Australian psychiatrists on the world stage

Abstract

Objective:

To nominate Australian psychiatrists no longer living who made a distinct international contribution and impact.

Method:

Personal choices were made in nominating five psychiatrists and with supportive arguments provided in reviewing their contributions.

Results:

The five nominated psychiatrists were John Cade, Aubrey Lewis, Leslie Kiloh, Bernard Carroll and Issy Pilowsky.

Conclusion:

Background information allows the contributions of the five nominees to be both considered and celebrated.

A colleague recently asked me how many Australian psychiatrists I thought had made an international impact, so stimulating this contemplative piece. In a rare moment of prudence, I judged it wise to avoid any listing of current psychiatrists and thus I consider only those no longer alive.

The question first invites some reflection as to what is meant by ‘impact’. Is impact displayed by a distinctive research finding, providing a new therapeutic paradigm, challenging some psychiatric zeitgeist, being a unique and notable teacher or by some other contribution? Surely, impact is not gauged by volume of publications, number of invited international lectures or any other metric that simply weights performance or output.

My first nomination – one that I suspect would be universally accepted – is John Cade. His landmark identification of lithium as an effective treatment for mania and as a mood stabiliser changed the landscape for those with a bipolar disorder and their kin. His seminal ‘case report’ published in the Medical Journal of Australia in 1949 was an open study of the impact of lithium on 10 patients and remains till today the most highly cited paper published by that journal. Such a report, an uncontrolled study with few patients, would struggle to find a publisher today. His claims about the efficacy of lithium went unnoticed in most parts of the world for more than two decades, with several academic psychiatrist luminaries in the United Kingdom and in the United States firmly rejecting its suggested role as a mood stabiliser. Application studies, particularly by the Danish researcher Mogens Schou, formally established its efficacy in the seventies, while, by the early nineties, lithium had been quantified as generating hospital savings in the order of US$145 billion in the United States alone (Kirschner et al., 1994). Since then, lithium has also been recognised as an augmentor of antidepressant drugs and for its anti-suicidal properties, while it is universally listed as a first-line medication for managing those with a bipolar disorder.

Cade is therefore ranked so highly because of his introduction of a non-derivative medication that has continued to be of untold benefit to so many patients with a bipolar disorder, assisting stabilisation of mood, improving quality of life and directly and indirectly reducing suicidal risk.

My second nomination is Sir Aubrey Lewis. His name is unknown to many younger regional psychiatrists. He was described (in a newspaper article about the opening of the Aubrey Lewis unit at Royal Park in 1990) as ‘the man Adelaide forgot’. Highly informative reviews of Lewis’ career have been provided by Gelder (1976), Shepherd (1977) and Marley (1983).

Lewis was born in Adelaide in 1900 and graduated in medicine from the University of Adelaide in 1923. After 2 years engaged in anthropological research on Australian aborigines, he went to the United States and was mentored by Adolf Meyer – a man whose leadership he admired, although he judged his teaching as ‘notorious for its obscurity’. In 1928, Lewis moved to England and the Maudsley Hospital. His MD thesis, passed by the University of Adelaide in 1934 and which generated several classic papers, involved careful evaluation of 62 depressed Maudsley in-patients – albeit qualitatively assessed as multivariate analyses had not entered the research domain. Shepherd (1977) observed that Lewis produced a stream of papers in the 1930s on various topics, while his ‘most ambitious and best known … are his studies on melancholia’, and with his ‘historical survey of melancholia … (being) … a tour de force of balanced scholarship’ (p. 8). Most commentators judged that he delivered a definitive view on how the depressive disorders might best be modelled, arguing for a unitary model as he could not find convincing evidence supporting the endogenous–reactive or neurotic–psychotic dichotomy binary model – a dichotomy which Shepherd states Lewis viewed as ‘meretricious’ (p. 8) – but in his thesis Lewis also intriguingly argued for the avoidance of classification.

The last conclusion frustrated Eliot Slater, who observed that ‘The sceptical approach to psychiatry is not enough’ (see Gelder, 1976). However, Lewis, who recognised that scepticism – and episcopacy – was derived from the Greek word meaning ‘to examine’ and ‘to look to’, judged that psychiatry suffered from ‘too many theories balanced uncertainly on too few solid facts’. More prosaically, his failure to find any support for contrasting melancholic and non-melancholic depressive conditions may well have reflected cohort nuances: all were in-patients and thus his sample was over-represented if not dominated by those with melancholia. Against that simple explanation (a lack of variation in depressive types across the sample), Leslie Kiloh and Garside (1977) extracted data on 58 variables from Lewis’ clinical descriptions of each individual and held that his quantitative (multivariate) analyses of that data set did identify support for the binary model. At times, Lewis’ scepticism led him to therapeutic nihilism. For example, he was dismissive about the value of tranquilisers, antidepressant drugs and electroconvulsive therapy (ECT), and he distrusted psychotherapy’s broader claims.

In 1936, Lewis became Clinical Director of the Maudsley Hospital and, when its medical school was renamed the Institute of Psychiatry, he was appointed to its inaugural Chair, where he remained for two decades. He was never its director as, uniquely, it never had such a position. In that absence, Lewis positioned himself as primus inter pares. The success of the Institute led to the US National Institute of Mental Health (NIMH) adopting its philosophy and much of Lewis’ model.

Gelder (1976) judged Lewis’ greatest achievement as creating the Institute of Psychiatry with its attendant ‘intellectual ferment’, and where he attracted researchers from all over the world, and focussed on mentoring future clinical and research leaders, judging that psychiatry lacked ‘men of intellectual distinction’. His research topics ranged broadly (albeit with a focus on melancholia and obsessive compulsive disorder), but Shepherd judged that his contribution to research was more made by ‘his tenacity of purpose and his ability to organise research’ and that his interest in social aspects of psychiatric illness led him ‘to one of his great achievements, the establishment of the Social Psychiatry Research Unit’. Lewis personally taught respecting a Socratic approach, commenting frequently that ‘Medicine can be learnt but cannot be taught’, and brought history, scholarship and a scientific approach to his teaching. Lewis also established the Maudsley Monographs, together with a host of other educational, research and mentoring strategies. Gelder judged that Lewis’ influence as a teacher of psychiatry was as equivalent in its impact as Osler’s was on medicine in his day.

He was respected by leaders of other medical specialities and appointed to numerous national and international bodies, being the first psychiatrist to serve on the Medical Research Council. Gelder summarised Lewis’ strengths as combining a ‘rare combination of intellectual power, scholarship, wit, determination and common sense’.

Lewis’ intellectual strengths saw him held in awe. Marley (1983) notes that with ‘thought and tongue prodigiously swift, his argument marshalled instantaneously and without apparent need for reflection, Lewis was virtually unassailable on his own ground’ and that ‘there was a terrier-like quality in the way he seized and harried vapid notion’ but that ‘Redoubtable as he was, when one persevered beyond the initial Socratic exchange, zest, wit and warmth were the hallmarks of his dialogue’ (p. 97).

Thus, Lewis is nominated for his skilled empire building, for training and inspiring many future luminary leaders of psychiatry, for his international contribution to psychiatry and for his intellectual brilliance which brought psychiatry and psychiatrists’ credibility from the medical community.

My number three nomination is Leslie Kiloh. It could be argued that Kiloh was not an Australian psychiatrist, as he only came to Sydney in his early 40s (in 1962) when he took up the inaugural Chair in Psychiatry at the University of New South Wales, before retiring in 1982. While my nomination weights his studies after arriving in Australia, his earlier work needs to be overviewed and recognised.

After active service in the Second World War, Kiloh took up a position at the neurological unit at King’s College Hospital in London, before moving to Newcastle-upon-Tyne where, with Sir Martin Roth and other colleagues, he focussed on subtyping the mood disorders – becoming one of the world’s leading exponents of the binary view – and on undertaking treatment studies principally of the tricyclic antidepressants. His Clinical Electroencephalography monograph, co-written with Osselton, first published in 1961 and with second and third editions in 1966 and 1972, was long regarded as the definitive electroencephalography (EEG) reference work. His 1951 paper on ocular myopathy resulted in the diagnosis of a new medical condition: the eponymous Kiloh–Nevin syndrome. His several papers in the late 1950s and early 1960s on imipramine advanced its acceptance as an antidepressant, while his 1961 paper on pseudo-dementia is regarded as a classic – although it took over a decade to be viewed as a definitive piece of work.

Following his move to Sydney, he published extension articles on depression subtyping, employing multivariate analyses, with results arguing for the independence of endogenous and neurotic depression (i.e. the binary model for the depressive disorders), while, as noted earlier, his re-analysis of the Lewis data argued again for the binary model. Thus, for some two decades (before and after his move to Sydney), Kiloh was one of the key international flag carriers for the binary model and in arguing for endogenous depression (i.e. melancholia) as a categorical psychiatric disorder.

In establishing and heading the University of New South Wales School of Psychiatry, Kiloh selected a group of academics with disparate research interests, with most flowering after their appointment. He set up and led a clinical psychiatry unit and later was also Acting Director of the Psychiatric Research Unit (PRU) at Callan Park Hospital, and which was established to provide a neurological and neurosurgical service to state psychiatric facilities. While this institution focussed on neuropsychiatric assessments (and later segued into the Neuropsychiatric Institute [NPI] at Prince Henry Hospital), Kiloh initiated psychosurgery: modified prefrontal leucotomy, and later – drawing on the expertise of Bristol researchers – electrode implantation strategies for treatment-resistant patients with severe depressive and obsessive compulsive disorders, the severity of which was captured by the evocative and clinically meaningful phrase of ‘tortured self-concern’. Published results from these interventions were encouraging but results less so for amygdaloid surgery for those with severe rage episodes. This latter led to a temporary ban on such surgery until completion of a 1977 Ministerial Committee of Inquiry and subsequent creation of a Psychosurgery Review Board. Psychosurgery at the PRU was effectively brought to a close by the impact of the Inquiry and by the political climate in the 1970s, with both the public and many professionals in the new climate of anti-psychiatry equating such procedures with the feckless and often catastrophic use of lobotomies as practised in the United States.

In the late 1980s, deep brain stimulation (DBS) was developed as a strategy for assisting some patients with Parkinson’s disease and it was subsequently introduced into Psychiatry as a therapeutic option for the same group of patients that Kiloh had focussed on nearly two decades previously (using electrode implantation) and with a similar logic. If Kiloh’s work in this domain had not been discontinued, I suspect that Australia’s contribution to the development and application of DBS would have been distinctive and with Kiloh appropriately accorded seminal status and international recognition.

The definitive English textbook influencing psychiatry trainees in Australia and in much of the western world at this time was ‘Clinical Psychiatry’ with its third edition edited by Mayer-Gross, Slater and Roth. The publisher invited Martin Roth and Leslie Kiloh as authors of the fourth edition, aiming to publish it in 1983, with that invitation speaking to Kiloh’s status in the 1980s. The text had the potential to continue to educate psychiatrists in the British empirical model that Kiloh brought to Australia. While Kiloh completed his chapters for the publisher, Roth was unable to finish his set and the project lapsed.

My fourth nomination in this series is Bernard (Barney) Carroll. Born in Sydney in 1940, he later moved to Melbourne where he completed his medical degree and psychiatry training. Coincidentally, John Cade was one of his consultants. Carroll nearly took up employment with Kiloh at the PRU but instead moved to the States, first to the University of Pennsylvania, then to the University of Michigan. In 1983, he became Chairman of the Psychiatry Department at Duke University. As described by Carey (2018), Carroll helped ‘put it on the map, greatly diversifying its expertise’ and ‘reigned there’ until 1990, showing ‘an exacting scientific and ethical purism that rankled some’.

Carroll’s most distinctive scientific contribution was to develop the dexamethasone suppression test (DST) as a ‘laboratory test’ for melancholia with a key paper being published in the early 1980s (Carroll et al., 1981). Such a ‘meticulously studied’ (Rubin, 2019) laboratory test was a potential first for psychiatry. While Carroll continued to publish many papers quantifying its validity and utility to diagnosing melancholia, American researchers viewed and tested it more as a measure of depression and depression severity. Not being so designed, it was predictably marginalised, and psychiatry lost an opportunity to establish melancholia’s categorical subtype status by a laboratory test (and then iteratively define its discriminating features).

As an academic, Carroll applied a giant intellect to psychiatric research. An example, his chapter (Carroll, 1980) on diagnostic validity and how to pursue and establish validity for differing depressive disorders (via ten ‘rules’) remains a classic paper. He was also wise. Some of his aphorisms, for example, ‘To understand depression is to understand psychiatry’ have echoed with me over the years.

In the late 1980s, Carroll ‘began another kind of career’ (Carey, 2018): he ‘dissected psychiatric studies as they appeared, flagging sloppy work and sniffing out conflicts of interest’. He became an active critic of research that was less than rigorous or was misleading. He would dissect methodologies, analyses and interpretations, ‘using masterful English to write withering prose’ (Rubin, 2019) either to authors who over-reached in their published studies or to journal editors. The wise researcher would take such criticism as objective and useful, but many tended to view Carroll as carping. In addition, he actively campaigned (joining with a US Congress member) to expose instances of corruption or ‘mendacious science’ (Rubin, 2019) that he identified in a number of published drug trials, with his colleague Allen Frances judging that he became ‘the conscience of psychiatry’ (Carey, 2018). Rubin (2019) added that Carroll’s efforts led to ‘demonstrably higher awareness … that irreparable degradation of truth and trust in science can result from biased and fraudulent presentations and writings’.

Moving on, my fifth nomination is Issy Pilowsky. Pilowsky was born in Cape Town and undertook both his medical degree and MD there, with his thesis focussing on hypochondriasis. He then moved to Sheffield in England and worked with Erwin Stengel, where he advanced his work on hypochondriasis and, in 1967, published the Whiteley Index of Hypochondriasis (Pilowsky, 1967). He moved to Sydney in 1966 to become a senior academic at the University of Sydney, where he impressed our trainee group with his intellect and humour, and brilliantly taught us some of the nuances of psychotherapy, before taking up the position of Professor of Psychiatry at the University of Adelaide which he headed (as well as being Dean for a period) for 25 years.

His seminal paper on abnormal illness behaviour was published in the late 1960s (Pilowsky, 1969) and focussed on patients ‘with physical complaints for which no adequate organic cause can be found’ (p. 347). He listed 16 differing diagnostic labels such patients might receive, observing that such ‘patients roam a sort of medical no man’s land, in which there is never a closed season and where they are constantly peppered with treatments and diagnoses’ and with the managing doctor often feeling that ‘he is the prey, and the patient the hunter’ (p. 347). He drew on Mechanic’s definition of ‘illness behaviour’ to suggest that patients so labelled are viewed by their doctor as wanting to be regarded as ill but lacking objective pathology to justify such a judgement, and that it then becomes the doctor’s (or psychiatrist’s) task to clarify the nature of the abnormality ‘in terms of a number of considerations’. In listing candidate considerations, Pilowsky demonstrated intellectual rigour, clarity and practicality.

His paper, with the objectives of identifying the key clinical issues, providing a better understanding of clinical nuances and offering an approach to addressing such patients in order to avert patient doctor loggerheads and reduce diagnostic errors, was succinct, focussed, thoughtful and original, evidencing a high level of pattern analysis and clinical wisdom. At the wider level, and in many ways driving my nomination, it offered a model for consultation liaison psychiatry more generally and was quickly embraced by its specialist practitioners, leading to international as well as regional impact. By drawing on Mechanic’s medical sociology background, Pilowsky’s model could be viewed as providing a sociological perspective but, to me, it moved abnormal illness to a psychological domain with relevance to understanding a heterogeneous group of psychiatric conditions via a broad conceptual model. This is in contrast to the alternate approach (still maintained in diagnostic manuals) of seeking to delineate and differentiate conditions such as hysteria, hypochondriasis and psychogenic pain at the micro level, and where such microscopic dissection can risk losing the ‘big picture’ and an understanding of why a patient presents with prioritised somatic features at a particular time.

Together with colleague Neil Spence, Pilowsky developed the Illness Behaviour Questionnaire (Pilowsky and Spence, 1975), essentially an expanded version of his 14-item Whiteley Index of Hypochondriasis, and designed to provide information about the attitudes, views, affects and attributions of illness in patients whose physical complaints more reflect manifestations of a psychiatric illness, and thus dimensions of abnormal illness behaviour (AIB). AIB is best understood as set out in a detailed publication (Pilowsky et al., 1984) where the authors argue for its application as an aid to clinical assessment by reference to patient scores on its scales (measuring the degree of hypochondriasis, denial, disease conviction and four other constructs). Development of such a measure was a natural clinical extension of Pilowsky’s AIB model, but it is the model itself and its appreciation and take-up by consultation liaison psychiatrists that leads me to nominate him.

Background reading informed me of the solid worth of these five nominees and I hope that other readers, similarly, come to celebrate the lives and contributions of these men.

At the beginning of the paper, I mused about how international ‘impact’ might best be identified. In overviewing the contributions of the five nominees, any attempt to isolate a single distinctive attribute (e.g. Cade – master clinician researcher; Lewis – academic and administrative brilliance; Kiloh – research originality; Carroll – quintessential researcher and research critic; Pilowsky – parser of illness behaviour) limits their breadth. While no single attribute model appears salient, there is a field focus on mood disorders. Clearly, all were exceptionally committed clinicians and passionate researchers, all were leaders, and all accepted a wide range of administrative responsibilities. Some were scholars of high order but, as noted, had multiple other skills. Some were accommodating and gentle in manner and others more provocative, some struck gold in their research pursuits and others experienced frustration as they fell short of a goal, only to return to the field. All were inspiring in their fidelity to their vocation, their vision and their creative perception.