Monday, February 26, 2018

Finland: Lithium!

In medicine, population wide survey has its place not forgetting that when many modern psychiatric drugs went through the so called "robust" double blind control trial, it is never really all that double blind as many of the drugs tested have side effects that could easily biased both patient and researcher. The patient realising that he/she is taking the "real" drug might want to report improvement or the opposite. The observing researcher will realise very quickly and may unfortunately be biased even if unintentional.

I remember questioning the presenters of Olanzapine on this especially as patient reported great craving for food and put on weight, the presenter refused to answer my question.

Then there is the question of Bipolar or Unipolar. Well, my view is this and Psychiatrist might not like to admit it: we might get it wrong. If risk of suicide is high why use something that might provoke suicide. The same Finnish team that did the research came up with the answer on using Lithium in Unipolar Depression!

© 2012 Am Ang Zhang

Finland & Unipolar Depression: a nationwide cohort study.

Prof Jari Tiihonen, et al/  Here are the essential points and full summary here.

Little is known about the comparative effectiveness of long-term pharmacological treatments for severe unipolar depression. We aimed to study the effectiveness of pharmacological treatments in relapse prevention in a nationwide cohort of patients who had been admitted to hospital at least once as a result of unipolar depression.

Our nationwide cohort study investigated the risk of readmission to hospital in 1996–2012 in all patients in Finland who had been admitted to hospital at least once for unipolar depression (without a diagnosis of schizophrenia or bipolar disorder) in Finland between Jan 1, 1987, and Dec 31, 2012.

Data from 123712 patients were included in the total cohort, with a mean follow-up time of 7·9 years (SD 5·3). Lithium use was associated with a lower risk of re-admission to hospital for mental illness than was no lithium use. Risk of hospital readmission was lower during lithium therapy alone.

Our results indicate that lithium, especially without concomitant antidepressant use, is the pharmacological treatment associated with the lowest risk of hospital readmission for mental illness in patients with severe unipolar depression, and the outcomes for this measure related to antidepressants and antipsychotics are poorer than lithium. Lithium treatment should be considered for a wider population of severely depressed patients than those currently considered, taking into account its potential risks and side-effects.

The following is an extract from The Cockroach Catcher:

“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.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows.
Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.
Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.
Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.
Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.

Could Lithium be the Aspirin of Psychiatry? Only time will tell!.

Sunday, February 18, 2018

The Cockroach Catcher & Adolescent Days: Prickly! Prickly! Prickly!

©2016 Am Ang Zhang 

The Cockroach Catcher remembers his Adolescent days fondly, I mean my Adolescent In-patient days fondly. There was much politics to deal with and this time he used Ping Pong!

The Cockroach Catcher:  Chapter 24  Ping Pong

t is the nature of life that now and again you have to do people favours. Sometimes you do it in case you need favours back. More often than not it is about doing the right thing.
         One of my outpatient colleagues was female and ethnic. When she realised that I became in charge of the adolescent unit, she said to me, good, now I can get some of my patients admitted.
         It was very difficult to decide if there was racism or sexism. It was true that many of her referrals did not get to be admitted and most of the time the nurses had justifiable reasons. One nurse in particular warned me from day one that I should not touch any of her cases.
         Nurses are very powerful in an adolescent unit. They have front-end dealings with patients from pre-admission to admission to discharge. For someone new like me it would have been foolish not to take notice of such a clear cut warning. But anyone who knows me well enough would not expect me to be easily intimidated.  I would not have an all out fight but I have my ways.
         However, this consultant did not help herself in matters. Before my arrival she had been writing to the Health Authorities about her difficulties in getting patients admitted. Luckily for the nurses all the blame was laid on the previous consultant who was eventually suspended and dismissed.
         By then, the nurses felt that they were in some position of authority and my emergence was not exactly met with fanfare, although there was for some a sense of relief as my success at the Children’s Unit in the last ten months was beyond anybody’s expectation except mine. The nurses working in the Children’s Unit, including the wife of the charge nurse at the adolescent unit, warned me that adolescents were different.
         It was also difficult to turn up at a place that had been running on auto-pilot for some time. The staff began to feel that doctors might not indeed be necessary except for this silly rule that they alone could prescribe.
         The consultant in question was known to have an “over-understanding” approach to cases and she felt sorry for a number of patients where there was a strong social element to the problem. Due to shortage of beds, we did try to limit admission to genuine psychiatric cases.
         However when I was asked by the Health Authorities handling her complaints to look at one of her cases again what choice did the nurses think I had? Quite simply, admit or else.
         But the decision was always mine!
         One of the boy’s problems was that he lived with mum and had not been to school for nearly a year.  As the consultant requested an assessment at a psychiatric unit, Education Department refused even to look at him until that had happened.
         A stalemate.
         In the meantime, Education Department had saved the better part of thirty thousand pounds and they had a legitimate reason.  He was first kicked out of school because he used threatening language with a female teacher when asked to read his story. 
         Mother also reported how threatening he was to her at times.
         From this bit of history he was definitely no good for our unit. The last time the unit had to be closed in the middle of the night was precisely because of violence to female staff.
         We too had a legitimate reason not to admit him.
         I took the charge nurse Martin on one side and asked him to tell me what he would think if we were dealing with a brand new referral.
         I discovered months later that he found me genuine and really wanted to give me a chance to make a go of it. As such he had to tell me the problem. 

©2016 Am Ang Zhang 

         The problem of anarchy.
         There was amongst some staff a strong anti-authority feeling.  There was no doubt they were let down by the previous consultant and some of the nurses could have been hurt.  Following the incident, an outside consultant was employed to provide a report at great expense to the NHS Trust.  I could have told them the problem free of charge.
         Such is management nowadays that the dirty work has to be done by an outsider.  We were still in the investigation period and no doubt everything I did would be under scrutiny.  The survival of the unit would depend on the outside consultant’s report. I had lunch with him on many occasions and luckily his NHS views were in fact very close to mine. Six weeks he had to be with the unit and six weeks was a long time.
         So I was lucky in that there had to be a truce.  We could not let personal prejudices override clinical decisions.
         In the end and some thousands of pounds later we managed to keep our unit running and in some little way I changed my view about outside consultants. The good ones are good and this one was a practising inpatient child psychiatrist so there was no need really to say too much about politics and anarchism. He understood because he experienced it himself, and he found a way to deal with it.
         So running an adolescent unit is like running a mini-country. In our democratic age, the wisest thing to do is to bring about the changes you want when you are riding high, and then leave.  Do not wait to be kicked out.
         As psychiatrists, we do have certain power conferred by the Mental Health Act and that is often a sore reminder of the difference between us and the other staff – more so as we still had two Sectioned patients in the unit at the time: one anorectic on tube feeding and one psychotic.
         Martin the charge nurse said he would visit the boy Leroy at home to assess him and if I could agree to a time-limited admission we might have a “goer”. He thought that Leroy was probably “all barks” only.  His father was from the West Indies and the one time Martin met Leroy he was just loud and boastful and not as threatening as mother always made him out to be.
         In the two years I lived on a Caribbean island, I discovered that many of the children there were in fact very gentle and timid, and they were never rude to their parents. I know not all the islands are the same and generalisation can be very dangerous.
         “But you may have to speak with Kevin.  He visited the last time.”
         Kevin was the one who warned me not to even think about it. There were many ways to deal with violence in our kind of unit.  More often than not if the adolescent patients sensed that there was no leadership they ran wild.
         I decided on a direct approach. 
         “I am going to be frank with you, Kevin. I want you to go out with Martin and see this boy again and I want him in a.s.a.p. unless you can convince me that there is a good reason why he should not have the benefit of a six week assessment. I know you think I am doing a favour and I can tell you now, I am. Sometimes in life you have to because not doing it is going to hurt a lot more people, including ourselves.” 
         “Six weeks then.”

©2016 Am Ang Zhang 

         My new junior, who was a very timid girl, decided to go out on the visit too when she realised that there would be protection. Leroy had just turned thirteen and she told me that she thought he might well have the King’s disease.
         “You mean what they claim King George VI had?”  I thought it was very clever of the drug firms wanting to push the new drug for Social Phobia to involve the King.  “Don’t forget King George VI had lung cancer and metastasis could do strange things.”
         No problem.  Leroy agreed to come in when he learned that we had two ping pong tables and that Martin played County Championship League.  My junior said she was glad she went and she really did not understand what the fuss before was about. I told her that even in adult psychiatry, reports on patients could often paint an unreal picture and the mildest people could be made to appear like big monsters.
         It was suggested that the only time there might be trouble would be when the boy came to be admitted, and therefore he should not come in his mother’s car but in a hospital bus instead, accompanied by some of the big male nurses. I might have given in to the idea but my junior came to my rescue. She would go with the charge nurse and bring him in her car. Mum could drive down on her own.
         “It is a hospital lease car anyway.”
         “The last time a male nurse offered to take a female patient home he was accused of touching her and he was suspended.”
         “Was he guilty?”
         “No, but he died of a heart attack. We shall send our bus but you can be the medical escort.”
         I remember once escorting a Manic Depressive (Bipolar 1) from Hong Kong to London and I had to inject him en route, sitting right at the back of a BOAC[1] 707. That was an experience. So I reminded my junior, “Don’t forget the rapid sedation pack – just kidding.”
         Why should all the fun be left to the nurses, I thought to myself but I was never going to let her drive, Crown Car or otherwise.
         Leroy looked as if he was going to camp, with his new white trainers and sports outfit that father presented over the weekend together with the latest sunglasses.
         Martin told me sometime later that father called him wanting to know if I was “Cool, man. You know what I mean, man.”
         “I told him you were actually Chinese. He said he did not want no white doctor putting no funny thing into his boy.  I also told him the consultant would be happy to see him any time he liked.”
         Martin reckoned he was doped up heavy with something from the way he was slurring his speech. He was all right as long as I was not white.
         “Good, no more racism. Not from us.”
         Father also gave Leroy a new sports-bag to carry all his stuff. It was really too big for him and my junior reported to me the verbal duel between mother and son. 
         “You are blocking the way with that stupid bag.”
         “Dad gave it to me.”
         “He is stupid.”
         “He is not.”
         “Why didn’t you go live with him?”
         “You took his house.”
         “He shouldn’t hit me and you are copying him. Stupid bag, you are not going to Jamaica, you know, stupid sunglasses.”
         “Tag Heuer, they are the best.”
         “Move your stupid bag. Stupid Nike bag.”
         She turned to my junior, “He does not really want to go in, and that is why he is so slow.”
         With that he moved.
         “Have you read Jay Haley[2]?”  Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's.
         “I have read Bateson.”  Gregory Bateson was the well known social scientist who wrote Steps to an Ecology of Mind, and Mind & Nature.
         I am beginning to like her. She is going to be a good psychiatrist.
         So Leroy arrived and was at a bit of a loss standing outside the Nurses’ Office.
         It was time for mother to leave.  We tended not to let mothers stay too long for admission for obvious reasons.
         “Aren’t you going to give me a kiss then?  Why aren’t you crying? I thought you did not want to come in.”
         Did she not realise that maybe the boy was not that stupid? After a year shut up in the house with a mother like that, he would take up any chance to be away for six weeks!
         He did kiss her and started to cry.

©2016 Am Ang Zhang 

         My junior cried too. I thought she did because she felt sorry for the boy.
         “Leroy is a lamb, isn’t he?” Martin said to me later.
         “So we shall be fine then.”
         He smiled.                                             
         For the first weekend inpatients were normally not granted home leave to allow for settling in and from then on the weekend leaves would be dependent on their performance at community meetings and on how they were assessed by their fellow patients. They had to ask for a grade and if the grade was not good enough they were not allowed home. This system had been running for years and I really did not want to rock the boat at such an early stage.
         It was all stage-managed by the teaching staff, who unfortunately found this the only way whereby they could have any control over the children’s behaviour.
         The first weekend Leroy was fine except when mother visited. There was some silly argument and he took himself to the toilet and did not come out until he was assured mum was gone.
         Then he said he missed his dad, who did not have a car and mum refused to drive him down as the last time she drove him somewhere he hit her after some argument.
         “He wanted a new game from dad and dad promised he would get him one if he could get home leave,” Kevin told me the real reason he wanted to be home.
         That is very much the modern way a parent relates to a child. They do not know any other way.
         “Psychology, you see,” he told Kevin over the phone. “I want to help the China Man.”
         “I need everybody’s help!”
         “Do you agree that Leroy has Social Phobia[3]? Everything fitted in with the criteria in DSM IV.” My junior plucked up courage to ask me during supervision.
         It was good to keep oneself on one’s toes with juniors who had just arrived from London and who read up on everything.
         “What’s wrong with shyness?” I joked, “Do you want me to put him on SSRI (Selective serotonin reuptake inhibitors)?”
         “It is supposed to work.”
         “If he starts taking SSRI at thirteen, what is he going to do for the rest of his life?!”
         “The newer short acting ones are supposed to be better.”
         “Take one advice from me; think the opposite, the opposite to what the big Pharmas tell you. In pharmacology, shorter acting drugs are more addictive. That was what I learned in Medical School and is still true if you think carefully about it.”
         By Community Meeting time nobody had a hard word to say about Leroy, but they all noticed he did not socialise much. He had to ask for his grade as per time-honoured ritual. He could not. Everybody tried to urge him. My junior sat next to him and tried to hold his hand. He rushed off to the toilet and locked himself in again.
         “To lock yourself in a toilet is a down-gradable offence and to do it twice in a week is just not on. And, Doctor, we have to be very strict with these rules.  Otherwise we shall start having problems again,” said a teacher.
         So, I was warned. My junior got rather emotional and said that was just too much for her. It was her first case and why couldn’t they be more understanding?
         Martin interjected and said that of course if there were psychological reasons the consultant could grant a special home visit like half a day so that everybody could save face.
         I liked that. Saving face. But then how popular would I be with the teachers? 
         What about Leroy’s face?
         I knew whose face I wanted to save.
         So I arranged to see Leroy straight away.  No, I did not ask him why he could not speak up for himself. I knew already.
         “I hear you are a very good ping pong player.”
         “Table Tennis, you mean.”  He was speaking to me.
         “O.K. Table Tennis. You know he is good.”  I said, pointing to Martin.
         “Yeah, that is why I am not playing him.  I played with Gerry.”  Gerry was his nurse.
         “The fat one.”
         He smiled a little, thinking I was rude.
         “He was a bit slow.”
         “You must have given him a good run.”
         Smile again.
         “I hear you did not play with the kids though.”
         “How did you know? They are no good.”
         “Well, how about this? Have you ever played a Chinese?”
         “We hold the bat differently, you know.”
         “We’ll play three games and if you win you can go home for half a day and if you don’t, you stay.”
         The look on my junior’s face was something to be seen. Martin put on a look to pretend that he knew I would come up with something, although he admitted later that what I suggested was the last thing on his mind. 
         The scene was set for a three game match between the consultant and his patient to decide if his patient could go for a short week-end leave.                        
         Even the headmaster came out to watch, shaking his head in disbelief.
         It was spring, still cold but sunny. The sun was streaming in. I lost the first game. I had not played for fifteen years. I took off my jacket.  I barely managed the second.  That brought some cheers.
         From certain quarters.
         He beat me bad on the last one. I did not get past 9 and that was bad for ping pong – sorry, Table Tennis.
         I thought everybody forgave me. I did not give the game to him. He beat me fair and square. The situation was too surreal for anyone to remember to get cross.
         The girls clapped as they all loved him and wanted to mother him, especially the older ones, even when many of them did not have a chance of home leave as their weight was not good.
         I became their hero.  Nobody reported me to the General Medical Council.   Not that time, anyway.
         Mother was horrified but thought that if he had been good and had not attacked any female he would be fine. She would just take him to his father, who would buy him his game.
         On Saturday I was there for a new admission. My junior rushed in saying there was a disaster.  Leroy would not go with mum because she did not want to buy him a Diet Coke from the Petrol Station next door.  She said there was a pack from Tesco sitting at home and the Coke from the Petrol Station was too expensive.
         “After all that!” I exclaimed to myself.
         He just sat near the door. I went out, waved my arm in a table tennis move and asked him to follow me to the car.
         “Cool wheels,” he said, “but it’s for old people though.”
         I ignored him, opened the car boot and gave him a can of drink – still cool from the overnight frost.
         I knew where his problem was.

May 30, 2016 ... In The Cockroach Catcher, in the opening chapter I recalled an Anorexia Nervosa patient that has been “dumped” by her Private Health Insurer.

Jun 14, 2016 ... ... of childhood psychological problems. Indeed it was a sad day when the unit closed. From The Cockroach Catcher: Chapter 48 The Last Cook ...

Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ...
Apr 25, 2014 ... ... then the Tate also rejected Picasso………” The Tate now of course has several Mondrian works. Now you can read the whole chapter here: ...

Jun 29, 2011 ... In The Cockroach Catcher I got my Anorectic patient to play the cello that was banned by the “weight gain contract”: Jane got on well with me.

Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ...

Jul 20, 2016 ... The following is an extract from The Cockroach Catcher: “Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he ...

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

[1] BOAC – British Overseas Airways Corporation, now British Airways
[2] Jay Haley - A brilliant strategist and devastating critic, Jay Haley was a dominating figure in developing the Palo Alto Group's communications model and strategic family therapy, which became popular in the 1970's. 

[3] Social Phobia (now renamed Social Anxiety Disorder): Everyone feels nervous from time to time. Going on a first date or giving a speech often causes that butterflies-in-your-stomach feeling, for example. Or maybe you feel shy at a party among a group of strangers, but then slowly warm up to them and have a great time.

Wednesday, February 7, 2018

Scarlet Fever & Mahler: Sadness and Creativity!

After decades of decreasing scarlet fever incidence, a dramatic increase was seen in England beginning in 2014. Investigations were launched to assess clinical and epidemiological patterns and identify potential causes.                              Lancet.

The strangest finding is that there is no evidence of any genetic mutation of the bacteria concerned nor resistance to antibiotic treatment. Perhaps we need to look closely at Ed Yong’s masterful new book, I Contain Multitudes, which tells the stories of the microbes that swarm within and around us.

Are we too clean? Do we use too much "Antibacterial" laced cleaning things? Or is the new near religious fervour in not using antibiotics to blame? We simply do not know.

But Scarlet Fever reminds me of Mahler.

 ©2013 Am Ang Zhang

Mahler wrote Kindertotenlieder to five poems written by Rückert. Rückert wrote 428 poems following the death of his two children from Scarlet Fever. 

Mahler lived in an age when bacteriology was very much in its infancy. There was still little understanding of the role Streptococcus played in a range of illnesses from Scarlet Fever to Rheumatic Heart Disease and Radium was often used to treat Streptococcal related conditions.  

Mahler’s own daughter tragically died from Scarlet Fever four years after writing Kindertotenlieder and Mahler himself contracted Rheumatic heart disease. When there was still little understanding of the etiology of diseases, superstition came into play so much so that Mahler did not want to write a ninth symphony. It was the start of the Curse of the Ninth Symphony.

Das Lied von der Erde was indeed the result as it was composed after his Eighth Symphony and he did not want to name it his Ninth. 

Mahler conceived the work in 1908 when he was already unwell with his heart condition. A volume of ancient Chinese poetry under the title of The Chinese Flute (Chinesische Flöte) repoetized by Hans Bethge was published in German and Mahler was very much taken by the vision of earthly beauty expressed in these verses. Fate he felt has been unkind to him but he felt able to accept it in his own fashion.


Mahler died on May 18th 1911 in Vienna.

"I think it is probably the most personal composition I have created thus far."    Gustav Mahler

The first performance of Das Lied von der Erde was conducted by Bruno Walter after Mahler's death. 

Bruno Walter described it as: "the most personal utterance among Mahler's creations, and perhaps in all music."

My first encounter was in the early 70s with the recording by Janet Baker and Waldemar Kmentt (with Kubelik conducting the Bavarian Radio Symphony Orchestra). I still think it is one of the very best performances of Das Lied von der Erde.