Barry Blackwell's Reply to Edward Shorter

Barry Blackwell: The Baby and the Bath Water

       Ned Shorter’s comment gives added scope to the issue raised in my essay. One could go further to note that throughout our everyday life we are constantly retaining or discarding all manner of ideas, situations or acquisitions, often on slender or intuitive grounds. However, we tend to cling to what we need, value or pleases us.

       But in scientific matters we rely on epistemology to rid us of those domestic reflexive responses in evaluating our own or colleague’s opinions or conclusions. (OED: epistemology; “The theory of knowledge, especially with regard to the methods, validity or scope”).

       As a trainee at the Maudsley in the early 1960s under Aubrey Lewis and Michael Shepherd, a core concept of the curriculum was a rigorous and skeptical analysis of all therapeutic claims, a reaction to centuries of speculative dogma and deductive reasoning bolstered and backed up by charismatic clinicians and their reputation among peers (Blackwell and Goldberg 2015).

       It was Aubrey Lewis’s goal for the Institute he founded to transform European psychiatry into a scientific discipline on an equal footing with the rest of medicine while America was still mired in psychoanalytic mania (Goldberg, Blackwell and Taylor, 2015). This scrupulous ideology sanctified controlled double blind trial designs which promptly rid the world of insulin coma, but snared me in trouble over Schou’s discovery of lithium prophylaxis, the outcome of astute conclusions based on careful scrutiny of individual patients including his own brother who suffered from treatment resistant recurrent unipolar depression. Unfortunately, the design he chose to support his hypothesis was seriously flawed, encouraging us to make a critical rejection of the conclusions. With hindsight, we were wrong for the right reasons, but in the language of the metaphor “we threw the baby out with the bathwater.” Something we were justly castigated for. 

       So, this essay, with that title, was triggered by confronting a similar dilemma while writing two book reviews that together constitute a detailed biography of John Cade and his rediscovery of lithium for acute manic excitement in 1949 (Schioldann 2009; de Moore and Westmore 2016). This was the first substance, a metallic ion, to be effective for a specific psychiatric disorder, work which, years later, became the primary stimulus to Schou in his discovery of lithium prophylaxis for recurrent bipolar disorder.

       I will not recapitulate the conclusions arrived at in my two reviews but read them for yourself and note they are heavily influenced by the fact that Cade and his discovery have attained a reputation of mythic proportions in Australia and around the world that is impervious to epistemological dispute in the absence of striking new contemporary or collateral evidence which is lacking.  Both baby and bathwater remain intact, but the latter is somewhat muddied, blurring an observer’s conclusions.

       Finally, I shall make a gentle riposte to Ned’s defense of insulin coma. Undoubtedly the treatment did something for some patients that encouraged a personal conviction of value among some clinicians (Cade was among them). Many more would maintain that, like chlorpromazine, it produced sufficient transitory benefit to justify discharge from an institution, but relapse and readmission were frequent outcomes.

       The epistemology of insulin shock therapy leaves much to be desired. To begin with, patients were selected of good prognosis, recent onset and likelihood of remission. In fact, the remission rate did double but it did not reduce the relapse rate. The side effects were severe obesity, prolonged or irreversible coma, brain damage and death (1-5%).

        The first and conclusive double-blind study was performed at the Maudsley in 1957 and published in the Lancet where it attracted international attention, provoking an immediate decline in the treatment (Ackner, Harris and Oldham, 1957). Opinions were also influenced worldwide before and after the Maudsley study (Bourne 1953; Bourne 1958). Bourne’s succinct opinion was that “It made them (physicians) feel like real doctors instead of just institutional attendants.”

        The world took note (Russia was slow), but the overall impact was clear, the baby was gone from the bathwater and nothing of significance remained.

References:

Ackner B, Harris A, Oldham AJ. Insulin treatment of schizophrenia, a controlled study. Lancet 1957; 272 (6969) 607-611.

Blackwell B, Goldberg DP, Sir Aubrey Lewis (minibio) on INHN.org in Biographies; 1.29.2015

Bourne H. The insulin myth. Lancet, 1953; ii 265, 964-968.

Bourne H. Insulin coma in decline. Amer.J. Psychiat. 1958, 114; 1015-1017.

de Moore G, Westmore A. Finding Sanity: John Cade and the taming of bipolar disorder. Australia: Allen & Unwin; 2016.

Goldberg DP, Blackwell B, Taylor DC. Sir Aubrey Lewis on INHN. Biographies. 02.09.2015.

Schioldann J. History of the Introduction of Lithium into Medicine and Psychiatry. Melbourne: Academic Press; 2009.

December 7, 2017