It’s all happening at the moment, folks. I used to moan that we
never got enough publicity. Suddenly I am nostalgic for those good
old (quiet) days.
We have been talking on prison suicides (a predictable and
self-inflicted disaster for which someone, and we all know who,
should be held accountable). There has been the regular drum beat
that antidepressants spell the end of civilisation (no they
There is a Panorama running on Monday night about problems in
mental health care. I haven’t seen it, but am confident about two
things. First, that my long interview will be reduced to ten
seconds, missing out all the important bits and second, yet another
Chief Executive will be heading for the tumbrils.
Their life expectancy is not much better than a first world war
On the other hand, if you want something funny (funny peculiar I
am afraid, not funny ha ha) listen in to the Life Scientific (BBC
R4, Tuesday 14 February).
On the move
And I have been using my new bus pass. How long I will have it
remains to be seen, since 30 minutes after it dropped on the mat,
Simon Stevens was on the radio announcing that stopping perks like
free bus passes was the only way to save the NHS.
But before he removes the only good thing about turning 60 I
have been on the move. Health Education England to talk about the
mental health workforce – yesterday the new data on career
destinations of Foundation Year was slipped into the public
It’s bad news for the profession – numbers of those going into
higher training has declined for the fifth year running – but
actually a little glimmer of light for us – psychiatry has shown a
small but definite upturn.
Then back on the bus for multiple trips to the Department of
Health and NHS-England– IAPTS, Out of Area Placements, CAMHS leads,
addiction services and the lack of them, and so on.
Then the Ministry of Justice, followed by a stroll round the
corner to talk sex with the Bishops, and then back to Home Office,
and more Prevent.
We continue to work with them, DH, GMC, the police services and
Uncle Tom Cobley about this.
Come to the Presidential Lecture on 14 March for a real bean
fight about this, as we let Derek Summerfield off the leash.
But in the meantime we continue to steer the difficult path
between our legal duties to prevent terrorism (a duty on every
citizen), our duty to try and help those with mental disorders who
might also pose some risks to themselves or others (familiar
territory) and our duty not to cross ethical lines.
Knowing our history
One of the reasons I like psychiatry is that we as a profession
are aware of past and present misdemeanours - political abuse of
psychiatry in the old Soviet Union, or more recent dubious
practices by psychologists in Guantanamo Bay. We know, and need to
know, our history.
Which brings me by a tortuous and twisting path to history,
which is what I want to write about today. I and probably you need
a break from NHS politics and the constant game of “Cherchez
So I want to talk about America and a despotic ruler who many
think is mentally ill. No, no, no, not him – I said this was
history. We are talking George III.
Most of us only know two things about George. He lost us America
and he went mad, although those with a degree in Advanced King
George Studies might have heard that he wasn’t actually mad, but
suffering from porphyria.
You may have caught last Monday (31 January) a BBC 2 documentary
called “George III: The
Genius of the Mad King”, which challenges all the above, as
well as including a cameo from the Queen, standing next to a
historian in full flight, whilst her expression says “I have no
idea who you are, but you are clearly deranged”.
I shall leave the “Losing America wasn’t George’s fault” to
others, and stick to psychiatry. Now making retrospective
psychiatric diagnoses of historical figures is fraught with
difficulty. There usually aren’t medical notes, and even if there
are, the meaning of the words used have usually changed over time.
The disorders themselves may also have changed.
However, one advantage of being a monarch is that there is
plenty of material to study, especially as now we can read the
letters he wrote whilst ill and when well. Even then, caution is
needed. The illness of a King was a delicate matter – one of his
doctors resorted to hiding the unpalatable truth behind Latin even
in his private diary, writing that “Rex noster insanit” - Our King
The most likely diagnosis
The most likely diagnosis is that he was suffering episodes of
mania, a severe version of what we now label “bipolar
The over excitement, pressure of speech, sexual disinhibition,
excessive disorganised activity, sleep problems and so on are
characteristic. We are taught to look out for grandiose delusions -
such as believing one is, or is related to royalty, as another
feature of mania.
This doesn’t work so well when the patient is a genuine King,
but the records give plenty of other evidence of delusional
thinking common in mania.
Watch the programme also if you want to know why 5 December 1788
is the birth of our speciality and indeed ourselves.
But what about the porphyria? Everyone who has seen “The Madness
of George III”, with the King so brilliantly played on stage and
screen by Nigel Hawthorne, will remember that the film concludes by
informing the audience that the King wasn’t mad at all, but had a
rare metabolic disorder that only looked like madness.
The script suggests that the pompous doctors, played as comic
turns, overlooked this, and it was only his servants who noted that
the King’s urine returned to its normal colour as his mind returned
- a classic sign of an episode of porphyria.
It was two psychiatrists, the mother and son team of Ida
MacAlpine and Richard Hunter, who first proposed this diagnosis in
True, there were symptoms that might have suggested porphyria, a
genetic disorder which has been found in some members of the Royal
Houses of Europe. But later critics highlighted serious mistakes
and inconsistencies in the sources, and that mania was more
The question resurfaced ten years ago when scientists analysed a
lock of the King’s hair, hoping this would prove that he had
genetic evidence of porphyria, but they failed to extract any DNA,
so it is as you were.
Why did the theory of porphyria gain such traction over the
years? MacAlpine and Hunter were disillusioned. They were fed up
with psycho analysis, and instead believed that most mental
disorders were caused by either known (such as porphyria) or as yet
unknown organic physical conditions.
Diagnosing an organic metabolic disorder in one of the most
famous “madmen” in history would be a wake up call to modern
psychiatry, and also remove the stigma or taint of mental illness
from the Royal Family.
What can we learn?
Are there any lessons here for us? MacAlpine and Hunter’s wish
to remove the stigma associated with mental illness remains a noble
But instead of directly combating that stigma, their preferred
method was to say that he wasn’t really mad at all, but had an
organic and hence legitimate disorder.
They were probably mistaken in their preferred diagnosis, but
that misses the point. It is wrong to go looking into the urine,
even if Royal, solely to prove that this is a real disorder, as
opposed to unreal mental illness, which was MacAlpine and Hunter’s
We do research to better understand bipolar disorder, and to
develop better treatments, but not to prove it exists.
Now let’s fast forward to King George’s descendants to see how
much times have changed. And a quick warning that the noise you are
about to hear is the sound of a name being dropped.
Last week I hosted a private dinner at the Royal College of
Psychiatrists attended by HRH Prince Harry on how we can improve
the mental health of our current serving and ex serving
These things are off record, but I can say (and I swear I am not
grovelling) that he was bloody good, and impressed even the old
lags like me around the table.
The Heads Together campaign which the younger Royals lead is
directly challenging the Hunter/MacAlpine assumptions that there is
a hierarchy of illness, in which physical illness is placed above
mental illness. King George would have approved.
Professor Sir Simon Wessely