Blackwell’s Additional Reply to Edward Shorter’s Comments
(Barry Blackwell: The Baby and The Bath Water)
Ned Shorter’s comments give added scope to the issues raised in my essay. One can go further to note that throughout our everyday life we are constantly retaining or discarding all manner of ideas, situations and 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 and reflexive responses in evaluating our own or colleague’s research results, conclusions or opinions. (OED: epistemology; the theory of knowledge, especially with regards to the methods, validity or scope.)
As a trainee at the Maudsley Hospital and Psychiatric Institute in the early 1960s under Aubrey Lewis and Michael Shepherd a core concept of the curriculum was the 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 remained mired in psychoanalytic mania (Goldberg, Blackwell and Taylor 2015). This scrupulous ideology sanctified double-blind trial designs which promptly rid the world of insulin coma therapy (ICT), 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. 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; in the language of the metaphor we threw out the baby along with the bathwater.” Something for which we were justly castigated.
So, this essay, with that title, was triggered by confronting a similar dilemma while writing two book reviews that 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 with which, years later, became the stimulus for 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 acquired a reputation of mythic proportions in Australia and around the world that is impervious to epistemological dispute in the absence of contemporary or collateral evidence which is lacking. Both baby and bathwater remain intact, but the latter is somewhat murky, blurring an observer’s conclusions.
Ned identifies two discrete issues, arriving at a consensus of what is the baby and what is the bathwater, and secondly how do we tell them apart? He lists important issues of the day about which he gives categorical “throw” or “keep” decisions. Neurotransmitters, a close call (although this garnered a Nobel Prize), mood stabilizers we keep, but ICT and psychoanalysis we “throw.” Later he equivocates; he might keep ICT which he alleges I would “trash.” Are there different criteria for “throwing” and “trashing”?
These questions raise the need to better define the baby before disposing of it. For example, shouldn’t we be careful to distinguish psychotherapy from psychoanalysis? Perhaps the biggest problem confronting psychiatrists today is their inability to combine therapy and medication management due to reluctance of insurance companies to pay for either more than brief med-checks or time for consultation between prescriber and therapist.
ICT is a particularly interesting dilemma. Some providers were firmly convinced of aspects of its efficacy (Cade was among them) and others maintained that, like chlorpromazine, it produced sufficient benefit to justify discharge from an asylum although relapse and readmission were frequent outcomes.
The epistemology of ICT leaves much to be desired considering the extent of its use worldwide. Patients were often selected with good prognostic features, recent onset and likelihood of remission. The remission rate did double but did not reduce the relapse rate. Side effects were often severe (1-5%) including obesity, prolonged or irreversible coma, brain damage and death.
The first and conclusive double-blind study was performed at the Maudsley in 1957 and published in the Lancet attracting international attention and provoking an immediate decline in treatment (Ackner, Harris, and Oldham 1957). Opinions were also influenced worldwide before and after the Maudsley study (Bourne1953; Bourne1958). Bourne’s succinct opinion was that “It made them (physicians) feel like real doctors instead of just institutional attendants.”
The world took note and the impact was clear, the baby was gone along with the bathwater and nothing of significance remained. Nevertheless, use lingered on in Russia and in a few places elsewhere. In this regard Jay Amsterdam’s comment on Ned’s reply (Amsterdam 2018) casts light on why this was so and, perhaps, how enthusiasm of a misplaced kind influenced Ned’s faint praise for ICT. Jay’s contribution was based on moonlighting as a resident at a private psychiatric hospital in Philadelphia in 1975. Almost two decades after most psychiatrists had stopped using insulin coma the owner-psychiatrists continued to do so. Their technique was quite primitive and the patients treated were mainly adolescents with personality disorders “discordant with parental expectations.” Certainly, these were results that deserve to be “trashed.”
My final concern has to do with what criteria we apply to make distinctions between throwing and keeping? Ned suggests, and I agree, that we have lost all confidence in the inadequate criteria by which the FDA defines efficacy and the skill with which the industry has corrupted that process (Blackwell 2016). Ned proposes to substitute something he calls “clinical science”: the “gut feelings” of “experienced clinicians.” This is a cogent reminder that the earliest clinicians who discovered lithium, chlorpromazine and imipramine did so in an asylum environment where skeptical physicians, nurses, patients and relatives had witnessed nothing of benefit. When improvement occurred at long last no epistemological standards were necessary; they believed what they saw.
But if we move forward a decade or so to the early 1960s at the time of thalidomide and the setting up of the FDA to determine the “safety and efficacy” of both the old and new drugs, the American Pharmacopeia was stocked with placebos, panaceas and snake oil endorsed by eminent physicians without proof or validity of their efficacy. To equate the opinion of skillful clinicians with science is to dismiss the significant difference between hypothesis and truth – a gap that can only be filled by systematic inductive research. The suggestion that a talented consensus can replace that process is a reductio ad absurdum.
The fact that Congress, Big Pharma and leading members of our profession have suborned and corrupted the FDA along with trial methodology should not lead us back to “clinical science” as an alternative. What needs to occur is for Congress to rescind the legislation that enabled this travesty to occur (Blackwell 2016). Of course, the Zeitgeist has worsened and change will be difficult to achieve with a President and Congress up to their necks in a swamp, a legion of lobbyists backed by the deep pockets of industry and the silent acquiescence of leading academic institutions, professional organizations and many of their members.
Ackner B, Harris A, Oldham AJ. Insulin treatment of schizophrenia, a controlled study. Lancet 1957; 272 (6969) 607-611.
Amsterdam JD. on INHN.org in Controversies; 12.07.2018
Blackwell B, Goldberg DP. Sir Aubrey Lewis on INHN in Biographies; 01.29. 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.
Goldberg DP, Blackwell B, Taylor DC. Sir Aubrey Lewis on INHN in Biographies; 02.09.2015
Schioldann J. History of the Introduction of Lithium into Medicine and Psychiatry. Melbourne: Academic Press; 2009
March 8, 2018