An Erudite Encounter with: Sam Gershon

Professor S Gershon graduated from the medical school of the University of Sydney in 1950 and moved to Royal Park Hospital in Victoria for his psychiatry training, where Dr John Cade, who had identified the therapeutic effects of lithium, was Psychiatrist Superintendent. As a Senior Lecturer in the Department of Pharmacology at the University of Melbourne, he developed a productive relationship with Dr E M Trautner in the Department of Physiology and its chairman Professor R D Wright examining the scientific basis of psychiatric disorders and their treatment. This was pivotal when he later moved to the United States to assume successive chairs before becoming Vice Chancellor for Research in the Health Sciences at the University of Pittsburgh. Throughout this time, he researched and promoted the use of lithium and was instrumental in the introduction of lithium into clinical practice in the United States and also in securing its approval from the Food and Drug Administration (FDA) for the treatment of mania. He remains active as the Editor of Bipolar Disorders and is now Emeritus Professor of Psychiatry at the University of Pittsburgh.

Walking along the famous Miami Beach listening to Professor Gershon providing a personal history of lithium—focusing on its discovery and promulgation—the truism ‘history is written by the victors’ comes to mind. It’s difficult to determine from his account whether he sees himself as one of those on the winning side of the ‘lithium war’, but there is no doubt that he is one of those ‘ion men with mettle’¹ who consciously decided to pursue the difficult questions in psychiatry. Along the way, he mentored many and remains an inspiration for many more.

• The best career advice I ever received was … Career advice is as common as the viruses in a sneeze. In my case, as a medical student, I had no contact with research, no interest in it and no idea of what the beast was. The best, prejudiced, advice I can offer others is to secure the enormously great gift of a really committed mentor with a unique breadth of scientific knowledge and the personality to commit themselves to the pursuit of a question in close contact with their student. Delivery of this article is a gift of knowledge to the recipient.

• My favorite idea in psychiatry is … I had and still have many favorite ideas in psychiatry. Early on, it was simple: what makes thoughts and thinking work at all, and why differently in different people? Later, in medical school, what are all these abnormalities and diseases and what is similar or different about them? From here on, there were only many more questions.

At my time, in medical school, the explanations and understanding of these psychiatric illnesses in biological terms were essentially nil. We had no etiology, no understanding and no treatment. It is perhaps useful to give two examples of how different those times were. First, I spent part of my early residency in psychiatry in Ballarat at a large old Victorian hospital with 2000 patients. The medical staff comprised the superintendent, a most junior resident, a resident slightly senior to myself and myself. The superintendent was kept very busy filling out report forms on each patient, and, at least in all male patients with the diagnosis of schizophrenia, the etiology, as written in the superintendent’s own hand, was ‘masturbation’. The second example was in the area of treatment. We seemed to essentially have two choices: a sedative, of which there were many, from all chemical and pharmacological classes and electroconvulsive therapy (ECT).

So, understandably, my interests were skewed in the direction of treatment. Furthermore, I realized that we had no specific treatments for anything. Indeed, at that time, ECT was used for everything. Being naturally a difficult person, I thought backward. In my ignorance, I could not see making a frontal attack on causation, but as my experience developed and increased, I thought about looking for specific treatments for specific disorders. And in 1960, I wrote a paper entitled Lithium: A Specific Psychopharmacologic Approach to the Treatment of Mania (Gershon and Yuwiler, 1960); this was the beginning of a search that led to many other places and questions.

• What makes you tick? Experiences to date have given me a path and energy to continue along it with enthusiasm. However, the most important stimuli that got me to this step in the road were not my courses in medical school or the clinical training in my psychiatric residency. The magic potion was that, from the beginning of my psychiatric training in Melbourne at the university there, I met and had access to academic and research faculty who could really enlighten me. I could raise and share questions with faculty and explore ideas and ways of possibly answering these questions. And there was a world of questions that needed answering. The most important ingredient was the opportunity to find a dedicated mentor in the form of Dr E M Trautner. Thus, for the first time in my life, I thought I could contemplate doing research and get my rewards and energy [my kick] out of this new academic activity.

• One really important but soluble question in psychiatry is … Rather than a question it might be better to consider an approach. One approach would be to start by looking for a treatment for an illness, a symptom or disease, that which might be specific to that ‘entity’. Then try to use this ‘treatment’, ‘drug’ or ‘key’ to expose the inner workings of the process(es), that is, to use this as a key to unlock the etiology of a disorder. As yet, we do not have a complete picture of these kinds of puzzles, but I do believe we have come a long way from what was known when I started as a medical student.

• What is the future of psychiatry? This question has very many aspects, such as medical and resident education, concerns about clinical care and, in the United States, care for veterans; other aspects are the state and progress of basic research in the neurosciences and translational research from this phase. Also not to be forgotten are nomenclature and diagnosis and, the white elephant in all the rooms, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Basic neuroscience research is in my view the only one among the areas listed that has made impressive progress. However, even with this enormous advance, therapeutic advancement has essentially been absent, and this peculiarity needs to be considered carefully because the clinical scientists have usually argued that if we only have more basic neuroscience or that which is new and ‘relevant’, we could have better therapeutic interventions. In conclusion, I would say that the future of psychiatry from my vantage point remains uncertain until it identifies a solid foundation.