Anorexia Nervosa: Olanzapine (Zyprexa)-Veganism

Girl in a Chemise circa 1905 Pablo Picasso (1881-1973) Tate Collection

Mental Nurse Zarathustra recently had two important posts on Anorexia Nervosa: One on the use of Olanzapine (Zyprexa) and the other on Veganism.

Mental Nurse: Anorexia and Olanzapine

……..Here’s the thing though. As we know, Olanzapine has a fair few side effects. Two of these are:
1. It makes you sleep until doomsday.
2. It makes you so hungry you eat the contents of the fridge.
Could these side effects be the reason for the improvement in these anorexic patients, rather than any antipsychotic effect? God no, says our consultant. The Olanzapine is being used to reduce the levels of intrusive anorexic thoughts that are causing distress to the patient. It’s being used as an antipsychotic, not simply to make people drowsy and hungry.
Though the burning question is, if that’s the case, why isn’t he keen to try, say, Aripiprazole? You know, the antipsychotic that isn’t supposed to make you fat and sleepy. Admittedly Aripiprazole is also a bloody awful antipsychotic that rarely seems to reduce psychosis, but that hasn’t stopped him prescribing it en masse to his psychotic patients.

Read the full post here.

In the opening chapter of The Cockroach Catcher:

“’It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.’

“Those were more or less the words said at the transfer meeting by the nurse from the private hospital where Candy had been for the past eighteen months. She had been compulsorily detained twice and she had been put on Olanzapine. Olanzapine is one of a new group of drugs licensed for Schizophrenia and has been found to induce a voracious appetite especially the bingeing of carbohydrates. Some psychiatrists have started using it for this specific effect. In Candy’s case she managed to fight the biochemical effect of Olanzapine.”

You can read the complete chapter here.

At least in my days there was still honesty and most Child Psychiatrists who used to prescribe Olanzapine (Zyprexa) to Anorectics did not pretend to be using its main effect.

Now that there is EBM, it is well known that the major Pharmaceuticals ghost write articles in pushing for off-label use by doctors. Because of medical confidentiality issues, it is difficult to find out if the so called patients were genuine.

I am amazed that given Olanzapine (Zyprexa) has been in so much trouble in the US, UK and Europe still have not done much to curb its off-label use.

Perhaps one should not forget Lena Zavaroni, former child singing prodigy who died aged 35, following a 22-year battle with anorexia. She had various drug treatments and ECT, and eventually a neuro-surgical procedure that was not a lobotomy according to the hospital but was meant as a “cure” for her depression. She died shortly after of unrelated pneumonia. That was in 1999. It was before Dr Crippen, Jobbing Doctor, Angus Dei and other blogs. Otherwise the neurosurgeon Brian Simpson might have a lot more explaining to do. Anyway, neurosurgery was not part of NICE Guideline on Treatment of Depression.

Have we really learned anything about the treatment of Anorexia in the ten years since her death? Why are we going the same way, only the drug is different!

Mental Nurse: Case Study Vignette - Anorexia and Veganism

“…….Kate has announced that she’s becoming a vegan. She now insists that she won’t eat any meat, fish, dairy or poultry products, and has taken out a membership to PETA. She states that this is because vegan diets are “healthier” and because she is ethically opposed to the use of animal products.

The multidisciplinary team, on the other hand, believe that she is doing this because she wants to restrict her intake of carbohydrates, fat and protein, and also because of anorexic thinking patterns that involve the demonisation of certain food groups.

The dietitian states that a vegan diet will make it much more difficult for the ward to refeed Kate and bring her BMI back up to a safer level. We could get around this by giving Kate nutritional supplements. However, while this would help her to gain weight, it wouldn’t do anything to treat the anorexic thinking patterns. Indeed, arguably we’d be running a risk of reinforcing them by colluding in the avoidance of these food groups.

So, is it ethical to compel Kate to eat animal products?”

Zarathustra talked about the role of the multidisciplinary team and of course its collective view. In my opinion, contrary to widely held views, a good Adolescent In-patient Unit dealing with Anorexia Nervosa patients needs to be able to accommodate and hold opposing views in its team, just like a well functioning family. These patients themselves more often than not come from families that try to avoid conflicts at all costs.

Conflict containment that is more or less non-existent in the families these patients come from.

As to the vegan diet, it is not impossible to have a vegan diet that has high calorific value. That, the dietician should know. I have seen many vegans in the Caribbean becoming quite obese from the high yam and sweet potato diet. (There you go: these are two food items that can be part of a vegan diet!)

The trick with Anorexia Nervosa is you need to be inventive and inventive every single day. Think Jay Haley, think Hobson’s choice. The patient can still be a vegan. She does not need any drugs. She does not need any ECT or neurosurgical procedure.

In the end, Anorexia Nervosa could be a rewarding condition to deal with:

“If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative. Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.” The Cockroach Catcher

Have a good fight!!!

Anorexia Nervosa: What If!

A Brief History of Time: Anorexia Nervosa

Anorexia Nervosa: a cult?

A Brief History Of Time: Food and Medicine

In Chinese culture, food is important in the promotion of good health and much has been documented in Traditional Chinese Medicine textbooks. This knowledge, generated by several thousand years of experience by keen observers, does not sit nicely with modern science especially that of Western medical science. There are believers and non-believers especially. It would be foolish to fully endorse everything, and yet it would be even worse to reject all that it could bring.

On the other hand, in recent times, illegal mixing of western medicine into so called natural products has given such natural remedies a very bad name. The FDA has yet to deal with the large number of slimming preparations that contain modern slimming drugs.

Not all things natural are safe either, and even the ever so popular glucosamine has its problems.

There is so much that could be learned from experience, as shown by the hands only CPR which can be traced to China over two thousand years ago.

Many Chinese today believe in traditional ways: we know it works, we just may not yet know how it works.

There may of course be a more sinister explanation to all the mystique. Early rulers of China and some later ones realised that in order to govern you must not educate your people. So rituals and superstition were introduced instead to keep people from harming themselves. After all, people were needed to serve their rulers. Even today certain knowledge is not widely disseminated or shared, and worse still, the wrong knowledge is disseminated.

The Cockroach Catcher has a rule about any food product: if it claims to deal with all the most common illnesses, one should become suspicious. On my travels I often come across claims of natural substances that manage to deal with high cholesterol, high blood sugar, high blood pressure, and Alzheimer for good measure, all at the same time.

CAVEAT EMPTOR

It was just a little over a year ago I started blogging after my book The Cockroach Catcher was published. I would like to indulge in a bit of nostalgia and quote you some passages from the book and a few of my favourite postings on Food and Medicine.

From The Cockroach Catcher:

“The garden was filled with the fragrance of the white tropical jasmines. That fragrance is only second to that of the Osmanthus (Gui Hua), 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.”

One of the earlier postings was indeed a tribute to what the Cockroach Catcher’s mother taught him:

Antioxidants and cooking 31st January, 2008:

”The Cockroach Catcher however goes by what his mother taught him from an early age. In Chinese cuisine, soup is often seen as an important part of a meal. The process of slowly cooking various ingredients is part and partial of that of producing something that is nutritious, delicious and revitalizing. To save energy, we invested in a highly efficient ‘shuttle chef’, which is basically a double pot, consisting of a smaller inner pot and a larger outer insulating chamber. You first of all heat up the food in the smaller pot, and then seal it in its insulating outer chamber to let the cooking process continue in a slow fashion for a few hours or over-night. Another doctor friend of ours discovered that she could achieve the same slow cooking by putting an ordinary pot into a cool box!

"Imagine the disappointment when we first tried to make consommé with good quality meat and found an ever so slight rancidness setting in over-night. Something was not quite right. To solve this problem, we had to go back to basics. We tried adding one more traditional ingredient: gouqizi (derived from Lycium). Eureka! The presence of the antioxidant meant no more rancidness whatsoever. The French always knew and used red wine in their famous Boeuf Bourguignon and Coq au Vin.”

Chinese New Year and the Goose 9th February, 2008: Then the posting on goose drew some attention from Foodie blogs and my wife was invited to post the recipe on: World Foodie Guide 21st February, 2008:





How To Make Chinese Teochiu Goose. Goose fat is the new ‘black’ and was sold out at Christmas time a couple of years back in England.

Loquat and Medicine: 16th May, 2008

Loquat (Eriobotrya japonica)

A good friend who read my book The Cockroach Catcher said she wished I had written a lot more about the village and I posted:

“As a result of modernization, in one generation we have seen the passing of something that provided us with a uniquely enchanting experience that no modern developments with their charming 'cool' shops can ever hope to match. Are we being over-romantic to ignore the hardship many of us put up with during that period, not to mention the struggles of many of our parents to provide for us? Have we forgotten the leaking roof, the rudimentary toilet facilities and our constant battle with cockroaches and other pests, not to mention poisonous snakes and the like? I have to say that on balance, it was still a sweet memory. Who can fail to remember the constant supply of fresh fruits and vegetables from our own land? The chickens we reared and their eggs poultry were just out of this world. I have conversed with a few friends and relatives about this, and they all seem to agree.”

You can read all about it here.


The Cockroach Catcher still marvels at some of the ancient remedies from a modern scientific standpoint as in: Ancient Remedy: Modern Outlook

Sometimes health claims rebound in a peculiar way and my posting on Ribena has turned out to be a great favourite with readers.

Finally, be wary of outrageous claims and take everything in moderation.

“Over time health benefits have been associated with red wine, olive oil, chocolate, almonds, pomegranate, blueberry, green tea and coffee. The Cockroach Catcher is skeptical of extreme claims, but for the record I do take all the items mentioned above, in moderation. It is indeed more important that you should enjoy what you eat and drink and not just what researchers tell you, and in moderation.”

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Coffee in Panama – Faking Is Not All Bad

In my earlier blog Anhinga in Costa Rica - Faking Is Not All Bad I reflected on how in my child psychiatric practice, I came across a number of children who seemed to have made good use of faking. Indeed I came to the conclusion that faking might not be all bad.

Panama has been associated with some fabricated plots. There were the John Le Carre book The Tailor of Panama that was turned into a film, the location shoot of the Quantum of Solace (in Panama, doubling as a country in South America), and the Canoeist faking death, just to mention a few.

Panama ©2009 Am Ang Zhang

Then there was the coffee scandal.

In 1996 in California, a certain  Michel Norton, owner of Kona Kai Coffee was sentenced to 30 months in prison. Apparently for an extended period of time (some reckoned a decade may not be an over estimate), cheaper and “lower grade” Panamanian and Costa Rican coffee were used to pass off as “Pure Kona Coffee”.

Cheaper, certainly, as you would not otherwise be doing it. But, INFERIOR? I think many would certainly dispute that. I do not think you can really use an inferior product to pass off as something superior and fool people for long.

So the Ambassador of Panama in Washington D.C. wrote to the New York Times:

To the Editor:
I read with amusement about the indictment of a coffee supplier on selling fraudulently marked beans to retailers (news article, Nov. 13).
Without making light of the charges, I am pleased that the coffee buyer for Peet's Coffee and Tea is uncertain that he can tell the difference between the ''cheaper'' Panamanian beans allegedly substituted for the more expensive Kona.
Panama's coffee is among the world's best. In fact, members of my staff have seen Panamanian beans for sale at high-end coffeehouses for little less than Kona. Perhaps we can arrange a taste test of Kona and Panamanian coffee for the sellers mentioned in the article. I am sure that no one will be more pleased with the results than my native coffee growers.

EDUARDO MORGAN
Ambassador of Panama, Washington

The Cockroach Catcher was fortunate enough to have visited both Costa Rica and Panama. Costa Rica coffee is quite well known but few people realise that Panama produces coffee. I was determined to find out more about coffee grown in Panama.

Plants need to struggle to produce the kind of ‘poison’ against diseases, and coffee apparently is no different. This is well known for wine: vines grown in abundant sunshine may produce wine with a high alcohol content but does not produce enough of the ‘poison’ that humans love — we call the ‘poison’----- anti-oxidants.

Now even for the wonder malaria drug, Artemisinin, the plant Artemisia annua if cultivated with good fertilisers will not produce the anti-malaria ingredient at all.

Yes, plants need to struggle. Shade, and a misty atmosphere all work together to help the coffee shrubs struggle and help certain varieties of to develop health conferring properties, although the yield is lower than if you apply fertilisers and cut away the shading trees.

Misty Boquete, Panama ©2009 Am Ang Zhang Berry picking ©2009 Am Ang Zhang

  My friend's coffee©2012 Am Ang Zhang

Happily the shading trees provide a sanctuary for birds. Panama is famous for the number of bird species both resident and migrating, and for a number of years, has achieved the highest Christmas bird count as audited by the Audubon Society. A traditional coffee plantation (known as Finca) can play host to nearly 280 varieties of birds.

Well, call it chance or luck, someone bought a Finca in Boquete in Panama. Unfortunately a fungal blight wiped out most of the coffee plants that were originally there. A quick research by the owner showed that one variety of coffee called by the unlikely name of Geisha is resistant to the fungal disease. Remember, it can probably produce the ‘poison’. This tree grows taller, yield is lower but the coffee it produces is just wonderful.

In the last few years, in international cupping competitions, this coffee came first. Yes: FIRST.

The name: La Esmeralda Especial, from the Hacienda Plantation.

But wait for this, in 2007 the price fetched at auction was US$130 per pound. That is expensive. Or is it? With espresso extraction you can get 40 cups to the pound. Is that not under $4 per cup, and since you can extract a second cup – water based “decaf”, is that not under $2 per cup? Here is the latest tasting note.

As I was preparing this blog, news came about:

Coffee Linked to Lower Dementia Risk
Over time health benefits have been associated with red wine, olive oil, chocolate, almonds, pomegranate, blueberry, green tea and coffee. The Cockroach Catcher is sceptical of extreme claims, but for the record I do take all the items mentioned above, in moderation. It is indeed more important that you should enjoy what you eat and drink and not just what researchers tell you, and in moderation.

Next time in Trivial Pursuit you will know the answers to: What is the best coffee in the world? What country has the highest count of birds at Christmas?

Birding in Boquete, Panama ©2009 Am Ang Zhang

Happy cupping.

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Mercury in High Fructose Corn Syrup ---Autism: What If!

The Cockroach Catcher was an accidental resident of Barbados for nearly two years and saw the tail end of the sugar cane industry there. Alas, high labour cost and the general switch over to sweetening with High Fructose Corn Syrup (HFCS) means that cane sugar produced in the traditional manner can only remain as a novelty item that is sold in souvenir shops at a high price and probably never consumed by the purchaser.

What is little known is that High Fructose Corn Syrup is produced by a complex chemical process involving enzymes and chemicals such as caustic soda and hydrochloric acid.

In the Washington Post yesterday:

Study Finds High-Fructose Corn Syrup Contains Mercury

“Almost half of tested samples of commercial high-fructose corn syrup (HFCS) contained mercury, which was also found in nearly a third of 55 popular brand-name food and beverage products where HFCS is the first- or second-highest labeled ingredient, according to two new U.S. studies.

“HFCS has replaced sugar as the sweetener in many beverages and foods such as breads, cereals, breakfast bars, lunch meats, yogurts, soups and condiments. On average, Americans consume about 12 teaspoons per day of HFCS, but teens and other high consumers can take in 80 percent more HFCS than average.

"Mercury is toxic in all its forms. Given how much high-fructose corn syrup is consumed by children, it could be a significant additional source of mercury never before considered. We are calling for immediate changes by industry and the [U.S. Food and Drug Administration-FDA] to help stop this avoidable mercury contamination of the food supply," the Institute for Agriculture and Trade Policy's Dr. David Wallinga, a co-author of both studies, said in a prepared statement.

“In the first study, published in current issue of Environmental Health ,researchers found detectable levels of mercury in nine of 20 samples of commercial HFCS.

“And in the second study, the Institute for Agriculture and Trade Policy (IATP), a non-profit watchdog group, found that nearly one in three of 55 brand-name foods contained mercury. The chemical was found most commonly in HFCS-containing dairy products, dressings and condiments.” The Washington Post reported.

Abstract here; PDF of the full text here.

This is serious matter, considering that most food items sold in the US that are vaguely sweet contain HFCS, from so called fruit juices to tomato ketchups to health granola bars, jams and cereals, not to mention soda drinks.

The frightening part of the story was that the FDA knew about this since 2005, yes 2005.

One of the lead authors, Renee Dufault, was working for the FDA when she reported her findings that mercury was detected in 45% of HFCS products. No explanation was given as to why the FDA kept quiet. In March 2008 she retired from the FDA and decided to conduct further research for Environmental Health, using fresh samples randomly taken off shelves in retail shops in the latter part of 2008.

The discovery of the complex chemical process for converting corn starch into HFCS came at a time when corn based oil product was in commercial decline because of health concerns raised. Despite the highly complicated process involving three enzymes (believed to be genetically modified and therefore highly stable) , the cost of producing HFCS is still much lower than that of producing sugar from cane.


Where did the mercury come from?

The Institute for Agriculture & Trade Policy (IATP) report is very educational and is worth a read here.

I quote from the Executive Summary:

“We live in a truly global food system. Our system typically is geared more toward producing lots of cheap calories, and then selling those calories to consumers, than it is toward meeting other goals like reducing fossil fuel use or producing food that is healthy.

“In stark relief, new science shows just how blind to healthfulness some processed food makers have been. Just published online in the journal, Environmental Health, is a science commentary reporting that mercury was found in 9 of 20 samples of commercial high fructose corn syrup (HFCS), a common sweetener of foods and beverages. The HFCS came from three different manufacturers.

“Mercury is a potent brain toxin that we know accumulates in fish and seafood, although diet is not the only route by which we are exposed. When babies are exposed to elevated mercury in the womb, their brains may develop abnormally, impairing learning abilities and reducing IQ. For these youngest children, the science increasingly suggests there may be no “safe” level of exposure to mercury. And yet for decades an increasingly common ingredient in processed foods, HFCS, has been made using mercury-grade caustic soda.”

“……. In fact, we detected mercury in nearly one in three of the 55 HFCS-containing food products we tested. They include some of the most recognizable brands on supermarket shelves: Quaker, Hunt’s, Manwich, Hershey’s, Smucker’s, Kraft, Nutri-Grain and Yoplait.

"No mercury was detected in the majority of beverages tested. That may be important since sweetened beverages are one of the biggest sources of HFCS in our diets.

"On the other hand, mercury was found at levels several times higher than the lowest detectable limits in some snack bars, barbecue sauce, sloppy joe mix, yogurt and chocolate syrup.”…..

Caustic soda and hydrochloric acid can be manufactured cheaply from sea water using an electrochemical process aided by mercury cells.

A longtime enigma of these plants has been their “missing mercury.” The nine mercury cell plants operating in 2003 reported consuming 38 tons of mercury, but emitting only eight tons into the environment. What happened to the other 30 tons? The plants could not account for that. This month’s Environmental Health study suggests that the missing tons of mercury may have ended up as impurities in the plants’ products such as caustic soda that are then added to the food supply.

It is scientifically possible to use a non-mercury based method and in fact one senator tried to introduce legislation some time back to force the industry to stop using the mercury method. He unfortunately failed.

That senator happened to be Barack Obama, now president of the United States. Could that be why the papers were published soon after his inauguration? I will leave it to you to draw your own conclusion.

In the report it was pointed out that despite major concerns over the years that fructose, being only metabolised by the liver, may have serious health implications, HFCS is favoured by manufacturers because the products sweetened by HFCS have a long shelf life. Could this in fact be due to the preserving property of the mercury? Even microbes do not like mercury!

The corn lobby has always been very strong in the US and the FDA even allows food sweetened with HFCS to be labelled natural. Natural?

Here is the table extracted from the Institute for Agriculture & Trade Policy report. It indicates the food products for which total mercury was detected, highest to lowest. (Measurements are in parts per trillion.)

What if the Cockroach Catcher was wrong?! Perhaps the level of mis-diagnosis of Autism in the United States in recent years might not have been high as speculated. There was just too much mercury in the food and drinks consumed by the American people! So even removing mercury from vaccines was not much help. Mercury readily passes from mothers to babies in breast milk.

Perhaps corn should be reserved for bio-fuel and Barbados could start growing sugar cane again. Of course non-mercury method could be used but the cost would be much higher.

What if the rate of Autism would begin to level off and even decline! What if indeed!

Autism posts:Autism: Leo Kanner

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Autism: Gene Disruption?

Autism, the Brain and Tiger Woods

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Alaska Zyprexa: DOJ at last.

A follow up to my earlier posts:

Alaska, Good Friday Earthquake and Zyprexa
Alaska Zyprexa: Follow Up

Alaska

In the final days of any government, there is a need to settle matters as the new administration may indeed have totally different ideas. Is Eli Lilly lucky in having a settlement with the Department Of Justice (DOJ) on the 15th of January 2009, just five days before the new President is sworn in? Only time will tell.


The settlement amounts to $1.415 billion: largest amount paid in the history of the DOJ.

The detail of the settlement is here.

Zyprexa (Olanzapine) is only approved by the Food and Drug Administration (FDA) for the treatment of schizophrenia and certain types of Bipolar Disorder. Unfortunately this is in competition with a number of other so called atypical antipsychotics.

According to the New York Times:

“Among the charges, Lilly has been accused of a years-long scheme to persuade doctors to prescribe Zyprexa to two categories of patients — children and the elderly — for whom the drug was not federally approved and in whom its use was especially risky.
“In one effort, the company urged geriatricians to use Zyprexa to sedate unruly nursing-home patients so as to reduce ‘nursing time and effort,’ according to court documents. Like other anti-psychotics, Zyprexa increases the risks of sudden death, heart failure and life-threatening infections such as pneumonia in elderly patients with dementia-related psychosis.
“The company also pressed pediatricians and family practitioners to treat disruptive children with Zyprexa, court documents show, even though the medicine's tendency to cause severe weight gain and metabolic disorders is particularly pronounced in children. In the past decade, Zyprexa's use in children has soared.”

Eli Lilly must have spent some good money as they have catchy slogans like:

“5 at 5″: to promote the drug’s side effect of sedation to nursing-home doctors: 5 milligrams of the drug at 5 p.m would help patients sleep

“Viva Zyprexa”: a campaign way back in 2000 to make the drug an “everyday agent in primary care” despite the fact that primary care doctors don’t typically treat schizophrenia and bipolar disorder. And this is long before the “Viva Viagra” campaign years later.

Off-label use in many ways makes a mockery of the role of the FDA, as safety of the drug thus used cannot be guaranteed. Yet for medicine to move forward, off-label use has its place. In my traditional way of thinking that may be tried at teaching hospitals and other centres of excellence, but only if they can be truly independent of the influence of drug firms. The truth of the matter is that the “off-label” period should only be brief as there is no reason why the usefulness of any drug’s so called side effect should not become part of any approved status.

But off-label for over ten years? Well!

Again according to the New York Times:

“In the United States, most of Zyprexa’s sales are paid for by government programs because so many of those taking Zyprexa are indigent or disabled. Zyprexa had sales of $4.8 billion in 2007, making it the biggest seller by far for Lilly, whose revenue that year was $18.6 billion. Depending on dosage, the drug can cost as much as $25 for a daily pill.
“Zyprexa has generated more than $39 billion in sales since its approval in 1996, making it one of the biggest-selling drugs in the world.”

The $1.415 billion settlement seems like a small percentage of nearly $40 billion of revenue.

The big question is: will its off-label use continue?

Did You Catch These: 2008

There are not many Child Psychiatry Blogs out there and the Cockroach Catcher feels compelled to fill in the gap and bring you the latest in the world that concerns child psychiatry.

Today happens to be a year since I published my book The Cockroach Catcher and first started venturing into the blogosphere. Below is my personal review of the year’s postings.

Child Psychiatry seems to prefer the As:

Autism, ADHD, anorexia nervosa , adoption .

There are of course the notable Bs:

Bipolar and ADHD: Boys and Breasts

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

Bipolar Disorder in Children

Two of the longest blogs were:

Adoption Adoption Adoption, which highlighted the plight of a young child dumped in Hong Kong by her Dutch adoptive parents, who happened to be diplomats;

and Asperger's Syndrome, Libel and Thalidomide, which summarised a number of notorious cases, including the plot of Gordon Brown to tax the compensation for thalidomide patients.

One of my personal favourites is:

Anorexia Nervosa: What If!


Medicine blogging is a world wide phenomenon and generally ethical which offers a glimmer of hope to a profession that is being sidelined in the U.K. But we will fight on.

And for those who have not yet discovered the world of Medical Grand Rounds, check these out:
Grand Rounds

On looking back at my year’s Medicine blog, I find my all time favourite to be: Teratoma: One Patient One Disease? A thirty year puzzle finally got answered.

This is best read as a follow-up to Teratoma: An Extract, which is in fact a chapter from my book.

Nobel Prize: Morality and Medicine is worth reading for the morality question that was raised. On the question of morality, let the blog Chiropractic: Strokes and Class Action be a warning to those who seek to remove the primacy of medical discipline.

There is a very useful contribution from a colleague:

A Brief History of Time: CPR (Cardiopulmonary Resuscitation) A quick read may help you to save someone’s life at a wedding or some other social event.

To counter balance the more serious postings, try the more light hearted:

Wine, Media and The Mind.

A surprisingly large number of readers searched and looked at:

Golf, Cholera and Tiger Woods.

However, who would have guessed that the posting that won the highest number of hits was: Picasso and Tradition?

Is this proof that culture is not completely dead?

Of the postings about food, you will be surprised at the material presented in: Quinoa: the super grain

My personal favourite and that of FOODIES: Chinese New Year and the Goose

Chinese New Year, the Year of the Ox, will be arriving soon, time for another dose of quality meat and fat.

Wine buffs should take a good look at:
Pleasure Principle and Wine, which is of course my very personal view.

Now on to something close to my heart: Cockroaches

Of these, the most popular blog seems to be: Seroxat and Ribena,

about two school girls taking on a giant.

Others worthy of another look include:
Bipolar Disorder in Children

ADHD: Why?

Alaska Zyprexa: Follow Up

It Pays To Be A Taditionalist: Seroxat

Bipolar and ADHD: Boys and Breasts

Antipsychotics: Really?

Those regular readers of The Jobbing Doctor, Dr Rant and NHS Blog Doc will realise the significance of:

Hemlock: Biology, Shakespeare, Socrates, House, M.D.

Additional coverage of this can be found in: Ward 87, Chez Sam, Witch Doctor, NHS Exposed and Dr Grumble. The cover-up was rather sad for medicine and for mankind. It would be sadder still if the powers were to try to control blogging.

Important links in the year:
NHS Blog Doc
Mental Nurse
Jobbing Doctor
And of course Huffington Post.

If you need more clues, you can find some earlier blogs in:
Did you catch these?
Did you catch the May Blogs
Blogging Addiction Disorder (BAD)

Finally, may I take this opportunity to thank all past readers for their support and encouragement. Do please keep the comments coming and the debates going!

Can They Draw: From Picasso to Matisse

EBA-Evidence Based Art Critique

It was in a BBC documentary a few years ago about the Turner Prize when the obvious question was asked: "Can xxxxxx xxxx (one of the nominees that year) draw?" The art experts participating in the discussion were all artful dodgers who managed not to give a straight answer.

A couple of years back I was in The Hermitage Museum in St Petersburg and saw their famous Matisse collection amongst a host of other treasures.

The Dance Hermitage St Petersburg

Matisse’s poster-like presentations led a few fellow travellers to ask the same question: Can Matisse draw?

Picasso is one of the artists that I have featured on this blog.

Juggler with Still Life 1905 NGA

Yes I am a great fan of Picasso but if anyone should ask me that same question of Picasso, I know what my answer would be and I would produce my evidence.

Earlier this year I was visiting some old school friends in Washington D.C., where in a few days time the world's media will descend to witness history in the making: the inauguration of Barack Obama.

National Gallery of Art Washington D.C.

At the National Gallery of Art (NGA) there, the answers to both the Matisse and Picasso questions can be easily found.

For the occasional museum visitor Picasso may be synonymous with cubism and paintings like this one:

The NGA had these as well.

Picasso Family of Saltimbanques, 1905

Tragedy, 1903

Read more about these here and here.

Now Henri Matisse:

We saw the paper cut-outs:

Mmmm: Can Matisse Draw?

Then we saw these paintings by Matisse:

Lorette with Turban, Yellow Jacket., 1917

La Coiffure, 1901

Can Matisse draw?!

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Don't Tell: A New Way To Market A Drug

Warning - Contamination of Weight Loss Products

The period after Christmas is traditionally the time of the year when many try to reduce weight, using whatever means available to do so. Many look to so called “Natural Products”, and in the market there are weight reduction products which make claims that are not regulated. It is also well known that active prescription only drugs have been sneaked into many such natural products in an attempt to make a quick buck. This of course involves some drug firms manufacturing the pharmaceutical ingredients in the first place.

According to the FDA, it looks like Sanofi-Aventis (a major European drug company) has secretly introduced a controversial diet drug Zimulti into a diet pill called Phyto Shape. In fact, more than 25 weight loss products against which the FDA warned consumers were found to contain undeclared prescription-strength medicines that could endanger people’s health.

The picture is now becoming sinister, like in a John Grisham novel.

The obesity drug Zimulti was denied approval in the U.S. and in October was pulled off the market in Europe out of concerns over psychiatric side effects, including depression. This drug belongs to a group called rimonabants, and has been sold in Europe under the name of Acomplia.

The FDA says in a Q&A that another powerful drug, Sibutramine, a controlled substance that is the active ingredient in Abbott’s approved prescription weight-loss pill Meridia, has been found in products such as 24 Hours Diet and ProSlim Plus. Some of these diet aids contain more than three times the recommended daily dosage of Sibutramine, putting people at risk of harmful side effects such as increased blood pressure, tachycardia, palpitations, and seizure.

There appears to be a new and serious way to market a drug: DON’T TELL.

Evidence Based Medicine (EBM): Ice

Three doctors went to a bar to conduct an experiment. The first drank brandy and ice, the second whisky and ice and the third gin and ice.

All developed a bad hangover the next morning.

They came to a conclusion: ice was the culprit!

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1 Nature

2 Food

3 Child Psychiatry
4 Medicine

5 Leisure Health

6 Cockroach

Antipsychotics: Really?

Primum non nocere

“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.
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?

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

Other Links: Mental Nurse This Week In Mental List.

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