Barry Blackwell’s response to Gordon Johnson’s response

Barry Blackwell’s review of Gregory de Moore and Ann Westmore: Finding Sanity: John Cade, Lithium and the Taming of Bipolar Disorder

         I appreciate Gordon Johnson’s response which provides an opportunity to explain in more detail the statement that “I made the wrong decision for the right reasons” in describing Schou’s original paper on Lithium prophylaxis as “A Therapeutic Myth.”

       The wrong decision was failing to recognize that lithium does indeed have a profound preventative effect in recurrent bipolar disorders. At the time I made that statement I had only just completed my residency training during which I was mainly preoccupied with my own research on the MAOI and tyramine interactions and had never treated a patient with lithium. The truth of its effect was something I discovered after I left the Maudsley and became my own person in independent practice.

       Gordon is correct to note that the right reasons included two components. The research design and the culture of the Maudsley. But added to this was the Zeitgeist at the time my statement was made.  

       I began my residency in 1962 during the early creative years of psychopharmacology when all the first discoveries in all the major drug categories were serendipitous and dramatically effective enough to be persuasive without elaborate trial designs and statistics. Never the less it was also the era of thalidomide and a burgeoning awareness that medicine had graduated from an apprenticeship profession into a scientific discipline in academic medical centers. An infantile pharmaceutical industry had matured and was marketing powerful and sometimes dangerous drugs. Drug regulatory agencies evolved along with appropriate methods to distinguish effective drugs from placebos, panaceas and snake oil, endorsed by “experts”. The double-blind placebo-controlled study became the prototype before its feet of clay was recognized.

       The modern Maudsley, led by Aubrey Lewis, was dedicated to epistemology and a determination to develop an institution that would turn the sad state of psychiatry (which Lewis witnessed during his 1938 tour of Europe), into a scientific discipline worthy of an equal place in academic medicine (Goldberg, Blackwell &Taylor, 2015).  This was the climate I entered in 1962.

       So, it was not “Unusual and controversial to impugn the scientific integrity of an author for reasons of bias based on outcome in a family member” It was mandatory! In this case that decision was based on a number of features in trial design. First was heterogeneity of the patient sample with some cases, including Schou’s brother, suffering from recurrent unipolar depression. This led us to do a small pilot study of Maudsley patients with that diagnosis treated with imipramine and evaluated by Schou’s method, producing identical outcomes to lithium which we suggested might be due to regression to the mean. This aspect of our paper is seldom mentioned.

       Important is the fact that our critique led Schou and others to develop more appropriate research designs. It is also noteworthy that Schou later recognized that, in patients like his brother, outpatients labelled as recurrent unipolar depression might include some with mild hypomanic episodes which went unremarked. This may also be true of Lange’s early observations in Denmark, disparaged by Kraepelin.

       Based on the above I stand by my earlier statement that use of the term “Therapeutic Myth” was indeed wrong for the right reasons evoked by a combination of faulty research design and the culture at the Maudsley, widely viewed as critical but which played a vital role in restoring the respect and dignity of our profession, resulting in Sir Aubrey receiving a knighthood from Queen Elizabeth II.

References:

Goldberg D, Blackwell B, Taylor D. Professor Sir Aubrey Lewis, The Maudsley Hospital and the Institute of Psychiatry. On INHN in Biographies. 02.19.2015.

April 5, 2018