Dr Lebogang Phahladira, who grew up in rural home near Bela-Bela in Limpopo and studied by candlelight for his matric exams, has just returned from Canada, where he received the Global Schizophrenia Award that was conferred by the Schizophrenia International Research Society.
He was a joint winner alongside Professor Natália Bezerra Mota, a computational psychiatrist at the Federal University of Rio de Janeiro in Brazil, reports Daily Maverick.
“It’s easy to do research in developed countries,” said Phahladira, “but in Africa, we work in resource-constrained settings with competing priorities, where mental health is low down on the list for funding and other opportunities. To be recognised by peers on an international front is very humbling.”
Phahladira was raised by his grandparents in a remote part of Limpopo near Modimolle (Nylstroom), without electricity. He recalls studying for his matric exams by candlelight. At the time, his parents were based in Johannesburg and wanted to shield their son from unrest in the city’s townships.
In 1999, aged 16, Phahladira matriculated from Meetsetshehla Secondary School, which had been built by a local farmer. He had always wanted to become a doctor and was accepted to study at the then Medunsa (Medical University of Southern Africa)
outside Pretoria.
Cause and effect in psychiatry
While completing his Bachelor of Medicine and Bachelor of Surgery degree at Medunsa, his specialisation interest switched from gynaecology to psychiatry. He said in most scientific fields, including medicine, cause and effect are quite linear, whereas psychiatry was different, which intrigued him.
“In medicine, blood results or an X-ray would tell you a condition could be TB, or whatever. But in psychiatry, every patient is different. Every patient’s symptomatology is different – the way the disease presents is different. And patients with the same disease respond to different kinds of medication, which makes it fascinating. Mental health and the brain and the mind are fascinating. There is a lot we don’t know, so it is an important area for continuous research, trying to solve some of the mysteries of mental illness.”
In 2012, Phahladira completed postgraduate training in psychiatry at the University of Cape Town, after which he joined Stellenbosch University as a senior lecturer. Here he is a member of the Psychosis Research Programme headed by Professor Robin Emsley.
Phahladira obtained his PhD last year, which focused on the long-term outcomes of schizophrenia.
“We examined the factors that influence the long-term trajectory of the illness. The understanding is that if we treat patients very early at the onset of illness, at the break of symptoms of psychosis, there is a narrow window of opportunity where we can prevent the poorer outcomes,” he says.
Phahladira said his initial research interest had been pathological gambling, but he decided to focus on schizophrenia due to expertise on the disease at SU. One of the research unit’s ground-breaking initiatives is using long-acting injectables to treat psychotic patients.
He again uses the word “fascinating” to describe schizophrenia.
“It is the only illness of humankind that affects everything that defines who we are as human beings. It affects what we think, it affects what we believe, it affects what we perceive, what we hear. Sometimes what we feel, it affects what we remember. And that was one of the attractions for me – to try to dig a little bit deeper and contribute some new knowledge on this illness.”
Discussing factors that could trigger the onset of schizophrenia, he says: “There are people who hold a strong view that maybe schizophrenia is a neurodevelopmental disorder. So the full expression of the disease in late adolescence to early adulthood may stem from as far back as pregnancy – the nutritional status of your mother, the mode of delivery, childhood trauma, abuse, or neglect.
“It’s still a mystery, but in most cases there might be precipitating factors like stress, use of cannabis, migration is an increased risk, for example, moving to a dense urban centre.”
Be wary of ‘putting patients in boxes’
Phahladira now lives in Cape Town, and has co-authored 35 peer-reviewed journal articles. He works mostly at the Lentegeur Hospital in Mitchells Plain, a mental health facility affiliated with Stellenbosch University, where he heads the adult psychotherapeutic unit.
“We’ve got people with all kinds of personality disorders — borderline personality disorder, narcissistic personality disorder, bipolar, and so on but sometimes even just voluntary patients with depression or anxiety disorders.”
He said in the field of psychiatry, diagnostic tools remain controversial with “significant limitations”. Classifying mental health disorders is often not clear cut, he added, and to each patient’s unique presentation influences diagnosis, choice of treatment and prognosis.
“So those classifications, they’re helpful to some degree, but the problem with a lot of mental disorders is that they’re not categorical.
“There is a high degree of shared symptomatology. For example, a person with schizophrenia may hear voices and those kinds of experiences might be present in another patient with bipolar disorder.”
He says mental healthcare workers should be wary of “putting patients in boxes” or sharing a diagnosis with them.
“I always say to my patients that the diagnosis does not matter. What matters is how we understand your symptoms. To what extent do they cause impairment in your life and what possible treatment interventions can we offer you? So the labels are less important than the individual patient experiences. And I think many of us forget that.”
In some circumstances, particularly in the private sector, such “labelling” is done to unlock medical scheme benefits that cover medications, he adds.
The World Health Organisation (WHO) estimates that schizophrenia affects about 24m people, or one in 300 worldwide.
In South Africa, there is little reliable prevalence data, but existing research suggests around 1% of people might be living with schizophrenia.
“The prevalence of schizophrenia and other psychotic disorders varies between countries, and rural and urban areas,” says Phahladira. “The increased number of people accessing mental health services may be explained by the increase in population, migration, substance abuse and other environmental factors such as trauma and violence.”
He points out the inextricable link between poverty and unfavourable mental illness recovery. Simply put, without money, early detection and the prolonged treatment and medication required to get better is often inaccessible.
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