- Depression is a medical illness which affects one’s mood, body, thoughts and feelings.
- There are several types and sub-types of depression.
- Although the exact cause is unknown, several biological, genetic and psychosocial factors have been identified as playing a role.
- With appropriate treatment 80 percent of sufferers will improve and 60% will recover fully.
Depression, which must be distinguished from sadness or “the blues”, is a common and legitimate medical illness. Everyone feels down or low at some stage, but when these lows last for long periods and affect general functioning and behaviour, the person may be suffering from a Depressive Disorder.
Although depression is defined as a disorder of mood, it affects more that just one’s mood, and includes symptoms affecting the body (e.g. low energy, sexual dysfunction), thoughts (difficulty concentrating, indecisiveness) and feelings (depression, irritability). It is a medical illness like high blood pressure, diabetes or heart problems and not a sign of personal weakness. Depression cannot be wished away and sufferers cannot simply pull themselves together. However, with appropriate treatment 80 percent of sufferers will experience relief of symptoms, and up to 60 percent may recover fully.
Who is affected?
Depressive disorders are common and approximately 6-10 percent of the population will experience a depressive episode in any given year. More women than men are affected (2:1), with some estimating that as many as one in five women (20 percent) will experience an episode of depression during any given year. There is a however a possibility that depression in males are underdiagnosed because of the structuring of diagnostic criteria. All races and socio-economic classes are affected equally, but it is possible that clinicians may under-diagnose depression and over-diagnose schizophrenia in patients from racial and cultural backgrounds different from their own.
The average age for a first diagnosed episode of major depression is about 40 years, while for bipolar disorder it is 30. Fifty percent of patients have onset between 20-50 years. Depression can begin in childhood or in later life, but this is less common and tends to present differently in different age groups [e.g. childhood (2%) – apathy; adolescence (5%) – behavioural problems; elderly (25 to 50%) – physical complaints].
Depressive disorders are more likely in those individuals who are socially isolated and have no close interpersonal relationships or who are divorced or separated.
There are several different types and sub-types of depressive illness, just as heart disease may present in different ways. Three of the more common forms are:
- Major Depressive Disorder (MDD) – defined as a depressed mood or loss of interest and pleasure in almost all activities for at least a period of two weeks. Several other symptoms must also be present. These include sleep disturbances, appetite disturbances, change in energy levels, difficulties thinking and concentrating, and sexual difficulties. These symptoms interfere with usual behaviour and functioning.
- Dysthymia – many of the same symptoms as those for a MDD are present, but they tend to be less severe and interfere less with immediate functioning. They are, however, chronic and may continue for years, so that the sufferer seldom feels really happy and cannot enjoy life. Due to the long-term impairment of functioning, many do not realise their full potential. Dysthymia can therefore have severe long-term consequences and be severely disabling.
- Bipolar Disorder – used to be called manic depression. This is much less common than the two previously mentioned depressive disorders and only 2% of the population is affected over a lifetime. Males and females are affected equally. This type of depressive disorder involves episodes of depression and episodes of mania/euphoria. The switches between these two states may be fairly sudden and dramatic, but are more commonly gradual in onset. Both mood states may co-exist – mixed bipolar disorder. During episodes of mania, judgement is often impaired and this can result in socially embarrassing behaviour, sexual indiscretions, excessive spending and unwise business decisions. Bipolar disorder tends to be a chronic, recurring condition and is generally considered to have a poorer long-term outcome than Major Depressive Disorder.
Other types of depressive illness include:
- Minor Depressive Disorder (same duration, but less severe symptoms than MDD)
- Recurrent Brief Depressive Disorder (same symptoms as MDD, but episodes last less than two weeks)
- Premenstrual Dysphoric Disorder (experiencing depressive symptoms that occur during the last week before menstruation for at least one year)
- Post-partum Depression (depression following childbirth, more severe and of longer duration than transient "Baby Blues")
Depressive Disorders may also be related to drug and alcohol abuse as well as to prescription drug usage (Substance Induced Mood Disorders) and to medical illnesses (Mood Disorder Due to a General Medical Condition).
Exactly what causes depression is not known, but research has revealed several possible causes and contributory factors. These include both biological/physical and social/psychological factors. There is often a combination of factors at play in an individual’s history and environment and different people become depressed for different reasons.
Sometimes a specific trigger may be identified, but at other times people seem to become depressed for no reason at all. This is more likely when the person has experienced previous depressive episodes.
- Neurotransmitters: Studies have shown that brain chemicals (neurotransmitters) play a mediating role in the development of depression. When the functioning of brain chemicals is disturbed, depression can occur (e.g. following the use of recreational drugs such as Ecstasy). Several different neurotransmitter systems may be involved, but the two that have been more frequently implicated are serotonin (5-HT) and norepinephrine (NE). Studies have also shown a third brain chemical, dopamine, to play a role in both depressed and elevated moods.
- Hormonal factors: Increased secretion of cortisol from the adrenal gland during stress is associated with depression. Hypercortisolaemia has been shown to damage the hippocampus (an area of the brain associated with hormonal and behavioural regulation). Thyroid gland disorders are often associated with mood disorders. All patients suffering from a MDD should be tested for hypothyroidism (i.e. underactive thyroid). Studies have shown about 10 percent of patients, especially those with Bipolar Disorder, have detectable concentrations of anti-thyroid antibodies (produced by the body in order to fight disease which in this instance turns upon the body itself). There is also an association between anti-thyroid antibodies and post-natal depression. Alterations in the pattern of growth hormone release have also been observed.
- Neuroanatomical/Neurophysiological considerations: CT Scans and MRI studies, although inconsistent, have shown differences in the size of some of the brain structures (e.g. caudate nucleus) in depressed patients as well as alterations in blood flow to certain areas. Mood disorders involve pathology of the limbic system (emotional centre, memory function). The basal ganglia (stooped posture, motor slowness) and the hypothalamus (changes in sleep, appetite and sexual behaviour) have also been implicated.
- Genetic factors: Inherited factors are an important component in the development of mood disorders. Having a close relative who has suffered from a depressive disorder, especially Bipolar Disorder increases the likelihood of developing depression. People with a genetic susceptibility are more vulnerable to depression in the face of various stressors.
- Recreational drugs/medication: Some drugs (recreational and prescription) and alcohol can cause or exacerbate depression. The reason is possibly because they interfere with the regulation of brain chemicals or the physical structure of the brain (excessive alcohol and sleeping tablets cause shrinkage of the brain).
- Medical illness: Illness including strokes, Parkinson’s disease, Cushing's disease and thyroid disease, among others, may be a contributory physiological factor.
Stressful life events (e.g. loss of a loved one, illness, financial worries) more often precede the first episode of mood disorders than subsequent episodes. It is believed that the initial episode in a mood disorder results in long-lasting changes in the biology of the brain (e.g. the functional state and interaction of neurotransmitters; also possibly a loss of neurones and a decrease in synaptic contacts). This increases the person's vulnerability to subsequent episodes.
A family’s style of interacting with different members, the family environment (e.g. a broken home) as well as its coping patterns may increase a vulnerability to a depressive disorder. An individual’s underlying personality type (e.g. dependent, obsessive compulsive) may also be a contributory factor.
Depression affects different people differently. Some people may present predominantly with physical symptoms such as backache, headache or stomach complaints that do not respond to treatment. Others may complain mostly of disturbed sleep, loss of energy and appetite changes. Not everyone experiences all the symptoms of a depressive or manic episode. The severity of symptoms may also be different in different people.
These many different presentations can sometimes make it difficult to recognise and diagnose a depressive disorder. A sufferer may not seek medical help because they may not realise that they are suffering from depression and that it is a legitimate medical illness.
The most commonly reported symptoms are as follows:
- A depressed or low mood or feeling of sadness
- Increased irritability
- Increased anxiety or a feeling of nervousness
- Loss of interest or pleasure in activities that were previously enjoyed
- Tearfulness or a feeling of wanting to cry, but a possible inability to do so
- Decreased sexual interest or other sexual problems
- Changes in appetite resulting in either weight gain or weight loss when not dieting
- Changes in sleep pattern
- Changes entailing either difficulty falling asleep, frequent waking during the night or waking up unusually early in the morning and not being able to return to sleep. Sleep may also be increased with a desire to be asleep most of the time.
- A feeling of being chronically tired and energy-less or amotivated
- A slowing down or speeding up of physical activity (including speaking very softly or slowly)
- Feeling worthless, useless and helpless
- Feeling inappropriately excessively guilty (and possibly blaming oneself for being depressed or unable to “snap out of it”)
- Difficulty thinking, concentrating or remembering
- Difficulty making decisions, even over simple matters
- A feeling that life is not worth living and frequently thinking about death and/or suicide
- Becoming increasingly socially withdrawn and feeling reluctant to entertain or go out visiting
- Not bothering to dress properly/self-neglect
- Multiple physical complaints, e.g. frequent headaches, backaches/stomach aches or constipation
- Alteration in menstrual cycle
Anxiety symptoms are also often experienced by persons suffering from a depressive disorder (in up to 90 percent of cases) and these include nausea, dizziness, breathlessness, heart palpitations, feeling worried and fearful, being tremulous or shaky, feeling sweaty, experiencing pins and needles in the hands and around the mouth or frequently having a runny tummy and passing urine often.
If you have been feeling low or irritable together with several of the above listed symptoms for at least two weeks, you may wish to complete a self-evaluation questionnaire to see whether or not you are depressed.
About half of patients who are diagnosed with a Major Depressive Disorder have had significant symptoms prior to the first diagnosed episode. In some the symptoms may be experienced fairly suddenly or acutely while in others there may be a long prodrome, and it is only retrospectively that changes in mood, behaviour and functioning are recognised.
An untreated depressive episode lasts from 6 – 13 months with the average duration being around 9 months. Most cases will improve, although a significant minority go on to develop a chronic depressive illness. Most treated episodes last about three months. However, medication should be continued for longer (six to nine months for a first episode), because withdrawal from medication too early is almost always associated with a relapse in depressive symptoms.
As mentioned previously, it is believed that the first episode in a mood disorder brings about long lasting changes, which increase susceptibility to subsequent episodes. It is also thought that if the initial episode is treated early enough, with adequate medication and for long enough, some of these changes may be prevented.
About 5 – 10 percent of patients who have initially been diagnosed with a MDD will experience a manic episode 6 – 10 years after the first depressive episode. The average age for that switch is 32 years and it usually occurs after two to four episodes of depression.
Major Depressive Disorder is a recurrent illness. While each episode usually responds to treatment it tends to be a chronic disorder and patients do tend to relapse (i.e. condition deteriorates again before an episode is completely resolved).
Recurrences of major depressive episodes are also common and for a patient who has required hospitalisation for the initial episode (i.e. severe depression). There is a 30 – 50 percent chance of recurrence within the first two years and a 50 – 75 percent chance of recurrence within five years. The likelihood of relapse or recurrence is much less in those who continue to use prophylactic psychopharmacological treatment (i.e. either continue with antidepressant medication or make use of a mood stabilising drug).
Usually as more depressive episodes are experienced, the time between episodes decreases and the severity of the depression increases. Men are more likely than women to experience a chronically impaired course. A poor prognosis is also more likely with a co-existing anxiety, dysthymic or substance abuse disorder
When to call a health professional
If, after reading the preceding information, you believe that you or a family member or friend may be suffering from depression, speak to your family practitioner. He or she may suggest life-style changes, medication or referral to a mental health professional, i.e. psychologist or psychiatrist.
All thoughts of suicide, threats or attempts should be taken seriously and professional help sought as soon as possible. People who are planning suicide often talk about it either directly or indirectly and they may make arrangements to get their affairs in order, e.g. settling debts, altering or making a will, getting rid of personal items or letters. People who feel suicidal are often reluctant to seek help and may need a great deal of encouragement and ongoing support.
Some possible warning signs to take note of:
- Increased anxiety or agitation
- Increased use of drugs or alcohol
- Expressing suicidal thoughts or intent
- Slowing down physically
- Extreme feelings of worthlessness or guilt
Those most at risk manifest the following risk factors:
- Male sex, age over 45 years
- A history of alcohol dependence
- An unwillingness to accept help
- Displays of rage, violence or irritation
- Recent loss or separation
- Unemployment or retirement
- Being single, widowed or divorced
- Prior hospitalisation for psychotic illness
In order to diagnose a depressive disorder the health professional or family doctor would do a full evaluation including questions regarding family history, personal history of illness and recent stressors. Other family members and friends may be interviewed in order to obtain further information and to assess the level of support. A physical examination may be carried out or requested in order to exclude underlying physical illnesses, which could cause or contribute to a depressive disorder. Special investigations such as blood tests or sometimes even a brain scan may be requested if an underlying organic problem is suspected.
Specific diagnostic criteria have been set down in the DSM–IV (Diagnostic and Statistical Manual of Mental Disorder, 4th edition) to diagnose a Major Depressive Episode. These are described below:
The presence of five of the following nine symptoms occurring for most of the time during the same two week period, resulting in a change in the level of functioning. The symptoms cause significant distress or obvious changes in social and occupational functioning.
One of the first two symptoms following must be present in order to make the diagnosis:
- A depressed mood (possibly irritability in children)
- Loss of interest or pleasure in previously enjoyed activities
- Appetite changes with significant weight loss (when not dieting) or weight gain
- Increased sleep or insomnia
- Slowing or speeding up of physical activity
- Fatigue or loss of energy
- Feeling of worthlessness or excessive or inappropriate guilt
- Decreased ability to think or concentrate, or indecisiveness
- Recurrent thoughts of death or recurrent suicidal ideation
A physical examination may also be required to evaluate underlying physical illness, which may cause or worsen depression, e.g. thyroid illness. It is important to detect medical problems, as these require separate, appropriate treatment.
Thirdly, a treatment plan has to be formulated that takes into account both immediate symptoms and the patient’s future well-being. This would include medication, psychotherapy, lifestyle changes and the addressing of stressors. Stressful life events are associated with an increased relapse rate in mood disorder sufferers.
Cognitive Behavioural Therapy (originally developed by Aaron Beck)
This is a short-term structured therapy using active collaboration between patient and therapist in order to reach the therapeutic goals. This treatment approach is based on the theory that one’s feelings and behaviour are controlled by how one thinks and perceives one's world.
Those who become depressed tend to see themselves negatively, believe that others see them in a similar light, expect to fail or experience continued difficulties, feel hopeless and have negative expectations of life and the future. The therapist uses various techniques to identify and demonstrate the negative thought processes, which are then challenged. Patient and therapist then work together on changing negative thought patterns and beliefs, so that a more realistic and positive mindset may develop. Overall therapy is relatively short, lasting up to 25 weeks.
Interpersonal psychotherapy (developed by Gerald Klerman)
The underlying hypothesis in this therapy is that disturbed social or personal relationships may cause or precipitate a depressive episode. The depression, in turn, impacts negatively on the relationships, which then further exacerbates the illness. Therapy deals with one or two current interpersonal problems and helps the patient understand how depression and interpersonal conflicts are related. The interpersonal therapy programme usually consists of 12 – 16 weekly sessions.
Psychodynamic psychotherapy (developed by Freud, Kohut, Jacobson and Abraham)
This therapy is based on the idea that current behaviour and life experience is influenced by earlier experiences, hereditary traits and present reality. It takes into account the effects that emotions and unconscious material can have on human behaviour. This is usually a long-term open-ended therapy which may continue for years and is often less interactive.
This is not usually a primary therapy for the treatment of a MDD, but helping to identify negative interactions within a family can help to reduce stress and thereby decrease relapse. Family therapy examines the role of the mood-disordered member in the overall psychological well-being of the whole family. It also examines the role of the entire family in maintaining the patient’s symptoms. Family therapy may also provide emotional support for the family of a sufferer.
AntidepressantsPharmacotherapy for depressive disorders has advanced considerably over the past twenty years and there are now a large number of drugs to choose from. All antidepressants are equally effective providing an adequate dosage is taken for a sufficiently long time. Different drugs may be prescribed for different individuals, depending on the symptoms presented.
Some antidepressants are more energising, while others may cause weight loss or gain. A decision regarding which drug to use is often made on the basis of tolerability of potential side effects.
Antidepressants do not act rapidly. A certain dosage and concentration has to be reached before they become effective. This usually takes about a month but may take six to eight weeks in the elderly. It is important to persevere and to use the prescribed drug at the correct dosage for long enough.
Patients often feel significantly better after two to three months on antidepressants, but it is important that medication be continued for as long as your doctor advises. For a first episode of depression, this usually means taking medication six to nine months on optimal dosage after symptom relief has been achieved, two to five years for a subsequent episode and possibly life-long if episodes recur frequently and are severe. Stopping medication too soon increases the likelihood of relapse and the development of a chronic recurring illness.
The different types of antidepressants1. Selective serotonin reuptake inhibitors (SSRIs)
These are among the newer antidepressants, which have been available from 1988. They act on the neurotransmitter (brain chemical) serotonin. Some of the trade names in this class include paroxetine (e.g. Parax, Paxil), fluoxetine (e.g. Deprozan, Lorien, Prozac), citalopram (e.g. Cilift, Depramil), escitalopram (e.g. Cipralex, Lexamil), sertraline (e.g. Zoloft, Serdep) and fluvoxamine (e.g. Faverin, Luvox).
This group of drugs, together with the other newer agents, is the most widely prescribed due to the favourable side-effect profile and relative safety if taken in overdose. Different drugs in this class are also registered for treatment of anxiety disorders, panic disorders, post-traumatic stress disorders, obsessive-compulsive disorder and social phobia.
Side effects may be present during the first few weeks of therapy, but usually disappear after a while. These are often diminished by starting medication in low dosages and gradually increasing until a therapeutic dosage is reached.
Common side-effects include:
• Nausea (take medication after food to prevent this)
• Headache (improves after a while; start with low dosages)
• Sleep disturbances
• Decreased appetite
• Sexual disturbances (sexual problems may change, but if worrisome, discuss with your doctor as treatment options are available)
2. SNRI (serotonin and noradrenaline reuptake inhibitors)
This class of medication is closely related to the SSRIs, but have an additional mechanism of action in that they also affect noradrenaline reuptake. Two medications in this class include venlafaxine (e.g. Efexor, Odiven) and duloxetine (e.g. Cymbalta, Cymgen).
There is some evidence that this class of medications may be more effective in preventing relapse episodes of depression. They are also used when the depression is accompanied by painful physical symptoms such as headaches and muscle pain. Their side-effect profile is similar to that of the SSRIs.
This is an older group of drugs, which has been in use since 1957. These drugs affect predominantly noradrenaline. Some of the drugs in this class include amitriptyline (e.g. Limbitrol, Trepiline), imipramine (e.g. Tofranil), clomipramine (e.g. Anafranil), nortriptyline and others.
Tricyclics are also used for the treatment of anxiety disorders, sleep disorders, pain relief, migraine prophylaxis and bedwetting (imipramine). Some patients, particularly the elderly, find the side effects of these drugs more difficult to tolerate.
Tricyclics are not safe in overdose, and in the event of more tablets being taken than prescribed, medical advice should be sought urgently. Despite the side-effect profile, tricyclics are extremely effective antidepressants.
Common side effects include:
• Dry mouth
• Dizziness (due to decreased blood pressure – alleviated by standing up slowly)
• Blurred vision (this will usually go away with time so new glasses or lenses are not necessary)
• Drowsiness (less of a problem with imipramine and lofepramine)
• Weight gain
These side effects are often transient. They may be managed by altering diet, water intake and rising slowly from a lying or sitting position.
3. Monoamine oxidase inhibitors (MAOIs)
The group includes phenelzine and tranylcypromine (e.g. Parnate).
This is an older group of antidepressants, which is used less frequently today. These agents act by inhibiting an enzyme called monoamine oxidase, which usually breaks down serotonin, noradrenaline and dopamine in the brain. This results in an increase in these neurotransmitters, the deficiency of which is associated with depressive illness.
Certain foodstuffs containing tyramine (e.g. cheese, red wine, processed meats and many others) also require monoamine oxidase for their metabolism. The inhibition of this enzyme results in an excess of tyramine, which acts upon the blood vessels to cause a rise in blood pressure. This rise may sometimes be fatal. For this reason, patients taking MAOIs need to observe dietary restrictions. The danger of any food or drug reaction persists for about 14 days after stopping treatment with a MAOI. A washout period is therefore required before starting a different antidepressant.
MAOIs are thought to be particularly useful in treating atypical depression. They’re also useful when depression isn’t responding to other drugs and in phobia and panic disorder.
Common side-effects include:
• Headache – may be a warning sign of a severe increase in blood pressure
• Sexual problems
• Drug interactions – discuss all medications, including over-the-counter drugs, with your doctor before taking
• Interactions with certain foods
Again most of these side effects usually improve after taking the medication for a few weeks.
Some antidepressants do not fit into the aforementioned groups and many of them are newer agents.
Two examples include:
• Reboxetine (e.g. Edronax). This antidepressant inhibits noradrenaline reuptake and there is more neurotransmitter available in the synaptic cleft. It is generally considered to be an energising antidepressant. It may cause insomnia, dry mouth, vertigo, sweating and some sedation initially. Not a good choice if there is a high level of anxiety associated with the depression.
• Mirtazapine (e.g. Beron, Remeron). This drug belongs to a new class of antidepressant called NaSSAs (noradrenergic and specific serotonergic antidepressants), which are particularly useful if anxiety and insomnia are problems. Side effects include sedation and weight gain.
• Agomelatine (e.g. Valdoxane). This antidepressant has a novel mode of action in that it works on melatonergic receptors and not on the noradrenergic or serotonergic receptors. It’s useful in patients with prominent insomnia as part of their depressive features
Some general points regarding antidepressants
It is important to inform your prescribing doctor of the following:
• Any known illness, especially cardiac problems, epilepsy, diabetes, thyroid disease, liver disease, prostate problems, glaucoma and high blood pressure.
• Any other medication that you may be taking. Ask your doctor or pharmacist about potential drug interactions before taking any other prescribed or over-the-counter medication, e.g. cough syrup, beta-blockers, anti-histamines or antacids.
• Breastfeeding, pregnancy, or plans to fall pregnant in the near future. Some medications can affect your baby.
It is also a good idea to try and avoid alcohol while taking antidepressants. Alcohol acts as a central nervous system depressant and can worsen depression or undermine the benefits of the medication. It also increases the likelihood of drowsiness – hence the risk for accidents while driving or operating machinery.
Electroconvulsive therapy (ECT)
It is not known exactly how ECT works, but it remains the most effective treatment for severe depression. The brain displays similar changes after ECT as after taking antidepressant medication, but the onset of improvement is more rapid with ECT.
ECT is a treatment which involves electrical stimulation of the brain while under a general anaesthetic. A muscle relaxant is also given before treatment is initiated. Because of bad publicity (films such as “One flew over the cuckoos nest”) and general anxiety about using electricity near the brain, it is a much underused therapy.
As a general anaesthetic is required, it is only reserved for severe depression or treatment-resistant depression or when a rapid improvement is important (as in post-natal depression which responds particularly well to ECT) and where physical health is good enough for an anaesthetic. ECT is also useful for patients who cannot tolerate the side effects of medication (such as the frail, elderly and pregnant women). Several ECT sessions are required for full therapeutic benefit, usually at a rate of three per week.
Self-help is not a treatment for a depressive illness on its own, but it can contribute towards accelerating recovery and it can help to maintain the benefits of treatment.
- Reading books/acquiring information. This helps to provide an understanding of the illness which can be important for both the sufferer and the family.
- Eating an adequate diet, so as to maintain blood sugar levels. Foods, which promote serotonin production, can be increased e.g. bananas, pumpkin pips and Horlicks. Stimulants which increase anxiety should be avoided e.g. coffee, colas and chocolate. Vitamin supplements/tonics may be useful if you are very run down, or if life is normally lived in the “fast lane”. Consider taking omega-3 fatty acids, particularly EPA.
- Sleeping sufficiently – but not too much.
- Exercise – begin gradually and slowly increase the intensity and amount of time spent exercising. There is considerable evidence to show that exercise can have a profoundly positive effect on mood in people with depression. Being out in the fresh air also helps to put a different perspective on problems.
- Relaxation – to decrease tension and anxiety and to improve sleep. E.g. meditation, yoga, aromatherapy and massage.
- Hobbies/interests – which help to occupy the mind and decrease pre-occupation with negative thoughts.
- Regular breaks/holidays
- Life-style changes – expecting less of oneself; maybe lowering standards a little; delegating; asking for assistance.
- Avoid alcohol/recreation drugs and cigarettes – these often worsen depression and anxiety.
One cannot alter a genetic vulnerability or a history of loss, but much can be done to decrease stressors (see self-help). A balanced life-style with adequate social interaction and support, and knowledge of what comprises depression, so that help can be sought at the right time, can all help to prevent depressive episodes.
Previously reviewed by Dr Piet Oosthuizen, Dept. Psychiatry, University of Stellenbosch, January 2008
Reviewed by Dr Stefanie van Vuuren, Psychiatrist, MB ChB (Stell), M Med (Psig) (Stell), FC (Psych)SA, May 2014