Tuesday, 27.10.2020

Barry Blackwell: Treatingthe Brain: An Odyssey
Prologue

 

The title for this book emerged as it was being written. Originally it was to be a compendium of the biographies of selected pioneers in psychopharmacology and early controversies in the field published on the INHN website between 2013 and the present. Instead it morphed into something more substantial and sinister.

The material invited a comparison between two distinct epochs in the history of the field. The “Golden Era”- three decades from 1949 to 1980, was an innovative period when all the first drugs for specific psychiatric disorders were discovered, leading to the emptying of asylums and initiating care in the community, thus creating an optimistic, proud and highly productive profession. This contrasts with four decades, from 1980 to the present, characterized by dwindling innovation, corporate corruption in the pharmaceutical industry, professional and academic complicity in a cultural climate ofavarice, political malfeasance, ethical lassitude and research gridlock.

This comparison deserves the metaphor of “An Odyssey” – the Greek term Homer chose to describe the vicissitudes of Ulysses’ sea voyage back home from Troy to Athens. OED defines an Odyssey as “A long and adventurous journey or process.” Such journeys often include triumphs and tribulations, victories and defeats, often triggered by the Greek emotions of Hubris (excessive pride) leading to Nemesis (downfall or retribution). An outcome that seems to distinguish the two eras this book examines.

The contents of the book’s 21 chapters derive from knowledge gained in a career beginning at Cambridge University and Guy’s Hospital in London, graduating in 1961, which lead to psychiatric residency and a basic pharmacology fellowship at the Maudsley Hospital and the Institute of Psychiatry with training in epistemology, descriptive psychiatry and rigorous formulation of clinical problems.

This was followed by a brief interlude in suburban family medicine that included collaborative work on the validation of the General Health Questionnaire (GHQ) among the first rating scales to record the symptoms and natural history of milder forms of affective disorders seen in primary care.

In 1968, aged 34, I migrated to America to become the Director of Psychotropic Drug Research for a pharmaceutical Company in Cincinnati that was recovering from their disastrous research and marketing of thalidomide as a hypnotic in pregnant women. That catastrophe led Congress to establish the FDA parameters for proving the safety and efficacy of all drugs, early research in which I became involved.  I was mentored by Frank Ayd, a consultant to the company, an early pioneer and founding member of the ACNP. We did research in prisoners, he sponsored my Fellowship in the ACNP and together we planned and implemented the unique Taylor Manor Symposium in 1970 to which Frank invited all the scientists and clinicians involved in the discovery and development of each of the first drugs to treat every category of mental illness.

After two years I was appointed Professor of Psychiatry and Associate Professor of Pharmacology at the University of Cincinnati. The first faculty member not an analyst I took over the Psychosomatic Unit founded by George Engel and extended its research activities in developing a model and cognitive-behavioraltreatment methods for forms of abnormal illness behavior.

In 1974 I became Professor and Founding Chair of Psychiatry at Wright State University in Dayton – a community-based program, one of more than 30 funded by the Federal Government in the hope of graduating humanistic primary care physicians willing to work in under-served urban and rural settings. Also, as Professor of Pharmacology and Medicine, I developed interdisciplinary innovative educational programs and a broad research palate. Inevitably the experiment failed and when the charter class graduated I resigned and accepted another innovative challenge.

In 1980 I accepted the position as Professor and Chair of Psychiatry at the urban Milwaukee Campus of the Wisconsin School of Medicine in Madison. Its goal was to offer medical students and residents an inner-city experience in a largely Medicaid population. We recruited faculty and built a successful psychiatric residency program. I managed the consultation-liaison program and became involved in research and practice among the homeless population with mental illness, leading to a sabbatical at the NIMH as staff person to a federal inter-agency task force on homelessness.

In the early 1990s managed care evolved, mental health was separately capitated and within a short space of time five inner city hospitals merged and/or went bankrupt. Increasingly large health care “not for profit” corporations evolved with the mantra, “No Margin, No Mission,” and an eagle eye on the bottom line. Primary care disciplines couldn’t compete economically.  The corporation closed our inpatient program, effectively terminating the residency program in psychiatry. Soon afterwards the corporation gave the family medicine faculty the choice of ceasing to treat Medicaid patients or being fired. The chair of family medicine moved to join the corporation and within a few years became its CEO, earning $4 million annually.

These events marked the end of my academic career and for a brief time I worked as a consultant to Blue Cross and Blue Shield, then as Medical Director of a small managed care company where I enjoyed the challenge of overseeing the management of my colleagues’ difficult cases.

My academic career in all its settings included research on the educational and clinical challenges faced, funded from salary and never by industry, federal agencies or foundations. It incorporated students, residents and faculty in medicine, psychiatry, pharmacology, pharmacy and other allied disciplines with results often published in leading journals.

In 1998, aged64, I took down my shingle and embarked on a three-year exploration of my spiritual life at the local Catholic Seminary where I enrolled in a Master’s program studying religion and philosophy alongside male seminarians and women seeking a second career as parish administrators. With the help of a spiritual director (a very kind and wise nun) I recognized I was spiritually handicapped, quit the seminary and went back to work as the only psychiatrist at four Catholic Charities clinics in Milwaukee and neighboring counties where I saw a Medicaid or uninsured population unable to find a private psychiatrist willing to see such patients. It was rewarding work, collaborating with well-trained social and psychological therapists in adjacent offices and soliciting free drug samples from generous pharmaceutical representatives. This job ended abruptly when the pedophile crisis threatened to bankrupt the archdiocese and they could no longer afford the portion of my work that was not pro-bono.

Around 2004 I accepted a job in the Wisconsin Correctional system as the only psychiatrist in a women’s minimum-security prison where half the 200 inmates had a mental illness. It was highly rewarding professionally and economically – I earned enough to pay my youngest son’s medical school tuition of $40,000 annually, but which provided no medical coverage despite a large faculty practice. The Dean’s office offered to loan him an additional $10,000 a year to buy insurance. Adam declined and applied for Medicaid which was granted plus an offer of food stamps. 

In 2008 my son graduated, I quit paid work and began a new life as an amateur historian, a vocation in which I have worked with and been mentored by Tom Ban.  For three years I assisted Tom with his work as senior editor of the 10 volume Oral History of Neuropsychopharmacology(OHP). I edited Volumes 7 (Special Areas) and 9 (Update), but also penned 57 brief biographies (Dramatis Personae) for Volume 4 (Psychopharmacology) and Volume 7. The OHP was published in time for the 50th anniversary of the ACNP in December 2011. 

After a brief hiatus, in 2013 I joined Tom in helping to found the International Network for the History of Neuropsychopharmacology (INHN.org) with responsibility for Biographies and Controversies.

The components of this Odyssey are primarily the fruit of our collaboration and Treating the Brain is dedicated to Tom Ban and Frank Ayd, two of the earliest pioneers and bothmentors who became colleagues and friends. That the Prologue includes a synopsis of my own career is a reflection on something I have learned in my historical writing. Biographies and controversies are strongly influenced by the cultural climate of their time and often colored by the innate idiosyncrasies of their author. This may emerge more clearly in the Epilogue.

The chapters in this volume are arranged in roughly chronological order, each with a preamble to clarify linkages between different postings and to emphasize the conceptual framework. This structure creates more of a mosaic than a portrait, another Greek word conveying a pattern created from an assembly of individual pieces (OED: Fr.Gk.Mousa; muse).

May 24, 2018