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Saturday, 23.09.2017

Barry Blackwell: Joel Elkes – An Integrative Life

Ross Baldessarini’s response to Barry Blackwell’s reply

 

Barry Blackwell’s comments on my recollections of early times with Joel Elkes are much-appreciated.  However, my experience with lithium during residency needs to be clarified.  I have characterized my willingness to take responsibility for clinical use of lithium carbonate under an IND from FDA in the mid-1960s for the entire Johns Hopkins Medical Center as a risky endeavor, and one that I would not undertake now.  This was not because other clinical departments interfered with our efforts, but because the risks were substantial and difficult to manage effectively.  Comments about risks of lithium treatment from Baltimore colleagues in internal medicine were offered and received in the spirit of collegial concern.  Most of these observations were from older physicians who were present when a series of case reports in 1949–1950 highlighted sometimes severe adverse medical outcomes when lithium was used as an uncontrolled salt-substitute for sodium chloride, often for medically ill patients who least needed exposure to such a potentially toxic material in unmonitored quantities (Corcoran, Taylor 1949; Greenfield ,Zuger 1950; Talbot 1950; Waldron 1949).

            In addition, the experience with lithium at Johns Hopkins was not a failed experimental trial, as Barry suggests.  The aim was to enable clinical experience with a promising treatment that was accepted internationally but disfavored in the US until the early 1970s, largely owing to concern about the toxic potential of lithium and its status as an unpatentable mineral with limited commercial value or industrial upport.  Joel Elkes was not involved in our work with lithium.  Findings from this work, pertaining to dosing, dose-serum concentration relationships, and adverse effects of lithium, were reported in collaboration with a senior faculty member of the Elkes department, Joseph H. Stephens, MD (Baldessarini, Stphens 1970).   Contrary to Barry’s suggestion that this experience “impaired my career” based on criticisms from medical colleagues or by a “frustrated attempt to study lithium,” it stimulated an interest that has grown over the years and encouraged a number of laboratory and clinical studies, that included developing evidence of an anti-suicidal effect of lithium (Tondo, Baldessarini 2015).  

 

References

 

Baldessarini RJ, Stephens J. Lithium carbonate for affective disorder: clinical pharmacology and toxicology. Arch Gen Psychiatry 1970; 22: 72–7.

Corcoran AC, Taylor RD, Page IH. Lithium poisoning from the use of salt substitutes. JAMA 1949; 139:685–8.

Greenfield I, Zuger M. Lithium chloride intoxication. NY State J Med 1950; 50: 459.

Talbot JH. Use of lithium salts as a substitute for sodium chloride. Arch Intern Med 1950; 85:1–10.

Tondo L, Baldessarini RJ. Suicide in bipolar disorder. Chapt 37 in The Bipolar Book: History, Neurobiology, and Treatment, edited by Yildiz A, Nemeroff C, and Ruiz P. New York: Oxford University Press, 2015, pp 509–528.

 Waldron AM. Lithium intoxication occurring with the use of a table salt substitute in the low-dose sodium dietary treatment of hypertension and congestive heart failure. Univ Hosp Bull 1949; 15:9.

 

Ross J. Baldessarini

August 11. 2016