The idea that all men are created equal is a very attractive one. It is also politically correct and it pleases every modern open-minded person.
©2013 Am Ang Zhang
It is a generally held view that world wide the rate of schizophrenia stays the same regardless. However, according to some reports, in England
Could it be that doctors and especially psychiatrists in England
Although puzzling, it cannot be denied that at any one time half of our psychotic patients were Ethnic, and all of our eating disorders were white.
Sohan
I cannot forget Sohan. I should not
have asked what his name meant in Punjab when
he was brought to see me by his mother and grandmother. I was told Sohan meant “beautiful”.
Sohan came to see me because he was
afraid. He was afraid he was turning into a woman. He was polite and rational
and told me that he had this dream that he was turning into a woman. He was
about to finish school and would be going to India
I was not able to work out what his
fears were but said I would be happy to talk to him again when he returned from
his vacation. As he would be working shifts it would not be such a problem.
He never did keep his appointment but I
was called to the hospital by my adult psychiatrist colleagues as Sohan was
admitted to the acute psychiatric ward. He had swallowed a large number of
coins but as they were being excreted no operation would be necessary. He
wanted to see me because he said I would understand.
I went up to see him the same day they
called. He was quite pleased to see me. The next thing that happened he pulled
up his top. He had a big one-sided breast.
“You see, Doctor, that was what I told
you.”
My colleague came round at the time.
“Sorry, old chap. Forgot to tell
you. We put him on the usual[1] but
in four days he came up with that. We
have asked a surgeon to look at it and he reckoned a mastectomy would be
required. We have now switched him to one of these new drugs. But no question,
he is schizophrenic.”
How sad. Did he predict the future or did doctors re-create his
future?
Masud
That Masud was having his Manic episode
was not in dispute. He was missing from home and then the police called the
parents who both worked at the airport. He tried to board a plane with his
father’s passport and a first class ticket to Karachi
In less than 24 hours he managed to
spend more than six thousand pounds that he had saved and by the time he
reached us he could hardly tell the time of the day or his mother’s name.
By then, no one in the unit had any
problem with the diagnosis of bipolar disorder, current episode manic.
He was indeed quite confused when we
got him but it probably was more due to the lack of sleep for some days than anything
else we could think of. To be on the safe side an MRI was done and it did not
reveal any space-occupying lesion.
He was put on Lithium and made an uneventful recovery. As it was a
first class ticket unused we managed to get his refund. His parents were happy
to have him back and they put money into his account to compensate for what he
wasted. At any rate a nice outfit and a nice computer could not be such a
waste.
He was back to his job at the airport
and luckily his boss was one of father’s relations.
The family saw to it that he took his
medication religiously and he stayed well for over nine months.
One day father called the unit to say
that Masud was confused and speaking gibberish and they thought he might be
having a relapse. They got hold of me and the story of confusion at his first
episode crossed my mind but I asked the parents to check his temperature. 40
degrees C.
“Get him to the hospital. Whatever it is he is not ours, not this time.
But wait. Has he overdosed on the Lithium?”
“No. my wife is very careful and she
puts it out every morning, and the rest is in her bag.”
Phew, at least I warned them of the
danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the
best.
“Get him admitted and I shall talk to
the doctor there.”
He was in fact delirious by the time
they got him into hospital and he was admitted to the local Neurological hospital.
He was unconscious for at least ten days but no, his lithium level was within
therapeutic range.
He had one of the worst encephalitis they had seen in recent times
and they were surprised he survived.
Then I asked the Neurologist who was
new, as my good friend had retired by then, if the lithium had in fact
protected him. He said he was glad I asked as he was just reading some article
on the neuroprotectiveness
of lithium.
Well, you never know. One does get
lucky sometimes. What lithium might do to Masud in the years to come would be
another matter.
I found that people from the Indian
subcontinent were very loyal once they realised they had a good doctor –
loyalty taking the form of doing exactly what you told them, like keeping
medicine safe; and also insisting that they saw only you, not one of your
juniors even if they were from their own country. It must have been hard when I
retired.
Yosef
Yosef’s family was from Morocco , but he was born and brought up in England Morocco
There was no question he was having a
psychotic breakdown. The family was not very forthcoming with any family
history but said they wanted to wait for father to return from Morocco
Yosef managed to run away from our unit
the following Friday and was brought back in the early hours of Saturday by the
London
Now, I really cannot tell you the exact
club as they would be very upset. But some of our nursing staff did know of
people who went there. It was a very trendy place and it was very much public
knowledge that people did drugs there and they did it in a big way. Not just
Ecstasy, but all things imaginable. This was despite the fact that they
searched people before they were allowed in. I had absolutely no idea where the
drugs came from and the official line was that they did not tolerate drugs.
Out of interest and for his sake we ran
a drug screen on him, quite an exhaustive one as I felt it was important to
know if he was suffering from drug induced psychosis. The
screen came back all negative. There was no alcohol either.
Perhaps some of them do not need drugs,
just the wrong genes.
So he was too weird for the club to
handle. That must be a first.
He had refused medication since
admission which meant his psychosis was not going to disappear overnight. Luckily
we had an arrangement with the adult secure ward and they would take over any
young psychotic patient who needed to be detained under the Mental Health Act.
Our ward was very much an open ward and the perimeters were impossible to
secure.
We did not have any rights to restrain
him. If he decided to leave he could as
he had his rights, and he reminded the staff of this in his most psychotic
phase.
So we were basically babysitting him
until a bed could be found in the adult secure ward. He walked out twice but
became cold and hungry and came back. Thank goodness for British weather.
It also made me wonder about human
rights – for some patients their rights were also their handicap. We certainly
could not secretly dope him by putting tasteless antipsychotic in his food or
drink.
It is a good rule and protects people
against bad doctors and perhaps dictatorial tyrants, but the latter would
probably just change the law.
In the mean time our teenage psychotic
would have to go over to a Secure Acute Adult Mental Heath Ward after sedation.
The Nurse sent by the adult secure ward
for him was like an animal tamer, a version of horse whisperer for humans. The
necessary papers were signed, and the injection was ready. They now had the
power of reasonable restraint and as they pulled his trousers down for his
injection he cried out like a baby,
“Doctor, Doctor, save me!”
I just did.
He did not give them any trouble at
all.
He was put on depot medication as he
could not be trusted to take any other.
Horses for courses or was it the other
way round?
Over the years I have not really
shifted from the view that sometimes the old fashioned secured ward is good.
The idea of an open place for Yosef would horrify me. What if something happened
to him when he ran away?
Father came back from Morocco Morocco
for years and he had just gone to Morocco
Martina
Martina was already at the adolescent
inpatient unit when I arrived. She was supposed to be schizophrenic. The family were refugees from Sudan
Martina was not very communicative but her
records and observations by her outpatient psychiatrist indicated that the
diagnosis was robust enough. However, after over a year in hospital she was not
improving and we had tried the newer antipsychotic without making much headway.
There was one thing left to do – to put
her on Clozapine.
I was once at one of these big drug
firm meetings when all the big boys on the newer antipsychotics were there.
Having filled my plate from the
delicious buffet, I sat next to two nicely clad representatives.
“So you ladies are from Novartis?” I
did my usual stunt.
“How did you work that one out?”
“Well, you two have the best designer
outfits and I guessed you must be from the makers of Clozapine.”
They were there to see what the
opposition might come up with but as far as I was concerned no other
pharmaceutical would touch them for decades.
When they have a drug that works so
well, even research is sometimes redundant.
The U.S. was very
slow in approving the drug even when the rest of Europe
has been using it. At an APA conference I once sat next to a doctor of Chinese
ethnic origin. He was employed in the U.S.
The blood problem could have been a
disaster. (A small percentage of
patients will develop leucopaenia, a lowering of white cells, and die if
unchecked. Stopping the medication as
soon as possible will reverse the process – hence the regular blood test.) But for a drug so definitely superior
Novartis have managed to turn the potential disaster into a perpetual gold
mine. The need for regular blood test and a national registry for the supply
depending on the result of the blood test mean that Novartis will have the
monopoly for a long, long time to come. I heard stories of the drug being
smuggled into the U.S.
With Clozapine, the
change in Martina was almost miraculous. At least, the family thought so. We
were able to get her into one of these special shelter places run by Catholic
nuns. Her negativity literally disappeared and my junior continued to give me
glowing reports on her.
At the time of the lunch meeting,
Martina was already at the special shelter. I asked the reps what the youngest
age on Clozapine was and learned that at that time
in England
You learn something new every day and
it started me thinking about another aspect of psychosis, drug use and
ethnicity.
It has been a concern of mine that we
have been told that globally the rate for schizophrenia has been stable. Recent concerns over cannabis
and psychosis highlight certain anomalies.
If Cannabis is “causing” psychosis, and
the overall rate for psychosis is stable, then some part of the population must
be spared of the psychosis to balance out. Some consider this to be a good
enough reason not to do much about the increased use of cannabis.
By the same token, if ethnic minorities
are experiencing a higher rate of psychosis, then
the local non ethnic group must have a correspondingly lower rate to balance
out the figures.
“The University of Queensland
His team collected 188 schizophrenia studies dating from 1965 to
2002 from 46 countries.
The report debunks a popular textbook
definition that schizophrenia will affect 10 in every 1000
people no matter where patients live.
It says this rate is too high and more
likely, between seven and eight in 1000 people, although this varied from
region to region
Our data shows that the incidence and
prevalence of schizophrenia varies much more around the
world than previously acknowledged.”
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