Mental Health


I want to do a series of entries all in the hope of raising awareness around mental health. The hope is to challenge the stigma and ignorance around the matter.

While I was in one of the wards of the Sterkfontein Psychiatric hospital I met two very interesting patients. They had both been diagnosed with Schizophrenia and were both on medication and that’s where the tales of 2 cities began.

The first patient, lets call him Peter. White male in his mid 30’s, he was diagnosed 10 years ago after weeks of bizarre behavior. He was brought in by his family and Schizophreniform was the diagnosis made at the time and treatment was initiated. He responded well to the medication, his family participated in counseling and he is now an outpatient who just comes in for his scheduled check up. He seemed well groomed, euthymic and reactive (this is how you say normal in Psychiatry), however there was a sign or two of residual symptoms I was able to note but nothing alarming. Peter works for his family and lives what he calls a ‘relatively normal life‘.

The second patient, lets call him Tshepo; a black man, also in his mid 30’s. He was brought to the hospital by the police after he was involved in an altercation with a security guard. He’s convinced that the security guard had been following him and trying harm him for years and he was just defending himself. On further investigation, Tshepo tells you that he’s been living on the street for 8 years now. His family and community chased him away as his behavior, too, became bizarre. They believed that he was possessed by demons and would harm the people in the community. He spent years on his own moving between neighborhoods, where his symptoms worsen. The diagnosis of Schizophrenia was made upon admission and he’s had a poor response to medication, including Clozapine.

Risk factors, socioeconomic status and genetics asides. These two cases started off in an almost parallel universe to each other. Both man developed Schizophreniform in their mid 20’s, elicited bizarre behavior and eventually found their way to a hospital. There’s no telling that if Tshepo had been brought in sooner, he would have responded to medication better, or that he would, too, be an outpatient living a ‘relatively normal life.’ The sad part is that we will never know. I was saddened by his history but the inspiration to write only came after I made my way home that day to tell my family about my first day in Psychiatry and my very well educated sister asked me if black people also suffered from mental health, in her words “no, it’s a white people disease, isn’t it?” 

Unfortunately that is the general perception in our black communities, mental health isn’t something that is accepted or even seek out. Parents hear that their children are performing poorly at school and start calling their them stupid or get frustrated with them. Never realizing that it could be because they have ADHD or an Adjustment disorder. We distance ourselves because of the stigma and ignorance we continue to perpetuate. I’m not disregarding cultural and religious belief, but I’m challenging every person reading this to find a way to bring awareness to our family, friends and community. Mental health doesn’t discriminate, it can affects anyone; any age, gender, sex, race or religious background.

How many people are roaming our streets everyday with undiagnosed Schizophrenia, Delusional disorders, Schizoaffective, or mood disorders with psychosis that we have separated ourselves from because we want to protect family names, the community’s dignity or refused to deal with the burden of the disease. It’s nobody’s fault and instead of rejecting mentally ill individuals and leaving them out on our streets where they may post a danger to themselves and to others, where they are vulnerable to mob attacks and other form of abuse, we should take them to hospitals and mental facility that specialize in aiding them, just a Peter received aid. 

Let’s educate ourselves and let’s educate our people. 

They are patients, not disease presentations.

Having Family Medicine as my first clinical rotation felt like a cursing and a blessing. A curse because of the extensive gap in my clinical knowledge and reasoning, and a blessing because it’s a rotation that really makes one think about the type of doctor and ultimately person they want to be. It made me question everything I thought I knew about doctor-patient interaction. It was an amazing experience seeing the actual practice of Mcwhinney’s principles; a doctor who knew his patients’ names, history and diagnosis before he even read through their files. Being committed to the patient, the patient’s family and understanding the psychological, social and environmental background from which they come from. Both the acute and chronic management was founded upon a relationship where the patient’s opinion and views were considered and discussed, allowing for the decision and commitment to be mutually made by both parties.

However the high of the experience only lasted so long, shortly into my first day at the general practice I was allocated to, I started feeling an overwhelming sense of sadness. I had seen sick patients before during hospital practice day in third and fourth year but somehow it felt differenct this time. I guess I realized that my experience of sick patient was mostly being told to percuss their chest for a pleural effusion after 3 members of my clinical group had already done so. I’d greet and ask for consent all the while knowing that the choice has already been removed from their hands. For as long as I can remember I’ve always looked at a disease as an isolated organ or a system, imagining the changes, breakdown and death of tissue. The way the drugs would interact with receptors, how systems would get blocked and how pathways would proceed. As I stood in that consultation room, all of a sudden it wasn’t an organ or a system that I saw, it was a 65 year old woman named Marie* who had gotten diagnosed with hypertension 10 years ago, her blood pressure has been getting worse in recent months and it’s not because she had been defaulting on her medication. She also reported getting this left sided chest pains for the past month, but the hypertension and chest pain were not her reasons for encounter. Today she brought with her 3 year old great granddaughter, Sarah*. Sarah’s mother and Marie’s granddaughter died from Tuberculosis after months of struggling with AIDS two years ago. Marie has been looking after the child since. She’s complains that Sarah has been acting different for a few weeks now and just two days ago while bathing her, she noticed vaginal discharge and a swollen labia. She’s been having nightmares and more frequent chest pains since then. Although she’s suspicious, she refuses to believe her own gut feeling because the only male in Sarah’s life is Marie’s son 38 years old Paul* who moved in with Marie 3 months ago to help her out financially. I quietly sat in that consultation holding back tears, feeling helpless as I realized that I lack the emotional maturity to handle such a delicate situation.

I found myself asking a very important question, ‘do we receive the proper psychological training to deal with our clinical years?’ Or is it just estimated that in a difficult situation we will know what to do, that our skin will be thick enough and that the decision we will make will be the right one. The only conduct that I have is that I must respect autonomy, make sure that my practice not only uphold justice but is also non-maleficence and therefore completely beneficent to the people I serve. I’m supposed to be patient-centred but what happens when my baggage becomes too much to bear, how do I tell Marie that her only son and household provider is also abusing her great granddaughter? This is the part where I should rely on my community resources; refer Marie to the Teddy Bear clinic at Charlotte Maxeke Academic Hospital or an equally equipped organization to deal with the matter. How do I even say it out loud? I’m supposed to follow queues but she has a blank stare on her face. What do I say? How do I go on with my day and see another patient after this? I do not know how to keep going and ignore the feelings that I’m not supposed to have. I don’t know how to smile when I really feel like crying. I don’t know how to tell you it’s going to be okay when I can’t begin to imagine what you’re going through. I can’t minimize your situation, pain or anxiety to a statistic. 

I was never told and I was never ready. How could medicine hurt me so much? We are taught everything from a scientific point of view, it isn’t infertility until you’ve been trying for longer than a year, HIV is not a death sentence if you take your ARVs, changing your diet and exercise reduces morbidity in hypertension etc. We’re so focus on dealing with the disease but we fail at addressing the illness. We don’t know what the inability to conceive, even if it isn’t scientifically diagnosed as infertility means to a couple or the family dynamics. We don’t understand a person’s ability to grasp that their lives will never be the same because of their status. We don’t understand that sometimes it isn’t a lack of will but rather the feasibility in having dietary changes and exercise, especially when we don’t engage the patient in details; substitute for food types and what type of exercise to do. We’re told to be biopsychosocial doctors in a biomedical setting.

Over the past two years, I’ve learned about diseases’ pathophysiology, presentation, complications, differentials and management. My main priority has always been to remember it in that order, essentially make a diagnosis and treat the disease. I never learned to remember a patient’s name, I never learn to address their illness, help them understand or come to term with their condition and how it may be impacting their livelihood.

I also understand that it doesn’t help me to point fingers at the ‘system.’ I am a student doctor and it’s time for me to take responsibility for my learning and the type of person I want to be. At what point do I stop allowing myself to be a product of a system I consider flawed? I needed to ask myself ‘what makes a good doctor?’ is it someone who has the highest possible marks in pathology but struggles with the patient interaction and expressing empathy or is it someone who’s great at expressing empathy and social interactions with patients but struggles at pathology? In my opinion, we have to thrive at both, we have to be socially aware, trade with caution and understand that we are trusted to deliver healthcare, to promotes health and rebel against the mediocracy seen in the public setting, in our schools and even amongst our peers. How long are we going to continue to hide behind the lack of resources as an excuse to continue providing a poor service?

A good doctor is more than a healthcare professional, a doctor is a teacher, a leader, an advocate and an agent for change. We need to stand for the very patients we treat, we need to promote ethical and moral behaviour. Challenge structures that we disagree with in the hope to transform the medical world not only for ourselves but for those who are coming after and those that are coming to us. Academics will make me a great scientist, social awareness makes you a great socialist and empathy makes you a great human being. As an aspiring doctor I need the all package, I need to pursue and learn more than what is made available to me in the classrooms and in the ward setting.

I am truly grateful for this experience, I’m grateful for having learned how to look at patient as a whole rather than a disease. I found myself trying to remember at least one detail about the life of every patient I saw, their spouse’s name, what their children are studying etc. And after a patient had received a negative prognosis, I’d sit with them in silence and let my presence represent a sense of support. I do not know that I’ll become a family physician, but I know that I’ll take their values with me everywhere I go.