W. Edwin Fann: A History of the Tennessee Neuropsychiatric Institute.
Thomas A. Ban’s comment*
My years at the TNI and Vanderbilt
Leo E. Hollister’s interview of Thomas A. Ban
LH: Well, you had nineteen pretty good years in Montreal. Why did you leave?
TB: I accomplished the task of organizing a division of psychopharmacology. It was the first division of psychopharmacology in any psychiatry department in the world. But then……… In 1976, at age 65, Heinz (Lehmann) retired form the chairmanship (of the Department of Psychiatry. McGill University). And, in the same year I accepted an offer from Vanderbilt and moved from Montreal to Nashville.
LH: So, you went to Vanderbilt?
TB: I went to Vanderbilt.
LH: Vanderbilt has always been very strong in clinical pharmacology.
TB: Yes. Now, clinical pharmacology was a division of internal medicine at Vanderbilt that was directed by John Oates. We did our research in clinical psychopharmacology at the Tennessee Neuropsychiatric Institute, part of the department of psychiatry, located on the premises of Central State Hospital. TNI was established from a center grant of NIMH and supported by the Department of Psychiatry and the Division of Mental Health of the State of Tennessee. The late Earl Usdin, Dan Efron and Morrie Lipton played a major role in getting the center grant for establishing the TNI.
LH: Now, who was the chairman of the Department of Psychiatry when you went to Vanderbilt?
TB: Marc Hollender.
LH: He was rather supportive of psychopharmacology, wasn’t he?
TB: He was very supportive of my activities but I don’t know how supportive he was of my predecessor. Marc was a psychoanalyst, a very well organized, honest man, dedicated to teaching. After my arrival he referred to me for consultation some of his long-term patients in analytic psychotherapy and we became friends after one of his patients with a phobic-anxiety-depersonalization syndrome promptly responded to phenelzine, a monoamine oxidase inhibitor he prescribed on my recommendation. A few months later when the patient developed delayed and retrograde ejaculation we wrote it up and published it. A couple of years after my arrival the director of the outpatient clinic died. It took about a year to find a replacement and during this time I spent three half days a week at the clinic supervising residents, and answering their questions related to the use of psychotropic drugs. The questions the residents asked and my answers to their questions were recorded, and Marc decided to edit and organize the material in a logical sequence. Then we complemented the material by a few additional questions and answers. It became a book with the title of Psychopharmacology in Everyday Practice, published by Karger in 1980. Marc and I were very pleased when we learned that our book was translated from the original English into Japanese and Dutch.
LH: I think that having you two on the same book was quite an achievement.
TB: And he really worked on that book. He kept on editing my answers until they were crystal clear.
LH: So, it wasn’t primarily a tag along authorship.
TB: It would have been a very different book if he had not done his part.
LH: What do you think of writing books? I always thought you make more money digging ditches.
TB: You are probably right but I never looked at it like that.
LH: Well, it’s not only the money; that’s probably the least of it. It’s the fact that you hope it will have some influence but even then, you’re always dubious about it.
TB: Writing a book forces me to conceptualize the findings in our research and integrate it with the information in the literature. And, that, in itself, I find a rewarding experience. Now, I should add that it takes me a long time to write a book or a review because I keep on conceptualizing and re-conceptualizing my findings until I find the way to express what I would like and be able to communicate it.
LH: That’s one of the beauties of writing a book. You can philosophize, or tell anecdotes or things that are more personal. And, I find it rather discouraging that many of the new books are lacking this personal touch. All you’ve got is a lot of information. It does not make any sense to write a book if the author’s personal touch is not there.
TB: I think not only books but also reviews should have the identity, the conceptualization of the reviewer. A good review should be more than a summary of all the papers.
LH: Now, when you went to Vanderbilt there was the beginning of a budding institute there, wasn’t there?
TB: The Institute, the Tennessee Neuropsychiatric Institute was founded about ten years before my arrival.
LH: That was when Fridolin Sulser went there?
TB: Yes, Fridolin went there about that time. I think he got to the Institute just a little bit after Jim Dingell.
LH: Now, didn’t John Davis spend some time there?
TB: That’s correct. John Davis was the first clinical director of TNI. But I think John Davis and Dave Janowsky his close associate arrived considerably later than Dingell and Sulser. And, when John left for Chicago, Dave Janowsky, Eddy Fann and other members of John’s team left as well. There was no one there on the clinical side for two or three years before I came.
LH: Did you take John Davis’ place?
TB: Yes, I was John’s successor. But there was a period of time between John’s departure and my arrival during which all the funds of the Institute were used by the preclinical division. The Institute also had a Center grant which just expired around the time of my arrival. At the time John arrived the Institute was prosperous whereas at the time of my arrival virtually all the money the Institute had was used by the pre-clinical division. There was not enough money there to operate a clinical research service safely.
LH: So, you came there when they ran out of money.
TB: The Center grant expired and it was up for renewal. To be able to present an acceptable research grant proposal I had to organize a clinical unit first.
LH: Could you transfer your ECDEU grant there?
TB: Our ECDEU grant with Dr Lehmann was terminated few years before I left McGill. In fact just about the time I moved to Nashville, ECDEU’s Biometric Laboratory was closed, and some of the professional staff of the Laboratory, Bill Guy and David Schaffer joined me at Vanderbilt.
LH: Did the funding for the continuous operation of TNI come from the state or private sources?
TB: It came from three sources: the State of Tennessee, Vanderbilt University and the National Institute of Mental Health.
LH: You were at Vanderbilt when Earl Sutherland was there, weren’t you?
TB: He died before I arrived.
LH: So, you never had a chance to know him.
TB: No, I just knew that he got the Nobel Prize.
LH: Now, what was your primary thrust at Vanderbilt in psychopharmacology? Were you continuing to test new drugs?
TB: I continued with clinical investigations and we tested several new drugs but the primary thrust of my research was in developing a methodology that would identify the treatment responsive forms of illness, or sub-populations within the diagnostic categories to psychotropic drugs. Development of a pharmacologically valid psychiatric nosology was central to my research during the past 40 years Since pharmacokinetic factors did not seem to explain why one patient in the same diagnostic category responds whereas the other remains refractory to the same psychotropic drug given in the same dose, as early as in 1969 in the concluding remarks of my Psychopharmacology I noted that the “introduction of therapeutically effective psychotropic drugs focused attention on the pharmacological heterogeneity within the diagnostic categories of mental illness.” For some time I believed that biological measures would identify pharmacologically homogenous groups within the diagnostic categories of mental illness but by the mid 1980s it became evident to me that this was not the case and that biological measures were state dependent epiphenomena of mental illness. I published a paper on this with the title, Prolegomenon to the Clinical Prerequisite: Psychopharmacology and the Classification of Mental Illness
LH: It’s in an interesting title.
TB: The paper was an extension of my presentation on Psychopharmacology and the Classification of Mental Illness at a symposium on the 15th CINP Congress that was held in San Juan in 1986, in the same hotel we are now. After my presentation I went to the beach with Corneille Radouco-Thomas, who was at the time the editor-in-chief of Progress in Neuropsychopharmacology and Biological Psychiatry, and in the course of our conversation he told me that he would be interested to publish my presentation in his journal. He even suggested Prolegomenon to the Clinical Prerequisite as a possible title. I thought it was a good suggestion and the paper was published in his journal in 1987. In Prolegomenon, I argue that it’s not only unrealistic to expect that biological measures would provide pharmacologically meaningful clinical categories of mental illness in the foreseeable future, but I argue also that we need clinical end-points to render findings with biological measures clinically interpretable.
LH: Now, as someone who has been interested in methodology of studying drugs, are you happy with the way things are today? You know that most of the companies now have in-house help that is able to develop a protocol and also have the statistical help to analyze the results. They usually vend out the writing of the paper to some professional writing group and all the investigators do today is gather data. It seems to me like a very dull way to do business.
TB: This is correct and very unfortunate. But I wouldn’t blame the companies for doing that. They are business organizations responsible to their shareholders to generate maximum profit. It is the task of the profession that the new psychotropic drugs are optimally used in individual patients. To meet regulatory requirements companies must demonstrate that their drug is not toxic and is efficacious in treatment in at least one of the consensus-based diagnostic groups of mental illness. By the accepted standards a drug is proven efficacious if it is statistically significantly superior to placebo in two clinical studies in that population. We have been aware for some time that our consensus–based diagnoses are pharmacologically heterogeneous, so, it would have been the task of academic psychiatry to extend clinical drug development with clinical psychopharmacological research to identify the treatment responsive subpopulation to psychotropic drugs. I have been rather frustrated for some time that this is not done at the universities…,
LH: Do you think our clinical tools are sensitive enough to pick up minor differences in the pharmacological profile of psychotropic drugs.
TB: I don’t think that the current methodology of clinical investigations with behavioral rating scales focused on the detection and demonstration of efficacy has the necessary sensitivity. But there are some findings that indicate that the Diagnostic Criteria of Research Budapest-Nashville, we developed at Vanderbilt in collaboration with Bertalan Pethö’s group at Semmelweis University, has the necessary sensitivity. The DCR is based in part on Leonhard’s classification of endogenous psychoses. As you might know, some 40 years ago Frank Fish had shown that one subpopulation of unsystematic schizophrenia in that classification, affect-laden paraphrenia, responds selectively to phenothiazine neuroleptics. There are also some indications that the Composite Diagnostic Evaluation or CODE System provides the necessary sensitivity for the detection of differences in the pharmacology of psychotropic drugs.
LH: That’s an interesting and ambitious undertaking. Let me go on to another facet of your multi-faceted career. I recently picked up a copy of Thirty years of CINP, a book you and Hanns Hippius edited some years back. More recently, of course, I’ve been going through your History of the CINP that you and Oakley edited together. You’ve been interested in history for a long while, haven’t you?
TB: All through my professional career I have been interested in the conceptual development of disciplines like psychiatry and neuropsychopharmacology. I also enjoy figuring out or reviewing developments that lead to our current state of affairs. It is difficult for me to see how research could contribute to the development of a field if it is not done in a historical context.
LH: It would help to have the historical context to put things in. I’m generating a letter, currently, to the Journal of Psychiatry because they had a letter saying neuroleptic drugs are unpleasant to take. I thought that was common knowledge thirty years ago. And, the problem, it seems to me, is that the indexing systems now that are giving this search of the literature so easily and complete, go back only to about fifteen years. And, it’s like there’s no history beyond fifteen years ago.
TB: It is very disappointing that we have the capability to review historical development properly with the help of computers and we don’t use this capability fully.
LH: Now, you and Oakley, are undertaking a similar task with the ACNP history, is that right?
TB: This is, more or less, the case. It would be more correct to say that we are ready to undertake the task.
LH: Well, I think these kinds of interviews are very good, historically, but I’m still a print man. This project with all the visuals is important but I still would like to see something in written in print.
TB: I’m very glad to hear that, because we would like to see these interviews transcribed and in print as well.
LH: You know, David Healy has been doing something similar to what you are doing but, actually, he is writing up these interviews rather than filming them. And, I found the first volume of his interviews very interesting. But there are of course several different approaches to presenting a coherent historical account.
TB: We seem to have the necessary information in these interviews to present in print a coherent account on the history of the field. Do you think it would be a worthwhile undertaking?
LH: I think it’s a worthwhile undertaking, yes.
TB: We are ready to do it. That’s all I can say.
LH: You see the problem is that many organizations start off with no concept that they are going to want, someday, to know what their history was, and so they ignore it for the first decade or two. And, then, all of a sudden, someone says, “Gee whiz, we’ve got a history!”
TB: As you know we have already put in print the history of the CINP. I think it will be much easier to reconstruct the history of the ACNP because ACNP’s record keeping has been much tidier from the beginning. And I have a feeling that probably in the “Oakley era” that began with his election as Secretary/Treasurer in 1979 we will be able to find all the records we need.
LH: You know there’s a depository of information that they’re setting up with Vanderbilt now. It’s fine, but really, I don’t have any old notes. I, periodically, cleaned out my files and pitched them. I guess some people are compulsive about keeping things.
TB: I think it is very fortunate that finally we have an archive. It was Oakley who got the necessary funds to start it.
LH: Well, Tom, you’ve not only been a historical figure but now you’re a major historian of both of the large organizations connected with the world of psychopharmacology. And, I certainly wish you well in your venture to put it in a coherent, logical and written form. I think a lot of what comes out of these interviews are personal things, the people you’ve met along the way and people who have influenced you and so on.
* Extracted from Leo E. Hollister’s interview of Thomas A. Ban on December 9, 1996, in San Juan, Puerto Rico. The full interview was published in Volume 4 (Psychopharmacology, edited by Samuel Gershon) of the series An Oral History of Psychopharmacology. The First Fifty Years. Peer Interviews (edited by Thomas A. Ban), Brentwood: American College of Neuropsychopharmacology; 2011, pp. 15 -31.
November 28, 2019