Chile to Nanking: Bipolar Disorder & Lithium

Chile: Salar de Atacama & Bipolar Disorder.

Santiago, Chile was the starting point of our recent cruise round Cape Horn. We had a wonderful guide who took us from Santiago city to the Valparaiso port, where we boarded our cruise liner. She was infectiously enthusiastic. She told us that apart from copper, agricultural products and wine, Chile produced something that was very important for her brother.  He suffers from Trastorno Afectivo Bipolar (Bipolar Disorder) and Chile is the world’s largest producer of lithium.

Wikimedia Commons SalarDeatacamaFromChaxa.jpg

Lithium Bipolar and Nanking

May 09, 2008

Nanking Poster: THINKFilm

On July 2, 1996, the anniversary of Ernest Hemingway’s own suicide, Margaux Louise Hemingway, his grand daughter was found dead in her studio apartment in Santa Monica, California at age 41.


On November 9, 2004, Iris Chang (張純如), who was propelled into the limelight by her 1997 best-selling account of the Nanking Massacre “The Rape of Nanking: The Forgotten Holocaust of World War II”, committed suicide. Earlier she had a nervous breakdown and was said to be at the risk of developing Bipolar illness. She was on the mood stabilizer divalproex and Risperidone, an antipsychotic drug commonly used to control mania. There was a detailed report in San Francisco Chronicle.

My sentiments about the treatment of bipolar illness are expressed in The Cockroach Catcher:


“I am a traditionalist who believes that Lithium is still the drug of choice for Bipolar disorder. Tara’s mother was well for ten years. She was taking only Lithium and no other medication.”

The anti-suicidal effect of lithium has been confirmed by a number of recent studies in both the U.S. and in Europe.

According to the results of a population-based study published in the 2003 Sept. 17 issue of The Journal of the American Medical Association (JAMA. 2003;290:1467-1473, 1517-1519), Lithium reduced suicide rates of patients with bipolar disorder but divalproex did not. Risk of suicide death was about 2.5-fold higher with divalproex than with lithium.

Another paper published in 2005 (Arch Suicide Res. 2005;9(3):307-19) reviewed the existing evidence.

“The article reviews the existing evidence and the concept of the anti-suicidal effect of lithium long-term treatment in bipolar patients. The core studies supporting the concept of a suicide preventive effect of lithium in bipolar patients come from the international research group IGSLI, from Sweden, Italy, and recently also from the U.S. Patients on lithium possess an eight- time lower suicide risk than those off lithium. The anti-suicidal effect is not necessarily coupled to lithium's episode suppressing efficacy. The great number of lives potentially saved by lithium adds to the remarkable benefits of lithium in economical terms. The evidence that lithium can effectively reduce suicide risk has been integrated into modern algorithms in order to select the optimal maintenance therapy for an individual patient.”

The JAMA paper highlighted the declining use of lithium by psychiatrists in the United States and observed that:


"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.

Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?

Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium.

My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?


Bipolar disorder: divalproex er vs placebo
May 19, 2009


Just before I retired, it has become fashionable to use anticonvulsants as a mood stabiliser. Being a traditionalist, I felt then that the evidence was not clear and I tended to stick with the trusted lithium.

Well my doubts were confirmed:Journal of the American Academy of Child & Adolescent Psychiatry:
May 2009 - Volume 48 - Issue 5 - pp 519-532
doi: 10.1097/CHI.0b013e31819c55ec
New Research


A Double-Blind, Randomized, Placebo-Controlled Trial of Divalproex Extended-Release in the Treatment of Bipolar Disorder in Children and Adolescents
WAGNER, KAREN DINEEN M.D. et al.

Conclusions: The results of the study do not provide support for the use of divalproex ER in the treatment of youths with bipolar I disorder, mixed or manic state. Further controlled trials are required to confirm or refute the findings from this study. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(5):519-532.

An earlier Harvard study showed that Lithium reduced suicide risks by as much as 9 fold.

Lithium for Manic-Depressive Disorder (Bipolar Disorder):

Cade, John Frederick Joseph (1912 - 1980)

Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

Related Posts:
Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

Lithium Bipolar and Nanking
Bipolar Disorder in Children

Mahogony: Swietenia macrophylla

Mahogony (Caoba)

Swietenia macrophylla©Am Ang Zhang 2011

Seeds & Fruits of Swietenia macrophylla©Am Ang Zhang 2011

Caoba (Mahogany) - Swietenia Macrophylla

Mahogany is one of the world's premiere furniture hardwoods. Old growth trees can reach 40m in height and 1.5m in diameter. Its crown is rounded with extending branches. The wood is of excellent quality and used in fine furniture construction, woodworking, instruments, and architectural carpentry. The tree does not fare well in singles species plantations, due to attack by the shoot-borer (Hypsipyla grandella), which leaves the tree forked. Extensive pruning of young trees and planting in low concentrations are necessary.

The seeds may indeed offer some chemical molecule that may be useful for  treating diabetes.

Nature Posts:

It’s a Bird, a Reptile, a Mammal: It’s Platypus

ECOLOGY: First Bees, Now Bats. 

Paraguay: Technology Meets Ecology 

Hong Kong: Humpback Whale

Tasmania: Whales & Dolphins-Mother & Baby

Toucan: Darwin & Infra-red Technology

Cashew: Hard Nut!

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

Mystery Objects?

©Am Ang Zhang 2011

Clue: they are from a tree!!!

Answers via Email to Cockroachcatcher (at) gmail (dot) com.

Nature Posts:

It’s a Bird, a Reptile, a Mammal: It’s Platypus

ECOLOGY: First Bees, Now Bats. 

Paraguay: Technology Meets Ecology 

Hong Kong: Humpback Whale

Tasmania: Whales & Dolphins-Mother & Baby

Toucan: Darwin & Infra-red Technology

Cashew: Hard Nut!

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

Pride & World Class Medicine

Pride:

Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in Hong Kong or the rest of the commonwealth.

Why?

We provide World Class Medicine without trying. A quote from a fellow blogger, Dr. No.

What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.

Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals.

Can we continue to practise World Class Medicine even if we wanted to?

Here is a reprint:

Tuesday, May 24, 2011

NHS 1978: Hope, Faith & Supermarket

It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.

Patients or their relatives are used to trust the judgement of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.

David Cameron is no different and he has stated so on record.

I am not here to analyse his faith.

I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978:

The Mayo of the United Kingdom
The year was 1978 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.

Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom.  

Money or funding never came into it and we truly had a most integrated service. 
We used to practice real, good and economical medicine.

The unusual cases:

Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.

As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.

Supermarket:

Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.

But supermarkets can get things wrong too. In Spain after the Christmas of 2009 there were 4 million unsold hams.

©Am Ang Zhang 2010

Back to the patient:

Would my patient be dealt with in the same way in 2011?

     GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.

     Paediatrician to me: ? Psychosis or even Catatonia. 

           Seen same day and admitted to Paediatric Ward, DGH.

     Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.

     Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.

     Radiologist (Hospital & no India based): Tell tale tooth: Teratoma.

     Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.

     Patient unconscious and transferred to GOS on same day. Seen by various Professors.

     Patient later transferred to Queen’s Square (National Hospital for Nervous Diseases), 

             Seen by more Professors.

     Regained consciousness after 23 days.

     Eventually transferred back to local Hospital.

None of the Doctor to Doctor decisions need to be referred to managers.

We did not have Admission Avoidance then. 

How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.

The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.

Not to mention the operation etc. and the transfer to the Centres of excellence.

Here is an extract from my book The Cockroach Catcher:  Chapter 29 The Power of Prayers

          …………Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.

          Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.

          A good doctor is one who is not afraid to ask for help but he must also know where to ask.

          “Get me Great Ormond Street.”

          “I already did.”

          She is going to be a good doctor.

          “Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”

          Who needs consultants when juniors have that kind of network?  This girl will do well.

          “Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”

          “Yes, you do and thanks a lot.”

          I told mother that we were transferring her daughter to the best children’s hospital in England if not in the world and the doctor would stay with her in the ambulance. She would be fine.

“........Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome. 

"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."

David Cameron, if it was your plan not to have an integrated service, then there is not much we ordinary people could do except pray. If it was not your intention, then could you let us have an integrated service! That way you would not need many accountants and you will save money in doing so.


Just like Mayo Clinic:


“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”


But it is probably too late:

Pulse: GP consortium chairs are overwhelmingly opposed to any requirement to include hospital consultants on their boards, viewing it as a serious conflict of interest that would undermine the commissioning process, finds a Pulse survey.

King’s Fund: Million £ GP.

Sir Roger Boyle: 'It is horrific that the NHS's future is threatened'
NHS : Andrew Lansley, his Doctors and MPs.

See also:

The NHS wasted over £22 million on ISTC.

Teratoma: One Patient One Disease?

Leadership Lessons from Mayo Clinic
NHS Reform: Dr House & Integrated Service.

Osthmanthus

                                        Osthmanthus fragrans©Am Ang Zhang 2011

In The Cockroach Catcher:

The examinations were finally over and I was back home in the village that I had more or less abandoned for the most of the last five years.  I could not remember skies as bright and temperature as high, but it was a nice interlude from the mad preparations and the nerve-wracking examinations.

         We had an unusually dry May. The worst of the 1966 rains seemed like a distant memory and the crisp blue skies somehow made the heat tolerable. Even back then we seemed to be complaining of the ever rising temperatures in Hong Kong. The way we had been complaining about the rise every year, the temperature should really have reached 110 or more by now. The air-conditioning of offices, followed by that of private homes, necessarily led to the feeling of higher ambient temperatures in the streets.

         The garden was filled with the fragrance of the white tropical jasmines.  That fragrance is only second to that of the Osmanthus (Gui Hua)^[1], the flowers of which are tiny and appear more towards winter. We used to collect the Osmanthus flowers, dry them and use them to flavour our best teas.  Jasmine is more a late spring and summer flower and we had a big bush. By nightfall the cooling hill breeze brought with it occasional whiffs that made you want summer to last forever.

         It was a peculiar time for those of us who had lived in or around the university for the past five years.  We left home as school children and now we were back, and with any luck the majority of us would in a few weeks become fully fledged doctors ready to apply our skills.

         We had changed and the rest of the family probably not as much; and yet it was a time to savour – the last of the old before embarking on the new and brave.

         It was good to be reminded of the fine cooking back home, of an older and more sedate time when shopping was done twice a day for fresh ingredients.  This practice of course still continues in some parts of the world.

---

[1] Osmanthus (Gui Hua) - Osmanthus fragrans is a flower native to China that is valued for its delicate fruity-floral apricot aroma. It is especially valued as an additive for tea and other beverages in the Far East.

Read more:

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

Review on Amazon

Readers' views.

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

Royal Marsden & Rashomon Moments

Yesterday I posted about the various famous hospitals that may be for sale.

The Royal Marsden NHS Trust

William and Catherine meet patient Ellis Andrews at the new Oak Centre

for Children and Young People at the Royal Marsden Hospital. (Kirsty Wigglesworth - Reuters)

The first dedicated cancer hospital in the world, founded in 1851, is still the best. With the Institute of Cancer Research, the Royal Marsden is the largest comprehensive cancer centre in Europe, seeing more than 40,000 patients from the UK and abroad each year. It has the highest income from private patients of any hospital in Britain, testifying to its international reputation.

But then something I saw today gave me a Rashomon moment!

Telegraph:

A report by the Organisation for Economic Co-operation and Development (OECD) has found that, despite record spending on health care, cancer survival rates in Britain are worse than in Slovenia and the Czech Republic.

Survival rates for breast cancer, prostate cancer and cervical cancer were below the average for the 34 developed countries in the study.

Mr Lansley lays the blame for the poor performance on the previous government’s failure to make sure that extra investment in the NHS reached the front line. He claims patient care was ignored in favour of increased salaries and botched computer systems.

 Rashomon (1950) was made by one of Japan’s top directors Akira Kurosawa when Japan was just recovering from the Second World War. The director even had difficulty finding a horse for a crucial part of the film. I am sure many working in the field of mental health have heard of the Rashomon Effect, although many may not have had the chance to see the film. I used to keep a copy to loan to my staff. The Film, in black and white, was extremely well made and has been hailed by other film directors as near perfect. It just shows how lack of funding does not necessarily mean lack of quality.

Rashomon is fundamentally about truth and subjective truth. At the end of the film you are still not too sure but you have some idea. The story was simple enough:

“This landmark film is a brilliant exploration of truth and human weakness. It opens with a priest, a woodcutter, and a peasant taking refuge from a downpour beneath a ruined gate in 12th-century Japan. The priest and the woodcutter, each looking stricken, discuss the trial of a notorious bandit for rape and murder. As the retelling of the trial unfolds, the participants in the crime -- the bandit (Toshiro Mifune), the rape victim (Machiko Kyo), and the murdered man (Masayuki Mori) -- tell their plausible though completely incompatible versions of the story.”

(from the: New York Times Review: March 1, 2008)

The murdered man was in fact a Samurai who had the task to maintain the honour of the Samurai tradition, even as a ghost. This was to some the most shocking part.

We know people lie: but GHOSTS?

So what is going on? Best cancer hospital in Europe if not the world and the worst figure for cancer survival!

Is this just an excuse to sell off Royal Marsden.

Or did they treat too may foreigners so that the survival figures of their country was better than ours.

If the Royal Marsden cannot help our Cancer doctors, why are we treating so many Medical Tourists?

Or is this the future, or should we become Medical Tourists to other countries.

With the way the government is charging ahead with the Reform, it is difficult to tell who might be telling the truth.

Remember: even ghosts lie!

Rashomon has remained one of the top hundred films ever made. The ending at least gave the poor monk, who probably would have committed suicide or would nowadays be reaching for Prozac or other SSRIs, some hope.

A baby was heard crying. It was an abandoned baby. The woodcutter, who was poverty stricken, decided to adopt and look after this poor baby. He had six children – one more mouth would hardly make much difference.

There is hope in the world still.