Migration and exile – some implications for mental health in post-apartheid South Africa

A sense of belonging and historical continuity are basic psychological needs. Weil has similarly argued that to be rooted is perhaps one of the most important and at times least recognised human needs. Strongly linked to the concepts of belonging and rootedness is the concept of ‘home’ and what meaning this holds for different people. Turner (1957, 1956, in Magat) proposes an idea of home as a folk concept, which is prevalent in human discourse, and which can be a structure, a feeling, a metaphor or a symbol. It may serve as a centre, which contains an integration of past, present and future and ultimately contains an element of reconciliation between immediate (proximate) and ultimate (abstract) concerns.


Historical context of migration and exile
Exploring the phenomenon of migration is not an easy task as it is complex and also specifically linked to certain historical periods.This study focuses on only some of the most relevant aspects.
The type of immigrants and the reasons behind the decision to immigrate are anything but homogeneous and have changed dramatically over time.In the late 19th and early 20th centuries a lot of immigration took place from Europe to America, Canada, Australia, New Zealand and also South Africa, often as a means to escape political or economic hardship.Today we see many different trends, which reflect the socio-political dimensions of our times.
Umberto Eco 4 argues that we must distinguish between the concepts of immigration and migration.He believes that the former refers to a phenomenon where people move from one country to another.This movement can be placed under political control, can be restricted or encouraged, can be planned or accepted.Migration, on the other hand, must be seen as some kind of natural phenomenon, which takes place and cannot be controlled.It occurs when an entire people move from one territory to another.In this process the number of people who move is not of importance but rather the extent to which the migrants change the culture of the place to which they have migrated.In the process of immigration people take on the customs of the country to which they have immigrated, while migrants transform the culture of the territory they have migrated into.Interestingly enough Eco considers what is happening today in Europe to be a phenomenon of migration, with European countries trying to handle it as immigration.He warns that 'The Third World is knocking at our doors, and it will come in even if we are not in agreement'. 4e may not agree with Eco's provocative views but it is certainly a fact that the phenomenon of globalisation has greatly influenced the movement of people across countries and The age of globalisation and the socio-political changes that have taken place in South Africa in the past decade have created powerful contexts within which the issues of belonging and finding a 'home' have become very relevant to all South Africans.This article explores the phenomena of migration and exile, which are strongly characterised by an attempt to find a place one can call 'home' and where one can belong, and then shows how these experiences can provide a useful framework for understanding a multicultural context such as the one in South Africa.Some of the implications of these phenomena for mental health, specifically the link between schizophrenia and migration, will also be discussed.

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articles Volume 12 No. 3 September 2006 -SAJP continents, with terms such as 'trans-nationals' and 'living across contexts' to be found in the literature. 5,6is perspective leads to a situation where belonging to only one nation is no longer seen as necessarily a universal phenomenon and perhaps not even an unavoidable position.Christiansen and Hedetoft 7 are of the opinion that the reality of 'multiple belonging' may in fact be found in the social, cultural and political lives of many people.Castle and Davidson 8 also point out that we are seeing an erosion of the concept of citizenship based on belonging to a single nation, and that we must look for a redefinition of citizenship based on globalisation.
The phenomenon of exile is of particular interest as it has specific pecularities, which distinguish it from other types of migration.The term originated in ancient Greece where certain citizens were banished from Athens for political reasons.What distinguishes it from other experiences of migration is that exiles are forced by ideological, political or religious circumstances to leave their countries of birth and that it is impossible for them to return. 9 far as South Africa is concerned, we have witnessed a number of specific phenomena.During the apartheid era many people left the country for political reasons or to avoid conscription, and many were forced into exile fearing arrest or even death.For these people there was no possibility of returning to the country of their birth until a change in the political system had taken place.This created a very specific grouping of people, many of whom returned after 1994, and many of whom had been born abroad but still considered South Africa their home.
Bernstein 10 believes that the experience of South African exiles is quite different from the accepted understanding of exile as it did not occur as a result of losing a war a coup, or a revolution that failed.Political activists who left South Africa during the years of the apartheid regime saw themselves as still very much part of the ongoing and escalating struggle back home.There was a constant stream of exiles over a period of three decades, made up of quite different groups of people depending on the historical period during which they left the country.A further interesting phenomenon is that, unlike other exile phenomena where people left their homelands with their families, South African exiles left mostly as individuals and were not able to make contact with their families, sometimes for many years. 10 post-apartheid South Africa a large number of South Africans have chosen to leave the country of their birth because of political and economic uncertainty and increasing levels of crime and violence. 11Many young white professionals left the country after completing their tertiary education and families have been deeply affected by this, finding themselves with family members scattered all over the world.The main areas of destination for South Africans seem to be Australia, New Zealand, Canada, the UK and the USA. 11

Theories of immigration
A number of theories have been conceptualised in an attempt to explain the psychological and sociological processes linked to the phenomenon of immigration.Some of these theories overlap with Eco's view on migration. 4LaFramboise et al. 12 have highlighted the following as the most significant.
Assimilation.This view postulates that a person entering a new culture needs to be absorbed into the dominant culture.
Until this has taken place and he or she perceives acceptance into the new culture, the individual will suffer from a sense of alienation and isolation.
Acculturation.This view holds that through the process of acculturation a person becomes a competent participant in the majority culture, but will always be identified as a member of a minority culture.Often this is an involuntary process as the person has no choice but to follow this route, more often than not to survive economically.
Alternation model.This model by LaFramboise et al. 12 is a more recent attempt to describe the process whereby it is possible for a person to know and understand two different cultures.
It may be that in the era of globalisation there is a greater possibility of maintaining this type of position as people lead a more transcontextual life. 13However, this may not always have been the case, as in the instance of 'older' immigrants and in the case of exiles and refugees.Although the idea of having a choice of moving between cultures is appealing, the authors do not believe that the model of alternation sufficiently addresses the ambiguity and often existential distress experienced by those living between cultures.
Multicultural model.LaFramboise et al. 12 argue that this model promotes a pluralistic approach to understanding the relationship between two or more cultures.It is seen as a way for cultures to maintain distinct identities while working together to serve a common or national need.Berry 14  LaFramboise et al. 12 question whether a multicultural society can be maintained over time without proper protection from institutions and ethnocultural compartmentalisation. 15 This is an interesting question to be asked in the South African context with our emphasis on the rainbow nation metaphor.
Fusion model.According to LaFramboise et al. 12  This would lead to a homogenisation of cultures and necessitates a totally non-hierarchical attitude towards one another's cultures.One can ask whether given the power dynamics at play this would ever be possible

Individual and family factors and migration
Falicov 13 argues that the uprooting from cultural meaning systems is one of the essential disturbances of migration.It can cause psychological stress, cultural stress, marginalisation, social alienation and psychological conflict.It represents a kind of ambiguous loss, which has been compared to death. 16wever, in the case of the immigrant it is always possible to fantasise about the possible return and reunion with loved ones, unlike in the case of the exile.
It is also important to note that the phenomenon of immigration is not a homogeneous one -even within the context of a specific family, it may be experienced quite differently.Although it is often believed that the process of immigration may be easier for a child who is likely to learn new things more quickly and who is less attached to a larger community than to his/her family context which usually is part of the migration, other factors must also be taken into consideration.Firstly the child is usually not part of the decision to immigrate, and secondly his/her main support system consists of the adults in the family who may be greatly affected by the move and unable to provide the security and support the child needs. 9The needs and stressors of the adults often take precedence, while children may often be ignored in this process.
Developmental phases must also be taken into consideration.
The period of adolescence, for example, is a particularly sensitive one, with peers and acceptance by peers being particularly important.This is probably the phase of development when the need to 'belong' is at its strongest.Entering a new school system feeling different, often accentuated by not being able to speak the local language and not knowing local acceptable ways of behaving, may be extremely traumatic for an adolescent.Grinberg and Grinberg 9 argue that often during this period the effects of migration will be seen mainly in the school environment where the young person has to find and carve out a place for him/herself.
In the foreword to DiNicola's book A Stranger in the Family, Andolfi 17 describes the situation where immigrants find themselves caught between two different cultures.He describes this as sitting between two chairs and as 'one of the most serious existential predicaments'.
Andolfi 17 argues that although this 'in between' position may be considered an added resource that offers more than one choice, allowing greater mobility between two cultural alternatives, this is only possible when we can move easily from one chair to another, without fear of losing our original position.Grinberg and Grinberg 9 use the interesting analogy of migration as a triangular Oedipus concept where each country represents one of the parents towards which the individual experiences feelings of ambivalence as well as conflicting loyalties.
Ambiguity therefore seems to be one of the core experiences of immigration, which requires flexibility of 'movement' in order to be managed successfully.It also connects with the concept of liminality, which refers to a threshold position, where one is forever negotiating an outsider/insider state. 18The process that the immigrant may have to go through may also be similar to that of the individual leaving his or her family of origin, where a balance has to be found between belonging and differentiation.
Grinberg and Grinberg 9 make the important point that the receiving society is also impacted by immigration.This community may feel threatened with regard to its cultural identity, which is closely linked to its language and beliefs.Another aspect which adds to the discomfort and dilemma of the immigrant is that of language.Often an immigrant has to learn a new language when entering a new country, and even when the language spoken is the same there may be peculiarities of vocabulary or accent, which further add to complexity of experience.Grinberg and Grinberg 9 argue that language plays a determining role in one's knowledge of the world, other people, and oneself.It also provides a basis of support for one's identity.
Grinberg and Grinberg 9 make the salient point that one's own language, the mother tongue, is never as libidinally invested as when one lives in a country where a different language is spoken.All childhood experiences, memories, and feelings about early object elations are connected to language.Special meanings become embedded in it.
Schaff (in Grinberg and Grinberg 9 ) argues that language is a social product with a genetic and functional link to all the practical activities carried out in our society.He considers it one of the most traditional elements of culture, as well as the one most resistant to change.
In a way having to learn a new language when entering a new country is like a child entering a world in which s/he feels small and not very competent.Immigrants' inability to speak the local language properly, or speaking it with an accent, is often derided by the dominant culture, adding to a sense of inferiority and incompetence.This is often accompanied by a great sense of anxiety.It has been shown that children tend to acquire a new language more quickly, firstly because they are more receptive but also because they don't want their peers to see them as different. 9This can be problematic in a family context where the children are more proficient in the new language than their parents, causing a shift in the family hierarchy and making the parents dependent on their children for communicating with the outside world.

Citizenship and nationality
More than anyone in a civil society, the immigrant has to face the apparent dichotomy between citizenship and nationalism.
Nationalism has the potential to be a highly emotive issue, described by Ignatieff 19 as 'a language of blood, which can end in ethnic cleansing, but … also language of belonging: a call to home … As a cultural ideal nationalism is the claim that while men and women have many identities, it is the nation, which provides them with their primary form of belonging.'Citizenship, on the other hand, has been described by Magat 3 as a formal membership that allows a person to benefit from certain privileges granted only by the state.When citizenship is acquired and is therefore a choice and not a birthright, as in the case of immigrants, it can potentially be experienced as 'an ultimate act of belonging and commitment'.

Finding your 'home' in South Africa
The experiences of migrants and exiles may be of relevance to a multicultural society such as South Africa.The ambiguities and discomforts described by these groups may well be similar to those experienced by the people of our multicultural nation with its 11 official languages, where the large majority of people do not use their mother tongue to communicate with others.This makes the issue of language particularly salient.
For most South Africans really being understood is restricted to specific communities and is neither a national nor even a daily experience.Although the issue of language is easily abused Coming home may mean making peace with the past, dealing with the challenges of the present and planning for a future that is quite different from anything ever dreamt of.
One cannot belong to a place, a community, or even to a family or relationship that does not welcome one's presence and to some extent accommodate one's psychological and other more concrete needs.Furthermore, belonging is not merely restricted to blood ties or ethnic roots but also involves a sense of commitment, loyalty and an emotional connection with the 'home' one has chosen. 7Many countries treat immigrants, exiles and refugees as outsiders or even outcasts and have at best merely tolerated their presence.Tolerance of difference is not sufficient to create a sense of home.Finding your home in South Africa may be linked to finding a sense of safety and achieving resolution.
The issue of belonging and home holds different meanings for different people.
During the liberation struggle a very specific group of migrants was created, namely the political exiles who were forced away from South Africa and had to make a new home elsewhere, cutting off their essential ties with family and friends.
Steyn et al. 20  The actual return 'home' was also extremely difficult, and Steyn et al. 20 describe the process of readjustment as being acutely stressful and complex.Grinberg and Grinberg 9 argue that ultimately no return is solely a return, but that it is in fact a new migration.Neither those who return nor those who stayed behind are the same, as they have both felt the impact of the separation and in some way might reproach the other for having abandoned them.Steyn et al. 20 furthermore argue that this is also due to the fact that while in exile the relationship to 'home is … complex and complicated, resulting in an intense return characterised by conflict.Once again exiles who fought so hard to bring about the political changes that could allow them to return, might have ended up being strangers in their own land.' The impact on family life has also been enormous.As mentioned earlier, another peculiar characteristic of South African exiles was that they often left as individuals, leaving their families behind.Contact with them was almost impossible and had a profound impact on a number of lives. 10 many black South Africans were subject to the group areas act, the system of 'independent' homelands and migrant labour, r, flu-like symptoms, drowsiness or worsening of seizure control, especially within the first month of starting treatment with lamotrigine.Exceeding the recommended dose at the initiation of therapy may be associated with an increased incidence of rash requiring withdrawal of therapy.Abrupt withdrawal may provoke rebound seizures.Risk may be reduced toxic epidermal necrolysis have been reported especially in patients who also used valproate.Although the majority recover on drug withdrawal, some patients experience irreversible scarring and there have been rare cases of associated death.The initial presentation of a rash can be mistaken for an infection; physicians should consider the , which increases the mean half-life of lamotrigine nearly two-fold.All patients who develop a rash should be promptly evaluated and LAMICTIN withdrawn immediately unless the rash is clearly not drug related.Rash has also been reported as part of a hypersensitivity syndrome associated with a variable ilure.It is important to note that early manifestations of hypersensitivity (e.g.fever, lymphadenopathy) may be present even though rash is not evident.If such signs and symptoms are present, the patient should be evaluated immediately and LAMICTIN discontinued if an alternative aetiology cannot be rn should be reported to the patient's physician.Antiepileptic agents (such as phenytoin, carbamazepine, phenobarbitone and primidone) which induce hepatic drug-metabolising enzymes enhance the metabolism of lamotrigine, halving its elimination half-life.Sodium valproate, which inhibits hepatic drug-metabolising enzymes, reduces the metabolism of The ideal of multiple belonging may hold true for most South Africans who have strong cultural and ethnic roots in their birth communities, but also a wider South African national identity.
The ability to alternate between cultures and show a constant sense of curiosity when dealing with difference, rather than mere tolerance of each others' differences, may greatly help in dealing with the complex context of which we are part.
Linking the search for 'home' with achieving some kind of resolution may be of relevance.This idea may resonate with O'Reilly Byrne and McCarthy's 21 concept of the 'Fifth province', used in Irish mythology to describe a place of imagination and possibility where there was the hope of conflict being resolved through dialogue.These authors make use of this term in a therapeutic context as an approach to deal with diversity in an ethical manner, but it may also be useful as an analogy for a place of psychological resolution.Finding the 'fifth in South Africa may remain the pursuit of those who live in this country.

Migration and mental health
A number of perspectives have been put forward on the connection between migration and mental health.Grinberg and Grinberg 9 are of the opinion that migration, which by definition represents a crisis situation in a person's life, may act as a precipitating factor in the development of a psychotic state.They discuss a number of psychodynamic perspectives all of which suggest that psychosis occurs primarily because of a sense of object loss, a void or an absence of the mother figure, which leads to an emotionally significant separation. 9In general, a person who immigrates may develop different forms of pathology depending on personality structure, circumstances and very significantly the depth of the individual's feelings of loneliness and helplessness. 9Bughra 22 also puts forward a complex model hypothesising that migration is not a phase but a series of events, influenced by a number of factors over a prolonged period of time.He concludes that a complex of factors interplay to create a picture lending itself to the development of schizophrenia specifically, although other mental health disorders are also implicated.
Traditionally it was believed that a rapid and successful process of acculturation could lead to less mental health problems. 23wever this perspective has been challenged by work such as that of Vega, 24 who argues that in fact maintaining links with one's traditional culture may help 'buffer' the negative mental health impact of immigration.
However, many of the phenomena inherent to the migration and exile process discussed so far are likely to have an impact on mental health, potentially resulting in adjustment disorders, mood disorders, anxiety disorders and schizophrenia.Recently in the literature there seems to have been considerable interest in migration as a putative risk factor for schizophrenia specifically.In his review article on migration and mental health Bughra 22 gives a thorough overview of a number of studies that have focused on the impact of migration and mental health.
Of particular interest is the work of Cochrane and Bal 25 who hypothesised that high rates of schizophrenia among migrant groups were linked to: (i) sending countries having a high rate of schizophrenia; (ii) schizophrenia predisposing people to immigrate; (iii) migration producing stress and elevated rates of schizophrenia; (iv) high rates being explained by misdiagnosis, often as a result of cross-cultural factors; and (v) differences in symptoms.
A high incidence rate for schizophrenia has been reported for persons of African Caribbean background in the UK 26,27 and of Surinamese Dutch Antillean and Moroccan background in the Netherlands. 28Recently increased risk of developing schizophrenia was found in all migrants in Denmark, particularly those from Australia, Africa and Greenland. 29 a meta-analysis of schizophrenia and migration Cantor-Graae et al. 29 reported a mean weighted effect size of 2.9 (95% confidence interval (CI): 2.5 -3.4) for the risk of However, genetic factors alone cannot explain why individuals from these countries develop a higher risk for schizophrenia when they migrate.A broad spectrum of migrant groups have been implicated in these studies. 30Between-population variation of this type rather strongly supports the notion that the social environment may play a causal role.A social environment factor that may explain a common mechanism involved in this process is social defeat. 31Social defeat can be defined as the chronic stressful experience of outside status.
Social defeat could arise whenever an individual is forced into a subordinate position in relation to a dominant group and could also arise through internal migration to areas of increased urban density, because of a highly competitive atmosphere in urban areas.Referring back to the theories of assimilation and acculturation described earlier we can see how the person trying to integrate into a foreign society may end up feeling like a second-class citizen; similarly an exile finding himself or herself in a strange country with little hope of return may also feel ultimately excluded.LaFramboise et al. 12 argue that much of the research on acculturation shows that minorities are often relegated to lower status positions within the majority group, frequently as a result of discrimination.Social defeat may be a common experience of many people in South Africa today as they attempt to find their place in a multicultural, varied society.
Some interesting animal studies using the defeated intruder paradigm have shown that social dominance may even have an effect on synaptic dopamine levels. 32Furthermore, studies of primates have shown a strong relationship between dopaminergic activity and social rank. 33,34ntor-Graae et al. 30 concluded that disturbed brain dopaminergic function resulting from long-term experience of social defeat could provide a common pathogenic mechanism for the increased risk of schizophrenia in urban residents and migrants.This biological tendency connected to the psychosocial factors discussed above may well play a contributory role within a multifactorial model.
Overview of the relevant literature therefore highlights the fact that the link between migration and mental health is not a simplistic and linear one but reflects a complex interplay of factors that should be taken into consideration by the relevant mental health practitioners.

Conclusion
Longing for a place called 'home' and the longing to belong and be rooted are very common human experiences.This is particularly true in the case of those who have to leave the country of their birth, such as migrants and exiles.In South Africa we have a multicultural context, with all people struggling to define for themselves what it means to truly belong to this country.In this sense South Africans may share some of the socio-psychological experiences that characterise migration and exile phenomena, as they are also faced with having to negotiate a number of different cultures in their daily interactions.
The ability to move between cultures without having to give up one's own traditions and norms, and developing an attitude of curiosity in approaching difference rather than diffidence or at best tolerance, may go a long way towards creating a context in which all people living in this country may come to call it 'home'.
Recent research on immigration discussed earlier has shown that giving up one's culture to fit in with a dominant culture may not be in the person's best interests when it comes to mental health. 31Feeling displaced and not belonging may in fact deeply affect many people who may feel alienated in the context of the new South Africa.It is therefore essential that mental health professionals in this country become more aware of issues of culture and how these affect interpersonal and intrapsychic functioning and mental health issues.Escobar 23 argues that cross-cultural research is extremely important in advancing our knowledge of risk and protective factors for mental disorders as well as the fact that study of the mental disorders of specific ethnic groups can generate hypotheses that apply to general psychiatry.The effect of migration (including social defeat) on the incidence of schizophrenia should be investigated further in the post-apartheid South African context.
With regard to this a number of lessons may be learnt from the as a political expedient, often at the expense of other people's rights, one cannot deny or ignore the deep psychological meaning that it has in the life of every individual and group.In attempting to create a home in this country South Africans are experiencing a number of conflicting transitions.For decades the majority of this country's inhabitants did not feel that they belonged in the country of their birth.Now they have to redefine their identity from that of second-class citizens to fully equal citizens; a number of people who fled the country in exile for fear of their lives are being welcomed back and have to readjust to a country that may feel very unfamiliar; many people no longer feel safe or at home in the new South Africa and are choosing to leave; and many white people who felt safe in the old dispensation are struggling with the issue of whether they can still call this country home.In the South African context articles pg 52-64.indd57 8/31/06 2:42:34 PM 58 Volume 12 No. 3 September 2006 -SAJP there may be an inherent tension between the conditions for belonging laid down on a national/societal level and the experiences of individuals struggling between their language and their national identity.Today all South Africans have to ask themselves whether they truly belong to this country and what 'home' signifies to them.
make the very relevant point that South African exiles were not a homogeneous group, as they comprised a number of very different people, ranging from those who feared death to professionals who left of free choice.Their research reveals that South African exiles had very different and ambivalent feelings towards 'home'.On the one hand this concept included a fear of returning, while on the other it involved an idealised view of this eventual return.References: 1. Judd LL, Akiskal HS, Schettler PJ, et al.The Long-term Natural History of the Weekly Symptomatic Status of Bipolar I Disorder.Arch Gen Psychiatry 2002; 59: 530-537.2. Goodwin GM, Bowden CL, Calabrese JR, et al.A pooled Analysis of 2 Placebo-Controlled 18-Month Trials of Lamotrigine and Lithium Maintenance in Bipolar I Disorder.Z/2.5/280 -282, 29/2.5/0472respectively.Each tablet contains 25 mg, 50 mg, 100 mg and 200 mg lamotrigine respectively.S3 LAMICTIN ® P2, P5, P25, P50, P100 and P200 Dispersible Tablets.Reg.No's.36/2.5/0407,29/2.5/0303-304, 32/2.5/0459,29/2.5/0305,32/2.5/0460respectively.Each tablet contains 2mg, 5 mg, 25 mg, 50 mg, 100 mg WARNINGS: Severe convulsive seizures including status epilepticus may lead to rhabdomyolysis, multi-organ dysfunction and disseminated intravascular coagulation, usually with fatal outcome.Closely monitor patients (including hepatic, renal and clotting parameters) who acutely develop any combination of unexplained rash, fever, flu-like symptoms, drow by tapering off the withdrawal over a period of two weeks.Skin Reactions: Reports of adverse skin reactions, have generally occurred within the first 8 weeks after initiation of treatment.Majority of rashes are mild and self-limiting; however serious, potentially life-threatening skin rashes including Stevens-Johnson syndrome and toxic epidermal necrolysis possibility of a drug reaction that develop symptoms of rash and fever during the first eight weeks of therapy.Additionally the overall risk of rash appears to be strongly associated with high initial doses and exceeding the recommended dose escalation, concomitant use of valproate, which increases the pattern of systemic symptoms including fever, lymphadenopathy, pruritis, facial oedema, abnormalities of the blood and liver and thrombocytopaenia.The syndrome shows a wide spectrum of clinical severity and may lead to disseminated intravascular coagulation and multi-organ failure.It is important immediately established.Caution advised when treating patients with renal failure.The possibility of a suicide attempt is inherent in bipolar disorder, and close supervision of high-risk patients should accompany drug therapy.INTERACTIONS: In patients taking oral contraceptives, any change in the menstrual bleeding pattern should be reported to lamotrigine and increases the mean half-life of lamotrigine nearly two-fold.Reports of central nervous system events including dizziness, ataxia, diplopia, blurred vision and nausea in patients taking carbamazepine following the introduction of LAMICTIN, which resolve when dose of carbamazepine is reduced.PREGNANCY AND LACTATION: Safety no subsequent dose escalation should not be exceeded.The transition regimen should be followed to prevent recurrence of depressive episodes.The transition regimen involvesescalating the dose of to a maintenance stabilisation dose over six weeks after which other psychotropic and/or anti-epileptic drugs can be withdrawn, if clinically indicated.Refer to pac step-wise reduction of dose.Children (less than 18 years of age): Not recommended.Elderly (over 65 years of age): No dose adjustment required.Hepatic impairment: Initial, escalating and maintenance doses should generally be reduced by 50 % in patients with moderate (Child-Pugh grade B) and 75 % in severe (Child-Pugh grade C) he drowsiness, insomnia, dizziness, tremor, vertigo, parasthesia.Headache, dizziness, nystagmus, tremor, ataxia, drowsiness, insomnia, diplopia, blurred vision, nausea, gastrointestinal disturbance (including vomiting and diarrhoea), tiredness.Serious, potentially life-threatening skin rashes, including angioedema, Stevens-Johnson syndrome and toxic epidermal n APPLICANT: GlaxoSmithKline South Africa (Pty) Ltd., (Co.reg.no.1948/030135/07), 57 Sloane Street, Bryanston, 2021 • Lamictin Horizontal 6/14/06 10:45 AM Page 1 articles pg 52-64.indd58 8/31/06 2:42:44 PM articles 59 Volume 12 No. 3 September 2006 -SAJP they too are struggling to find a new definition of 'home'.They may have hoped for a major social and economic transformation in their lives, and anticipated feeling like true citizens of their country for the first time -only to experience few practical changes in their day-to-day living conditions and ongoing racist attitudes which may make them feel like secondrate citizens in their country of birth.Many white people have immigrated in search of a new 'home' and what they perceive to be a safer life and a better future for their children in the midst of affirmative action and black empowerment.Many Afrikaners who have stayed behind are struggling to defend their language and culture in the midst of a society which they perceive to be hostile and threatening to their sense of 'home'.A large part of the white population has strong European roots and represents fairly recent immigration to this country ranging articles nce in Bipolar I Disorder.J Clin Psychiatry 2004; 65(3): 432-441.3. Khan A, Ginsberg LD, Asnis GM, et al.Effect of Lamotrigine on Cognitive Complaints in Patients With Bipolar I Disorder.J Clin Psychiatry 2004; 65(11): 1483-1490.For full prescribing information, refer to package insert.S3 LAMICTIN ® 25, 50, 100 and 200 Tablets.Reg.No's., 25 mg, 50 mg, 100 mg and 200 mg lamotrigine respectively.PHARMACOLOGICAL CLASSIFICATION: A 2.5 Antiepileptics.INDICATIONS: For the prevention of mood episodes in patients (over 18 years of age) with bipolar disorder, predominantly by preventing depressive episodes.CONTRA-INDICATIONS: Known hypersensitivity to lamotrigine.

1 Prevent bipolar depression during manic or depressive episodes 2 without destabilising mood 2 whilst improving cognitive functioning 3 lamotrigine 2 , 5 ,
LACTATION: Safety not established.DOSAGE AND DIRECTIONS FOR USE: It is important to adhere to the recommended dosages especially in combination therapy with valproate where one-tenth to one-fifth of the normal dose is used.Do not exceed the maximum dosage.Because of the risk of rash the initial dose and lly indicated.Refer to package insert for full dosage recommendations on the Transition Regimen; Maintenance stabilisation total daily dose following withdrawal of concomitant psychotropic or anti-epileptic drugs; Adjustment of lamotrigine daily dosing following addition of other medications.Discontinuation: Patients may terminate LAMICTIN without a (Child-Pugh grade C) hepatic impairment.Escalation and maintenance doses should be adjusted according to clinical response.Renal impairment: Caution advised; reduced maintenance doses should be used for patients with significant functional impairment.SIDE-EFFECTS AND SPECIAL PRECAUTIONS: Commonly reported: skin rash, irritability, e and toxic epidermal necrolysis have been reported.In Bipolar Disorder trials, agitation, somnolence, arthralgia, pain, back pain, have also been reported.MANAGEMENT OF OVERDOSAGE: In the event of overdosage, the patient should be admitted to hospital and given appropriate supportive therapy.Gastric lavage should be performed if indicated.25, 50, 100 and 200mg B I P O L A R D I S O R D E R Prevent depressive episodes.Maintain stability.205.06 pg 52-64.indd59 8/31/06 2:42:55 PM 60 Volume 12 No. 3 September 2006 -SAJP from first-to third-generation immigrants.This latter group is of particular interest as many were born in South Africa and yet hold a second passport indicative of an allegiance to another country.However, these people have contributed much to this country and have strong emotional and economic attachments to South Africa.We are also seeing a growing number of refugees from other parts of Africa who bring with them unique problems, often giving rise to xenophobia.After the 1994 elections the metaphor of a rainbow nation where different colour people living side by side produce a beautiful whole, was very appealing and provided a unifying image to a nation deeply divided.It invited all South Africans to be part of a new nation, and allowed everyone to feel as if they belonged to the 'New South Africa'.Twelve years later one may well ask whether the invitation has become reality and what still needs to be done to make a true home of this country.