Celebrity & Other Suicides: Maudsley & Lithium!
One of my ex-juniors, now retired, called to ask if I have read about another celebrity suicide. How very sad! If we look back there has been many such suicides and it is sadder that many are very talented people. Iris Chang & Nanking: Denial!
Dr. Baldessarini of Harvard:
“Lithium is far from being an ideal medicine, but it’s the best agent we have for reducing the risk of suicide in bipolar disorder,” Dr. Baldessarini says, “and it is our best-established mood-stabilizing treatment.” If patients find they can’t tolerate lithium, the safest option is to reduce the dose as gradually as possible, to give the brain time to adjust. The approach could be lifesaving.
In recent write ups about antidepressants, there is no mention of Lithium. The Cockroach Catcher first worked with one Australian Psychiatrist that worked with Cade and I was, so to speak, very biased towards Lithium. Yes, Lithium has side effects that might be serious. But hang on, you get to live to experience it. Think about it.
"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. After all it is less than one eighth the price of a preferred mood stabilizer that has a serious side effect: liver failure.
Perhaps it is in the British History:
First, why a small group from the Maudsley Hospital in the 1960s could, in an almost malicious manner, have sown scholarly confusion about the true effectiveness of lithium. Aubrey Lewis, professor of psychiatry and head of the Maudsley, considered lithium treatment “dangerous nonsense” (47). Lewis’s colleague at the Maudsley, Michael Shepherd, one of the pioneers of British psychopharmacology, agreed that lithium was a dubious choice. In his 1968 monograph, Clinical Psychopharmacology, Shepherd said that lithium was toxic in mania and that claims of efficacy for it in preventing depression rested on “dubious scientific methodology” (48). Shepherd also scorned “prophylactic lithium” in an article with Barry Blackwell (49). Moreover, Shepherd was publicly contemptuous of Schou. He told interviewer David Healy that Schou had put his own brother on it, and that Schou was such a “believer” in lithium that he seemed to think “really there ought to be a national policy in which everybody could get lithium”
Atacama where Lithium is extracted © Am Ang Zhang 2015
Lithium: The Gift That Keeps on Giving in Psychiatry
At the recent American Psychiatric Association annual meeting in San Diego Harvard Medical School
Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.
These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).
Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless.
Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?
APA Nassir Ghaemi, MD MPH
- In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)
- We haven’t developed a drug that’s more effective than any other drug since the 1970’s
- All we have developed is safer drugs (less side effects), but not more effective
- Dose lithium only once a day, at night
- For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium (Originally by Dr. Frederick K. Goodwin)
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 $
I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here. It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.
Latest: British Journal of Psychiatry
Tuesday, June 18, 2019
Marine Iguana: Ugly? Smart?
The Cockroach Catcher was quiet for a while as he was in Galapagos puzzling over what Darwin discovered years ago. Marine Iguanas only exist in Galapagos and I must say I am still pondering if it was evolution or natural selection!
I have always known that marine iguanas can hold their breath to avoid detection by sharks and they reduce their heart rate by 50% to keep foraging under the cold Galapagos sea water, but I did not know that they can shrink their body when food is in short supply and that includes their skeleton!
Every few years, a weather event called El Niño takes place, taking much of the iguanas’ food with it.
The largest iguanas are the first to die, because the largest bodies require the most energy.
So, the iguanas have come up with a solution, and managed to do something that no other vertebrate can do – they shrink. They can lose up to 20% of their size, by literally shrinking their skeleton.
But they don't shrink over the course of generations - they’re able to do this during their lifetime. Over a period of months, they break down their bone tissue before building it back up again after the storms.
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
ECOLOGY: First Bees, Now Bats.
Paraguay: Technology Meets Ecology
Hong Kong: Humpback Whale
Tasmania: Whales & Dolphins-Mother & Baby
Monday, May 13, 2019
Lithium: Why? Why? Why?
Antidepressants or Lithium! Side Effects but you will live to experience it!
One of my ex-juniors, now retired, called to ask if I have read about another celebrity suicide. How very sad!
Dr. Baldessarini of Harvard:
“Lithium is far from being an ideal medicine, but it’s the best agent we have for reducing the risk of suicide in bipolar disorder,” Dr. Baldessarini says, “and it is our best-established mood-stabilizing treatment.” If patients find they can’t tolerate lithium, the safest option is to reduce the dose as gradually as possible, to give the brain time to adjust. The approach could be lifesaving.
In recent write ups about antidepressants, there is no mention of Lithium. The Cockroach Catcher first worked with one Australian Psychiatrist that worked with Cade and I was, so to speak, very biased towards Lithium. Yes, Lithium has side effects that might be serious. But hang on, you get to live to experience it. Think about it.
"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. After all it is less than one eighth the price of a preferred mood stabilizer that has a serious side effect: liver failure.
Perhaps it is in the British History:
First, why a small group from the Maudsley Hospital in the 1960s could, in an almost malicious manner, have sown scholarly confusion about the true effectiveness of lithium. Aubrey Lewis, professor of psychiatry and head of the Maudsley, considered lithium treatment “dangerous nonsense” (47). Lewis’s colleague at the Maudsley, Michael Shepherd, one of the pioneers of British psychopharmacology, agreed that lithium was a dubious choice. In his 1968 monograph, Clinical Psychopharmacology, Shepherd said that lithium was toxic in mania and that claims of efficacy for it in preventing depression rested on “dubious scientific methodology” (48). Shepherd also scorned “prophylactic lithium” in an article with Barry Blackwell (49). Moreover, Shepherd was publicly contemptuous of Schou. He told interviewer David Healy that Schou had put his own brother on it, and that Schou was such a “believer” in lithium that he seemed to think “really there ought to be a national policy in which everybody could get lithium”
Atacama where Lithium is extracted © Am Ang Zhang 2015
Lithium: The Gift That Keeps on Giving in Psychiatry
At the recent American Psychiatric Association annual meeting in San Diego Harvard Medical School
Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.
These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).
Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless.
Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?
APA Nassir Ghaemi, MD MPH
- In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)
- We haven’t developed a drug that’s more effective than any other drug since the 1970’s
- All we have developed is safer drugs (less side effects), but not more effective
- Dose lithium only once a day, at night
- For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium (Originally by Dr. Frederick K. Goodwin)
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 $
I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here. It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.
Latest: British Journal of Psychiatry
Wednesday, May 8, 2019
Singapore Health Care: NHS to learn from old Colony!!!
Singapore ©2013 Am Ang Zhang
The Cockroach Catcher recently visited Singapore and is most impressed with how a city state emerged from British Colonial rule to become a shining example to the rest of the world both in terms of Employment, Education, Rule of Law and most importantly Health Care.
Until now, most health care in England has been “free” at the point of delivery. This indeed may be where the trouble really is.
When I was growing up in Hong Kong, education was not free nor was it compulsory. Yet most of us valued it. Every single bit of book, pencil and paper were paid for by hard working parents. There was no abuse of any of those items. Primary education became compulsory (and free) from 1979, yes, late.
Well, one thing I have to admit about British Colonialist is that they generally leave a good government behind. How that is achieved is a mystery to many but in general a stable government with a single policy for 150 years or so may well be one of them. In recent years, the Civil Service in Hong Kong and Singapore had been very efficient and whatever corruption there may have been had been contained or controlled.
Old Singapore Today©2013 Am Ang Zhang
Citizens of England might be surprised to hear that for most of us, health care is not free.
No, not for those of us who pay national insurance and taxes and if we include VAT, that is just about everybody.
Singapore: NO! NOT FREE!
Singapore’s health delivery is not free at any point. This has the singular advantage of preventing the over-utilisation of any of its healthcare services. As England struggled to stem the flow of new EU citizens from coming to use (or abuse) our NHS, Singapore’s system simply see to it that it would not happen. Yet there is a safeguard in public health for what is known as a catastrophic situation which happened during the SARS outbreak.
Singaporeans are considerably healthier than Americans, yet pay, per person, about one-fifth of what Americans pay for their healthcare.
So how does Singapore achieve such impressive results?
The key to Singapore’s efficient health care system is the emphasis on the individual to assume responsibility towards their own health and, importantly, their own health expenditure.
The state recovers 20-100 percent of its public healthcare outlay through user fees. A patient in a government hospital who chooses the open ward is subsidized by the government at 80 percent. Better-off patients choose more comfortable wards with lower or no government subsidy, in a self-administered means test.
I've heard a lot of smart people warn that co-payments are penny-wise but pound-foolish, because people cut back on high-benefit preventive care. Unless someone is willing to dispute Singapore's budgetary and health data, it looks like we've got strong counter-evidence to this view: Either Singaporeans don't skimp on preventive care when you raise the price, or preventive care isn't all it's cracked up to be.
More details on how Singapore's system works:
- There are mandatory health savings accounts: "Individuals pre-save for medical expenses through mandatory deductions from their paychecks and employer contributions... Only approved categories of medical treatment can be paid for by deducting one's Medisave account, for oneself, grandparents, parents, spouse or children: consultations with private practitioners for minor ailments must be paid from out-of-pocket cash..."
- "The private healthcare system competes with the public healthcare, which helps contain prices in both directions. Private medical insurance is also available."
- Private healthcare providers are required to publish price lists to encourage comparison shopping.
- The government pays for "basic healthcare services... subject to tight expenditure control." Bottom line: The government pays 80% of "basic public healthcare services."
- Government plays a big role with contagious disease, and adds some paternalism on top: "Preventing diseases such as HIV/AIDS, malaria, and tobacco-related illnesses by ensuring good health conditions takes a high priority."
- The government provides optional low-cost catastrophic health insurance, plus a safety net "subject to stringent means-testing."
So in Singapore private clinics are responsible for 80% of primary care but public hospitals cover 80% of hospital care!
Singapore has some of the best public hospitals in the Far East if not the world so much so that even those with private insurance often chose to have their operations in a public hospital but staying in a more private room if their insurance covers it. Public hospitals of this level of excellence become the natural competitor for the private market and helps to keep overall cost down without the need of draconian legislation. Such good public hospitals also provide some of the best training grounds for future generations of top class doctors.
Singapore together with Iceland has one of the lowest Infant Mortality rates in the world, a third the figure of the USA.
Singapore: Now ©2013 Am Ang Zhang
Read also:
The Singapore health system – achieving positive health outcomes with low expenditure by John Tucci
Wednesday, May 1, 2019
Suicide: The Answer, my friend may be Lithium!
Yes, ’n’ how many deaths will it take till he knows
That too many people have died?
The answer, my friend, is blowin’ in the wind
The answer is blowin’ in the wind
Bob Dylan.
Atacama where Lithium is extracted © Am Ang Zhang 2015
Lithium: The Gift That Keeps on Giving in Psychiatry
One might ask why there has been such a shift from Lithium.
"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."
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.
Some felt it has to do with how little money is to be made from Lithium.
Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?
Fremantle: Medical Heresy & Nobel
Tasmania & SIDS: The wasted years!
My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?
©Am Ang Zhang 2013
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 $
The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”
“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”
Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.
“Get him admitted and I shall talk to the doctor there.”
He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.
He had one of the worst encephalitis they had seen in recent times and they were surprised he survived.
Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.
Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.
I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.
Latest: British Journal of Psychiatry
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