Complexities of mental health

* Addictions are often associated with the complexities of mental health.

The relationship between addiction and mental illness is a complex one, and with addiction “extremely high” in the Western Cape, treatment services are under severe pressure.

So says the Western Cape Health Department whose spokesperson, Maret Lesch, told the Echo that alcohol and tik were major problems, with heroin addiction growing at a rapid rate.

And the stories shared with us have revealed that many people who suffer from the combined pressures of mental illnesses and addiction end up homeless.

Candy (not her real name) tells a story so tragic it’s hard to believe it is true.

She lives in a tent as a backyard dweller. Three weeks ago she was discharged from a psychiatric hospital, where she had been admitted by family and friends during a psychotic episode. Her previous admission to a psychiatric hospital was by a stranger who found her walking the streets.

This is a cycle Candy has been caught in for years. She regularly loses touch with her family, all of whom have individually tried to help her themselves, and failed.

Their only failure, however, is that they are, not trained to diagnose nor even recognise what Candy is presenting with.

Most of the times Candy becomes psychotic, she is hospitalised, often in other provinces. When she stabilises, she is released with medication. And because she is an addict too, she pawns or sells her prescription meds for street drugs. Sometimes she does sex work to earn cash.

She started that in her teens, she admits. For some years, she was relatively stable and found medication that worked. For some time, nobody knew of her past.

Candy’s aunt says she was a sweet child, but that she had a hard time growing up with a mother who regularly tried to commit suicide, sometimes selecting one of her children as the child to take out with her. Her mother’s behaviour was never officially diagnosed.

Candy’s mother married five times and Candy left home early and went to live with her aunt. Candy, who used street drugs to numb herself, says her aunt had
no idea she was a sex worker. Candy is nearing 50 and her latest diagnosis is borderline personality disorder compounded by bipolar disorder.

Her family is desperate. They can’t take her in, she won’t take her medication, they don’t know what she is addicted to, and if they approach her, she threatens them physically and says she will set gangs on them. And she has attempted suicide many times. Recently, one of her children succeeded.

A homeless man in Muizenberg is there because he lost a number of family members in quick succession and it simply broke him.

An elderly homeless woman says she is the last of her family alive: she has no one left to help her. A man in FIsh Hoek tells a story so convoluted it is impossible to follow. He is “completely sane”, he says and can’t understand why his family has shut him out.

His eyes fill with tears. “I haven’t done anything wrong,” he says. “I love my family.”

When he is done chatting, he says, he is heading off to get some dagga, because it helps him feel better.

The mix of these issues is very complex says Ms Lesch, who adds that the use of certain drugs can bring on a latent mental illness. She said this is true for some drugs and some illnesses for instance cannabis and methamphetamines, that can unmask a latent psychotic disorder.

And while help is available in hospitals across the peninsula, the onus of care for mentally ill patients who are also addicts – and homeless – still falls to their families.

She said the provincial health department has four specialised psychiatric hospitals – Alexandra, Lentegeur, Stikland and Valkenberg hospitals – and two sub-acute facilities, New Beginnings and William Slater, that provide a wide range of services for patients with mental illness.

“The first port of entry into psychiatry is usually through the primary health service, which is responsible for the assessment and treatment of patients or referral to higher levels of care if necessary,” Ms Lesch said.

Ms Lesch said there is a complex relationship between addiction and psychiatry, with psychiatric illness making a person more vulnerable to addiction and addictive disorders that can lead to psychiatric illness.

She said patients with addictions were not excluded from psychiatric care.

Although drug addiction is a psychiatric disorder that is listed by the World Health Organisation among the psychiatric illnesses, it is not treated primarily by psychiatry in South Africa.

Here, the lead department for drug abuse and addiction, is the Department of Social Development (DSD) while the Department of Health (DoH) plays a supportive role.

Ms Lesch says the Prevention of and Treatment for Substance Abuse Act, which deals with the treatment of addiction and this Act is hosted by the DSD, while the Mental Health Care Act deals with mental illness and is hosted by DoH.

“The interface between these two disorders is not always clearly delineated, but it is helpful to think about what the focus of the problem is. If the focus of the presentation is substance use, patients are treated by addiction services and if the focus of the problem is mental health problems, the patient is treated by psychiatric services,” she said.

Ms Lesch said that substance use disorders are extremely high in the Western Cape, this includes alcohol, the methamphetamine (tik) epidemic and a growing problem of heroin abuse.

“Psychiatric services are under pressure, particularly as a result of the high rate of substance abuse, acuity of patients and other social factors. Individuals with these disorders often have very high levels of co-occurring mental and physical health problems,” she said.