Wednesday, February 10, 2021

Madness and Ethnicity: Part B


          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 the ETHNIC population has twice as high a rate for developing psychosis than white Caucasians.  Why should that be? 

          Could it be that doctors and especially psychiatrists in England are reluctant to diagnose the most serious of mental illness in the white population, but not so for the ethnic groups?  Could it be that ethnic people by virtue of their migratorial history inadvertently put their descendants at risk? Could the rate of drug abuse be a contributory factor?

          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.

         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 for a holiday with his grandmother. After the holiday he would start work with one of the airport caterers which already employed both his parents.
         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?

         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. The passport had a different forename and a keen eyed staff at check-in spotted the anomaly. He looked much too young anyhow, but he was well dressed in a brand new Armani outfit and Gucci shoes carrying a new Apple. He looked like a young executive. He became rather abusive saying he was a CEO of a big company and he was going to sue.
         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’s family was from Morocco, but he was born and brought up in England. He had been acting strange for some time and the last straw came when his mother tried to stop him going to this “no good” place in the East End of London. He went most Fridays, not returning until late Saturday afternoon. His mother had no idea where he slept on those Friday nights and decided one day to stop him. He attacked her and the two older sisters called the police. At the time father was in Morocco seeing to some family matter.
         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. They seemed to be afraid to say much, which I later worked out to be very much a cultural thing. Women cooked and did the chores and the rest was left to the men. They could not even tell me what the family business was.
         Yosef managed to run away from our unit the following Friday and was brought back in the early hours of Saturday by the London police, who had a call from the club. He was too wild for the club to handle. When he started arguing with the bouncers, they called the police. He still had the hospital band on his wrist and that was why the Police brought him back.
         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. He was not too surprised. His own uncle had been in a mental hospital in Morocco for years and he had just gone to Morocco to sign the papers for his younger brother’s admission to the same hospital as his uncle’s. Schizophrenia.

         Martina was already at the adolescent inpatient unit when I arrived. She was supposed to be schizophrenic. The family were refugees from Sudan. They were a small Sect of Catholics that were said to be persecuted.
         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. to carry out the first research into Clozapine.
         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. before it was approved by the FDA.  How could it have been done?
         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 there were two eleven year olds on Clozapine. Black ethnic groups are often prescribed a higher dose and very often with another antipsychotic. Asians have a slightly higher incidence of blood problem.
         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's Professor John McGrath, who led the research team, said the 21-page-report was the biggest and most comprehensive survey of schizophrenia rates around the globe.
         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.”

Madness and Ethnicity: Part A

No comments: