First Do No Harm: Antipsychotics-Really?

Primum non nocere: 

I was quoted in HuffPo as far back as 2008: Obama Interviews the Medical Blogosphere on Healthcare Reform.

Cockroach Catcher: I have come to the rather unpleasant conclusion myself that parents nowadays may not have been told the full story about Antipsychotics. How many of them have been made aware of their range of side effects when it is suggested that their very young child should go on such medication?

The Cockroach Catcher & Other Bloggers in The Guardian etc.

Here is a reprint: 

“First do no harm” has always been attributed to Hippocrates. In his Epidemics, Bk. I, Sect. XI, he advised, "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm."
As I mentioned in my last post, schizophrenia is mercifully rare in children under 18. The best estimate is about 1 in 40,000, as opposed to 1 in 100 in adults.

                                   Australia & Cade: Lithium & Toxicity.

I did of course see a few full blown Manic Depressives (Bipolar Disorder) in children between eleven and eighteen - single digit figure for a career in Child Psychiatry spanning 30 years must mean it is rare. With such cases, it is more important to use the right mood stabiliser and with my patients I prescribed mainly lithium.

It is now fashionable for Child Psychiatrists to diagnose Bipolar Disorder and treat with Atypical Antipsychotics, instead of mood stabilizers. Recent figures show that only a third of these so called Bipolars are prescribed mood stabilisers.

I have come to the rather unpleasant conclusion myself that parents nowadays may not have been told the full story about Antipsychotics. How many of them have been made aware of the range of side effects of Antipsychotics when it is suggested that their very young child should go on such medication? How many of them have been made aware that taking an Antipsychotic may in fact induce psychosis, a still disputed finding but one that should be a consideration? (For the latest data on side effects, see below.)

No parent would question an exotic diagnosis that absolves them of any responsibility, and a treatment that uses a fancy new medication. After all Havard is a good name and anything advocated by a psychiatrist from Harvard must be O.K.

“Branding” has inadvertently crept into child Psychiatry.

We bloggers who dare to reveal the hidden agenda cannot be the favourite of the likes of those who push the “new” treatments. So be it.

It is a challenge to the modern day Child Psychiatrist to suggest that their patient’s behaviour problem is caused by faulty parenting or family dynamics. To even suggest that is sure to bring on complaints and possibly litigations. In countries where insurers hold the purse string, writing a prescription saves the doctor valuable time. Psychotherapy or behaviour therapy costs more.

Even before the arrival of the newer Atypical Antipsychotics, their predecessors were used for behaviour control, in Russia and elsewhere. Why else should it be known as chemical lobotomy?

Many doctors feel more comfortable in prescribing Atypicals because of their purportedly better side-effect profiles. I do not mean to criticise the majority of busy Child Psychiatrists, for we have a long tradition of relying on publications of esteemed colleagues around the world.

Unfortunately, the big Pharmaceuticals too know of our trust in our colleagues, and over an extended period of time have engineered publications of favourable papers speaking for licensed and more frequently off-label use of the new drugs, especially Antipsychotics. It should not take a genius to work out that psychosis is a chronic condition that requires life long treatment, thus guaranteeing future income for pharmaceuticals.

There is also another aspect. What if the actual diagnosis of psychosis is suspect? We are entering a new era, when medical ethics seem not so important. I am not alone in doubting the validity of some of the diagnosis of childhood Bipolar Disorder. To put it plainly, the two thirds of the so called Bipolars may be just having behaviour problems and Antipsychotics are prescribed simply to control their behaviour.

The side effects of the newer Antipsychotics on children and young people

For the latest most comprehensive data on side effects of the newer Antipsychotics on children and young people we turn to an earlier article in The USA Today:New antipsychotic drugs carry risks for children
by Marilyn Elias 5/2/2006 USA Today

The USA TODAY's analysis focused on 1,373 cases received by the FDA from 2000 to 2004 in which one of the six atypical anti-psychotic drugs was coded as the primary suspect. These cases were used to count symptoms, diagnoses and deaths.

To learn about patterns in atypical use, USA TODAY asked Medco Health Solutions, a prescription-drug benefit manufacturer, to query its member database.

• A condition called dystonia was most often cited as an "adverse event" suffered by someone taking one of the drugs, with 103 reports. Dystonia produces involuntary, often painful muscle contractions.

• Tremors, weight gain and sedation often were cited, along with neurological effects such as Tardive Dyskinesia (TD). Symptoms of TD can vary from slight twitching to full-blown jerking of the body. (No actual figure was quoted.)

• A condition called neuroleptic malignant syndrome, with 41 pediatric cases over the five years, was the most troubling effect listed, says child psychiatrist Joseph Penn of Bradley Hospital and Brown University School of Medicine. It is life-threatening and can kill within 24 hours of diagnosis. It's been linked to drugs that act on the brain's dopamine receptors, which would include the atypicals, Penn says.

The 45 deaths
Among the 45 pediatric deaths in which atypicals were the primary suspect, at least six were related to diabetes — atypicals carry warnings that the drugs may increase the risk of high blood sugar and diabetes. Other causes of death ranged from heart and pulmonary problems to suicide, choking and liver failure.

There is anecdotal evidence that even Aripiprazole (Abilify), the new Third Generation antipsychotic, still causes weight gain and quite severe extrapyramidal side effects.

There we have it.

There is often an assurance that the side effect listed on the Information Sheet is rare and it is a natural defence of most of us that somehow, bad things only happen to others.

Next time your Child Psychiatrist said, “Antipsychotics.”

I suggest that your answer should be: “Really?”

Links: Reidbord's Reflections----Abilify for depression?

“Researchers Fail to Reveal Full Drug Pay”

Grand Round (5) 12: SHARPBRAINS.
HOT NEWS:The Huffington Post

New York Marathon: Autumn Colours & Drowning!

The views along the New York Marathon route will be spectacular!

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

But please do not overdo the hydration. It is more dangerous than you think!

It is amazing that after over 40 years they are just beginning to realise that. Research on Marathon runners showed that many had low sodium, a sure sign of over-hydration. 

Marathons:

Marathons are often sponsored by bottled water companies and their main aim is to let the public get he image of runners with bottles of their water.

New England Journal of Medicine:

Of 766 runners enrolled, 488 runners (64 percent) provided a usable blood sample at the finish line. Thirteen percent had hyponatremia (a serum sodium concentration of 135 mmol per liter or less); 0.6 percent had critical hyponatremia (120 mmol per liter or less). On univariate analyses,hyponatremia was associated with substantial weight gain, consumption of more than 3 liters of fluids during the race, consumption of fluids every mile, a racing time of >4:00 hours, female sex, and low body-mass index. 

Modern marathon advice is to up the intake of salty food in the pre-race preparation. When dehydrated taking salt and water alone will not work: see below. 

Watermelon:

When I was growing up in the tropics, one of the fruits we were given after a long walk was watermelon with salt sprinkled on it. This was long before the current understanding of Oral Rehydration. My parents were careful to warn us then that just drinking water is no good. Why? They did not know!

Now I do but watermelon is still my favourite and in the tropics you can buy fresh water melon juice in the summer.

Chinese farm workers:

It has to be said that the diet of many Chinese farm workers was generally higher in sodium, from dried salted fish and vegetables. It is likely that the serum sodium of many such workers would have been at the high end of the normal range. Modern advice on cutting down sodium often does not take account of sweating in hot countries. A friend of mine with hypertension had an epileptic seizure when he went to work in Singapore. Luckily the medical services there were alert to the problem and he survived. He was on a low sodium diet and on diuretics amongst other medications.

Free water:

I also remember one very hot August day when we hiked down Grand Canyon to Angel Point. There were warnings everywhere of the risks and even fatalities on such walks. The National Park did have clean drinking water taps along the way and one particular girl overdid the drinking. She had a narrow escape, as the Ranger fortunately knew a thing or two about rehydration. He put some salt in a can of Sprite and reverted a potentially serious situation.

Thailand:

The first time we went to Thailand the most amazing dip was simply a bowl of sugar that has been mixed with salt and some chopped chilies for good measure. This dip was used for serving unripe mangoes, papayas, guavas and other local fruits, and gave me a taste sensation that was unforgettable. Same principle as ORT.

In Thailand, workers in rice fields, fruit orchards and vegetable patches manage to survive temperatures of over 100°F.

Golf:

The Cockroach Catcher plays golf in his holiday home in the tropics and he uses his own mix of diluted Pomegranate juice and a pinch of salt for Oral rehydration. I would never drink plain water alone.  This is one time where a bit of sugar helped the body to absorb salt and fruit juice is higher in potassium.

When the first public golf course was opened on the beautiful island of Kau Sai Chau in Hong Kong, drinking water was provided along the course. One player drank so much that he nearly died of water intoxication (result of drinking excessive amounts of plain water which causes a low concentration of sodium in the blood leading to amongst other problems: ‘brain’ swelling---cerebral oedema).

Cocktails:

It seems wrong to recommend alcohol but has anyone worked out why cocktails from hot countries would be served with the rim of the glass covered in salt!!!

Drowning:

I remember one of my professors telling us: the body survives dehydration much better than drowning. How right he was, as water intoxication is in a sense a kind of drowning.

Cholera:

I well remember Hong Kong’s cholera epidemic in 1961 and the major cause of death was the rapid loss of fluid due to a specific secretive action of the cholera germ. Patients could die in a matter of hours. The medical profession has long been of the strong belief that Intravenous Fluid (IV Fluid) is the only answer. In that situation, the patient is in shock and to find a vein means a cut-down: literally cutting through the skin to find one. It is a messy business as the patient is violently pumping out fluid in the most horrendous fashion.

Johns Hopkins established a centre in Calcutta in the 1960s to study precisely a better way to replenish the fluid. IV fluids were expensive to manufacture and required medical personnel to administer. Their Clinicians sought help from basic physiology and carried out the first carefully controlled study which showed that intestinal perfusion of cholera patients with saline solutions containing glucose strikingly reduced fluid loss. Put simply, the patients could just drink a glucose and salt solution and the glucose would allow the salt to be piggy backed and absorbed, thus sparing the need to use IV fluids.

“……These compelling findings, however, did not convince the medical establishment, who remained sceptical that such a simple therapy could substitute for traditional intravenous fluid replacement in severely stricken patients under epidemic conditions in the field.”

The World had to wait for a war, this time in Pakistan, when Bangladesh fought for its independence in 1971 and 9 million refugees poured into India and with them cholera. When IV saline treatment was exhausted, Dr Mahalanabis, who had worked at the Johns Hopkins Centre in Calcutta, took the gamble and decided to prescribe a simple solution of glucose and salt in the right proportion for the friends and relatives of the cholera patients, thus saving at least 3.5 million people.  Since that time it was estimated that such a simple and cheap remedy saved at least 40 million more lives.

No wonder The Lancet hailed the development of oral rehydration therapy (ORT) as "the most important medical discovery of the 20th century".

The scientists at Johns Hopkins and Dr Mahalanabis received the Pollin Prize of $100,000 in 2002.

“Ideas without precedent are generally looked upon with disfavor and men are shocked if their conceptions of an orderly world are challenged.” 

Bretz, J Harlen 1928. 

Ancient Remedy: Modern Outlook

Chinese farm workers have always worked in the heat of the fields but heat stroke seems to be rather uncommon. I wonder if our dried preserved plum has something to do with this. 

The Chinese preserved plum is said to quench thirst, and as a child I could never really understand the rationale. Now I know. It is preserved with salt, sugar and herbs such as licorice by a complex process. If you suck one of these plums and then drink water, you have the combination of sugar and salt that carries the salt back into the system. Why plums? Like a lot of fruits, plums contain potassium. This is oral rehydration therapy (ORT) the ancient Chinese way, before the science of modern ORT.


It has to be said that the diet of many such Chinese workers was generally higher in sodium, from dried salted fish and vegetables. It is likely that the serum sodium of many such workers would have been at the high end of the normal range. Modern advice on cutting down sodium often does not take account of sweating in hot countries. A friend of mine with hypertension had an epileptic seizure when he went to work in Singapore. Luckily the medical services there were alert to the problem and he survived. He was on a low sodium diet and on diuretics amongst other medications.

I also remember one very hot August day when we hiked down Grand Canyon to Angel Point. There were warnings everywhere of the risks and even fatalities on such walks. The National Park did have clean drinking water taps along the way and one particular girl overdid the drinking. She had a narrow escape, as the Ranger fortunately knew a thing or two about rehydration. He put some salt in a can of Sprite and reverted a potentially serious situation.

When the first public golf course was opened on the beautiful island of Kau Sai Chau in Hong Kong, drinking water was provided along the course. One player drank so much that he nearly died of water intoxication (result of drinking excessive amounts of plain water which causes a low concentration of sodium in the blood leading to amongst other problems: ‘brain’ swelling---cerebral oedema). Marathon runners are at greater risk than most as reported by the New England Medical Journal. There have been other notable cases of water intoxication elsewhere. I remember one of my professors telling us: the body survives dehydration much better than drowning. How right he was, as water intoxication is in a sense a kind of drowning.

The first time we went to Thailand the most amazing dip was simply a bowl of sugar that has been mixed with salt and some chopped chilies for good measure. This dip was used for serving unripe mangoes, papayas, guavas and other local fruits, and gave me a taste sensation that was unforgettable. Same principle as ORT.

In Thailand, workers in rice fields, fruit orchards and vegetable patches manage to survive temperatures of over 100°F.

On the other hand, Chinese dried plums are such neat, little, easy to carry things. Perhaps we should try to popularize this ancient remedy for the benefit of all. Be warned, only those made with sugar and salt work, not the ones with artificial sweeteners.

Latest:

Loquat, Winter Melon & Sapote

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 18^th 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.

Easter Passion: Bach, Beethoven and Mahler

Janet Baker
Das Lied von der Erde
Hong Kong
Literary Metamorphosis in Das Lied von der Erde

Proms: Mahler & Nature

Easter Passion: Bach, Beethoven and Mahler

The Cockroach Catcher: Berlin Wall, Appassionata & The Lives Of OthersS