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Monday, 12.04.2021

Barry Blackwell: Treating the Brain - An Odyssey 2021

 

Samuel Gershon’s comments

 

       In the interests of full disclosure, I have to say at the outset that Barry Blackwell is a friend and colleague of many years. However, there are facets of his life and work that have become known to me recently. One of these is the wonderful book of poetry he published in 2016 called Naked Poems but that is not the subject of this review. Before I discuss the biographies and science that this book is about I must conclude that that the autobiographical details and personal asides that form a part of each chapter are integral to this volume.

       Some details about the author: Barry grew up in the UK and trained in medicine at Cambridge and Guy's Hospital, London and post graduate degrees from Cambridge in Pharmacology and a masters in philosophy from London University. This is only his basic educational biography and doesn't include his time in industry and private practice. This also does not include his time at the Maudsley Hospital in London prior to moving to the United States. I think we have established that he can read and write!

       A publication of his demonstrates his scientific application to his clinical observations. Whilst he was a student in England it was reported that Parnate produced a serious side effect... a rise in BP and subarachnoid hemorrhage.

       He looked at this from all angles and scraps of information with this effect. He came to the conclusion that this reaction was the result of Parnate (MAGI) and an interaction with tyramine found in sharp cheeses.            This example presents a picture of a searching mind and that is what he brings to the discussions in this book. He didn't get the Nobel prize for this but this Sherlockian observation was heard around the world. Picking up on observations too good to leave alone and finding the answers is one aspect of his style and personality.

       Now to the content and plan of the book am reviewing.

       The Odyssey starts at what may be considered the new wave of care in mental hospitals and the descriptions of some of the people who attempted to improve the situation therein. His presentation starts with Ludwig Thudichum who was a true pioneer. Blackwell then moves to the American scene describing his meetings with workers in this field. He records the meeting with Enoch Calloway and his book, Asylum: A Midcentury Madhouse and its Lessons About Our Mentally ill Today. Then the story moves rapidly on to his contacts with Joel Elkes who came to Washington from England and brought with him his work on electrophysiology. "I met Elkes a number of times and he was man of considerable stature. He also devoted a considerable amount of time improving the level of psychiatric care in Israel. As most of the psychiatrists had come from Europe they mostly used insulin coma therapy for patients with schizophrenia. Elkes brought funds and resources to achieve modern levels of psychiatric care there."

       The book goes on to the debatable issues on the discovery, development and standard use of Lithium in practice. Blackwell also attempts to address some questions dealing with the debate and discussion regarding its discovery. Here, he has a personal role as well in regard to the claims of its prophylactic effects in recurrent depression. He and some of his colleagues at the Maudsley took a position on a report by Mogens Schou in which they raised questions about the study design. Here also we see Barry's analysis of the questions and concerns presented in a most objective and critical manner even as regards his own opinions on these matters. We see here, and repeatedly, that he has always evaluated data in a most sincere, honest and critical fashion. He presents the truth irrespective of his own positions at any previous time in the debate.

       Now we will somewhat arbitrarily take 1950 as the time of change in psychiatric treatment with the discovery and development of new classes of potential therapeutic agents. A small marker went aloft after the report by John Cade in Australia of the use of Lithium for the treatment of manic excitement. Major controversies arose at the time of this report; the discussion was whether this was a serendipitous observation, as there were in the literature before this time of lithium usage in Denmark and New York City. This debate has given rise to many publications debating these questions. The most authoritative and comprehensive is the detailed presentation by Johann Schioldann. professor of psychiatry at the University of Adelaide. His book is titled History of the Introduction of Lithium into Medicine and Psychiatry; 2009. Adelaide University Press.

       Barry goes on to the group of developers of new drugs which at that time seemed to improve the picture of treating serious psychiatric disorders. Delay and Deniker in France proposed chlorpromazine as the instrument of treatment for schizophrenia. We then have a number of different anti-depressants, anti-anxiety agents, etc., coming into use. This level of affluence in drug choices began to feel like the problems being solved and cures were going to become available. Gradually we reached a situation where there were competitions within classes of these therapeutic agents. A change of marketing practice gradually appeared where several companies were in the market place for the same indication. Blackwell had experience of this situation during the time he worked in one of these corporations. This experience made it clear to him that this trend would affect the intensity of marketing activity and the lengths to which it would go to influence public decision making. This has resulted in questionable ways of presenting reports of treatment trials with even sometimes use of ghost writers and consequent damage to credibility.

       We will need to increase efforts to improve the level of education in psychopharmacology before we can effectively address this problem. In conclusion, I would like to tell the reader that I learned a lot from this book. The style impressive, especially the method used to critically evaluate a conclusion offered after presenting a personal assessment. The comments on the drug industry are frighteningly correct and this seems to me to be even getting worse. I think Pharma has changed over time. In the early days of "new" drugs popping up and while I was on evaluation committees, the drugs were evaluated and if significant or even minor questions or problems were raised, the project was either killed or sent back to the drawing board. Nowadays it seems that approvals are given much more readily so that the product can get to market albeit with side effect warnings.

       Thanks to Barry Blackwell we have an important, insightful and timely contribution to this important field with impact not only for students and practitioners in the field of psychiatry but for anyone interested in this topic.

 

April 8, 2021