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.
| 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).
 |
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.
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