Appearing in the Australian, 24 September 2016
Bipolar disorder and depression: John Cade and the case for lithium
Finding Sanity: John Cade, Lithium and the Taming of Bipolar Disorder
By Greg de Moore and Ann Westmore
Allen & Unwin, 336pp, $33
Few people would have heard of John Cade but he was a man who truly made a dent in the universe. Another Australian researcher whose achievements were much greater than his recognition, he drew a line in the history of mental illness, and the line began with lithium, a simple mineral salt dug out of the ground.
It is hard, looking back at the 1930s, 40s and 50s, to understand how mental illness was perceived. The afflicted were often simply locked up and forgotten; treatment was primitive and often dangerous.
Even when Cade, who came from a line of physicians, was young he had an interest in these troubled people, especially those suffering from manic depression, the savage mood swings now known as bipolar disorder.
Rather strangely, it was his time as a prisoner-of-war at Changi, after the fall of Singapore, that set him thinking in a different way. As a doctor working in the harshest possible circumstances, he nevertheless retained a sense of intellectual curiosity, and he realised that malnutrition had a profound impact on mental state. This might seem obvious now but at the time it was a remarkable insight.
Cade decided to continue this line of research when he returned to civilian life and took up a position as superintendent at Bundoora Mental Hospital, on the fringes of Melbourne. He administered to a number of war-scarred veterans, trying to help them find a way back to normal life.
In fact, Cade emerges as a man of great compassion in Greg de Moore and Ann Westmore’s book Finding Sanity. This was an era when, for many men, compassion could look like weakness, but Cade always seemed ready and able to make emotional connections. He had an enduring, loving relationship with his wife, Jean, and solid bonds with his four sons. His Catholicism was a source of strength, especially when things were at their worst.
As it happened, the discovery of lithium as a treatment was almost accidental. In his shed — of course — he was conducting experiments, injecting urine from manic depressives into guinea pigs. In some cases he used lithium as a dissolving agent, and saw that the animals that received it became docile. Working from this, he realised the potential value of lithium and conducted more experiments, including taking doses himself. He was well aware that in large amounts lithium could be harmful, even deadly.
Eventually, he decided to try it on a patient named William Brand, an extreme manic depressive, during a bout of mania. The results were remarkable: Brand steadied to the point that he was allowed out on temporary leave. Cade recorded all this in careful, even pedantic notes, which he later turned into articles.
Unfortunately, Brand’s recovery did not last. Cade increased the dose, but with each increase the physical side effects grew worse. Eventually, Brand died of lithium toxicity, and although a subsequent inquiry absolved Cade, he blamed himself and discontinued his work with lithium.
But other doctors, made aware of lithium’s potential through Cade’s articles, picked up the baton. A way to calibrate doses, using new technology not available to Cade, was found. Another practitioner realised that giving patients small ongoing doses could, in many cases, prevent the extreme mood swings. The number of successful cases grew.
Eventually, after an extended break, Cade returned to using lithium as a treatment, clear in his thoughts about chemical causation.
He faced some determined opposition. Sigmund Freud represented the orthodoxy of psychiatric practice at the time, and to Freudians the idea that mental illness was caused by physical imbalances in the brain was heresy. The authors write:
John had studied but rejected psychoanalysis. It might be fine for the top end of Collins Street but it had produced negligible success in treating the most severe kinds of mental illness. He jotted notes in the margins of the Freudian books he consumed. On one occasion, he scribbled emphatically: ‘‘Not True. Simply not true.’’
Cade, ever practical, would go with what worked. This was a man who repaired his own shoes.
Over time, the use of lithium was refined, and soon other chemical treatments were developed. Cade never made much money from his discovery — there was nothing to patent, since lithium was a natural element — although he was promoted through a series of important medical positions. When he died of cancer in 1980, he seemed to be a man at peace, knowing he had done something useful.
De Moore and Westmore, both senior medical professionals, have a wealth of expertise that they bring to bear on the technical issues dealt with in the book, and they draw on Cade’s notes and writings, as well as the recollections of his sons. They are aware that this is a story strong enough to speak for itself, without undue embellishment or indulgence. John Cade, one suspects, would not have had it any other way.