, medical herbal medications like melatonin designed to alter habits associated
and psychiatric history and might also be useful as a first with bed/bedroom and promote
physical examination. option. Complementary and consistency in sleep patterns),
alternative approaches, including sleep restriction (behavioural
Psychiatric screening scales (e.g. acupuncture and Chinese herbal intervention designed to limit time
Beck Depression Inventory and medicine, have also been used to in bed to sleep only), cognitive
Hamilton Anxiety Rating Scale) and treat insomnia. therapy (intervention to change
sleep inventories (e.g. Stanford The question is always asked thought patterns regarding sleep
sleepiness scale and the Epworth when to prescribe a sleeping by identifying, dispelling, and
sleepiness scale) can also be tablet? Hypnotics are usually replacing dysfunctional beliefs
useful. The use of patient sleep indicated when daytime function and perspectives) and relaxation
logs/diaries can also be requested. is impaired, when insomnia training (training to control thought
In some cases a patient can also is associated with a medical patterns and somatic tension that
be referred to a sleep clinic for a condition and behavioural interfere with sleep). Appendix
formal assessment and possible approaches are ineffective. 2 provides an example of Good
polysomnogram. Furthermore the correct use Sleep Hygiene.
Although several questionnaires should be to prescribe hypnotics
exist to measure insomnia the initially nightly for 3-4 weeks. In References available on request
MHM Issue 4 | 2018 | MENTAL HEALTH MATTERS | 17APPENDIX 1 : THE INSOMNIA SEVERITY INDEX
The Insomnia Severity Index has 7 questions. The 7 answers are added up to get a total score. When you have your
total score, look at the ‘Guidelines for Scoring/Interpretation’ below to see where your sleep difficulty fits.
For each question, please CIRCLE the number that best describes your answer.
Please rate the CURRENT (i.e., LAST 2 WEEKS) SEVERITY of your insomnia problem(s).
Insomnia Problem None Mild Moderate Severe Very Severe
1. Difficulty falling asleep 0 1 2 3 4
2. Difficulty staying asleep 0 1 2 3 4
3. Problems waking up too early 0 1 2 3 4
4. How SATIFIED/DISSATISFIED are you with your CURRENT sleep pattern?
Very Satisfied Satisfied Moderately Satisfied Dissatisfied Very Dissatisfied
0 1 2 3 4
5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of
your life?
Not at All Noticeable A Little Somewhat Much Very Much Noticeable
0 1 2 3 4
6. How WORRIED / DISTRESSED are you about your current sleep problem?
Not at All Worried A Little Somewhat Much Very Much Worried
0 1 2 3 4
7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning
(e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood)
CURRENTLY?
Not at All Interfering A Little Somewhat Much Very Much Interfering
0 1 2 3 4
Guidelines for Scoring/Interpretation:
Add the scores for all 7 items (Questions 1+2+3+4+5+6+7) = ____________ your total score
Total score categories:
0-7= No clinically significant Insomnia 8-14= Subthreshold insomnia
15-21 = Clinical insomnia (moderate severity) 22-28 = Clinical insomnia (severe)
APPENDIX 2 : PRINCIPLES OF GOOD SLEEP HYGIENE
• Maintain regular sleep/wake schedule whenever possible (even on weekends and vacations)
• Exposure to light in the morning hours
• Avoid caffeine and nicotine, especially 4 to 6 hours before bedtime (after lunch). These substances can
disrupt sleep
• Avoid alcohol and heavy large meals before sleep
• Exercise regularly; avoid vigorous exercise within 3 to 4 hours of sleep (regular exercise can help sleep)
• Limit time in bed to time spent sleeping (and sex)
• Establish a regular, relaxing (stop worries) bed time routine. Get comfortable (comfortable sleep
environment) and relaxed before bedtime. Also follow a regular daytime routine.
• Avoid napping during the day, especially after 3pm. Limit naps to < 1 hour
18 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHMThe fine art of mental health treatment
te ron
ir
o-M
Adc
PUT BACK the PIECES with Adco-Mirteron
Adco-Mirteron
MIRTAZAPINE
S5 Adco-Mirteron 15. Each film-coated tablet contains mirtazapine 15 mg. Reg. No. 39/1.2/0217. S5 Adco-Mirteron
30. Each film-coated tablet contains mirtazapine 30 mg. Reg. No. 39/1.2/0218. For full prescribing information,
refer to the package insert approved by the medicines regulatory authority. 1046987 08/2017. Adcock Ingram
Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021. Tel. +27 11 635 0000 www.adcock.comPRACTICAL WAYS FOR
A FAMILY TO COPE WITH
SEVERE SCHIZOPHRENIA /
PSYCHOSIS IN THEIR FAMILY
By Cheryl-Anne Johnston
Holistic Counsellor and Case Manager
Sandton, Johannesburg
Cheryl@cjcounselling.co.za
RECEIVING BAD NEWS mental health professionals and from professionals, such as
Severe mental illness of a family specialists for assistance. Psychologists, Psychiatrists,
member has a major impact on Psychiatric Institutions and
parents, children, and spouses/ SEVERE MENTAL ILLNESS - Non Profit Organisations,
partners. The range of emotions WHO IS TO BLAME? such as the South African
experienced can be overwhelming, It’s well known that severe Depression and Anxiety Group.
such as anger, sadness, guilt and mental illnesses have a major Psycho-education has proved
shame. Grief is often experienced biological factor. Some people are effective in helping families
due to the losses that accompany more vulnerable physiologically to manage. It has been found
a severe disorder, such as the to certain disorders due to that educating children on the
loss of a relationship. Not only their genetic inheritance. For disorder has assisted them
does the person have to face instance some are vulnerable to in coping with a less negative
these emotional factors, but they depression, cancer or diabetes. emotional impact for them in
have to cope with the reactions With any severe disorder there are the future. It’s critical to learn
of others, such as their extended environmental triggers, which can more intimately about the
family, work colleagues, and social activate the disorder, such as diet, disorder so that you /family
groups. Depending on the culture, emotional stressors, traumatic members understand what the
family and the individual also has events, stressful lifestyles, or disorder is, what the symptoms
to cope with the stigma that often use of substances and often it’s are, how it’s treated and the
accompanies a diagnosis. An a combination of triggers which long term consequences.
individual and the family may need result in the disorder occurring.
help to get through this difficult
time and it’s advisable to contact PRACTICAL WAYS TO COPE
GETTING HELP AFTER THE
DIAGNOSIS
• The first step is to gain
information on the disorder
20 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHM• Social support is effective. treatment at all times. such as Psychologists or
Consider joining family support • Family Management/ Counsellors who utilise
groups, or going to talks on monitoring (be part of the cognitive behavioural
the disorder. The person team) Depending on the therapies or dialectical
will be able to learn about mental disorder, it can take behaviour therapy will assist in
the disorder, the techniques time to adjust the medications providing practical behavioural
others have used and have to the correct level for an techniques. It has been shown
the support of others going individual, or for progress to the use of calming techniques
through a similar issue. One occur. Dependent on the age is effective in helping families
can gain information on of the individual arrange an cope with the individual.
these groups or talks from sms or WhatsApp system
organisations such as Lifeline, with their professional/s • Looking after ones own mental
The SA Federation for Mental (Psychiatrists/Psychologists) and physical health as well as
Health and The South African so one can report back for that of the family. Focus on
Depression and Anxiety Group. instance on medication ALL members of the family, as
adherence, changes in often the plight of the mentally
symptoms, medication issues, ill individual consumes the
extreme behaviour and suicidal resources and attention of
thoughts. If the person is of the family, with the well-being
It has been found legal age, gain their written
that educating children consent to communicate with
their professionals for this
on the disorder has monitoring activity.
assisted them in coping • Tapping into external
with a less negative resources, such as official
emotional impact for support groups, day
them in the future programmes for the individual,
support from social groups,
friends, neighbours and
community groups. In certain
SO, WHAT DO WE DO? cultures where one knows
Studies indicate that the well being everyone in their community
of families and the individual with well, this has been shown to
a severe mental disorder can be act as an extended support
positively impacted by: structure which has had a
• Accessing treatment from a positive impact.
Psychiatrist and adhering to • Going to a professional,
MHM Issue 4 | 2018 | MENTAL HEALTH MATTERS | 21in a relapse or increase in
negative or highly disruptive
behaviour, increasing the
persons stress and the
family’s stress.
• Supervising and involving them
in daily tasks (allowing them
to perform functions, but not
micro managing them), and
keeping them active during
the day is critical for their
progress and recovery. For
instance doing voluntary work,
attending free activities where
they may be able to socialise,
and doing exercise have a
positive impact.
• Protecting them from external
negative influences. They
are highly vulnerable to
external influences and
protecting them from negative
influences has been shown
to be highly effective in
maintaining their progress.
Dealing with a severe mental
disorder within a family member
or partner is overwhelming. One
should seek as much knowledge
as they can, access as many
support structures as are available
and attempt to put in place long
term plans that ensure everyone’s
well being. Often finances are an
issue, and access to resources
are limited. There are many
of others being a low priority. they’re able to minimise stress. external support structures
Attempt to normalise the This involves a very good such as support groups, and
family by focusing on the well insight into self, the ability to counselling services, which are
being of everyone. understand ones emotions free, contact organisations such
• Developing personal skills. and accept them, allowing The South African Depression and
Some of the families who have them to adjust their behaviour Anxiety Group, Lifeline, SABDA,
been effective in coping have and plans. A Psychologist or Cape Mental Health and The SA
shown specific characteristics, Counsellor can help a person Federation for Mental Health,
such as confronting, rather to make these changes. who will be able to help with
than avoiding or escaping the • Having positive interactions information. Dealing with an
situation/stress. They opt to with a mentally ill individual. Individual who has a severe mental
analyse the problems using It’s often difficult, particularly disorder takes a village, you are
detailed analysis, find solutions when ones overwhelmed. not alone.
which are often creative, and Becoming negative and
change their way of thinking so directing criticism can result References available on request
22 | MENTAL HEALTH MATTERS | Issue 4 | 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.
By Dr Lavinia Lumu
Specialist Psychiatrist
Randburg, Johannesburg
lavinia.lumu@yahoo.com
WHO GETS
BIPOLAR?
B
oth men and women disorder. Family history of any mood that is becoming a growing
are equally at risk of disorder including major depressive public health concern because
developing bipolar. The disorder may predispose one to of the increased morbidity and
prevalence of bipolar bipolar disorder. mortality. International research
disorder is estimated at has demonstrated that bipolar
2- 4 % of the general population. disorder is slowly becoming a
The first episode in men tends to cause of disability in young adults
be a manic episode, while women Bipolar disorder and is also resulting in an increase
are more likely to first experience is characterised by in medical costs and loss to GDP
a depressive episode. Men tend to distinct extreme mood (Gross domestic product) due to the
present with bipolar disorder in their increased occupational disability as
episodes ranging from
early 20s and women more likely to a result of days away from work.
present in the mid to late 20s. Some mania, hypomania, Bipolar disorder is characterised
women may present with their first depression or mixed by distinct extreme mood episodes
episodes in the postpartum period features ranging from mania, hypomania,
with either postpartum depression depression or mixed features; which
or psychosis. result in impairment in various
Genetics and one’s family history domains of functioning.
predispose a person to bipolar Bipolar disorder (previously
disorder, indicating that bipolar referred to as “manic-depression’’) MANIC EPISODE
disorder is potentially a familial is a chronic and recurrent illness In order for a manic episode to be
24 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHMdiagnosed, an elevated, expansive or functioning. Symptoms may DSM-5 criteria:
dysphoric mood must be present for be severe enough to warrant
at least 7 days and three (3) or more immediate hospitalisation. • Significant weight loss when not
of the following symptoms must be dieting or weight gain (e.g., a
present according to the DSM - 5 HYPOMANIC EPISODE change of more than 5 percent
(Diagnostic and Statistical Manual A hypomanic episode is similar to of body weight in a month), or
of Mental Disorders) criteria: a manic episode in that there is a change in appetite
persistently elevated, expansive, • Insomnia or hypersomnia
• Inflated self-esteem or or irritable mood. The difference • Psychomotor agitation or
grandiosity is that the duration of the altered psychomotor retardation
• Decreased need for sleep (e.g., mood state persists for at • Fatigue, tiredness, or loss of
one feels rested after only 3 least four (4) consecutive days, energy nearly every day
hours of sleep) according to the DSM-5 criteria. • Feelings of worthlessness or
• More talkative than usual or The mood must be present for guilt feelings
pressured speech most of the day, nearly every day. • Social withdrawal or social
• Flight of ideas or subjective Functioning in the various domains isolation
experience that thoughts are remains intact, despite the altered • Diminished concentration and
racing mood state. During the hypomanic memory difficulties
• Inattention episode, three (3) or more of the • Recurrent thoughts of death,
• Distractibility symptoms of the manic episode recurrent suicidal ideas without
• Increase in goal-directed activity need to be present (4 symptoms if a specific plan, or a suicide
• Psychomotor agitation the mood is only irritable). attempt or a specific plan for
• Impulsive involvement in committing suicide
activities that have a high risk MAJOR DEPRESSIVE EPISODE
for negative consequences A major depressive episode Social, occupational, academic, or
(e.g. excessive spending, must either have symptoms other important functioning must
hypersexuality, gambling, of depressed mood or a loss also be negatively impacted by the
substance abuse etc.) of interest or pleasure in daily change in mood.
• Grandiose delusions or other activities (anhedonia) consistently
psychotic symptoms for at least a 2-week period. MIXED EPISODE VS. MIXED
Accompanied by the depressed FEATURES
During the manic episode, there mood and/or anhedonia, four (4) A mixed episode (DSM-IV-TR) was
is a marked decline in either or more of the following symptoms a description of a component of a
social, occupational or academic must be present according to the specific type of bipolar disorder. It
MHM Issue 4 | 2018 | MENTAL HEALTH MATTERS | 25was defined by meeting the It is sometimes difficult to or an unexplained onset of
diagnostic criteria for both a distinguish between the disorders symptoms. Brain tumours,
manic episode as well as a major because bipolar disorder is endocrine disorders e.g. hypo/
depressive episode nearly every progressive. If only antidepressant hyperthyroidism, auto-immune
day for at least a full week. medication is prescribed in cases disorders e.g. systemic
The term “mixed episode” is no of bipolar I or bipolar II, the patient lupus erythematous etc., are
longer used in the updated Diagnostic could develop mania, hypomania examples of illnesses that
and Statistical Manual of Mental or mixed features induced by the could be excluded.
Disorders (DSM-5). As of 2013, “mixed antidepressant medication. • Other psychiatric disorders
episodes” are considered a “specifier” that could mimic bipolar
of bipolar disorder referred to as “with WHAT IS RAPID-CYCLING? disorder include post-traumatic
mixed features”. Rapid cycling is defined as four disorder, anxiety disorders,
This specifier applies when or more manic, hypomanic, seasonal affective disorders etc.
a person experiences both or depressive episodes in any
symptoms of depressed mood and 12-month period. MANAGEMENT OF BIPOLAR
mania within the same episode. DISORDER
DISORDERS/ILLNESSES THAT The management of bipolar
WHAT IS THE DIFFERENCE MAY MIMIC LIKE BIPOLAR disorder includes pharmacotherapy
BETWEEN BIPOLAR I AND DISORDER in the form of mood stabilisers
BIPOLAR II AND MAJOR • Substance use disorders: (Lithium, Sodium Valproate,
DEPRESSIVE DISORDER? Various substances Lamotrigine, Carbamazepine
(alcohol, cannabis, cocaine, etc.) or second-generation
BIPOLAR II DISORDER
amphetamines, opioids etc.) antipsychotics (Risperidone,
can mimic mania, hypomania Quetiapine, Olanzapine,
or depressive symptoms and Aripiprazole etc.). In severe cases,
must be excluded before electroconvulsive therapy (ECT) may
making the diagnosis of bipolar be indicated. Hospital admissions
disorder. This is often difficult may be necessary in severe
to distinguish as the substance presentations. Bipolar disorder is a
Hypomania use disorder may be comorbid chronic illness and psychotherapy
to the bipolar diagnosis. is important to ensure compliance
• Borderline personality disorder: to medication. Occupational therapy
This disorder is characterised may be indicated for rehabilitation
by mood instability, impulsivity, after an episode.
Major chronic feelings of emptiness,
Depression
poor coping strategies and WHAT DO IF YOU ONE HAS
suicidality. The mood instability SUSPECTED BIPOLAR
manifests as mood fluctuations DISORDER?
within hours during the day. Suspected bipolar disorder should
Mania The mood states may shift be referred to a health professional
(May be
accompanied by rapidly. Unlike bipolar disorder (GP or psychiatrist) for a thorough
psychosis or where mood states persist clinical assessment and initiation
delusions)
for a specific period of time. of medication.
Borderline personality disorder
can occur comorbidly with
BIPOLAR I DISORDER bipolar disorder.
• Attention deficit hyperactivity
disorder: This is characterised
There are two main types of by impairment in attention,
bipolar disorders: Bipolar I and concentration and hyperactivity
Bipolar II. According to the DSM- and impulsivity. The overlap of
5 criteria, for the diagnosis of symptoms of bipolar disorder
Bipolar I to be made, there must and ADHD include distractibility,
be at least one manic episode impulsivity, inattention,
and major depressive episodes. irritability and the hyperactivity.
Bipolar II disorder involves a less Mood symptoms do not persist
severe form of mania referred long enough to meet criteria for
“hypomania” and major depressive a mood episode.
episodes. There are no manic • Medical illnesses: It is
episodes in Bipolar II. imperative that medical illness
In major depressive disorder there be excluded before making the
are no manic, hypomanic or mixed diagnosis of bipolar disorder
features present. Major depressive especially in cases where the
disorder can also be referred to as presentations are atypical in
“unipolar depression”. nature, are sudden in nature
26 | MENTAL HEALTH MATTERS | Issue 4 | 2018 MHMDOPAQUEL
(QUETIAPINE)
INDICATIONS1
Dopaquel is indicated
for the treatment of
schizophrenia and manic
episodes associated with
bipolar disorder
in Mental Health
HELPLINE
Dr. Reddy’s
Dr. Reddy’s 0800 21 22 23 www.sadag.co.za
1. Dopaquel Package Insert.
S5 Dopaquel 25/100/200/300. Each tablet contains quetiapine fumarate equivalent to quetiapine
25 mg/100 mg/200 mg/300 mg. Reg No’s 43/2.6.5/0429;0430;0431;0432. Dr. Reddy’s Laboratories (Pty)
Ltd. Reg no. 2002/014163/07. Third Floor, The Place, 1 Sandton Drive, Sandton 2196, South Africa. N E U R O P S Y C H I AT R Y
Tel: +27 11 324 2100, Fax: +27 11 388 1262, www.drreddys.co.za. ZA/12/2015/Dop/175. G O O D H E A L T H C A N ’ T W A I T
For full prescribing information refer to the package inserts approved by the medicines regulatory authority.DEACTIVATE
THE ANXIETY.
NOT THE
PATIENT.
Stresam deactivates
the anxiety - not their lives
Efficacy that delivers the ability to cope
Effective relief of anxiety1
Minimal effects on psychomotor performance, memory and vigilance2
No dependence or rebound after withdrawal1
Convenient dosing options3
STRESAM
Etifoxine Hydrochloride
50 mg
EFFICACY THAT DELIVERS THE ABILITY TO COPE
LEPETTA 083 415 6431 8918T
References: 1. Stein DJ. Etifoxine versus alprazolam for the treatment of adjustment disorder with anxiety: a randomized controlled trial. Adv Ther 2015;32(1):57-68. 2. Micallef J, Soubrouillard C, Guet F, et al. A double blind parallel group placebo controlled comparison of sedative and amnesic
effects of etifoxine and lorazepam in healthy subjects. Fund Clin Pharmacol 2001;15:209-217. 3. Stresam approved package insert, July 2006.
S5 STRESAM Capsules. Each capsule contains etifoxine hydrochloride 50 mg. Reg. No. A39/2.6/0072. Under license from Biocodex, France. For full prescribing information refer to the package insert approved by the medicines
regulatory authority. 201805071079316.
Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa. Telephone + 27 11 635 0000. www.adcock.comBy Dr Colinda Linde
Clinical Psychologist
Blairgowrie, Johannesburg
colinda@mweb.co.za
COGNITIVE BEHAVIOUR
THERAPY INTERVENTIONS IN
SOCIAL ANXIETY DISORDER
S
ocial Anxiety Disorder result. With time the anxiety and or group setting.
(also known as Social isolation tends to increase, and To date, research has provided
Phobia) is characterised the individual either withdraws evidence for the efficacy of two
by intense fear of or begins abusing substances forms of treatment available
scrutiny by others, for social phobia: specific
especially during performance medications and a particular form
- such as public speaking, or in of short-term psychotherapy called
general (meeting new people for cognitive-behavioural therapy
the first time, eating in public, With time the anxiety (CBT; the central components
talking on phone when others are and isolation tends being cognitive restructuring,
present, writing in front of others, to increase, and the training in social skills, and gradual
and so on). This condition has individual either exposure therapy.
historically been under-recognised in withdraws or begins Cognitive restructuring focuses
primary care practice, with patients abusing substances on identifying dysfunctional
often presenting for treatment only thoughts in two broad categories:
after the onset of complications over-focus on evaluation by
such as major depression or others and their opinions, and
substance abuse disorders. thoughts before, during and after
There is immense benefit in early (prescription medication or an exposure. As fear of scrutiny
diagnosis and treatment, as the alcohol, most frequently) in order and evaluation by others underpins
secondary effects of this form of to be able to function socially as Social Anxiety, a reality based
anxiety disorder can be severe. The well as at work. The condition intervention must be done. This
child or teen who can’t connect is also career limiting, in that an provides evidence which either
with peers is at risk for depression, inability to engage in small talk or does or doesn’t support the
as well as a deficit in social skills deliver presentations, significantly hypothesis (“everyone’s looking at
which can’t be developed as a hampers performance in a meeting me; if I make a mistake they will
MHM Issue 4 | 2018 | MENTAL HEALTH MATTERS | 29You can also read
