Wednesday, 28.10.2020

Barry Blackwell’s review
Gregory de Moore and Ann Westmore: Finding Sanity: John Cade, Lithium and the Taming of Bipolar Disorder.

Gordon Johnson’s commentary


            This is a definitive biography of Cade and his discovery of the anti-manic effects of lithium compiled from multiple sources including interviews with his family and colleagues whose contributions are duly acknowledged and referenced. The review is in two parts: a detailed summary of the book and a section where he comments on selected issues.

            Suffice to say the summary is excellent, thoughtfully prepared and a thoroughly readable introduction to the book which he describes as an elegantly written, beguiling and nuanced biography of an enigmatic man. It is a also a unique perspective on psychiatry and the life of the mentally ill in the institutions charged with their care.

            His discovery of the anti-manic effects of lithium and the “taming of bipolar disorder” is a book that does justice to Cade’s lasting contribution to psychiatry.

            The issues chosen for comment are those in which he had a personal interest or involvement.

            He felt obliged to defend what he felt was animus against the Maudsley in the section on the controversy surrounding the report on the prophylactic effects of lithium dismissed by Blackwell and Shepherd. He raises circumstances at the time that influenced their opinion, but now admits they were wrong. The fact that they had never used lithium is telling criticism expressed by Brian Davies, a registrar there at the time.

            This discovery that lithium prevented recurrence of episodes of mania and depression had a dramatic effect on lithium use and acceptance that had not followed its original use in mania due to toxicity concerns and labelled a poison in the US.

            The concern of current lithium use is raised as is the increasing use of mood stabilisers. This shift in prescribing is driven by the pharmaceutical industry, but a contributor is the avoidance of lithium due to concerns of toxicity and patient acceptance. This leads to deskilling of prescribers with less appropriate monitoring of lithium and poorer outcomes for patients. This is an issue the profession must address. Antipsychotic drugs with “mood stabilising" properties continue to multiply as do concerns with safety and patient acceptance. Hopefully, this may reverse the trend away from lithium.

            The comments concerning the fox in the hen house with the FDA and the industry may be questionable, as is the case in the similar organization in Australia, The Advisory Committee for Prescription Drugs, which is similarly dependent on fees from industry; but more mundanely, is just government making the user pay.

            Reflecting on discoveries points to Pasteur's aphorism that "chance favours the prepared mind” to best explain Cade’s discovery a conclusion that I also reached.

            The final comment conjures up a meeting between Themis the goddess of Justice and Hippocrates, a mere mortal the Father of Medicine, to assign credit to the humans who discovered how lithium might mitigate human suffering. I won’t repeat Themis’s decision, but everybody gets a mention. As might be expected, Hippocrates wasn’t impressed.

                In my judgment, Trautner's development of a plasma lithium assay was critical to allowing the safe use of lithium. Baastrup and Schou’s discovery that lithium could prevent recurrences of mania and depression led to the greatest clinical benefit of lithium. Gershon’s advocacy of lithium as a specific treatment for manic depression led to its regulatory approval in the US and availability to patients

May 25, 2017