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Saturday, 17.08.2019

Barry Blackwell: Treating the Brain - An Odyssey

Edward Shorter: Foreword

 

Barry Blackwell, a psychiatrist and psychopharmacologist with an international reach, has been known for his fluent pen and quick mind.  He worked for a while in industry and has spent many years laboring in the trenches of clinical psychiatry, and is therefore well positioned to write authoritatively about the disaster that psychiatry’s encounter with psychopharmacology has become.   The author is a rare combination of someone who has his psychiatry chops, a strong basic science background in psychopharmacology and an adept historical pen.  When, therefore, he produces a big book like this and modestly says – more or less – that it’s something he chipped away at in his spare time over the years, he must be attended to carefully.  The book is worth the read:  Some of it reprinted, some original text, it is a triumph of historical scholarship and of wise, mature reflection on the part of someone now in his 80s looking back on a history of triumph and tragedy.

The triumph occurs in the first part of the story, the years from 1940 to about 1980, when one successful drug class followed another and psychiatry acquired, for the first time, the ability to relieve misery of the mind.  The tragedy is from 1980 to the present, as enmeshment with industry has corrupted the discipline, trivialized (or falsified) its intellectual content and watered down the pharmacopoeia to the point where one asks of the many “antidepressants” if they actually work at all.

Blackwell’s path to psychiatry was not a direct one.  He writes disarmingly: “I was uncertain about a career in psychiatry. Clumsy from birth, I was not cut out for the fine finger work required for animal research: I shattered expensive glass pipettes and smudged endless smoked drums. Besides, I preferred humans to rodents and felt reluctant to relinquish the breadth of medicine for the narrower scope of psychiatry. The commanding officer of my reserve army Field Ambulance was a close friend and looking for a partner in his suburban London practice. So, I decided to try my hand at family medicine.”  After further misadventures, and despite his hatred of organic chemistry, he does in fact end in psychiatry.

And so he sets out to offer us what is essentially the lived experience of a life in psychiatry, set within a scholarly framework.  How to approach this vast subject?

First there is what might be called the omnium-gatherum approach; Blackwell moves like a vacuum cleaner across the expanse of psychiatric history, picking up piquant little details in no particular order: Heinz Lehmann’s wife was a nurse; Jean Delay had an improbably large number of publications only because he attached his name as first author to everything that his assistants wrote.  This actually makes for fascinating reading.

We find John Smythies opining that, “The way that the English girls I knew moved was honed by many hours playing hockey and by many hours astride the saddle – Italian girls did not play hockey. They flow and do not jerk.”  Exquisite.

In one chapter the vacuum cleaner lands, quite unexpectedly on “women pioneers” in psychiatry, a vastly understudied subject.  Blackwell then treats us to wads of detail on the lives of nine women – such as Victoria Arango and Rachel Klein – some of whom are well known, others not. 

Out of the blue appears a chapter that Blackwell wrote in 2014 on “the anxiety enigma.”  This is not part of a systematic assessment of the nosology, which Blackwell would certainly be capable of offering, but doesn’t.  Nonetheless, anxiety occupied center stage in psychiatry from the 1960s to the 1980s and these recollections are most welcome.

Yet, as I said, there is a second approach, and that is to identify great themes in psychiatry and to return to them time and again midst the flurry of detail.  And for Blackwell the big themes are (1) The tension between biological, psychological and social features of mental illness and its treatment that he identifies both in his own practice and as prevalent among the pioneers in psychopharmacology; (2) a kind of “great man” theory of history, in which advances are made by brilliant flashes of insight and determined action; and (3) the pharmaceutical industry has corrupted the inheritance that these pioneers left to psychiatry – and to society.

Apropos individuals who made a big difference in the psychiatry narrative, Blackwell introduces us to the whole world of Edward Mapother and Aubrey Lewis at the Maudsley.  These are among the most riveting sections of the book as so many people today have fond memories of these precincts.  But were it not for Lewis’s genius at inspiring – and were it not for the German influx of refugees from Hitler – English psychiatry would have been an inconspicuous presence internationally. So, the little round of clinicians that Lewis regularly convoked at the lunch table meant that England punched far above its international weight.  This is “great man” grist.   Karl Rickels, Heinz Lehmann and others get a similar fond treatment.

Blackwell knows his figures well enough that he refers to them affectionately by first name.  Idolizes would be too strong, but it is clear that Blackwell greatly admires the men and women who parade through these pages.  Of Frank Berger, the originator of meprobamate, he writes: “Berger [offers]  a lifetime’s treasure trove of wisdom; of truth in action.”   I share these sentiments, but wish merely to say that the approach is not skeptical nor critical. 

On the drugs sponsored by these men and women,  Blackwell’s view is that, generally speaking, meds are a great benefit.   But how about “prophylactic lithium”?  Blackwell and Michael Shepherd became famously embroiled in controversy with Mogens Schou in  1968 on this issue.  Here Blackwell rows back a bit, but not a lot, and still expresses dubiety about what other observers consider the most effective agent in psychiatry.

Some of the great figures are historically not without blemishes.   John Smythies, once he reached Saskatchewan, was on the wrong side of transmethylation theories and his reputation has suffered accordingly.  But Blackwell’s sympathetic account rehabilitates him as a contributor.

In one section, Blackwell tells of his own encounter with “the cheese factor” and the malentendu with Gerald Samuels.

On industry: Blackwell is scathing about the recent impact of the pharmaceutical industry.  He writes of industry-sponsored trials: “While they adhere to FDA minimal requirements for controlled studies, [the companies] have adopted other dubious ways to degrade the process and bias the outcomes.”

Industry has always existed to make a profit.  There is nothing sinister about this, although the companies were not supposed to invade the practice of psychiatry in order to pursue their commercial rivalries.  Yet Blackwell also laments the invasion of medical practice itself by the greenback.  He closes the book: “At age 84, I now live at the distal end of the stethoscope, a problem to be solved, seldom a person to be understood, often an aggrieved patient, greeted by Mammon in a doctor’s office.”

There is so much here, and it is so delectable, that this should be a book that readers take to the beach and relish as the children splash in the water.  These memories will live on for future generations.  We owe a debt to Blackwell.

 

August 8, 2019