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The Royal College of Psychiatrists Improving the lives of people with mental illness

Cape Town

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November 2011 Posts

04/11/2011 08:59:42

Organic psychiatry

Cape Town

Organic psychiatry was what attracted me to an elective in Cape Town and I was not disappointed. Differential diagnoses for psychotic presentations included HIV or opportunistic cerebral infections, temporal lobe epilepsy and tik (methamphetamine) psychosis – the single largest mental healthcare burden on the psychiatric wards. Tik is described as an ‘epidemic’ by psychiatrists here because its use has exploded among the urban poor of the townships. Methamphetamine can be easily manufactured using basic items including ephedrine and ammonium fertiliser, making it widely available (and commonly produced in rural farming areas). Cheap, tik is described as ‘the poor man’s cocaine’, since its effects last much longer. It is highly addictive and associated with aggression, hypersexuality and violence – resulting in high crime rates in communities already plagued by gangs, gun and knife crime.

Road sign
Most of the patients I met with tik psychosis were admitted for their own or others’ safety, until they had recovered in about a week. In others, however, methamphetamine formed the trigger for a much more enduring psychotic illness, in some the starting point for lifelong Schizophrenia. In Cape Town, tik played a role much like that of cannabis in the UK: patients who became abstinent from the substance recovered better, while those who returned to tik abuse, widespread among their peers, tended to relapse.

On the neuropsychiatry ward (five beds in a city with 17.8% HIV prevalence),I observed two unusual cases of psychosis and Multi Drug-Resistant tuberculosis in young women who were HIV negative. This presentation was unfamiliar to the team. After extensive research, they considered the most likely cause to be a rare neurotoxic response to Quinolone antibiotics prescribed for MDR TB. Another woman on the ward had a more predictable picture of HIV encephalopathy associated with an extremely low CD4 count. What intrigued me about these cases was the clear need to treat mental illness with physical therapy. In Britain, the law clearly distinguishes between treatment of the mind and the body. The Mental Health Act allows for treatment against a patient’s wishes for a disorder of the mind, but not for one of the body. This was upheld in a case where a patient with paranoid schizophrenia (Re: C) was able to refuse amputation of his gangrenous leg, despite it being life-threatening, because he had capacity to make that decision about his physical health, however unwise. This leads to difficulties with physical treatment (such as refeeding) for psychiatric disorders (such as anorexia nervosa).

Cape Town

In Cape Town, there were so many possible organic aetiologies for psychiatric presentations that doctors had to prescribe physical treatment for psychiatric disorders, in their patients’ best interests. For example, in the many patients with depression, psychosis or dementia directly attributable to their HIV infection, the treatment simply was Anti-Retroviral Medication – and this is what was prescribed. However, infectious disease specialists were loath to commence ARVs in patients who lacked the insight to commit to a life-long course, since the risks of non-compliance are high. Observing the practice of neuropsychiatry in Cape Town brought home to me theinconsistencies in the mind/body dualism upon which mental health legislation is founded. It may have its roots in religious separation of the ‘soul’ from the body, or in Cartesian traditions that reject the materialist view that mind and body are one. But artificially separating the mind from the body prevents us from seeing the whole person and encourages you to ignore physical complaints when treating the mind or forget psychiatric concerns when treating the body. I saw how this is potentially very dangerous, clinically, not to mention, detrimental to the relationship with a patient. It was exciting in Cape Town to observe the genuine enactment of the oft-quoted buzzword, holistic healthcare, as doctors considered every aspect of the individual in their diagnosis, treatment and management.

The Valkenberg Psychiatric Hospital shield - the raven 'valk' Valkenberg Psychiatric Hospital
14/11/2011 10:59:07

The tip of the iceberg

Red Cross War Memorial Children's Hospital
All psychiatry in Cape Town was under-resourced, under-staffed and under-funded, but this seemed to be most evident, or perhaps just most upsetting, in Child and Adolescent psychiatry. An excellent service is provided by the multi-disciplinary team of the Red Cross Children’s Hospital, but more than anywhere else I saw, they could only address the very tip of a very large iceberg.
Cape Town locals
The complexity of child and adolescent psychiatric need was vast. This was unsurprising, in conditions of extreme poverty, uprooting of family structures by premature death (often HIV, TB or trauma-related) and economic migration – most patients did not know their fathers and many were raised by extended family or friends. Some of the need related to other issues I had already encountered such as tik abuse, foetal alcohol syndrome and deprivation – leading to dropping out of school and involvement with gangs. Other problems were more broadly and complexly associated with the violent history of South Africa and its current struggle to leave its past behind.
In 2000, South Africa had the world’s highest per capita rape rate, with one in three surveyed women reporting rape in the past year. With a 40% lifetime risk, a South African woman has a higher chance of being raped than completing secondary school. Rates of sexual violence against babies and children are also extremely high, with 67,000 reported incidents per year representing a fraction of unreported abuse. It has been argued that one factor is a widespread myth that sex with a virgin can cure a man of AIDS, though its extent has not been quantified. The legacy of sexual violence was evident among patients I met, and nowhere so extensively as in child and adolescent psychiatry.
Womens' clinic
One thirteen year-old girl fortunate to receive extensive multi-disciplinary treatment as an inpatient had psychotic symptoms, low self esteem, obsessional traits, self harm, mood disorder and dissociative symptoms, with a long history of sexual abuse and inconsistent parenting. While her home environment was unsafe, she spent her weekends there and often returned with much of her progress undone after two days in the township. Poems she wrote about the abuse she had suffered provided a small insight into some of the trauma experienced at such a young age.

The team worked tirelessly with her challenging behaviour, to support her as she went through puberty and tried to cope with her childhood past – though still a child. Ultimately though, she was to be discharged back into a violent, risky home environment – since there were so many boys and girls just like her, in grave need of one of the few inpatient beds available. The team did amazing work with her, but it really was the tip of the iceberg. The ability of the CAMHS team to work non-judgementally with parents with as many social and psychiatric problems as their children was truly powerful to watch.

Valkenberg motto Street signs salvaged after the demolition of District 6, a vibrant coloured community bulldozed by the apartheid regime.

I will never forget my four weeks in Cape Town and hope, as I progress in Medicine, that I can make some small difference to the enormity of the problem that exists below the surface of what can currently be addressed. Organisations that extend some of the benefits of healthcare in the West to assist sustainable development will, I hope, work towards a world in which the scope of care offered is not so unequal on the other side of the world. My elective experience was one of contrasting frustration, sadness and regret, with inspiration and even hope. I could leave each day thinking how much more could be done with just a little more – another psychiatrist, another clinic, a little more funding for a few more psychiatric medications or psychological therapies. Or I could leave thinking how much was achieved with so little, how life-changing the treatment in the face of such unimaginable deprivation, suffering and trauma.
Even on a more optimistic day, there was no denying the sheer magnitude of inequality and plain unfairness of life in Cape Town – and the Western Cape is the country’s most prosperous province. How, as a doctor, do you get up each day and go to work in this context?
Cape Town sunset
The 19th century French quotation adopted as Valkenberg Hospital’s motto stays with me, as I approach the start of my medical career, in the magnificently privileged NHS environment. Sometimes to cure, often to relieve, always to comfort.
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About this blog

Roxanne Keynejad

 

Roxanne Keynejad is a final year graduate entry Medicine student at King's College London, having studied a first degree in Psychology with Philiosophy at the University of Oxford.

 

She is spending four weeks of her elective studying psychiatry at Groote Schuur and Valkenberg Hospitals, Cape Town, for which she received bursaries from the Royal College of Psychiatrists elective bursary fund and the Institute of Medical Ethics.