Serotonin Reuptake Inhibitors, Suicidality in Children and Adolescents.

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There has been a major controversy in the media because of the relationship between suicidality in children and adolescents and SSRI antidepressants.  The FDA (Food and Drug Administration) in America state that antidepressants increase the risk of suicidal thinking and behaviour (suicidality) in children and adolescents with major depressive disorder and other psychiatric disorders.  Anyone considering the use of an SSRI or any other antidepressant in a child or adolescent must balance this risk with the clinical need.  Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behaviour.  Families and care givers should be advised of the need for close observation and communication with the prescriber.  Pooled analyses of short term placebo / controlled trials of nine antidepressants (SSRIs and others) in children and adolescents with major depressive disorder, Obsessive Compulsive Disorder, or other psychiatric disorders have revealed a greater risk of adverse events representing suicidal thinking or behaviour (suicidality) during the first few months of treatment in those receiving antidepressants.  The average risk of such events on drugs was 4%, twice the placebo risk of 2%. No suicides occurred in these trials. This is a good and reasonable summary of the current situation.  It emphasises close monitoring in the early weeks and suggests close attention to risks / benefit of the medication.  Clearly the benefits will outweigh the risks in those with more severe depressive states.

 

It is interesting that efficacy could not be established for the SSRIs except for Fluoxetine in paediatric usage.  It is important as well to note that major depression increases the risk of childhood suicide about 12 fold.  More than half of the kids with this disease try to kill themselves, and about 7% do complete suicide according to USA Today 2004. One has to measure this against the fact that 2 in 100 children on antidepressants become more suicidal because of the pills and there were no reported suicides again according to USA Today 2004. The reasons for the increased suicidality might be due to the fact that the medications can increase impulsiveness and that as the children who have been depressed become more energetic this increases the likelihood of suicidality.  It is interesting that there isn’t evidence for the tricyclic antidepressants in children but the current controversy might drive clinicians because of the concerns about the SSRIs to go back to prescribing the tricyclic antidepressants which are generally regarded to have higher side effect rates. This would be a retrograde step.  The worry is now is that some severely depressed children wont get the antidepressant treatment they require because of the current controversy.  Indeed a report in USA Today states that some doctors ‘fear kids could be denied needed care’.  This is where the good clinician comes in who is able to weigh up the risks and the benefits, who is able to identify a depression as being severe and in need of antidepressant treatment.  Clearly mild depressions should be treated with psychotherapy.  The British Medical Journal 2004 came to a reasonable conclusion that doctors should not hesitate to use antidepressants for clearly defined depressive disorders but they should carefully monitor patients in the first weeks of treatment.  There is a signal for suicidality when you look at studies of antidepressants that is the SSRIs nevertheless a report in the Journal of the American Academy of Child and Adolescent Psychiatry 2004 stated that ‘none of the reported differences with regard to suicidality between any of the drugs and placebo are statistically significant’.  This report claims that there has been an underestimation of the reduction of suicidality in patients treated with antidepressants.  My own personal conclusion is that there is a signal for suicidality but this can be managed within the context of the doctor patient relationship and careful monitoring in the early weeks after prescription. It is difficult to communicate this common sense approach in the context of media controversy.

 

 

Suicidal Behaviour and The Male Brain

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About 80% of all suicides are male.  Alcohol and substance misuse is commoner in males and unemployment may be a more significant risk factor in males who complete suicide. It appears that it may be harder for males to find their role and identity in our society where ‘a credit card is all you need’.

 

It is hardly surprising then that the unemployed male who may see themselves at the bottom of the male hierarchy is more likely to suicide.

 

Unemployed males would appear to suffer significant identity diffusion, be on a different track to other males, employed and driving their BMWs.

 

Indeed the difficulties with the male finding a role and being lost are particularly a feature of young male adulthood.  The Sunday Times in 2004 stated that ‘the sperm bank is the perfect father’ and had another statement as follows ‘women longing for a baby (but) decide to go it alone’.  The male has become more marginalized in our society in recent times. Females have entered the workplace in great numbers but still have retain their fundamental biological role that is in reproduction.

 

The male brain has strengths in mechanics, engineering, and mathematics.  These talents do not help in the mental processing of psychological distress. In addition males tend to be more aggressive, impulsive, and are therefore at increased risk of engaging in fatal suicidal behaviour. Simon Baron-Cohen points out that good systematisers are also skilled at understanding and exploiting natural systems.  The males are therefore good as hunters and trackers.  The male is good at mechanical systems and constructing tools.  The male is good at making weapons and fighting.  Good systematising helps the male to be good at working on the stock markets.  Males are particularly good at climbing hierarchical poles.  The combination of low empathising (male) and high systematising (male) means a rapid ascent to the top of the ‘social pile’.  Males are more single minded.  Nevertheless all these feature may make suicide more likely.

 

Males in severe psychological distress using the ‘stiff upper lip’ strategy are particularly at risk.  It is possible that some of them feel that being in distress is to be unmasculine is to be lacking machismo, which is experienced as intolerable, who then in this highly distressed state undertake suicide.  Males are better at map reading.  The male language is sometimes more egocentric.  Males are more aggressive and get involved in more crime and homicide.  Systematising is our most powerful way of understanding and predicting the law – governed inanimate universe.  Understanding the inanimate universe is not much good when a human being male is highly stressed and contemplating suicide.  A great deal of this material is also covered in my book Autism and Creativity: Is there a link between Autism in Men and Exceptional Ability?  Published by Brunner-Routledge, 2004.  The extreme male brain theory of autism is based on superior systematizing.

 

The female brain according to Simon Baron-Cohen is hard wired for empathy, and the male to understand and build systems.  In the long term it is likely that the human genome will pinpoint multiple genes of small effect that control empathising and systematising.  Females are better at sharing and turn taking, at responding empathically to distress of other people, are better at being sensitive to facial expressions, and value relationships more.

 

Empathising is the drive to identify another person’s emotions and thoughts, and to respond to these with appropriate emotion.  Females are high in empathising and low in systematising. Females are much better than males at reciprocal communication.  Females are also better at reading non-verbal behaviour. Females tend to be more compassionate and tolerant.  Females have superior capacity at communication and interpersonal relationships which may mean that they are less vulnerable to completing suicide.

 

The female has a more clearly defined role with reproduction and rearing children. Females are more developed human beings in terms of empathy and interpersonal skills.  They have better social skills.  They have better capacity to make social connections and are therefore less alienated and socially disconnected.  This may reduce their suicide risk.  (Prof. Fitzgerald is Chairman of the Irish Association of Suicidology)

Adult Attention Deficit Hyperactivity Disorder: The European Perspective

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ADHDThe prevalence of Adult Attention Deficit Hyperactivity Disorder is between 1 and 5%.  Both DSM-IV and ICD-10 criteria recognise that symptoms of Attention Deficit Hyperactivity Disorder and Hyperkinetic disorder persist beyond childhood into adulthood. However neither classification gives fixed thresholds for the number of symptoms required to make a diagnosis in adults.  DSM-IV criteria suggests that adults with only some of the symptoms of Attention Deficit Hyperactivity Disorder should be given a diagnosis of Attention Deficit Hyperactivity Disorder in partial remission; however, this diagnosis seems to underplay the significant impairments seen in adults no longer meeting the full DSM-IV criteria.  There is no doubt that symptoms of adult Attention Deficit Hyperactivity Disorder should be judged with reference to developmentally appropriate norms. The expression of Attention Deficit Hyperactivity Disorder in adults is different from that in children and the diagnostic descriptions of symptoms are not easily applicable to adults.  For example physical activity in children is replaced by constant mental activity, feelings of restlessness and difficulty engaging in quiet sedentary activities in adults. Compared to the diagnosis in children, a diagnosis of Attention Deficit Hyperactivity Disorder in adults is also heavily dependent on self-reporting symptoms. For that reason an independent informant particularly one who had knowledge of the adult in childhood is particularly important. In addition school reports can be most helpful.  Girls particularly with Attention Deficit Disorder without the hyperactivity tend to be under diagnosed and under treated.  In Adult Psychiatry Attention Deficit Hyperactivity Disorder is probably one of the commonest missed diagnosis, the second most commonly missed diagnosis being Asperger’s syndrome.  What is treated is the comorbid anxiety, depression, or drug abuse and the underlying Attention Deficit Hyperactivity Disorder is left untreated with serious consequences.

 

The key element in diagnosis is the lifetime and persistent history of symptoms with impairment in either school, work, home, or interpersonal relationships.  This was emphasised at a recent meeting of the European Network for Attention Deficit Hyperactivity Disorder in Frankfurt.

 

Treatment should focus on psychoeducation for persons with Attention Deficit Hyperactivity Disorder, as well as pharmacotherapy, and in addition the treatment of comorbid disorders.  Stimulants like Methylphenidate are used in the treatment of adults. Long acting Methylphenidate for example Concerta is being used off label for adult Attention Deficit Hyperactivity Disorder.  Atomoxetine (Strattera) which is licensed for adults in the United States and is available in Ireland on a named patient basis is being used for the treatment of Attention Deficit Hyperactivity Disorder.  It is the first non-stimulant medication for Attention Deficit Hyperactivity Disorder.  I have found that the tricyclic antidepressants are unfortunately rather ineffective. The core symptoms of Attention Deficit Hyperactivity Disorder require pharmacological treatment.  The other behavioural associated problems or disorders can benefit from psychotherapy, cognitive, supportive, etc..

 

It is possible that Adult Attention Deficit Hyperactivity Disorder may belong to a more severe and more genetically effected condition. Morbidity and mortality are both increased in adults with Attention Deficit Hyperactivity Disorder. It appears that Attention Deficit Hyperactivity Disorder can result in more accidents including traffic accidents and alcohol and drug abuse.  There is evidence that where Attention Deficit Hyperactivity Disorder has been adequately treated the rate of substance abuse was less.  It is important to reiterate that in adulthood the features of Attention Deficit Hyperactivity Disorder that are most common are inattention, impulsivity, poor organisation, and restlessness. Attention Deficit Hyperactivity Disorder can be associated with creativity for example Kurt Cobain who had diagnosed Attention Deficit Hyperactivity Disorder in childhood, Oscar Wilde, Lord Byron, Ernest Shakleton, and Richard Brinsley Sheridan.

 

Adult Attention Deficit Hyperactivity Disorder is of critical importance in services treating drug problems, personality disorders, and forensic services.  The rate of Attention Deficit Hyperactivity Disorder in Mountjoy Prison is much higher than in a non-prison population.  A recent edition of the Journal (2003) Drugs:  Education Prevention and Policy emphasised the association of adult Attention Deficit Hyperactivity Disorder, Antisocial Personality Disorder and substance misuse.  Despite this clinicians have a reluctance to take Attention Deficit Hyperactivity Disorder into account at the diagnostic and therapeutic level.  The reluctance to accept the diagnosis is even more puzzling because of its very high heritability which is higher than many conditions psychiatrists treat.  There should be regional centres for the treatment of adult Attention Deficit Hyperactivity Disorder but this is not possible with the catchment area arrangement. Therefore one Consultant Psychiatrist in each catchment area should take a special interest in adult Attention Deficit Hyperactivity Disorder.

Persons of Genius with High Functioning Autism or Asperger’s syndrome.

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There are few conditions that have received as much coverage in the popular press in recent times or have been the subject of as much controversial debate as autism.  Public awareness regarding the condition has grown exponentially but many healthcare professionals may still lack confidence in making the diagnosis of autism according to Dr. Louise Gallagher who has conducted genetic research in autism at Trinity College Dublin.

 

This article aims to give an overview of the disorder of autism staring off with a clinical description and diagnostic criteria.  Theories on causation and a review of the current accepted interventions will also be outlined.

 

It can be associated with ability of genius proportions. Examples include Godel, Hans Christian Andersen, Gregor Mendel, Archimedes, and Charles Lindberg.

 

Autism is very commonly associated with low functioning and Learning Disability.  This is a false conception of the condition.  High Functioning Autism or Asperger’s syndrome can occur in persons with very high I.Q.

 

Clinical Description

 

Autism is a neuro-developmental disorder of childhood that was first described by Leo Kanner.  He described a group of children with impaired language, lack of eye contact, lack of social interaction and repetitive behaviour. In 1944, Hans Asperger published a paper describing a pattern of behaviours in several young boys who had normal intelligence and language development, but who also exhibited autistic-like behaviours and marked deficiencies in social and communication skills.  Asperger’s syndrome went largely unrecognised until the 1980s. Now it is commonly used to describe individuals with an Autistic Spectrum Disorder and normal intellectual functioning.

 

Asperger’s syndrome, and described the following difficulties in the first two years of life of children with the condition:

 

(a)       A lack of normal interest and pleasure in people around them.

 

(b)       A reduction in the quality and quantity of babbling.

 

(c)       A significant reduction in shared interests.

 

(d)      A significant reduction in the wish to communicate verbally or non-verbally.

 

(e)       A delay in speech acquisition and impoverishment of content.

 

(f)       No imaginative play or if it does occur it is confined to one or two rigid patterns.

 

Gillberg’s diagnostic criteria for Asperger’s syndrome:  social impairments; narrow interests; repetitive routines; speech and language peculiarities; non-verbal communication problems; motor clumsiness.

 

High Functioning Autism or Asperger’s syndrome is not uncommonly misdiagnosed as Schizoid, Narcissistic Borderline or Obsessive Compulsive Personality Disorder or Schizophrenia.

 

Genetic of Autism

 

Heritability estimates of over 90% have been made in relation to autism.  Louise Gallagher points out that approaches to genetic studies have involved candidate gene studies and genome-wide, affected, sib-pair linkage studies. Association studies with variants within the Serotonin transporter gene have been conducted based on the well-established findings of elevated platelet Serotonin. Findings between studies have been inconclusive to date.  Other genes, which have been studied, include UBE3A, GABRB HOXA1/B1, all of which have had conflicting reports of association.  Reelin and WNT have had initial studies reporting association but these require replication.

 

Seven genome-wide linkage studies have been published to date and a large number of regions of putative linkage have been identified.  The most convincing evidence has been found on Ch2q and 7q.  Efforts are underway to narrow these regions down to find candidate genes.

 

Interventions

 

A comprehensive management plan should be put in place once the diagnosis has been established.  Management involves a multidisciplinary approach involving the following:

 

(a)       Speech and Language Therapy.

 

(b)       Psychological assessment for appropriate school placement.

 

(c)       Education interventions.

 

(d)      Educational interventions.

 

(e)       Pharmacotherapy.

 

(f)       Theory of mind and empathy training (higher intellectual functioning).

 

Speech and Language Therapy is essential and should be provided regularly (at least once a week) for children with speech and language delay. Pharmacotherapy has limited application but Ritalin may be considered in the presence of marked hyperactivity although children with autism are reported to be more sensitive to the side effects. Risperidone has been shown to have some beneficial effects on global assessments of psychiatric morbidity but not on individual autistic symptoms.  Naltrexone has been reported to have beneficial effects on self-injury and stereotyped behaviours but well-controlled clinical trials are still required. SSRIs are widely used in the US but not in Europe. There are some reports of improvements in repetitive behaviours but randomised, controlled trials (RCTs) are required.  The use of Melatonin in sleep disorders including those associated with autism, has been reported as beneficial by a number of groups. Again there is an absence of well-controlled RCTs.

 

As mentioned above, the evidence supporting a casein and gluten-free diet is limited.  Knivsber et al. report an overall benefit in their review of the area but the studies in question have a number of methodological flaws including small sample sizes.  Secretin has not been shown to be helpful.

 

The following examples of people with High Functioning Autism or Asperger’s syndrome and contributors of genius.

 

Kurt Godel was very much a loner and a genius.  He was fascinated by mathematics and contributed greatly to it.  He was a linguist and an autodictat.  Even in junior school he was fascinated by mathematics and physics.  He was socially immature and had severe difficulties in social relationships.  He had non-verbal behaviour difficulties and had a tremendous capacity for focus on mathematical problems.  He was extremely naïve.  He suffered from severe depression.  His verbal contributions are characterised by extreme brevity. He was also quite paranoid and fearful of emissions from refrigerators.

 

Mendel was a genius who was also very much plodding in his work, hard working, and completely single minded. He proposed laws of inheritance that ultimately became the underpinning of the science of genetics.  He had severe difficulties in social relationships. He was extremely shy. In front of a class he was an extremely poor teacher. In teaching he never was fully certified and was always a substitute teacher.  He was a man of absolute routines.  He regarded his plants as his children.  He was a monk who became rather paranoid and saw his fellow monks as traitors.

 

Hans Christian Andersen was a great storyteller.  He was socially immature.  He had very significant social interactional problems.  He was very much a loner.  He never married.  He was a great writer of fairytales and showed enormous creativity in this area. He read an enormous amount of books. He was bullied and called names at school.  He was very much an outsider.  He spoke with a high pitch tone of voice.  He was extremely obsessive.  He was very ritualistic in his behaviour. He was very controlling and at meal times his food had always to be served first. He suffered very much from depression throughout his life. He had identity diffusion. He wrote endlessly and compulsively.

 

Archimedes was a great Greek mathematician and inventor. He was a loner. He was mechanically and mathematically minded.  He hyper focussed on his researches.  His interests were extremely narrow.  He would forget to eat his meals.  He was regarded as extremely eccentric.

 

Charles Lindberg was a great aviator.  He was a loner as a child.  He was painfully shy in social relationships, he was naïve in accepting an award from Hitler. He liked solitude. He was extremely logical and obsessed with aviation. He also worked on the issues in high altitude flying and on a pump that blood could be pumped if the heart was being operated upon.  This work was carried out at the Rockerfeller Institute.  His greatest achievement and one that he was well suited for was in flying solo across the Atlantic over Ireland to Paris.  The link between psychiatric disorders and genius has often been made and these are further examples of that link.

 

Godel, Mendel, Andersen, Archimedes, Lindburg had High Functioning Autism

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Autism is very commonly associated with low functioning and Learning Disability.  This is a false conception of the condition.  High Functioning Autism or Asperger’s syndrome can occur in persons with very high I.Q. and indeed ability of genius proportions. The following people demonstrate this high ability as well as High Functioning Autism:

 

Kurt Godel was very much a loner and a genius.  He was fascinated by mathematics and contributed greatly to it.  He was a linguist and an autodictat.  Even in junior school he was fascinated by mathematics and physics.  He was socially immature and had severe difficulties in social relationships. He had non-verbal behaviour difficulties and had a tremendous capacity for focus on mathematical problems.  He was extremely naïve.  He suffered from severe depression.  His verbal contributions are characterised by extreme brevity. He was also quite paranoid and fearful of emissions from refrigerators.

 

Mendel was a genius who was also very much plodding in his work, hard working, and completely single minded. He proposed laws of inheritance that ultimately became the underpinning of the science of genetics.  He had severe difficulties in social relationships. He was extremely shy. In front of a class he was an extremely poor teacher. In teaching he never was fully certified and was always a substitute teacher.  He was a man of absolute routines.  He regarded his plants as his children.  He was a monk who became rather paranoid and saw his fellow monks as traitors.

 

Hans Christian Andersen was a great storyteller.  He was socially immature.  He had very significant social interactional problems.  He was very much a loner.  He never married.  He was a great writer of fairytales and showed enormous creativity in this area. He read an enormous amount of books. He was bullied and called names at school.  He was very much an outsider.  He spoke with a high pitch tone of voice.  He was extremely obsessive.  He was very ritualistic in his behaviour.  He was very controlling and at meal times his food had always to be served first. He suffered very much from depression throughout his life.  He had identity diffusion.  He wrote endlessly and compulsively.

 

Archimedes was a great Greek mathematician and inventor. He was a loner. He was mechanically and mathematically minded.  He hyper focussed on his researches.  His interests were extremely narrow.  He would forget to eat his meals.  He was regarded as extremely eccentric.

 

Charles Lindburg was a great aviator.  He was a loner as a child.  He was painfully shy in social relationships, he was naïve in accepting an award from Hitler. He liked solitude. He was extremely logical and obsessed with aviation. He also worked on the issues in high altitude flying and on a pump that blood could be pumped if the heart was being operated upon.  This work was carried out at the Rockerfeller Institute.  His greatest achievement and one that he was well suited for was in flying solo across the Atlantic over Ireland to Paris.  The link between psychiatric disorders and genius has often been made and these are further examples of that link.

 

Controversies in the Diagnosis Autism Spectrum Disorders

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Certain aspects of Autism and Asperger’s syndrome remain controversial in Ireland.  These controversies cause enormous distress to families of persons with Autism. In reality these controversies are unnecessary and the distress to families is unnecessary, particularly as these families have sufficient demands on them with their child with Autism without unnecessary artificially created controversies.

 

The first controversy the families have to face is the controversy over narrow versus broad spectrum diagnosis of autism. The old fashioned concept of Autism, called Kanner’s Autism, which is a narrow conception of Autism is no longer believed by anyone.  Instruments called the Autism Diagnostic Interview and Autism Diagnostic Observation Scale are examples of instruments focussing on narrow Autism. Professor Michael Rutter pointed out that “the ADI-R is not a perfect instrument”.  He is 100% correct about this, indeed most of the ‘seasoned’ critics of the ADI-R believe it to be a highly imperfect instrument.  Adam Feinstein noted that at the International Meeting for Autism Research in London in 2008 that many of the most highly regarded researchers in Autism in the world ‘lambasted the tool (ADI-R) for missing many cases of Autism”, and that it was “an expensive and ineffective instrument”. It is extremely expensive and it is prohibitive for the developing world, and inhibits the possibility of research in Autism in the developing countries. At the 2008 meeting, which I attended, I heard researchers from Australia complaining about its prohibitive cost.

 

Professor Dorothy Bishop, Professor of Development Neuropsychology at the University of Oxford criticised the ADI-R for the vast time it takes for “training” in the use of the instrument, “time for administration and time for scoring, and consensus coding”.  Professor Bishop correctly pointed out that “if you could be shown that there were real benefits in accuracy of diagnosis from adopting this lengthy procedure” then she would be happy to go along with these tedious assessment procedure and instrument. There is absolutely no evidence for this tedious long-winded assessment procedure. Professor Bishop correctly concludes that “the originators of the instrument have never demonstrated that you actually need such a long process – it is really more an article of faith to them”. This has echoes of religious faith that has no place in science.

 

I have found the proponents of this instrument in a number of countries are fanatical in their support of the ADI-R, indeed have a “religious” faith in its value. Professor Bishop also points out that in relation to the ADI-R-ADOS that there are “plenty of children who come out as meeting criteria on one instrument only, and there seems to be no sensible guidelines as to how you proceed, other than to seek expert clinical opinion. Professor Bishop recommends “doing studies to see what is the minimal set of items you have to get reasonable diagnostic accuracy and I doubt that we really need a three our interview for each case”.

 

I am continuing to see parents with children with Autism who come to me in great distress and tears because they had been told their children did not meet criteria for Autism based solely on these tests, when it was absolutely clear to me and to the parents that the parents had classic Autism broader phenotype – Autism Spectrum Disorder. How long more am I going to have to deal with parents in tears?  I don’t think parents should have to suffer unnecessarily because of the above reasons. Their energy should be put into therapeutic activities for their children, not having to go from one professional to another to get a formal diagnosis.

Malaysia: Observations on Psychiatry and Society during a visit.

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When people think of Malaysia what first comes to mind are the Petronas Twin Towers of Kuala Lumper.  It has a population of about 25 million.  The British during their time there left good structures which are benefiting Malaysia today unlike the behaviour of the Dutch in Indonesia.

 

During my time there I spent most of my time in Penang and at the Penang Medical School associated with RCSI and UCD. The founder of Penang was Francis Light who is reported to have hit upon a cunning method of getting the surrounding jungle cleared to make way for the town.  He loaded a canon with Spanish Silver Dollars, fired them into the forest, and invited local labourers to hack their way through the undergrowth to get to the money. Alfred Russell Wallace who discovered the evolution of the species at the same time as Charles Darwin lived in Malaysia.  The climate is warm and balmy.  The cost of living is much cheaper than Ireland and one can have an excellent dinner for €8.  Some companies are moving out of Malaysia to China because of cheaper labour in the same way they are moving out of Ireland.  Welfare is provided through Religious Organisations rather than the State. There is massive pressure on the children at school particularly Chinese children and grinds start from the age of six onwards.  Walking around the parks one sees endless monkeys roaming free. I was also told that the hills behind Penang have interesting walks but cobra snakes tend to frequent these places.  I was told that they didn’t attack one if they weren’t disturbed.  I decided this was an experiment that I wouldn’t make.  The “Ryanair” airline of Malaysia is called Air Asia and works on the exact same model.  I observed construction workers from my hotel window working 40 storeys up without protection. It made me dizzy to watch them.  It reminded me of the Irish workers in the early days of Manhattan while working on the skyscrapers worked also without protection.  There are endless motorbikes there who weave in and out quite similar to the couriers in Dublin but much more dangerously and much faster. People on motorbikes wear their coats back to front as this helps the circulation of air.

 

The Penang Medical College is extremely successful. It is approximately ten years old now. On my first day I met the Dean Amir and the President of the College Rathlingan a Physicist.  I had a chat with Professor William Shannon from RCSI who told me about developments in general practice in Malaysia.  He pointed out that there was major need for development of professional training programmes for General Practitioners. I was told that Dean Muiris Fitzgerald has been a regular visitor particularly in relation to graduation issues.  They were looking forward to Professor Niall O’Higgins President of the Royal College of Surgeons in Ireland visit soon. Professor Noel Walsh was a distinguished Professor of Psychiatry at UCD and spent a number of years as a pioneer with the Penang Medical College where he learned to speak Malay to huge approval of the local population.  I also visited a Centre called the Lion Centre for children with autism which works along similar lines to Centres in Ireland.  They gave me a book called The Reach Way to Transformation which had a Foreword by Professor Noel Walsh.  He arranged for medical students to visit this Centre during their undergraduate training. I was told that medical education can cost up to 150,000 Euros but that there are scholarships.  I met quite a number of medical students who the previous year had been at the Royal College of Surgeons in Ireland for their earlier medical education.  I had eleven professional / parent contacts during my visit there including five lectures and meetings with parents of children with autism, meeting with professionals, visits to Inpatient Psychiatric Units, and Outpatient Child and Adult Psychiatric Services.

 

In the Child Psychiatric Outpatients I met Dr. Lai a Child Psychiatrist.  On his wall he had a poster giving 88 ways to praise a child and another poster stating that families must try to achieve marital and family harmony.  I observed custody and access discussions there which were identical to Ireland using the same language and just as acrimonious. In the Child Psychiatric Outpatients they used the Swan Scales for Attention Deficit Hyperactivity Disorder and also the Vanderbilt Attention Deficit Hyperactivity Disorder Diagnostic Teachers Rating Scale.  The rates of Attention Deficit Hyperactivity Disorder seem very common and the treatments were the same as in Ireland.  The standard of psychiatry was the same as in Ireland.  In the Adult Psychiatric Outpatients some of the conditions would be different from Ireland in that there was koro which is the feeling that the penis is being withdrawn into the abdomen, amok and latah.  It seemed easier to diagnose psychosis because as in Uganda I observed that patients were more willing to be explicit about their psychotic symptoms.  The Adult Psychiatrists were doing research work on Sertindole which is a medication for the treatment of psychosis.  There are about 10 million children under 17 in Malaysia, 14 Child Psychiatrists which works out at about one Child Psychiatrist per 800,000.  I was pleased that the interest of the services was in providing direct assistance to patients rather than sitting around in teams discussing patients. I liked the Malaysians very direct way of seeing patients and helping them out to the best of their ability without the ‘team games’ so prevalent in other countries.  Of course teams are very relevant for about 5% of referrals where one is dealing with very complex psychological, social and psychiatric situation.

 

I had an opportunity to lecture to professionals from Penang as well as from the mainland up to the Thai border and I became aware that people with multiple disabilities tended to be placed together. This was not ideal but persons with autism were beginning to be separated out for their own services.

 

I met Professor Leela Ryan who is a much appreciated Consultant Psychiatrist in the South Western Area Health Board in the Naas Hospital is now playing a major role in Psychiatry in the Penang Medical School and is a key figure there.

 

I met Professor Saroja who is head of the Psychiatric Department and during the Tsunami which hit Malaysia and drowned people she developed with her colleagues an excellent Early Intervention Programme which was used throughout Asia.

 

Because of overcrowding in some schools, schools have one group of pupils coming in the morning and a second group of pupils coming in the afternoon.  This reminded me of Makere University in Uganda where some students would attend in the middle of the night because of a lack of places etc. during the day. Many of the population were Muslim and I was very impressed by their behaviour and the kind of country they had created with brilliant Chinese businessmen and Indians.  Nevertheless I did notice some concerns in the front page of a local newspaper which had the headline “Hugging and kissing in public:  freedom or indecent behaviour?”.  Malaysia is a country which symbolises Asia and is worthwhile a visit.  There is a mix of private and public hospitals just as in Ireland and medical tourism is big business particularly from Indonesia.  The issues that they have to face particularly in relation to infections are massively different from the issues in Africa.

 

A Visit to Uganda

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Uganda is very much in the news at the moment because of the national elections and the unjustifiable controversy over Irish aid to Uganda, which in my opinion is well spent and accounted for.  Uganda is a very poor country, which has been ravaged by war in the not too distant past.  You can still see burnt out tanks at the side of the road.  Security is a big issue and expensive in Uganda.  My Hotel had three ring of security – the outer ring having armed guards. The second ring checked for guns which were not allowed in the Hotel.  The third or inner ring of security protected the bedrooms. Not surprising I did not see any of the “Irish glitterati” on holiday or buying holiday homes.  Uganda is on the equator, with wonderful sunshine and low humidity during my visit.

 

I also saw birthday parties for children in Uganda and weddings, which wouldn’t be out of place in Shrewsbury Road, Dublin 4. There is a privileged class as well. There is much greater in general family support in Uganda compared to Ireland.  Rejecting families of the kind that you see in Ireland are much less common in Uganda and when they occur, they occur within the more educated classes.

 

The people dress very neatly and well.  Because most of them are not overweight obviously then can carry clothes very well.  At weddings the attire is simply magnificent.  The average wage of people in the Hotel industry is 100 dollars per month. The hours are extremely long.

 

In Uganda particularly in the less educated classes polygamy is a status symbol and so a man having three, four or more wives is not uncommon. I wonder how Family Therapists or the Mater Hospital would handle this kind of family?

 

At the time I was there families were storing up on flour / grain for fear of social political implosion and there was a lot of anxiety and confusion about the upcoming presidential election.  The leader of the opposition had been jailed. It was December 2005 the beginning of the national elections.  I saw massive gatherings of political supporters with much noise.  There is considerable fear in Africa of the growth of the “Mugabe syndrome”.

 

As you walk around you see endless people walking appearing to walk forever and then other huge numbers of men sitting around under employed. The pace of life is about one fifth that of Ireland.  In the northern area where the Civil War is raging everybody has to go into the compounds at 3 p.m. in the evening for fear of attack or abduction.

 

Children are abducted and used as basically sex slaves for commanders of the rebel army.  When these come back or rescued they often describe that they have been the “wife” of a commander.  The higher up the commander that they have been the more status they have.  When they are abducted their first task maybe to kill their parents.  Caroline Moorehead pointed out that the Lord’s Resistance Army appeared to be defeated in 2002 but then abducted a further 8,400 children.  There are about 300,000 child soldiers in the world.

 

In one tribe the men sit around all day drinking a low alcohol brew and everybody drinks from this central container while the women go out to work the fields etc.  Children have their first taste of alcohol at baptism.  It is hardly surprising alcohol problems are a major feature.  Since the Afghan war drugs are being re-routed through Africa that formally went through Europe and this has led to increased drug problems in Africa.

 

The largest Hospital has a 9 year old CT scan which has scanned over 10,000 patients.  In this Hospital there is a ratio of 1 nurse to 20 patients during the day and 1 nurse to 50 patients at night.  The largest Hospital has a 1500 bed capacity and 80 to 100 deliveries per day of babies. I read in a newspaper that 53 is “a very advanced age”.

 

I attended psychiatric inpatient assessments and I saw HIV, syphilis, and many organic psychosis.  In the psychiatric setting it is not uncommon for HIV to present as an acute manic psychosis.

 

There was a great deal of police contact in relation to inpatients. I also saw traditional family problems.  An OPD session would have 50 patients for one psychiatrist.  There was 3 to 10 patients admitted per day in the Hospital. I worked with a psychiatric clinical officer which is basically a CPN who has permission to diagnose and treat psychiatric illness. She was superb in her diagnosis, assessment, and medical treatment.  Certainly we are going to see more of these performing throughout the world in the future.  Long waiting lists particularly in Child Psychiatry in Ireland could be solved if we had child psychiatric clinical officers who had extra training i.e. child psychiatric nurses with some extra training maybe in diagnosis and assessment so that they could assess people on the waiting list and referred more complex cases for multidisciplinary or child psychiatric assessment.  There was none of these endless wasteful multidisciplinary team meetings so common in Ireland.  The psychopathology was much more severe than we would see in Ireland.

 

The quality of the Registrars is similar to Ireland. I heard of one case while I was there where a traditional healer had fractured the skull of a patient.  This traditional healer as part of his treatment was to beat the patient.  The medications they use in the public service are Chlorpromazine, tricyclics, Haloperidol, diazepam, Chlordiazepoxide and lithium.  Psychologists have Cognitive Behavioural Therapy orientation.  In the Hospital the patients were uniformed in blue, green, etc..  The junior doctors wear white coats.

 

Every time a doctor or other health professional is taken from a developing country and retained in Ireland the government as part of its development aid should repay the full cost that the developing country had invested in training this health professional.  Ireland undermines health care in developing countries by taking vital health care professionals from them.

 

Christmas is a small event. I noticed no evidence in Entebbe Airport (famous for the Israeli raid on Entebbe) but I heard Silent Night being sung on the radio in Nairobi Airport three days before Christmas but that was about it.

Suicide In History.

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John Donne ‘No man is an island, entire of itself … any man’s death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee’.

 

Suicidium is derived from the Latin words ‘sui’ self and ‘caedo’ to kill.  The Romans said ‘sibim mortm conscies consciscere’ in other words “procure his own death”.

 

Ancient authors against suicide include Pythagoras, Socrates, Plato, Aristotle, and Virgil.

 

Suicide in Ancient Greece:

 

During the Trojan War, Ajax, one of the Grecian heroes, slew himself, in a fit of passion, brought on by offended vanity. Lycurgus, the legislator of Sparta, was one who completed suicide.

 

Suicide in the Bible:

 

Judas Iscariot AD 33, Pontius Pilate AD 36, Zimri 929 BC King of Israel, Eleazar 164 BC, one of the Maccabees, Saul 1050 BC the first King of Israel, Samson 120 BC Judge of Israel.

 

Suicide in the 19th Century:

 

According to Westcott there were 24 suicides per million in Ireland in 1883.  This can be compared with 48 per million in Scotland in 1881 and 101 per million in Sweden in 1887. The rate in Switzerland in 1881 was 240 per million, in Denmark 265per million in 1878 and in Saxony 409 per million.  In the 19th century Briere de Boismont put the number one cause of suicide as mental illness but motive only counted for the most commonest assessment or lack of assessment of suicide.  The third cause of suicide was alcoholism.  Of the 600,782 cases observed by Falret the following proportions were calculated by him ‘caused by misery 1 in 7, loss of fortune 1 in 21, gambling 1 in 43, love affairs 1 in 19, domestic troubles 1 in 9, fanaticism 1 in 66, calumny, wounded self-love, and failed ambition 1 in 7, remorse 1 in 27’ For Lisle the first cause of suicide was mental illness, the second one was unknown, the third was to avoid pain, the fourth was domestic troubles, the fifth was debts, the sixth was misery, the seventh was habitual roguery. There were unusual causes including political excitement, religious fears, suicide after crime, rivalry in business, disgust of military life, disappointment in love, nostalgia.  Westcott in 1885 noted while crime was falling suicide was increasing and that while it awakens sympathy on behalf of the unhappy victims, we should stimulate our exertions towards promoting the diminution of this plague.

 

In the 1850s suicide was not more common in industrial areas than in rural areas.  At this time those at high risk for suicide were doctors, barristers, and butchers. At low risk were quarrymen, ministers, and fishermen.  It took a whole generation before people realised that railways could be used for suicide.  Morselli stated the prevalence of men over women was least in youth, greatest in adults, whilst it becomes small in old age.  Anderson points out that in the middle of the 19th century what was distinctive about suicide in the city was its exceptional frequency among young people, especially young men.  Indeed between 1861 – 1870 the suicide rate for young men and women aged between 15 and 24 years were respectively as much as 71 and 58% higher than those of the rest of the country.  Morselli warned women that taking part in politics would lead to ‘infallibly to higher suicide rates’.  Morselli believed that the emancipation of women would lead to higher suicide rates.  Durkheim (1897) comment was similar.  He said ‘women kills herself less . . because she does not participate in collective life in the same way’.  In the 19th century in married female suicide was often blamed on seduction according to Anderson.  Unfortunately at this period novelettes presented suicide as the appropriate response to a girl in difficulties.  Victorian domestic servants according to Anderson were believed to have high rates of suicide, as well as unwanted pregnancy, drunkenness and theft. Honeymoon suicides were also not uncommon.  The effects of masturbation were also a source of massive anxiety.  According to Anderson the chaplain’s office in Clerkenwell Prison was possibly the first suicide prevention agency and it focussed on churchmanship and social work.

 

In the 1870s emigration to Canada was offered to some who attempted suicide.  Alcohol was also a huge factor in 19th century Suicidology.  As Anderson points out there was a belief in the 19th century that suicide could be reduced if the press stopped reporting it ‘in detail’. This has echoes of today.

Autism and MMR: A Medico-Media Catastrophe: Do We Now Have the Last Word?

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I read with interest a recent comment by Dr. Ronald Boland that in a survey of parents more than a quarter (were) ‘reluctant to vaccinate their children because of worries of vaccine safety and did not believe in infant vaccines at all’.  This is unfortunate.  It appears to me to be largely due to false information being distributed over the years through the media and by a publication in a prestigious medical journal, which under mines the great faith, the medical professional has in the peer reviewed process.  Six years after the report, an incredibly long time, ten of the thirteen authors of this article retracted what they wrote and stated that their original paper did not support the conclusion that the vaccine was to blame for autism.

 

It is interesting to see what the media has said about MMR and autism over the years.  The Daily Telegraph had the best headline ‘Chattering class endangers child lives over MMR’.  Claudia Winkleman in the Daily Telegraph has the following headline ‘I didn’t want the MMR – and now my baby has measles’.  She goes on to state ‘Jake tosses in his comfy cot and moans in his sleep. Yes I am a class A idiot: my son is ill – and it is my fault’.  Another excellent report in the Irish Times stated ‘Beware of giving bad reports a shot in the arm’.  Unfortunately this is what the media has done over many years. Misinformation and false information sells newspapers.  One might think that the media might have some concerns about false information and the potentially fatal affects of it.  A false story is a good story from the media point of view because it sells newspapers while truth is not of interest very often.  Many media outlets have lawyers to check on libel and maybe they should also have relevant medical doctors to check the veracity of medical information. Because of the focus on the ‘bottom line’ it is highly unlikely that this will take place. Of course doctors also have to take responsibilities for this because very few doctors ring up and point out to media sources the falsity of the information that they are giving out. Doctors only tend to respond when they are asked.

 

Another more recent media headline from the Sunday Times was ‘Vaccine patents and the MMR scare doctor’.  Another headline from the Irish Times ‘Parents urged to have rethink on MMR after measles cases treble’.  Another heading from the Medical Press ‘Latest figures show uptake rates from primary vaccines continue to fall’.  Colin Tudge writes in an article called ‘Mad, bad and dangerous: whether it is the MMR vaccine or GM foods, people distrust what scientists tell them’.  This was in the New Statesman.  The Irish Times in 2003 has a headline ‘Research finds no ill-effects from triple MMR injections’ and quotes Dr. O’Herlihy as saying that the Republic was witnessing the beginning of another outbreak of measles.  Dr. Ray O’Connor in an article entitled ‘MMR vaccine: controversies and fallacies in Modern Medicine’ states ‘measles is a particularly nasty disease.  Many doctors and parents have not seen a case of measles, and its severity – even on complicated cases – it is often forgotten’. He discusses the complications including severe cough, breathing difficulties, ear infections, pneumonia, and conjunctivitis.  He also discusses rare serious complications of measles including acute encephalitis and sub-acute sclerosing pan-encephalitis.  He puts the death rate at 1 to 2 per 1,000 infected people. The Irish Medicines Board in their newsletter points out that more than 500 million doses of MMR vaccine have been used worldwide and that there was no evidence to support the suggestion that single component vaccines should be administered separately.  They also point out that mono component vaccines given sequentially, children would be at risk of infection for longer periods.

 

Brian O’Shea in the Journal of the Irish Psychiatrist points out that the number of reported cases of measles jumped from 243 to 586 during 2000 / 2003.  More recently the Medical Research Council in the United Kingdom in a study of more than 5,000 U.K. children has ruled out any link between MMR, the measles, mumps, and rubella triple vaccine and autism.  This should be the last word but certainly will not.  There are many other authoritative reports and papers that have come to a similar conclusion.  Despite all this the Sunday Times in 2004 reports on a product that was made ‘by giving the measles virus to mice and extracting their white blood cells, which were then to be mixed with human cells before being infected into pregnant goats. After the goats gave birth their first milk was to be collected, and made into capsules and given to children’.  This was called a ‘combined vaccine / therapeutic agent’.  Professor Tom McDonald an immunologist described the recipe as ‘total bollocks’.  Another immunologist has a so-called ‘cure’ for autism who ‘sells a six month complete cure’ for autism, which he prepares in his kitchen using his own bone marrow. This has echoes of the potions of the early 19th century.  Those of us who work with children with autism are constantly being bombarded with ‘miracle cures’ for autism.  Unfortunately these raise parent’s hopes which are then dashed fairly quickly.

 

I have seen over 900 persons with autism and Asperger’s syndrome. I have never seen a person with autism or Asperger’s syndrome that was ‘caused’ by a vaccine. Autism is highly genetic. Autism is not a side effect of MMR.