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Tuesday, 10.12.2019

Eulogy for Donald F. Klein (1928-2019)

by

Barry Blackwell

      

         Don Klein’s life story is the history of modern psychopharmacology from its serendipitous origins between 1949 and 1980 and into our contemporary doldrums. Also, the tale of a consummate scientist gifted with the dual talents of creativity and critical thinking deployed during his career that began in an era of psychoanalytic hegemony and ended in NIMH-induced RDoC ambiguity.

         The full story is documented in Don’s three best-selling books and more than 400 scientific articles in the world’s leading refereed journals (Klein 2015). A more personal account is found through interviews available in two volumes of the Oral History of Neuropsychopharmacology (Ban 2011) prepared for the 50th Anniversary of the American College of Neuropsychopharmacology (ACNP). In Volume 4 (Levine 1994) Klein speaks with Leo Hollister and in Volume 9 (Blackwell 2007) with John Davis. Quotations from these interviews in Don’s own words are shown below in double quotation marks and italicized.

         Don “wanted to be a scientist since childhood,” an idea fostered by trips with his father to the New York City Natural History Museum and Planetarium. This was nurtured at the Bronx High School of Science and became focused at Colby College where he “stumbled on Freud; mostly sex so I figured this guy must have something going for him.” He committed to becoming “a research psychoanalyst” and was reluctantly reconciled to “medical training as a pre-requisite though it struck me as pretty foolish.”

         In 1947 he graduated top of his college class when “antisemitism was rife in society.” But, after a year of physiology and endocrinology at NYU he was accepted to Long Island College of Medicine where he became “a budding hematologist because psychiatry was lousy, and hematology was really engaging” tutored by a talented role model, Janet Watson, a pioneer in sickle cell anemia.

         After an internship with the Public Health Service during the Korean War he delayed the draft to become a first-year resident at Creedmoor State Hospital, a 6,000-bed locked asylum, in charge of 300 patients with “no supervision, no psychotropic drugs except paraldehyde and amytal, supplemented by ECT and nursing care.”

         Then, to avoid the draft, he spent two years at the Federal Narcotic Hospital in Lexington, KY, “a wonderful experience that turned me on to psychopharmacology,” where he ran the Admission Withdrawal Service of 70 beds and using methadone. His mentor was Abe Wikler, “the smartest guy I ever met,” who was writing his book “The Relationship of Pharmacology to Psychiatry” which they discussed together.

         During this two-year stint Don became involved in research on reserpine, chlorpromazine and LSD, secretly funded by the CIA as part of their infamous program concerned with brainwashing.

         But Lexington was “also run on psychoanalytic lines like Chestnut Lodge” and Don remained true to his earlier intent to become a psychoanalyst, an idea Wikler thought “was not so smart.”

         So, from 1957-1959 Don enrolled in the New York Psychoanalytic Institute he describes as “A long sad story. Essentially, I burned out two analysts and they got rid of me.” During this time Don became one of the first NIMH Career Mental Health Investigators which included an annual stipend of $5,000 to pay for his analysis. “But I was so refractory I quit before I used the money.” When Don called the NIMH and offered to return the money, “they said keep it, we’re sure you’ll do something useful with it.” He did.

         After two years, in 1959, he ended up at Hillside Hospital in New York working for Max Fink, a neurologist and psychiatrist with psychoanalytic training – “a complete nihilist who did not believe in diagnosis” - working on ECT while Don spent his time working on the new drugs; the only person in the hospital allowed to prescribe them. For almost two years “it was the best experience I ever had, ‘a Utopian opportunity.’” He studied chlorpromazine and imipramine defining optimum dosages, how long they took to work, how to deal with side effects, who the drugs worked for or didn’t. "Eventually we wrote two papers, one on about 100 patients treated with chlorpromazine and another 100 with imipramine."

         This body of work evolved into Don Klein’s first and unique contribution to psychopharmacology, the concept of “pharmacological dissection. In essence ‘patients’ symptoms and behaviors, lumped under the same label who looked similar but had different drug responses and must have had a different pathophysiology.”

         In 1969 his findings with psychotropic drugs led to “the first systematic textbook on ‘Diagnosis and Drug Treatment of Psychiatric Disorders,’ a collaborative effort with John

         Davis. More importantly it initiated a lifetime of research applied to understanding the diagnosis and treatment of what was known as ‘neurosis’” in DSM-II and became anxiety disorders in DSM-III.

         The major portion of this research was conducted during Don Klein’s tenure as Professor of Psychiatry at Columbia University and Director of Research at New York State Psychiatric Institute between 1976 and 2007, after which Don acquired Emeritus status until his death.

         His productivity was facilitated by a system of funding that allowed him to recruit, build and retain a stable research team at a time when the NIMH was cutting back on clinical research in favor of genetic studies and support for basic neuroscience.

         This oeuvre includes 171 scientific studies and articles, almost a third of Don Klein’s lifetime research. This massive body of work addresses every aspect of anxiety disorders including diagnosis, categories of treatment, theories of etiology (C02 and lactate induction, genetic and neurochemical theorizing), co-morbidity (physical and psychological), and developmental aspects sometimes based on collaborative work in children with Rachel Gittleman, his colleague and life partner.

         Almost contemporaneous with this Bob Spitzer began putting together a Task Force with a charge from the American Psychiatric Association (APA) to develop guidelines to replace DSM-II by 1980. A major issue was the waning popularity of psychoanalysis and the evolution of modern psychopharmacology. An especially tender spot was the analytic belief that “all mental disorders were due a single etiology; a defense against anxiety”; according to this ideology the new drugs, chlorpromazine and imipramine, were only of benefit in helping reduce anxiety to facilitate therapy. Therapists who prescribed drugs hoping for a cure were acting out sadistic impulses based on their frustration.

         At the time Spitzer chose the members of the task force it was considered an unimportant effort, “so Bob could recruit a bunch of skeptical people.” Who better than Donald Klein an aspiring psychoanalyst turned productive psychopharmacologist? Don describes the outcome as follows: “The real trouble came when we got to the neuroses. So, we ditched the term and turned to their common descriptive feature to replace it with Anxiety Disorders,” a term suggested by his wife, Rachel Gittleman, also a DSM-III consultant.

         Don describes the final outcome: “Eventually DSM-III was a totally unexpected profitable hit. So that was a tremendous surprise although it had its pluses and minuses. It’s been helpful in improving the reliability of clinician’s descriptive statements. However, I think it has deflected clinicians away from taking detailed developmental histories.”

         After DSM-III was launched in 1980, when its utility and benefits took hold, two decades of accolades and awards were showered on Don Klein in appreciation of what he had helped bring forth. These were:

· 1988. William R. McAlpin Award for Research Achievement - National Institute of Mental Health

· 1990. Gold Medal Award - Society of Biological Psychiatry

· 1991. Paul Hoch Distinguished Service Award - American College of Neuropsychopharmacology

· 1996. Lifetime Achievement Award - Society of Biological Psychiatry

· 1997. Exemplary Psychiatrist Award - National Alliance of Mental Illness

· 1999. Castillo del Pino Prize for Achievement in Psychiatry

· 2004. Distinguished Service Award - American College of Psychiatrists

· 2004. Distinguished Life Fellow – American Psychiatric Association

· 2005. Lifetime Achievement Award - Anxiety Disorders Association

Comment

         The DSM-III system brought sanity to insane places. Its multi-axial format, when ideally and patiently applied, was capable of accurately portraying the biological, social and psychological components of mental disorders bringing reliability to their diagnosis and credibility to the psychiatric profession. But poorly taught in training programs, taken for granted or ignored by academia, abandoned by the NIMH and slickly applied in practice, Axis 1 became an icon to medicalize and monetize the profession. History has dealt poorly with the DSM system. Credit belongs largely to Spitzer and Klein; the blame belongs elsewhere.

 

References:

Ban TA, editor. An Oral History of Neuropsychopharmacology. The First Fifty Years. Peer Interviews. Brentwood. American College of Neuropsychopharmacology. 2011.

Blackwell B, editor. Update. In: Ban TA, editor. An Oral History of Neuropsychopharmacology. The First Fifty Years. Peer Interviews. Volume 9. Brentwood American College of Neuropsychopharmacology; 2011.

Klein DF, Davis JM. Diagnosis and drug treatment of psychiatric disorders. Baltimore, MD: Williams & Wilkins. 1969.

Klein DF. Publications. inhn.org.profiles. February 12, 2015.

Levine J, editor. In: Ban TA, editor. Psychopharmacology. An Oral History of Neuropsychopharmacology. The First Fifty Years. Peer Interviews. Volume 4. Brentwood. American College of Neuropsychopharmacology. 1994.

Wikler A. The relation of psychiatry to pharmacology. The Williams & Wilkins Co., Baltimore, 1957.

 

December 5, 2019