South African Psychiatry - February 2024

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 51 Any client-facing service’s success or failure is dependent on the customer experience. This is also relevant in the healthcare sector where practitioners are not immune to patient scrutiny. Electronic reviews and ratings, comments, and criticism, are part of modern health care delivery. Online criticism, censorious posts and condemnatory blogs can be unpleasant to read and, when viewed by others, be damaging to a practitioners’ reputation. Healthcare practitioners (HCPs) are understandably upset and occasionally even distressed by critical reviews and poor ratings. Sadly, much of it is beyond a HCP's control. Yet, they can prevent, manage, and even learn from such situations. In a world where online comments and reviews occur frequently a HCP should anticipate an occasional bad review or critical remark. Depending on the quality of the service provided such comments may, at times, even be accurate and correct. If you are alerted to a critical review, you should not panic, overreact or take it personally. This can be difficult and, in general, HCPs struggle to distance themselves from criticism that is seen as a direct reflection of them, their personality or their clinical acumen. This is especially so when the comment or criticism may affect their reputation and hence their income. You should, under no circumstances, post an immediate response while still angry or frustrated or without having all the information available to make an informed decision. INITIALLY, AND AFTER YOU HAVE TAKEN A DEEP BREATH AND CALMED DOWN, IT MAY BE BEST TO SIMPLY COLLATE ALL THE RELEVANT INFORMATION AT YOUR DISPOSAL TO GET AN INFORMED OVERVIEW OF THE TREATMENT EPISODE. M A N A G I N G ONLINE COMPLAINTS AND NEGATIVE REVIEWS Volker Hitzeroth Volker Hitzeroth Social media is characterised by instant gratification, immediate feedback and an unhealthy quest for followers or “likes”. Unfortunately, this means that critical comments, negative reviews or poor ratings are posted on various sites for everyone to see. For healthcare practitioners such adverse publicity can be unpleasant and may cause significant reputational damage. This is the fourth of a series of articles highlighting the use, and risks, associated with social media in healthcare. MEDICO LEGAL

52 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 Ask your staff to collect all the information relevant to the patient’s care. This will enable you to peruse all the relevant information and to critically investigate the matter by relooking at the totality of the patient’s contact with your practice, including phone calls, messages, appointments, consultations, admissions, clinical outcomes, fees and follow up arrangements. You may also want to discuss the matter with your staff and/or a senior colleague. On occasion it may be appropriate to seek further advice or even contact your indemnifier. You should also not delete or hide a negative review or comment. IN MOST CASES THE BEST OPTION MAY BE TO SIMPLY IGNORE ANY UNPLEASANT COMMENTS OR POSTS. THIS IS USUALLY THE MOST SUITABLE COURSE OF ACTION TO TAKE, ESPECIALLY IF THE ONLINE CRITICISM IS RELATIVELY HARMLESS, NOT DEFAMATORY, DATED AND HAS FOUND NO REAL TRACTION. Occasionally however it may be appropriate to respond to negative comments, defamatory statements, or online criticism. If that is the case, then it would be best to respond promptly and personally after seeking professional advice. The aim of your response should be to prevent any escalation, avoid ongoing correspondence and to manage your reputation. It is not necessary, in your initial online reply, to provide a longer answer to any complaint, deny alleged negligence, shift blame, explain yourself, accuse the patient or set the record straight (certainly not on social media or in a public forum). BEWARE OF BREACHING A PATIENT’S CONFIDENTIALITY WHEN REPLYING TO PUBLIC POSTS. It may be tempting to set out a lengthy account of various clinical signs and symptoms, to share your differential diagnosis and elaborate on complex decision-making details. In most cases, this will risk disclosing confidential patient information without their consent, inflame the complainant and draw more attention to the issue. If you have sought appropriate advice and a considered decision has been made for you to respond, always ensure that the tone of your reply is warm, kind, and considerate, and that you project a caring attitude and genuine concern. YOU MAY WISH TO BRIEFLY THANK THE PERSON FOR BRINGING THE ISSUE AND THEIR DISSATISFACTION TO YOUR ATTENTION. Furthermore, you may wish to apologise for any problems, negative experiences, or complications experienced. Lastly, you should invite them to make direct contact offline with your practice where they can ventilate their concerns directly to you. This will create an opportunity for them to be heard and for you to address the complaint as best you can. It also ensures that the matter is removed from the public discourse, can be addressed promptly and privately, and hopefully resolves the issue. IT IS BEST NOT TO CONTINUE AN ONGOING ONLINE DIALOGUE OR TO CONTINUOUSLY ENGAGE WITH SOCIAL MEDIA COMPLAINERS. WHILE IT MAY BE NECESSARY TO RESPOND ONCE OR EVEN TWICE IT WOULD BE INAPPROPRIATE TO CONTINUE WITH A LONGER DEBATE. Make your initial response a kind and courteous one, acknowledge the problem and offer to resolve it at your practice. There is no benefit in continuously responding, explaining and answering. To the contrary, this may lead to an escalation, be seen as an invitation for others to contribute and risk further missteps from your side - all of which is contrary to what you were hoping to achieve, namely, to prevent any escalation, avoid having to spend more time mitigating the scenario and to manage your reputation. TRAIN YOUR STAFF TOO. THEY SHOULD IMMEDIATELY BRING ANY NEGATIVE POSTS OR COMMENTS TO YOUR ATTENTION, AND THEY SHOULD NOT ENGAGE A COMPLAINANT DIRECTLY ON THEIR OWN. FURTHERMORE, THEY SHOULD NEVER POST ANYTHING ABOUT YOU OR YOUR PRACTICE WITHOUT YOUR EXPRESS PERMISSION. Focus on the many positive reviews regarding your patient care that are likely to be found online too. By occasionally thanking a patient for a kind comment, complimentary review or appreciative post you are likely to demonstrate that you are interested in your patients’ care and wellbeing, have good interpersonal skills and “bedside”/“webside” manner and are a kind, caring and relatable clinician. FURTHER READING: https://www.medicalbrief.co.za/social-mediacomplaints-and-how-to-deal-with-them/ Volker Hitzeroth is Medicolegal Consultant at Medical Protection Society in London, United Kingdom. Correspondence: [email protected] MEDICO LEGAL

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 53 18 October 2023 ELECTION RESULTS TO MEMBERS COLLEGE OF PSYCHIATRISTS Triennium 2023 - 2026 It is my honour to announce the results of the election of the President, Secretary, Senators and Councillors of the College of PSYCHIATRISTS for the 2023 – 2026 triennium. The persons so elected take office immediately after the Annual General Meeting on 27 October 2023. President Prof Carla Kotze Honorary Secretary Dr Lebogang Simon Phahladira Representative on Senate Dr Mvuyiso Talatala Other members of the Constituent College Council BRACKEN, Craig Anthony BRUMMERHOFF, Ralf Arnold CHETTY, Indhrin RAMLALL, Suvira THELA, Lindokuhle THUNGANA, Yanga The Council is empowered to co-opt additional persons if deemed necessary to improve representation on a geographic or demographic basis, or to ensure university representation or to strengthen the Council. The election results will appear on the CMSA web page after the AGM on www.cmsa.co.za. Prof Johan Fagan’s term as the President of the CMSA continues until May 2025 and will remain in office supported by the Senior Vice President, Prof Zach Koto and Vice President Prof Johnny Mahlangu. May I take this opportunity to congratulate all our elected Office Bearers and Councillors. The CMSA led by our Councils and Senate, is anchored by the voluntary contributions of our members. Thank you for your ongoing commitment to the CMSA and what we stand for as an organization. My staff and I look forward to serving your Council as you strive to express the mission and values of the CMSA. Prof Eric Buch CHIEF EXECUTIVE OFFICE COLLEGE OF PSYCHIATRISTS

54 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 As I enter my third term on the Council of Psychiatrists at the CMSA I would like to express my sincere gratitude for the trust placed in me to step into the role of president. Serving as honorary secretary under Prof Suvira Ramlall during the previous term was a great privilege and learning opportunity. As president, I am deeply committed to advancing the field of psychiatry and contributing to the future mental healthcare providers that will be writing the CMSA examinations during this term. Although, the primary function of the CMSA is as national examining body, our mission will be to inspire excellence in psychiatric practice, research and education to ultimately champion the well-being of individuals and communities. Our college will uphold the highest standards of ethical leadership and professional conduct, while aiming to ensure trust, integrity, and transparency in all our actions. We are dedicated to fostering a supportive and inclusive environment within our college, encouraging mentorship, continuous learning and collaboration with all the different universities and organisations like SASOP. By embracing diversity and nurturing a community of empathetic, ethical and skilled diplomats and psychiatrists, we will better be able to address the unique mental health needs of our Rainbow nation. We will prioritise a review of the current regulations and portfolio of learning to ensure that the implementation of workplace-based assessments is feasible at all training sites, while aiming to minimise the administrative burden. Continuous evaluation and innovation in our training and examining methods to maintain rigorous standards will be pivotal. We will promote the latest evidence-based practices by including new diagnostic and therapeutic developments and addressing the role of rapidly evolving artificial intelligence in psychiatry. The CMSA is already investigating how AI can be used to assist with the examination processes and lessen the burden on our examiners. TAKING ON THIS TASK WILL NOT BE POSSIBLE WITHOUT THE GENEROUS CONTRIBUTIONS AND SUPPORT FROM EVERYONE WHO SERVES ON COUNCIL OR PARTICIPATE IN EXAMS AS CONVENORS, EXAMINERS, ORGANISERS, SIMULATED PATIENTS OR ANY OTHER SUPPORTIVE ROLE. It is only with the voluntary sacrifice by each and every one who contributes that we are able continue with this work. With all the expertise and dedication, I envision a future where our college stands as a global beacon of progress and innovation, guiding the way for mental health professionals to make a profound impact on society. VISION STATEMENT FROM THE COLLEGE OF PSYCHIATRISTS' PRESIDENT Carla Kotzé COLLEGE OF PSYCHIATRISTS Carla Kotzé Carla Kotzé is Head of Geriatric Psychiatry / Adjunct Professor; Weskoppies Hospital, Gauteng Department of Health / Faculty of Health Sciences, University of Pretoria. Correspondence: [email protected]

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 55 I f you are a hiker, or in fact anyone who enjoys activity reliant on your feet, you know that footwear is vital. Brand new footwear is great, but when it’s worn in just the right amount it’s perfect. With a hiking boot that state of perfection can last a very long time. In my case, some bootlace breaks didn’t really compromise the boot because the laces were long enough to simply knot the two broken ends together and continue. I could ignore the little imperfection and carry on enjoying the fact that my worn in boots created an environment for my feet that made a feeling of confidence in tricky climbing situations possible. Even a little problem with the upper edge of a sole could be repaired with some clever glue. On and on they went. It was a slow process of decline, but eventually time and use became apparent. I was wrong to assume they were good for use by ignoring areas of damage, because the boots did eventually let me down. Or maybe, I pushed them too far? Maybe I simply took their sturdiness for granted and didn’t pay enough attention to the damaged areas? Areas which perhaps could have been repaired earlier, but were now at the point of no return. 2023, was the year of ‘new’. A new diagnosis, a new way of understanding stubborn symptoms, new tests, new treatment team members. As much as it feels good to have new direction, new waypoints, and feel very new and definite shifts in my health, there’s a certain sense of uncertainty that falls instep with me too. PERHAPS IT’S NOT SO MUCH THE PRESENCE OF A NEW DOCTOR BUT THE ABSENCE OF A PREVIOUS ONE, ONE THAT WAS BY MY ‘TREATMENT SIDE’ FOR OVER A DECADE, WHICH CASTS A DIFFERENT GLOW ON 2024. The doctor-patient relationship can be such a clear, simple one. However, it can also be a complicated, twisty one. I think it’s difficult for any two humans, in any role, to go through a dozen years of treatment, trauma, hospitalisations, emergencies - one after the other, for hours, days, months, years to not have their relationship take on a somewhat different shape. No matter how one words it, it sounds awkward - tinged with ethical question marks, but I think really it’s just human. One can get locked in to so many labels within medicine: doctor and patient, prescription and recipient, specialist and patient, even perpetrator and victim when things go awry after a prescribed drug or two. As much as doctors come to know the intricacies of their patients - think yellow patient file (perhaps perceived as more than they actually do), not much is said for how much patients come to know their doctors. After riding too many medical rollercoasters together, good times and nearly dead times, it’s not only my doctor who came to know me well well, it worked the other way too. As patient I knew the capabilities of my doctor - their strengths and also weaknesses. I could see the astuteness of their diagnostic mind - and was the recipient of moments of true brilliance. But concurrently, I witnessed the exhaustion and the difficulty of having to receive and hold stories of excruciating pain from me whilst trying to maintain professional decorum, all the while a queue of equally in need patients waited outside their door and in the wards. Taking into account this is a process that must be repeated over and over, every day, for dozens of patients. However, sometimes being human takes over and doctor and patient spend moments simply as two people sharing a difficult path, and sometimes a gruelling win. There’s a familiarity that’s difficult to escape. While I think many positive things can come from these moments, knowing when familiarity threatens to become over-familiarity is key. The latter can quickly lead to a dropping of boundaries, on both sides, which can lead you to words and behaviour that may not belong in a doctor-patient relationship. OF TRUSTY BOOTS, F R AY E D L AC E S , AND THE YEAR OF ‘NEW’ Claudia Campbell Claudia Campbell PERSPECTIVE

56 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 In life sometimes the needs of those closest to you take the back seat whilst newer pressing needs with others crop up. I think many of us have done this with family, friends, and colleagues. It’s easier to put them off for a while, because for the most part you are often pretty sure of what ‘emergency’ means in their case. But, does this ‘freedom of familiarity’ apply to medical relationships too? How does one navigate boundaries tempered by hundreds of hours spent together - the human familiarity? There are obviously always two sides to a story. I am by no means the perfect patient. I have many lessfortunate traits that, without attention, can crop up. In fact, there are too many imperfections as a patient that I have, to succinctly list here. However, from now I am only going to speak as a patient receiving treatment, and my experience. I do not argue that it casts me in a slightly uneven light of victim - so please bear that in mind. As mentioned, 2023 was a year of ‘new’ things when it came to understanding my symptoms and treating them. A couple of new players entered the team and came up with a series of thoughts and approaches that have yielded many results, often difficult but quite often good too. However, this did not take away from the value of having a doctor on the team who knows the intricacies of my body and mind better than anyone else. THE FRUSTRATING PART FOR ME CAME IN WHEN WE/I NEEDED THEIR INPUT AND THEY WERE SIMPLY SWAMPED WITH TOO MANY PATIENTS. Although not a conscious choice, I think I became the easiest one to delay, cancel, not come back to - because the other emergencies were just so pressing (this is the purely subjective opinion of my husband and I). Perhaps they may have been right to do that at times, but not this time. That day, my situation was an emergency - a serious one. What was the ethically right decision for them to make in that moment though? I don’t think it’s a simple question, and concurrently one that’s easy to answer. However, at what point do you take the words ‘this is an emergency’ seriously enough to prioritise your very ‘familiar’ patient again? Take into consideration the fact the words of alarm were coming from a spouse, not only me as the patient. Can you presume to know your patient so well that you can tell their repeatedly professed emergency is not as serious as another patient’s? It’s a tricky one, and one that I believe highlights the limitations of time. There is so much pressure put on doctors by virtue of the sheer volume of patients and concurrent severity of symptoms. Being stretched to the limit seems to have become a very unfortunate and unavoidable hazard in the practice of so many avenues of medicine. That doesn’t take into account the impact general life has on doctor’s resources. There isn’t much room to have a ‘bad day’. Knowing this doctor as I do, I knew that it was not because of a lack of feeling care on their part. I felt the problem was that the ‘knowing me so well’ allowed a conviction that the emergency (it was a multiple day situation) did not require the same attention than the others. I’m fortunate to have additional doctors I could turn to at that time, because the emergency truly was a situation which required medical help. This was even more apparent after blood tests had been done and decisions could be made. So what happens now? What happens when not only my trust has been shaken, but the trust of my husband? Through his more objective eyes, my husband suggested “I think this relationship has run its course. It’s probably time to walk away. It’s not worth the trauma of this incident and the others before”. He wasn’t only speaking about my doctor’s relationship with me, he was speaking about the indirect one with him. AND SO, THE DECISION WAS MADE. I TERMINATED A 14 YEAR LONG DOCTORPATIENT RELATIONSHIP. THERE WAS A SENSE OF RELIEF IN THE DECISION, AND ON REFLECTION I’VE COME TO SEE THAT PART OF THIS RELIEF STEMS FROM STEPPING AWAY FROM A RELATIONSHIP THAT HAD GRADUALLY BECOME TOO FAMILIAR THAT IT BLURRED THE REQUIREMENTS FOR MEDICAL TREATMENT. I remain immensely grateful to this particular doctor and the enormous amount of care and concern they had for me over so many years. I do really owe my life to them. But I feel sad it was our natural humanness which ultimately became our demise. It’s made me wonder how one effectively builds and manages a doctor-patient relationship with such a long history, that has required two people to spend huge amounts of time together, in a wide variety of situations? At what point is a boundary stretched too far, when the process has been so gradual? At what point are the boot laces too frayed, the soles too cracked, and the leather too worn? What was the point of no return? However, when all is said and done I reflect on the wise advice I recently received: “… there were reasons for change. That there was change does not diminish what went before”. Claudia Campbell holds a post-graduate degree in psychology and has 10 years experience in the field of corporate transformation strategy. Claudia works in a voluntary capacity as a psychosocial facilitator, public speaker, and consultant. Due to various health challenges, Claudia’s personal life includes many experiences from the patient’s side of the consultation room. Correspondence: [email protected] PERSPECTIVE

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 57 We find ourselves living in challenging times having to grapple with multiple stressors in every aspect of our lives no matter where we live. However, there can be no comparison with the ongoing brutality unfolding before us on a daily basis as we switch on our TVs or go onto our phones. We cannot escape the suffering of millions of people. I write this as a neuropsychiatrist, but also as a global citizen, deeply concerned by the ongoing conflict in Gaza, particularly the devasting impact on women, children, and healthcare workers. I am also very troubled by the silence from our academic community and in particular my psychiatric colleagues who understand the mental health effects of violence and war. It is not controversial to talk about such matters. It’s a matter of justice. The situation in Gaza is nothing short of a humanitarian crisis. The constant barrage of violence, destruction, and loss of life is exacting a heavy and ongoing toll on the mental and emotional wellbeing of the Palestinian people, particularly the most vulnerable segments - women, children and the healthcare workers who should be supporting them- themselves traumatized and burnt out.1 They are experiencing unimaginable trauma that will leave lasting scars on their psyches, impacting future development, relationships, quality of life and perpetuating intergenerational trauma within families in Palestine and the occupied areas.2 The healthcare workers on the frontlines of this crisis are facing insurmountable challenges- operating without anaesthetics, lack of available painkillers and other essential supplies. And when they do have supplies, a lack of generating capacity for essential equipment. They work tirelessly in an environment where resources are scarce, infrastructure destroyed daily, and their own safety constantly at risk. I watched on Al Jazeera news channel, a cleaner’s commitment to his work (at one of the hospitals) where despite the chaos around him, continued to mop the floor to keep it clean for everyone around him. This highlights a respect for the dignity of his work and the impact it has for those around him. But functioning under these conditions is not only emotionally draining, but will lead to high levels of burn-out and trauma and PTSD.3 As a neuropsychiatrist, I am well aware, have seen and experienced myself (arriving as a refugee into South African many years ago), the long-lasting psychological effects of exposure to trauma and violence.4,5 These effects are felt for generations to come, and it is our collective responsibility to take immediate action to do whatever we can in our own way to mitigate this suffering. MY SMALL WAY WAS TO START A PETITION ON CHANGE.ORG, KNOWING FULL WELL THAT I WASN’T GOING TO CHANGE ANYTHING GLOBALLY, BUT I ATTEMPTED TO GENERATE AN AWARENESS AND DISCUSSION, AS I DO SO NOW. I implore all medical doctors, nurses and healthcare workers to use your influence and resources to advocate for an immediate ceasefire and implementation of a comprehensive humanitarian aid (not just a few trucks a day) into Gaza. It is critical that we prioritize the mental health wellbeing of all that have been affected, including the families of those kidnapped and killed by Hamas and particularly the Palestinian people who have endured trauma for years. We need to stand together and make a difference to the ongoing violence in the Middle East. Enough is Enough! REFERENCES: 1. Murthy RS, Lakshminarayana R. Mental health consequences of war: a brief review of research HOW TO RESPOND AS A CLINICIAN TO THE PALESTINIAN-ISRAELI CONFLICT Sandra Fernandes Sandra Fernandes PERSPECTIVE This article was originally published in the University of the Witwatersrand’s School of Clinical Medicine Newsletter (December 2023) and is reprinted with permission.

58 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 findings. World Psychiatry [Internet]. 2006 Feb [cited 2023 Oct 23];5(1):25–30. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1472271/ 2. Palosaari E, Punamäki RL, Qouta S, Diab M. Intergenerational effects of war trauma among Palestinian families mediated via psychological maltreatment. Child Abuse Negl [Internet]. 2013 Nov 1 [cited 2023 Oct 23];37(11):955–68. Available from: https:// www.sciencedirect.com/science/article/pii/ S0145213413001142 3. Altawil MAS, El-Asam A, Khadaroo A. Impact of chronic war trauma exposure on PTSD diagnosis from 2006 - 2021: a longitudinal study in Palestine. Middle East Curr Psychiatry [Internet]. 2023 Feb 8 [cited 2023 Oct 23];30(1):14. Available from: https://mecp.springeropen. com/articles/10.1186/s43045-023-00286-5 4. Munjiza J, Britvic D, Radman M, Crawford MJ. Severe war-related trauma and personality pathology: a case-control study. BMC Psychiatry [Internet]. 2017 Dec [cited 2023 Oct 23];17(1): 100. Available from: http://bmcpsychiatry. biomedcentral.com/articles/10.1186/s12888- 017-1269-3 5. Thabet AM, Thabet SS, Vostanis P. The Relationship between War Trauma, PTSD, Depression, and Anxiety among Palestinian Children in the Gaza Strip. Health Sci J. 2016; PERSPECTIVE Cardinal Woodpecker. Photo curtesy of Lennart Eriksson, Psychiatrist – Pennington, KZN, [email protected] Sandra Fernandes is Divisional Head of Neuropsychiatry, Department of Psychiatry, University of the Witwatersrand & Clinical Head of Neuropsychiatry, Tara the H Moross Psychiatric Hospital. Correspondence: [email protected]

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 59 I ’ve been blessed with many diverse experiences in life to date, that have gone under equally varied monikers. Apart from Partner and Father and the more usual, there’s Doctor, Professor (ok, only an Associate, and without a PhD which peeved Faculty…), Colonel (the spoken military greeting for Lieutenant Colonel) and … Papa Swiggs. Therein lies this story. My recently (finally) independent adult son picked up the nickname ‘Swiggy G’ at varsity. No one would ever tell me why. I’ve had the most sombre of thoughts, but a Google search does not reveal drugs or rappers or the dark web, but rather a food delivery service (think Mr D) in India. So, I didn’t resist when Papa Swiggs was appropriated by his friends to apply to me. Over the years at university and, more recently when itinerant souls returned ‘home’ to Cape Town and reunions ensue, Papa Swiggs has been known to host ‘A Swiggy Soiree’: a wine tasting and generously proportioned supper for the two dozen odd 20-something mates. They tell me they come for what they learn at the tasting, but I know it’s for the free hooch… And so it was when son James sprinted home to 35oC for some respite from the sleety Scottish squelch. The scheduled two dozen guests quickly swelled to 30-odd bodies – such is the diary planning of the last-minute-dotcom millennials – which torpedoed my selection of unusual single bottles, the last in my cellar, for the white wine flight. I can wring 24 tastes out of a 750ml bottle, 30 is a little harder. No matter, with partners sharing and frequent admonitions to pour less (especially as the evening progressed!), we manged to spread the love around. THE ‘GAME’ WAS TO GUESS THE GRAPE VARIETY AND I’D CLEARLY FAILED TO IMPART THE TAKE-HOME MESSAGE AT PREVIOUS SOIREES – THEY WERE FABULOUS WRONG ON ALL BAR ONE ACCOUNT THIS TIME AROUND. Boschendal’s Elgin Sauvignon Blanc, one of a clutch of single vineyard wines from newer ‘cool climate’ vineyards that are elevating this once large and mediocre producer into a world quality player, was perfect to sharpen focus with bracing nettle fruit, akin to splashing one’s face with ice-cold water early in the morning. The ‘pupils’ confidently called it chardonnay, which left me scratching my head… Grande Provence Chenin Blanc was chosen to highlight the grape’s signature fleshy, fruity core – think peaches and pears – with ripeness from A SWIGGY SOIREE David Swingler WINE FORUM David Swingler Attentive gang

60 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 WINE FORUM generous Franschhoek sun. The Pretoria-based engineer (who was also the baker, producing astoundingly good home-made sourdough breads on the night) not only nailed the chenin, but backed it up with ‘stone fruit’. They have something north of the Jukskei. Anthonij Rupert Wines offers an excellent spread of character and quality across it’s ranges, from affordable and widely available Protea wines to its flagship tier. The Cape of Good Hope portfolio is a great store of flavours from single vineyards rediscovered in far flung areas. The Laing “Groendruif” Semillon has its home in the Citrusdal Mountains and offered opulent lanolin viscosity around a thatch khakibos spine. A great example of the once ubiquitous (and sadly downtrodden) ‘green grape’. The punters were warming up and finally got out of the blocks identifying a Delheim Chardonnay, also single vineyard and ‘sur lie’; left to lie on its spent lees in oak barrel for nine months. It would have been hard not to. The creamy butterscotch notes were cut by a fresh lemon-lime acidity to achieve fabulous balance. ‘Single vineyard’ means many things but it’s a reasonable proxy for vines that have proven their quality and get top attention (and price) as a result. I anticipated that mindfulness may waver at this point and, as all the reds were unusual and hardly likely to have been on a poor student’s radar before, I showed these bottles ‘open’ with all identifying detail known. This was no longer a guessing game, rather a new frontier I hoped to take them over, a Rubicon for crossing. Dalrymple Pinot Noir 2013 from Pipers Brook in Tasmania was delicate, mature, and reminiscent of mushrooms and moist forest floors. It was also a reminder of politics and wine. China imposed tariffs on wine and barley to ‘punish’ Australia after thenPrime Minister Scott Morrison called for a probe into the origins of Covid-19 in 2020, angering Beijing. WINE EXPORTS COLLAPSED AND MANY PRODUCERS WENT TO THE WALL. GETTING PHILOSOPHICAL, THIS WINE ALSO GOT US TALKING ABOUT HARARI’S SAPIENS AND ITS HARROWING CHAPTER ON THE BRUTAL ‘DISCOVERY’ OF THE TASMAN ISLAND… I was recently privileged to be a guest of the Ambassador of the Argentine Republic and First Secretary Matias Almang to taste a burgeoning array of wine and gin making its way across the Atlantic to us. While Malbec has origins in Bordeaux France, Argentina has made it its own. The Finca Flichman Misterio 2020 would not have been in the glass of any of these young enthusiasts before but, considering the value for money, it and its soon-tobe-landed ilk are likely to be hereon in. La Syrah from Victoria in Australia was everything that quintessential Barossa Valley shiraz counterparts aren’t. Hot? Not. Smooth. Mature (2012) and balanced, a rally satisfying experience that rewarded patient cellaring. And finally, as was traditional, a magnum of Alto Estate Cabernet Sauvignon from 1997; said son and most of the guests’ birthyear. I say ‘traditional’ in the past tense because this was my very last bottle, secured in 1999 and stored for celebration. Which we duly did. After olives and hummus and baba ghanoush and homebaked bread and pasta bakes and salad and pumpkin fritters and fruit cake, inter alia, it was time for e-hail taxis as Papa Swiggs headed for bed. David Swingler is a writer and taster for Platter’s South African Wine Guide for 26 years to date. He has over the years consulted to restaurants, game lodges and convention centres, taught wine courses and contributed to radio, print and other media. A psychiatrist by day, David is intrigued by language in general, and its application to wine in particular. Correspondence: [email protected]

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 61 REVIEW Kim Laxton qualified as a psychiatrist in 2016 and is currently in private practice at Akeso Crescent Clinic, Johannesburg. She works within the life insurance industry in addition to teaching, academia and clinical practice. At SASOP 2021, she assisted in coordinating a parallel session: "The Art of Psychiatry and the Therapy of Play". This included the movie evening at the conference. She is an avid movie-goer, Funko-Pop collector and wildlife fanatic! Correspondence: [email protected] S ometimes going back into the movie archives can be a refreshing reminder of films dedicated to describing and telling stories about people suffering and experiencing mental health conditions. A Beautiful Mind is one such film. Directed by Ron Howard and released in 2001, the movie tells the story of John Nash, a Nobel Laureate in Economics. Played by Russell Crowe, and including names such as Christopher Plummer, Ed Harris and Paul Bettany. The scene is set in 1947, when Nash arrives at Princeton University as a co-recipient, with Martin Hansen, of the Carnegie Scholarship for Mathematics. He meets fellow math and science graduate students Richard Sol (Adam Goldberg), Ainsley Nielson (Jason Grey-Stanford), and Bender (Anthony Rapp), as well as his roommate Charles Herman (Paul Bettany), a literature student. After discussing how to approach women, Nash advocates for the “cooperative approach” which leads him to develop the new concept of popular dynamics that earns him an invitation to MIT. In 1953 Nash is invited to the Pentagon to study encrypted enemy telecommunications by way of looking for hidden patterns in magazines and newspapers to thwart a Soviet plot. The story of Nash’s mental health begins here, becoming increasingly obsessive in his search for these patterns, delivering his results to a secret mailbox, and comes to believe he is being followed. Over time Nash’s paranoia escalates into auditory and visual hallucinations, with bizarre behaviour as a consequence, and he is admitted to a psychiatric hospital by Dr Rosen (Christopher Plummer) where he receives “insulin shock therapy” and is prescribed antipsychotic medication. AS A PSYCHIATRIST, ONE LOOKS AT SUCH FILMS WITH A PROFESSIONAL EYE. Clearly much thought and research had gone into its creation, and the plot weaves itself through themes such as the impact of a mental health diagnosis (such as Schizophrenia), non-adherence to medication as a consequence of side effects, types of delusions and hallucinations, mental illness and its management in the time of John Nash, and finally opening up the discussion on how mental illness affects one’s functioning. Despite his diagnosis, Nash was awarded the Nobel Memorial Prize in Economics in 1994. As there is the inevitable love story, he dedicates his prize to his wife (Alicia Nash) played by Jennifer Conolly and their son. One is left with a mixture of feelings after the film has ended. Sadness, intrigue, fascination, bewilderment, and perhaps relief. But importantly the film highlights the importance of mental health and the impact it has on people’s lives. Overall, the film was a great success, however, as a psychiatrist one would likely view this movie with a critical eye, a film begging to be watched and discussed at a professional forum. And this is good in itself. Kim Laxton MOVIES FROM THE ARCHIVES A BEAUTIFUL MIND

62 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 MOVIES MOVIES Title: Bob Marley: One Love Release Date: 16 Feb 2024 Director: Reinaldo Marcus Green Based on the life of reggae singer and songwriter Bob Marley, from his rise to fame up until his death in 1981 Starring Kingsley Ben-Adir, Lashana Lynch and James Norton. Title: Dune Part Two Release Date: 1 March 2024 Director: Denis Villeneuve Paul Atreides the Fremen while seeking revenge against the conspirators who destroyed his family. Facing a choice between the love of his life and the fate of the universe, he must prevent a terrible future only he can foresee. Title: Zone of Interest Release Date: 02 Feb 2024 Director: Jonathan Glazer The commandant of Auschwitz, Rudolf Höss, and his wife Hedwig, strive to build a dream life for their family in a house and garden next to the camp. Title: Miller's Girl Release Date: 23 Feb 2023 Director: Jade Halley Bartlett. A creative writing assignment yields complex results between a teacher and his talented student. The film stars Jenna Ortega and Martin Freeman. Title: Wicked Little Letters Release Date: 1 March 2024 Directors: Thea Sharrock A genteel coastal town of the 1920s is scandalised when residents are plagued with obscenityfilled letters, in obscenities are accompanied by a theme of domestic abuse. Title: Iron Claw Release Date: 15 March 2024 Director: Sean Durkin The true story of the Von Erich brothers, who make history in the world of professional wrestling in the early 1980s, under the shadow of their domineering father and coach, on the biggest stage in sports.

HEALTH CARE PROFESSIONALS PATIENTS References: 1. Redilev [Professional Information]. Sandton, South Africa: Dr. Reddy’s Laboratories (Pty) Ltd; November 2016. S3 REDILEV 250. Reg.No.: 41/2.5/0460. Each film-coated tablet contains levetiracetam 250 mg. S3 REDILEV 500. Reg.No.: 41/2.5/0461. Each film-coated tablet contains levetiracetam 500 mg. S3 REDILEV 750. Reg.No.: 41/2.5/0462. Each film-coated tablet contains levetiracetam 750 mg. For full prescribing information please refer to the professional information approved by the Medicines Regulatory Authority. Dr. Reddy’s Laboratories (Pty) Ltd., 204 Rivonia Road, Block B, Morningside, Sandton, 2057. Reg.No.: 2002/014163/07. Tel: +27 11 324 2100. www.drreddys.co.za. R1164079-ZA-CO-02052023-001-31 May 2025 THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS ONLY. Redilev is indicated in adults and adolescents (from 16 years of age) as • Monotherapy for the treatment of newly diagnosed partial onset seizures with or without secondary generalisation • Adjunctive therapy to treat partial onset seizures, with or without secondary generalisation REDILEV INDICATIONS:1 Redilev is also indicated as adjunctive therapy in the treatment of: • Myoclonic seizures in adults and juvenile myoclonic epilepsy in adolescents (from 12 years of age), • Primary generalised tonic-clonic seizures in adults, and • Idiopathic generalised epilepsy in adolescents (from 16 years of age) Dr. Reddy’s HEALTH CARE PROFESSIONALS PATIENTS Reference: 1. Yelate [Professional lnformation]. Sandton, South Africa: Dr. Reddy’s Laboratories (Pty) Ltd; 2021. HELPLINE: 0800 21 22 23 www.sadag.org Dr. Reddy’s 1 S5 YELATE 30. Reg.No.: 44/1.2/0114. Each capsule contains duloxetine hydrochloride equivalent to duloxetine 30 mg. Contains sugar (sucrose). S5 YELATE 60. Reg.No.: 44/1.2/0115. Each capsule contains duloxetine hydrochloride equivalent to duloxetine 60 mg. Contains sugar (sucrose). For full prescribing information please refer to the professional information approved by the Medicines Regulatory Authority. Dr. Reddy’s Laboratories (Pty) Ltd., 204 Rivonia Road, Block B, Morningside, Sandton, 2057. Reg.No.: 2002/014163/07. Tel: +27 11 324 2100. www.drreddys.co.za. R1146516-ZA-CO-25022023-0743-31 Mar 25 THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS ONLY.

64 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS SASOP INTRODUCING THE 2023 – 2025 BOARD OF THE SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS (SASOP) President: Dr Anusha Lachman Honorary Secretary: Dr Alicia Porter President – Elect: Dr Anersha Pillay PsychMg Rep: Dr Melane Van Zyl Honorary Treasurer: Dr Thupana Seshoka Pubsec Rep: Dr Nokuthula Mdaka Past President: Dr Sebolelo Seape

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 65 SASOP We are pleased to inform you that the SA-ACAPAP Congress will take place from 7 - 9 March 2024. A draft programme is available at: www.saacapap.co.za WORKSHOPS Pre-booking for the workshops is essential as workshop spaces may be limiter. ACT FOR YOUTH: CORE PRINCIPALS AND PROCESSES: Thursday, 7 March 2024 | 08:30 – 12:30 Facilitators: Dr David Rosenstein, Cognitive Behaviour Therapy (South Africa) | Mr Hannes Wessels, Private Practice (South Africa) Acceptance and commitment therapy (ACT) is a third wave process based behavioural therapy for the treatment of a number of mental health disorders in childhood and adolescents. It has become one of the largest and most evidence based psychological therapies. This workshop aims to provide an overview of the important theoretical foundations of ACT and a few of the core practical applications for childhood and adolescent therapy. CHILD AND MENTAL HEALTH SERVICES - (CAMHS) STRENGTHENING Thursday, 7 March 2024 | 13:00 – 16:30 Facilitator: Dr Rene Nasson, Stellenbosch University (South Africa) DEMYSTIFYING SENSORY INTEGRATION IN NEURODIVERSITY (SAISI) Thursday, 7 March 2024 | 08:30 – 12:30 Facilitators: Ms Gina Rencken, University of KwaZulu-Natal (South Africa) | Ms Ray-Anne Cook, Private Practice (South Africa) Participants will explore sensory integration and its outcomes in neurodiverse older children and adolescents. Participants will gain insight and understanding into the difference between Ayres Sensory Integration (ASI) and other sensory-based approaches including sensory strategies. Practical solutions, experiential learning and case-based discussions will be included, with participants leaving with a nuanced understanding of the application of Ayres Sensory Integration to populations they serve. Prior to attending this workshops, participants will also receive free access to an online 4 hour asynchronous workshop, “Introduction to Ayres Sensory Integration” sponsored by SAISI. Completion of this online workshop is strongly recommended prior to attending the in-person workshop EARLY CAREER RESEARCHERS Thursday, 7 March 2024 • 08:30 – 16:30 Facilitators: Dr Marisa Viljoen, University of Cape Town (South Africa) SYMPOSIA To be hosted as part of the main congress programme on 8 an 9 March. ARFID (AVOIDANT RESTRISTIVE FOOD INTAKE DISORDER) - MORE THAN A FUSS ABOUT FEEDING Presenters: Dr. Carla Groenewald - Psychiatrist, Mrs Hanlie Degenaar - Head of Care2Kids and Senior Speech Language Therapist; Ms Michelle BachClinical Psychologist and Lecturer, Mrs Linda Retief - Occupational Therapist On behalf of SASOP CAPSIG, our Multidisciplinary Team from Northwest University will be presenting a novel framework for the assessment and management of ARFID. This diagnostic category is highly relevant to the field of Child and Adolescent Psychiatry and Allied Hearth Professions. As part of the Symposium, insights from the multidisciplinary audience will be invited to refine this framework for clinical use. CONTEXTUALLY RELEVANT TECHNOLOGY TO SUPPORT FAMILIES WITH NEURODEVELOPMENTAL DISABILITIES Presenters: Ms Marisa Viljoen, Ms Minkateko Ndlovu, Prof Petrus de Vries, Dr Nola Chambers, University of Cape Town Digital technologies are rapidly emerging as tools to support the identification of and intervention for autism and other developmental disabilities. This process was accelerated during the COVID-19 pandemic, when remote technologies sometimes weretheonlytools to reach and support infants, children, adolescents and theirfamilies. In principle, technologies therefore have enormous potential to empower families around the globe. However, there are many challenges to implementing digital technologies. One key challenge is the fact that cflildren and adolescents who may need support live in culturally, linguistically and socioeconomically highly diverse communities, and access to technologies may be hugely variable. SOUTH AFRICAN ASSOCIATION FOR CHILD AND ADOLESCENT PSYCHIATRY AND ALLIED PROFESSIONS 2024 SA-ACAPAP CONGRESS IN PARTICIPATION WITH AACAMH, PANDA-SA AND SAISI

66 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 SASOP Therefore, there is a great need to consider the accessibility, affordability, and cultural appropriateness of potential technologies across diverse communities. Another key challenge is the fact that clinical, educational and social care systems look very different around the globe. In this symposium, we will present four examples to illustrate how remote technologies were developed in culturally- and contextually-sensitive ways in participation with a range of stakeholder groups. KEYNOTE SPEAKERS Ms Lucy Jamieson Is a senior researcher at the Children's Institute, University of Cape Town. She has a BA (Hons) in Politics, an MA in Democratic Governance and is a PhD candidate in Sociology. She has 2 decades of experience in political campaign management, communications co-ordination and public consultation. Her areas of expertise are child rights, participatory democracy; governance; law reform & policy development and child protection. Dr Anusha Lachman Is the C&A consultant at the adolescent inpatient unit at Tygerberg Hospital and the Head of the Clinical Unit at Tygerberg Child Psychiatry. She is also the program convener for the MPhil in Infant Mental Health. Dr. Lachman's research interests include maternal and infant mental health, adolescent neuropsychiatry, and paediatric consultation-liaison psychiatry. Dr Heidi Matisonn Trained as a philosopher, I received my PhD from the London School of Economics in 2012 and am now a Senior Lecturer in Ethics based in the Ethics Lab, Department of Medicine, at the University of Cape Town. I am also an executive member of the SARETI (South African Research Ethics Training Initiative) programme and an honorary research associate in Philosophy at the University of KwaZulu-Natal. My current research focuses on building moral resilience among healthcare professionals. Dr Anna E. Ordóñez, M.D., M.A.S. Is the Director of the Office of Clinical Research at the National Institute of Mental Health (NIMH). She received her M.D. from the Pontificia Universidad Javeriana, in Bogotá, Colombia and her Adult Psychiatry and Child and Adolescent Psychiatry training at the University of California, San Francisco (UCSF). She is board certified both in adult and child & adolescent psychiatry. She has also completed postdoctoral research fellowships both at the NIMH and UCSF, and a master’s degree in Advanced Sciences in Clinical Research (M.A.S.) at UCSF. Prior to returning to NIMH, she held a faculty position at UCSF, where among other duties, she was the Medical Director of the Division of Infant, Child and Adolescent Psychiatry. She has also engaged in research studies of typical and atypical brain development and of evidence based psychosocial interventions to enhance psychological resilience in the United States, Costa Rica and Colombia. In addition to her current work at NIMH, Dr. Ordóñez is co-chair of the NIH UNITE E committee that is charged with evaluating and changing NIH policies, cultures, and structures to promote diversity in research. She is also an Associate Editor of IACAPAP’s official journal, Child and Adolescent Psychiatry and Mental Health and serves as liaison between IACAPAP and the journal. Prof Luis A Rohde, MD, PhD Is Professor of Child and Adolescent Psychiatry in the Department of Psychiatry at the Federal University of Rio Grande do Sul, Brazil, Director of the Program for AttentionDeficit/Hyperactivity Disorder at the Hospital de Clinicas de Porto Alegre, and Vice-Coordinator of the National Institute of Developmental Psychiatry for Children and Adolescent, Brazil. He is currently. He served as Associate Editor of the Journal of Attention Disorders (2018-2022), International Editor of the J Am Acad Child and Adolescent Psychiatry (2008-2017) and as Co-Editor of the European Child and Adolescent Psychiatry (2004-2013). He is Immediate Past President of the World Federation of ADHD and was former Vice-President of the International Association of Child and Adolescent Psychiatry and Allied Professions. He was also a member of the American Psychiatric Association working group for defining ADHD diagnosis in the DSM-5. Dr. Rohde’s research interests include different ADHD facets, neurodevelopment, and child and adolescent mental health epidemiology. He has published extensively in peer review international and journals (460 papers) and has been an author or co-author in over 50 book chapters and editorials. He is editor or organizer of 8 books addressing child and adolescent mental health published in Brazil, UK, Germany, and the US. He has almost 40000 citations per doc and an H index = 85 (google scholar). In 2020, 2021 and 2022, he was included as a “Highly Cited Researcher” in Psychiatry and Psychology for the last decade by Clarivate – Web of Science (top 1% in these fields)

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 67 SASOP PMB DEFINITION GUIDELINE FOR SCHIZOPHRENIA PsychMg wants to inform medical schemes, service providers and mental healthcare users of the Prescribed Minimum Benefit (PMB) Definition Guideline for Schizophrenia that was published on the Council for Medical Schemes (CMS) website on the 16 October 2023 (https://www.medicalschemes. co.za/publications/#2009-3569-wpfd-mentalhealth )(full content available electronically). This guideline updates the previous PMB Definition Guideline for Schizophrenia, published 30 September 2020. Most medical schemes did not adopt the previous guideline and whilst assisting the CMS with the latest guideline, PsychMg asked for a legal opinion (full content available electronically) from the CMS regarding the legal standing of the PMB Definition Guidelines. The legal opinion states that the guideline defines the PMB that should be available to patients with schizophrenia. Schizophrenia is listed as a PMB condition under the Diagnosis Treatment Pairs (DTP) and the Chronic Disease List (CDL) and the PMB entitlement for Schizophrenia includes benefits for in and outpatient care. Specific limitations are mentioned in the document, including: “The recommended maximum hospital stay is 21 days” “A maximum of 12 treatments (ECT)per cycle is recommended” “Family interventions should: • include the person diagnosed with schizophrenia if practical. • be carried out for between 12 weeks and one year. • include at least 10 planned sessions” “Psychosocial interventions should be delivered on an individual basis (one-to-one) over at least 16- 21 sessions for patients with schizophrenia. Interventions can also be applicable in group form, namely social skills training, cognitive remediation, psychoeducation, and multi-family groups, synergising the already known benefits with newer therapy models” As the diagnosis is complex, and only reliant on symptoms and signs (as no biomarker is available), the document recommends the PMB that should be available: “The diagnosis of schizophrenia must be confirmed by two mental health care practitioners” “A comprehensive multidisciplinary assessment should be conducted. • The assessment (see Table 1) should include a: o psychiatric history o medical history o physical examination o mental state examination o psychosocial assessment (psychological assessment is a component of the psychosocial assessment) o the psychosocial assessment must include a: o Neurocognitive assessment (social, cognitive, and motor development); and o Social skills assessment (routines, roles, values, interests, environment, attitudes, motivation, activities of daily living (ADL), family and relationships). o occupational functioning or educational assessment; and o an assessment of socioeconomic status. The guideline stresses the multi-professional approach to the diagnosis and management of patients with schizophrenia. Benefits for the diagnosis should thus be available for the services of:

68 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 SASOP • Medical practitioners including general practitioners (GP’s) and psychiatrists • Clinical and/or counselling psychologists • Occupational therapists • Social workers Benefits for the further management of the patient with schizophrenia should include: • Psychiatric (psychiatrists and/or GP’s) • Medical (psychiatrists and/or GP’s and or others) • Psychological (clinical and/or counselling psychologists) • Occupational (occupational therapists) • Physical wellbeing (physiotherapists) • Diet and metabolic control (dieticians) • Social wellbeing (social workers) • Nursing (mental health specialist nurse) Where no limitation of benefits is mentioned in the guideline, Annexure A of the Regulations to the Medical Schemes Act should be followed that states: “Explanatory notes and definitions to Annexure A: 2. Where the treatment component of a category in Annexure A is stated in general terms (i.e. “medical management” or “surgical management”), it should be interpreted as referring to prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition. Where significant differences exist between public and private sector practices, the interpretation of the PMB should follow the predominant public hospital practice, as outlined in the relevant provincial or national public hospital clinical protocols, where these exist. Where clinical protocols do not exist, disputes should be settled by consultation with provincial health authorities to ascertain prevailing practice. 2. A. In respect of treatments denoted as “medical management” or “surgical management”, note (2) above describes the standard of treatment required, namely “prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition.” Note (2) does not restrict the setting in which the relevant care should be provided, and should not be construed as preventing the delivery of any PMB on an outpatient basis or in a setting other than a hospital, where this is clinically most appropriate.” Provincial or national public hospital protocols include the services of all providers mentioned earlier and include the medication listed below. The medication that should be available as a PMB is listed in Appendix A of the document and includes: • Haloperidol • Chlorpromazine • Risperidone • Olanzapine • Quetiapine • Amisulpride • Aripiprazole • Ziprasidone • And depot preparations: o Flupentixol o Zuclopenthixol • Brexpiprazole • And long acting injectables: o Aripiprazole o Paliperidone o Risperidone The guideline recommends that a care or treatment plan be drafted and followed, which needs to include as far as possible all the treatments and professionals involved. The care or treatment plan can change depending on the condition of the patient. Please consult the PMB Definition Guideline for Schizophrenia document (attached) for more detail. Dr Kobus Roux Chairperson PsychMg

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 69 SASOP PMB DEFINITION GUIDELINE FOR SCHIZOPHRENIA DISCLAIMER: This schizophrenia benefit definition guideline has been developed for most patients who require standard care. These benefits may not be applicable to all patients, especially those with complex presentations or comorbidities. Section 15(H) and 15(I) should be applied to beneficiaries who are inadequately managed by the defined benefits.The medication that should be available as a PMB is listed in Appendix A of the document and includes: INTRODUCTION The legislation governing the provision of the Prescribed Minimum Benefits (PMBs) is contained in the Regulations enacted under the Medical Schemes Act, 1998 (Act No. 31 of 1998). It has become clear that medical scheme beneficiaries find it difficult to be fully aware of their entitlements in advance. In addition, medical schemes interpret these benefits differently, resulting in a lack of uniformity of benefit entitlements. The guideline covers the assessment, diagnosis, treatment, and management of schizophrenia. It aims to define the prescribed minimum benefits (PMBs) for the management of schizophrenia and to make recommendations and suggestions to enhance the overall care of individuals with schizophrenia. The primary objective of the PMB definition guideline is to: • Provide clear, comprehensive descriptions of the benefits, in terms of the provisions of the PMB regulations of the Medical Schemes Act, No. 131 of 1998. • Improve clarity in the funding decisions by medical schemes; and • Ensure protocols and algorithms developed by medical schemes are developed on best available clinical practice guidelines. This guideline is based on the best available evidence (safety, efficacy, effectiveness, and economic aspects) and clinical practice knowledge of schizophrenia. Our recommendations are put together by technical experts, healthcare professionals and the medical schemes industry. This Guideline should be read in conjunction with the supplementary information included as Annexure A to this guideline. This PMB Definition guideline was developed as a policy prescript in line with Section 15 (A) to (I) of the Medical Schemes Act, 131 of 1998, for the development of protocols and formularies, and should be viewed as such. ACKNOWLEDGEMENTS The Council for Medical Schemes (CMS) would like to acknowledge all stakeholders and members of the CAC who assisted in providing technical input and development of this document, including the following general practitioners, psychiatrists, and representatives from other healthcare professionals for their insights: Dr Eugene Allers (Psychiatrist) Dr Mvuyiso Talatala (Psychiatrist) Ms Carla Gerryts (Dietician) Dr Linda Blokland (Clinical Psychologist) Mr Winston Schoeman (Clinical Psychologist) Mr Michael Webber (Counselling Psychologist) Samantha Holle (Counselling Psychologist) Ms Mareldia Achmat (Counsellor) Ms Gerbri van Heerden (Occupational Therapist) Ms Natasha van de Heyde (Occupational Therapist) Ms Haneke Jonas (Occupational Therapist) Ms Karen Coertze (Physiotherapist) Claudia Schaft (Physiotherapist) The individuals mentioned below from patient advocacy groups, representatives from pharmaceutical companies, as well as different medical schemes and administrators; were also members of the clinical advisory committee set up to discuss member entitlements for schizophrenia. Their contributions were immensely valuable. Dr Lindiwe Mbekeni (Discovery Health) Ms Cassi-Lee Rubin (Discovery Health) Ms Cassey Chambers (South African Depression and Anxiety Group) Dr Moresi Mahlangu (GEMS) Dr Randal Hartnick (GEMS) Dr Lerato Motshudi (GEMS) Mr Fakir Chavoos (Pharmaceutical Task Group) Ms Demi-Lee Weitz (Medscheme) Ms Danielle Oosthuizen (Medscheme) Mr Fabian Bennet (Clinix Health Group) Ms Dina Louw (Afrocentric) Ms Vanessa Snow (Janssen-J&J) Ms Angela Riva (Jansen- J&J) Dr Lerato Motshudi (Akeso Clinics) Mr Kobus Kuhn (Financial Planning Institute) Mr Dewald David de Lange (Mediclinic) Special Thanks to Dr Shamima Salojee (chairperson) and Dr Edith Madela-Mntla for their contribution and development of the final PMB Definitions Guideline for Schizophrenia

70 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 SASOP GUIDANCE FOR THE ASSESSMENT AND MANAGEMENT OF SCHIZOPHRENIA This guideline provides recommendations for the: • Assessment and diagnosis of schizophrenia. • Treatment and care in schizophrenia. • Monitoring and evaluation of patients with schizophrenia; and • Rehabilitation and reintegration of mental health care users with schizophrenia. 1. ASSESSMENT AND DIAGNOSIS 1.1. Diagnosis in primary care 1.1.2. In primary health care, the diagnosis of schizophrenia involves ruling out other mental health disorders and determining that the symptoms are not due to substance use, medication, or another medical condition. 1.1.3. The diagnosis of schizophrenia must be confirmed by two mental health care practitioners, one of whom should be qualified to do physical examinations i.e., a medical practitioner (GP or psychiatrist). In primary care, one mental health care practitioner (MHCP) may make a provisional diagnosis for schizophrenia, but this must be confirmed by a medical practitioner (see Table 1). 1.1.4. Stable patients can receive maintenance treatment by the GP or any MHCP whose scope of practice incorporates care, treatment, and rehabilitation of mental health care users. 1.1.5. Those patients with a poor response to antipsychotic treatment, non-or poor adherence to medication, or who require psychological intervention that is not available in primary care, or who are a danger to self, others, or property, should be referred to secondary care without delay. 1.2. History and examination 1.2.1. A comprehensive multidisciplinary assessment should be conducted. 1.2.2. The assessment (see Table 1) should include a: • psychiatric history • medical history • physical examination • mental state examination • psychosocial assessment (psychological assessment is a component of the psychosocial assessment) • the psychosocial assessment must include a: o Neurocognitive assessment (social, cognitive, and motor development); and o Social skills assessment (routines, roles, values, interests, environment, attitudes, motivation, activities of daily living (ADL), family and relationships). • occupational functioning or educational assessment; and • an assessment of socioeconomic status. 1.3. Base-line investigations 1.3.2. The following baseline investigations (see Table 2) should be performed before initiating treatment and for monitoring the adverse effects of medication: • weight (plotted on a chart) • height • waist circumference • pulse and blood pressure • fasting blood glucose or glycosylated haemoglobin (HbA1c) • Liver Function Tests (LFT) Thyroid Function Test (TFT) • blood lipid profile • Treponema Pallidum Haemagglutination (TPHA) • pregnancy test (females of childbearing age) • Human Immunodeficiency Virus (HIV) Test, with consent • computerised tomography (CT) scan 1.3.3. An electrocardiogram (ECG) if: • this is specified in the medicine authorisation package insert. • a physical examination has identified specific cardiovascular risk factors e.g., diagnosis of hypertension. • there is a personal history of cardiovascular disease; or • the service user is being admitted as an inpatient. 2. TREATMENT AND CARE 2.1. Early intervention services for psychosis 2.1.1. A patient presenting with a first episode of psychosis may present with brief or attenuated psychotic symptoms, and other experiences or behaviours that are suggestive of a psychotic disorder. 2.1.2. The first-contact healthcare professional must refer such patients for assessment without delay to a

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 71 SASOP MHCP or secondary care service that incorporates an early psychosis intervention service, because they may be at increased risk of developing schizophrenia. 2.1.3. These individuals must be assessed by MHCPs in terms of Chapter V of the Mental Health Care Act. 2.1.4. Early intervention services for psychosis should be accessible to all patients with a first episode of psychosis, irrespective of the person's age or the duration of untreated psychosis (DUP). 2.1.5. Patients should be assessed without delay. If the resources to manage patients with a first episode of psychosis are inadequate at the primary care level, such a patient must be referred to a secondary care level of care. 2.1.6. Early intervention in psychosis services should aim to provide a comprehensive package of care that includes the assessment and management of patients with schizophrenia. 2.1.7. The management of schizophrenia must include pharmacological, psychosocial, occupational, and educational interventions for people with psychosis, consistent with this guideline. 2.1.8. The first-contact professional must initiate emergency antipsychotic treatment. Long-term antipsychotic treatment must only be initiated at the primary care level in consultation with a psychiatrist. 2.2. Treatment and care in secondary care (inhospital) 2.2.1. A care plan must be developed following the assessment based on a psychiatric and psychosocial assessment, as well as a full assessment of physical health. A copy of the care plan must be provided to the primary healthcare professional who made the referral, and the patient. 2.2.2. For people with first episode psychosis, offer: • psychoeducation • oral antipsychotic medication • psychological intervention, including individual Cognitive Behavioural Therapy (CBT); and • advice on the effectiveness of psychological interventions in conjunction with antipsychotic medication. 2.2.3. The recommended maximum hospital stay is 21 days. 2.2.4. Patients with symptoms and behaviour that suggest an affective psychosis or disorder including bipolar disorder and psychotic depression, follow the recommendations in the major affective disorders, including unipolar and bipolar depression (PMB code 902T). 2.2.5. Assess for post-traumatic stress disorder and other reactions to trauma because people with schizophrenia are likely to have experienced previous adverse events. For people who show signs of post-traumatic stress accompanied by recent significant trauma, including physical or sexual abuse, refer to the PMB definition guideline on acute mental health conditions (PMB Code 901T). 2.3. Return to primary care. 2.3.1. For patients who have responded effectively to treatment and remain stable, consider the option to return to primary care for further management by a GP and other MHCPs. 2.3.2. GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia when providing maintenance treatment in line with the recommended care plan. 2.3.3. Patients with schizophrenia who have high blood pressure, abnormal lipid levels, diabetes or pre -diabetes (as indicated by abnormal blood glucose levels in baseline assessment) or are physically inactive must be identified and monitored at primary care level in line with the best available guidelines in line with PMB Chronic Disease List for Hypertension and Diabetes respectively. 2.3.4. A Case Manager should be assigned for all mental health patient care users diagnosed with schizophrenia. A detailed care plan should be submitted to Case Management to coordinate optimal care for the patient both in and out-ofhospital. 2.4. Relapse and re-referral to secondary care 2.4.1. If a patient with an established diagnosis of schizophrenia presents with a suspected relapse (for example, with increased psychotic symptoms or a significant increase in the use of alcohol or other substances) to a primary healthcare professional i.e., GP, that patient should be referred to secondary care and a psychiatrist through the case manager without delay. 2.4.2. A patient being managed in primary care with poor response to treatment; non-adherence to medication, intolerable side effects from medication; comorbid substance use and/or who is a risk to self and others should be re-referred to secondary care. 2.5. General considerations for treatment and care 2.5.1. The treatment of schizophrenia is symptomatic and includes treatment for the primary symptom domains viz, positive symptoms (delusions and hallucinations) negative symptoms (impaired motivation, poverty of speech, and social withdrawal) and cognitive symptoms (memory impairment). 2.5.2. Antipsychotics are effective mainly for the positive symptoms of schizophrenia and is the cornerstone of acute exacerbation or recurrence of schizophrenia; hence effective therapy necessitates

72 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 SASOP new oral antipsychotic medication or a review of existing medication. 2.5.3. The negative and cognitive symptoms do not respond as well as the positive symptoms to currently available antipsychotic medication. Significant occupational and social dysfunction are associated with schizophrenia. Hence, psychosocial interventions are an essential component of the management plan. 2.5.4. Duration of untreated psychosis (DUP) i.e., manifestation of the first psychotic symptom to initiation of adequate antipsychotic drug treatment is associated with poorer overall outcome. Hence, patients should be initiated on antipsychotics as soon as possible after a first diagnosis of schizophrenia. 2.5.5. Intermittent long-acting injectable antipsychotic (LAI-AP) maintenance strategies (use of antipsychotic medication only during periods of incipient relapse or symptom exacerbation) is not recommended for routine use. 2.5.6. Pharmacological therapy should be tailored to the individual patient’s needs. Due consideration must be given to: • metabolic risk factors (including weight gain and diabetes). • sensitivity to extrapyramidal side effects (including akathisia, dyskinesia, and dystonia). • cardiovascular risk factors (including prolonging the QT interval). • hormonal factors (including increasing plasma prolactin). • other factors (including unpleasant subjective experiences); and • if a generic formulation is available, generic substitution is recommended. 2.6. Pharmacological treatment 2.6.1. Choice of first-line oral antipsychotic 2.6.1.1. Antipsychotics consist of various classes of medicine based on their pharmacological action (see Table 3). 2.6.1.2. To promote individualised therapy, clinicians should: • Discuss treatment options with the MHCU and family if available. • Record the indication, expected benefits, potential risks of oral antipsychotic medication, and the expected time for a change in symptoms and appearance of side effects. • At the initiation of treatment, prescribe a dose at the lower end of the licensed dose range and slowly titrate upwards within the given dose range as per the South African Medicines Formulary of Medicines Package Insert. • Justify and record reasons for dosages that are prescribed outside of the recommended range. • Accurately record the rationale for continuing, changing, or stopping medication, and the effects of any such changes. • Carry out a trial of the medication therapy at optimum dosage for 4 to 6 weeks, monitoring the patient continuously. 2.6.1.3. The choice of medicine must be in line with the criteria listed in 2.5.6 • It is recommended that monotherapy oral therapy is initiated at the lowest dose and slowly titrated upwards to the highest effective dose. • The monotherapy treatment initiated should continue for at least 4-6 weeks to evaluate response to the first-line antipsychotic. 2.6.2. Choice of second-line oral antipsychotic 2.6.2.1. For patients with an acute exacerbation or recurrence of schizophrenia, a review of the existing medication regimen must be conducted. • Consider errors in diagnoses, medical comorbidity as well as non-adherence to antipsychotic medication before concluding that a patient is resistant to a specific antipsychotic. • The clinical response and side effects of the patient’s current and previous medication should be considered. 2.6.2.2. Second-line antipsychotics are required when patients experience exacerbations of symptoms and/or poor response to adequate treatment with a first line antipsychotic. 2.6.3. Choice of third-line antipsychotics 2.6.3.1. Clozapine is the only antipsychotic with established efficacy in reducing symptoms and the risk of relapse for adults with treatment-resistant schizophrenia. 2.6.3.2. Clozapine should be prescribed for those patients who have not adequately responded to treatment with the chronological use of adequate doses of at least two different antipsychotic medicines for 6-8 weeks. 2.6.4. Use of depot/long-acting injectable antipsychotics 2.6.4.1. Depot/ LAI-AP with market authorisation in South Africa for intramuscular formulations should be considered: • to avoid covert non-adherence (either intentional or unintentional) to oral antipsychotic medication • when it is a clinical priority within the treatment plan

SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 * 73 SASOP • when patients are unwilling to accept a continuous oral antipsychotic maintenance regimen LAI-APs are a feasible alternative to oral antipsychotic (OAP) treatment; and • in the early stages of schizophrenia, LAI -APs may prevent relapse and recurrence in patients with a first episode of schizophrenia. • patient preferences and attitudes towards regular intramuscular injections, and access to outpatient mental health services must be taken into consideration when prescribing LAI-APs. 2.7. Non-pharmacological treatment 2.7.1. Electro-convulsive therapy 2.7.1.1. ECT is a safe and effective treatment for schizophrenia. The clinical indications for ECT in schizophrenia include: • treatment resistant schizophrenia • catatonia • suicidal behaviour with command type hallucinations • severe agitation • clozapine-resistant schizophrenia 2.7.1.2. Prolonged courses of ECT without measured improvement are not recommended for people with schizophrenia. A maximum of 12 treatments per cycle is recommended. 2.7.1.3. Longer courses may be required if progressive improvement occurs with each session. 2.7.2. Physiotherapy • Physical health is integral to health promotion efforts in patients with schizophrenia. • Encouraging healthier lifestyle choices and higher levels of habitual physical activity is recommended. • A Physiotherapist serves to assess any movement disorders, level of physical activity and develops a physical therapy care plan as part of the MDT at secondary level e.g., 2.7.3. Dieticians • Play an important role in improving the physical health of patients with schizophrenia. • Assess the nutritional status of a patient and recommend an appropriate diet. • Develop a care plan in line with the base-line assessment. 2.8. Psychosocial interventions 2.8.1. Psychosocial interventions should be delivered by qualified, trained therapists with the appropriate level of competence and duly registered to provide such services. 2.8.2. psychosocial interventions are recommended as adjunctive therapy to pharmacological therapy. 2.8.3. Psychosocial interventions can be classified into behavioural, cognitive, psychodynamic, humanistic, systemic, motivational, social, occupational, and environmental interventions. 2.8.4. Psychosocial interventions such as Individual CBT, cognitive remediation therapy and programmes for family intervention for patients with schizophrenia are recommended. 2.8.5. Psychosocial interventions should be delivered on an individual basis (one-to-one) over at least 16- 21 sessions for patients with schizophrenia. 2.8.6. Interventions can also be applicable in group form, namely social skills training, cognitive remediation, psychoeducation, and multi-family groups, synergising the already known benefits with newer therapy models. 2.8.7. A treatment plan should be followed and developed so that: • patients with schizophrenia can establish links between their thoughts, feelings, or actions and their current or past symptoms and/or functioning; and • perceptions, beliefs, or reasoning related to target symptoms can be re-evaluated. 2.8.8. The sessions should include: • patients monitoring their own thoughts, feelings, or behaviours with respect to their symptoms or recurrence of symptoms; and • reducing distress. 2.8.9. The role of the multi-professional team is critical in the management of patients with schizophrenia. Therefore, psychosocial interventions are recommended for full recovery. 2.8.10. Family interventions should: • include the person diagnosed with schizophrenia if practical. • be carried out for between 12 weeks and one year. • include at least 10 planned sessions; and • take account of the whole family's preference for either single-family intervention or multi-family group intervention. 2.8.11. Art Therapy i.e., the use of artistic methods to treat psychological disorders and enhance mental health, is a technique rooted in the idea that creative expression can foster healing and mental well-being.

74 * SOUTH AFRICAN PSYCHIATRY ISSUE 38 2024 SASOP 2.8.12. The following can be considered - art therapies e.g., dance movement, music or art therapy or drama therapy are recommended for people with schizophrenia, particularly for the alleviation of negative symptoms, during the acute phase or later, including in inpatient hospital settings. 3. MONITORING 3.1. General considerations for monitoring therapy 3.1.1. Monitoring the response to pharmacological and psychosocial therapy ensures that the effectiveness of therapy can be assessed and adjusted if needed. It also provides an opportunity for MHCPs to monitor other outcomes, such as the effects on any long-term conditions and the patient's ability to continue or return to employment. 3.2. Monitoring of pharmacological treatment 3.2.1. Pharmacological therapy must be monitored regularly and systematically throughout treatment period. Special attention must be paid to periods of up and cross-titration of antipsychotics. To ensure quality of care, regular monitoring must include: • response to treatment, including changes in symptoms and behaviour. • side effects of treatment, considering the overlap between certain side effects and clinical features of schizophrenia • the appearance of movement disorders • weight, weekly for the first six weeks, then at 12 weeks, at one year and then annually, because some antipsychotics increase the risk of metabolic syndrome (the statement regarding SGAs is not correct) • waist circumference annually (plotted on a chart) • pulse and blood pressure at 12 weeks, at one year and then annually. • fasting blood glucose or HbA1c, and blood lipid levels at 12 weeks, at one year and then annually. • Adherence to oral antipsychotics; and • overall physical health. 3.3. Monitoring of psychosocial interventions 3.3.1. Within the MDT, a lead professional should monitor and review access to and decisions about what psychosocial interventions to offer. 3.3.2. Psychosocial interventions should be monitored for a range of outcomes across relevant areas, including patient satisfaction and, if appropriate, family satisfaction routinely and systematically. 4. REHABILITATION AND REINTEGRATION 4.1. General considerations for rehabilitation and reintegration 4.1.1. The importance of case management is to co-coordinate integrated health and social care services of severely mentally ill people in the community. The end goal for rehabilitation is re-establishing social connections and getting back to social and vocational roles for successful reintegration, reintegration into society. 4.1.2. Only one out of seven patients recover after a first episode of psychosis despite mental health care and treatment. 4.1.3. The role of rehabilitation in schizophrenia is to complement psychotherapy and psychopharmacological treatments to improve functional outcomes and to promote recovery. 4.1.4. Psychosocial rehabilitation interventions should typically start from in-patient level if the patient had been admitted and continue into the long-term. 4.1.5. Various factors need to be assessed to establish an individual “functional diagnosis.”, which mostly definitely helps to determine an individualized intervention plan and to define life goals in collaboration with the patient. 4.2. MDT role in rehabilitation and reintegration 4.2.1. Role of Occupational Therapist • Occupational therapy interventions improve, maintain performance and occupational participation for people with serious mental illness. • Occupational therapists work in both hospital and community settings using a combination of individual and group interventions to enable skill development and building of their confidence in the execution of everyday tasks. • Interventions may include practical self-care; domestic skills, such as cooking and budgeting; work skills; leisure activities; development of social skills and carer support. 4.2.2. Role of Social Worker • Social Work practitioners have postulated that the psychosocial functioning or dysfunction in severe mental illness was mostly determined by the interaction between the individual needs, aspirations, and functional capacities on one side, and environmental (situations) expectations, opportunities, and resources on the other. • Interventions in this category may include family psychoeducation and support, family-aided ACT, and case management.

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Introducing Drug layer Barrier layer Outer enteric layer When depression hurts… References: 1. Chen Kuang, Yinghua Sun, Bing Li, Rui Fan, Jing Zhang, Yumin Yao, Zhonggui He. Preparation and evaluation of duloxetine hydrochloride enteric-coated pellets with different enteric polymers, Asian Journal of Pharmaceutical Sciences, Volume 12, Issue 3, 2017, Pages 216-226. 2. Jawahar, N. & Anilbhai, P.H.. (2012). Multi unit particulates systems (MUPS): A novel pellets for oral dosage forms. Journal of Pharmaceutical Sciences and Research. 4. 1915-1923. *For full prescribing and dosage information, please refer to registered package insert. S5 DULEVE 30 mg Capsules. Each capsule contains 30 mg Duloxetine (as Hydrochloride). Reg No.: A49/1.2/1198. S5 DULEVE 60 mg Capsules. Each capsule contains 60 mg Duloxetine (as Hydrochloride). (0)12 748 6400. 04/DUL/09/21/AD. Multi-layer benefits1,2 Drug layer Barrier layer Outer enteric layer Suspension coating technique for greater bioavailability Protects Duloxetine from acidic layer of enteric coating Protects Duloxetine from gastric acid Greater amount of drug available at the site Ensures optimal absorption Avoids Sub-therapeutic dose Features Benefits with TRIPEL (Tri-layered pellet) technology1,2

Introducing CLOBAZAM ADCO Indicated for the treatment of anxiety in neurotic patients, for pre-operative medication, and it may be effective in relieving the acute symptoms of alcohol withdrawal syndrome1 May be used as an adjuvant in epilepsy*1 • Unlike other benzodiazepines, CLOBAZAM ADCO has less sedative effects2 • Mild to moderate adverse events2 • Cost saving of 15 % versus originator3 *The dosage of CLOBAZAM ADCO should be determined by monitoring the EEG and plasma levels of the other medicines.1 References: 1. CLOZABAM ADCO 10 & 20 mg tablets Professional Information, 27 June 2023. 2. Faulkner MA. Comprehensive overview: efficacy, tolerability, and cost-effectiveness of clobazam in Lennox-Gastaut syndrome. Ther and Clin Risk Manage 2015;11:905-914. 3. Generics dictionary. http://www.generic.co.za/frontend/generics?utf8=%E2%9C%93&q%5Bactive_ingredient_ name_eq%5D=CLOBAZAM (Accessed: 03 October 2023). For full prescribing information please refer to the Professional Information approved by SAHPRA (South African Health Products Regulatory Authority). S5 CLOBAZAM 10 ADCO. Each tablet contains 10 mg of clobazam. Reg. No.: 55/2.6/0546. S5 CLOBAZAM 20 ADCO. Each tablet contains 20 mg of clobazam. Reg. No.: 55/2.6/0547. Adcock Ingram Limited. Reg. No.: 1949/034385/06. Private Bag X69, Bryanston, 2021. Customer Care: 0860 ADCOCK/232625. www.adcock.com 2023080110303342. August 2023. A calming touch NEW Clobazam 17919