Ilse Pauw is a holder of the Carter fellowship for mental health journalism from the Carter Center in Atlanta. This is part of her series of articles on mental health and stigma.
"Living with mental illness means living with a set of questions," says 43-year-old Sanette. "Will I get ill again? Am I still ill?
"You are in a quandary: you wonder, should I tell people and trust them, or not? And how will they react? I don't think anyone who hasn’t had a mental illness can begin to imagine what it is like living like this."
Sanette is one of the 25% of South Africans with mental illness who live by questions such as these every day.
According to Sanette, the warning signs of mental illness were present in her childhood. She describes herself as having been a "dark and highly-strung child" who had a hovering depression, and who was obsessed with thoughts of death and dying. She was a top achiever at school, but led an inner life of fear and anxiety about which no one knew.
After university, she spent a year working as a waitress in Germany and fell into a deep depression. Her condition got worse when she was on her own in London.
"My time in London was very scary. I felt so incredibly alone and frightened. My body and head just conked in; it felt as if the whole world was tumbling down on top of me. I believed that people around me – complete strangers – thought that I was an awful person and wanted to punish me."
Things got so bad one day, that she went to the nearest cinema and paid to see three movies in a row.
"I knew that for as long as I stayed there, I would be safe, and that I would be protected from the world. I was petrified that I would cause harm by blowing up buildings or setting the South African embassy on fire. I would check, and check, and check again to make 100% sure that I wouldn't do anything careless."
Sanette phoned her mother who, from Sanette's incoherent speech, realised that something was terribly wrong. Her mother tried to persuade her to come home, but she refused, and instead signed up for a Kontiki tour through Europe.
"I was very lucky that I somehow had the right people around me during that time. Two South Africans on the tour probably sensed that something was wrong, that I was vulnerable. They looked after me. I was on autopilot: I knew that I just had to hang in there and survive until I could go home."
Back in South Africa, her mother took her to a doctor who prescribed an antidepressant.
"I felt like such a failure. Your gap year is supposed to be fantastic. Mine was a huge flop. I was a nightmare as a waitress; I couldn't handle travelling on my own; the relationship I had had during that year had failed; and on top of it, I returned to South Africa fat, depressed, and on Prozac.
"I had anxiety attacks and shared a bed with my mother because I was so petrified of what was happening to me, and because I couldn't understand what was going on."
Sanette had to start her first job - at a newspaper - two weeks after her arrival. She says that this was, in retrospect, a good move, because she was forced to face the world again.
Today, she writes for a magazine in Johannesburg.
Sanette had started drinking at university, but started drinking heavily during her time in Europe. Over time, it got steadily worse and she started combining alcohol with painkillers, sleeping pills and appetite suppressants.
Predictably, her behaviour was at times inappropriate and bizarre. She would, for example, send out lengthy text messages in the early hours of the morning to people she hardly knew. She sometimes spent the entire weekend alone in her house, with only alcohol and pills to keep her company.
Over the years since things first started going wrong, Sanette has been hospitalised twice with the dual diagnosis of bipolar mood disorder (BMD) and substance dependence.
"I am very fortunate that I can always be open with my parents. They have been very supportive throughout, no matter how much my behaviour might have shocked them. I'm also fortunate that there are a couple of close friends I can trust.
"You can't tell everyone everything. I have great friends and am a spontaneous person but I have to filter out the really gory, shocking details of my substance abuse when I'm in the company of friends who are very religious. I'm scared I'll shock them too much."
After her first admission, she felt it necessary to tell two or three of her colleagues about her illness.
"I wish I had only spoken to one of them. People just like to talk too easily. By disclosing, you make yourself vulnerable and open to criticism and unhappiness."
Dr Ulla Botha, psychiatrist at Stikland Hospital, agrees: "Stigma and discrimination are real issues in the life of a person with a past or present mental illness. Misconceptions, fear and misunderstanding all contribute to discrimination.
"People who have disclosed, often report that they are treated differently, that they are not taken seriously, are not offered the same opportunities, and that they find it more difficult to find jobs."
Out of the closet
At the time of Sanette's second admission to hospital, it was easier for her to tell her boss and some of her colleagues that she wasn't coping and that she needed "time out".
"As a journalist it might have been easier for me to 'come out of the closet'. In a creative field such as journalism, it is more acceptable to be eccentric, to drink too much at times, be outspoken and to party."
She feels fortunate that most of her immediate colleagues who know about her illness have been supportive, or try to be. But even with them, it can get tricky at times.
"Everybody can be forgetful, or at times not concentrate as much as they should, or submit work which is not up to their usual standard. My illness is always in the back of people's minds. If anything happens, I get asked whether I'm okay, or whether it happened because I wasn't well at the time. I feel that I need to be extra careful and to watch myself all the time. My colleagues don't need to do the same."
"Even though I've come to accept my illness, I'm still secretive in a way. I don't have a problem with my colleagues knowing that I was depressed, but I'll never say that I'm bipolar. I also don't have a problem saying that I'm on antidepressants - antidepressants have become fashionable. But to tell someone that you are on mood stabilisers or antipsychotics is just a whole different ball game," says Sanette.
"This is not uncommon," says Botha who has done extensive work on mental health and stigma. "Certain illnesses are regarded as being more 'acceptable' than others. Many people are ashamed to admit that they are on psychiatric medication because of stigma. They feel that they need to lie about it or hide the medication. The tragedy is that many people who need to be on treatment stop taking it."
Nowadays, Sanette sometimes suffers the odd setback, but she usually feels strong, positive and in control.
"I work closely with my psychiatrist, whom I trust and respect. I try to lead a healthy lifestyle: I eat healthily, exercise regularly and have cut down on substances. I always hated exercise, but now I'm starting to enjoy it. I'm trying to find new ways of feeling good."
- (Ilse Pauw, Health24, September 2008)
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