The New York Times this past Wednesday, on p. B9, had an obituary
for Joel Elkes, a respected psychiatrist
who, the article seems to note (among other distinctions), established the
efficacy of chlorpromazine, an old-type antipsychotic later marketed under the
brand name Thorazine. Along with the fact that I had never heard of this doctor
before (which doesn’t necessarily mean much—there’s always something to learn
about the history of psychiatry and psychology), there are a number of
deficiencies with this obit. It’s almost in the realm of, “There are so many
problems with this, where do I begin?” [Edits 11/23/15.]
Incidentally, I don’t write a
letter to the Times about this
because I had written a letter to the paper about an obituary it ran for an
editor who died a few months ago that had a misleading bit of information about
one publisher she had worked for. I got a personalized response from an editor
in the Times obituary department (incidentally, for many years, I used to write
letters to the Times as a reader, and
occasionally got responses, and even a few of my letters published; but the
last of this was in 2004), and the response I was given some weeks ago, in my
view, wasn’t adequate (it didn’t concede anything). I may address this if/when
I return to my Prentice Hall mini-series.
Hence I am more apt to post my
objection to another Times obit here.
(By the way, independent of all this, I have considered doing a blog series of
sorts headed “Wrong Again: Errors in The
New York Times,” or some such title; I don’t lack for material [past or
future], but I hold off on doing this. But, coincidentally, it rather echoes
how members of the Editorial Freelancers Association used to enjoy a sport in
catching mechanical errors in the Times
back in the 1990s.)
##
True discoverers not mentioned.
Most fundamentally wrong about the Elkes obit is that, in any incisive history
on antipsychotic medications, Pierre Deniker and Jean Delay are noted as the discoverers of chlorpromazine, in a paper
presented at a conference in France in 1952. This is about two years before the
1954 study by Dr. Elkes that the Times
notes. The Deniker and Delay paper and 1952 date can be seen in the text and
reference list of Peter R. Breggin’s Psychiatric
Drugs: Hazards to the Brain (Springer, 1983), among other places. (I
believe the Harvard researcher Ross Baldessarini, M.D., in an edition of his Chemotherapy in Psychiatry, also mentions
these discoverers.) [Added 11/23/15: See this footnote for substantiating information, especially some reputable info from Dr. Baldessarini.] This is not a picky technical issue; it is a key part of
the history of these meds, cited over decades.
(While Dr. Elkes may have
authored the first paper on a controlled/blinded
study of the drug, which technical features of the study the obit notes, the
obit should have mentioned Deniker and Delay as important prior discoverers of
the drug.)
Drug class misstated. The
obit also notes that chlorpromazine is an “antihistamine,”
which is (as broadly stated) not correct. An antihistamine is a chemical that primarily
affects the histamine receptors in the human body. The chemical class of
chlorpromazine is phenothiazine. This class of medications, as do other types of
antipsychotics, have as their main action a “dopamine-antagonistic” effect.
While antipsychotic drugs may have histamine-affecting action that results in
certain side effects, i.e., among
their larger range of (often
unpleasant) side effects, these drugs’ main classification is not as an antihistamine, especially in a
therapeutic sense.
The obit, written by Benedict
Carey, who usually writes competently enough about psychological topics for the
Times, is rather childish at various
points in how it phrases things. (One phrasing, “…in the management of
psychosis, the signature symptom of schizophrenia,” is a little like the old
joke, “It’s a funny thing about people with a brain: they can be pretty smart
sometimes.”) It could be more helpfully said that—if you were to focus on what
gets classed under the term psychosis—chlorpromazine
mitigates paranoid and/or other types of thinking that ranges toward the
psychotic. In general, categories of the symptoms of schizophrenia include
abnormal ideation; trouble in perceptions (perceptual illusions [of a
fundamentally functioning type], as well as [in a more complex social sense]
misperceiving visually-based social cues, etc.); “negative” symptoms such as
absent “affect,” or sense of emotion; stereotypy in movement; etc. The term “psychosis”
as if it’s a specific symptom is decidedly vague.
Development of medications
mishandled. One paragraph is a bit misleading about the history and
types of antipsychotic drugs: “The dozen or so drugs developed since then for
psychosis are all based, at some level, on the molecular properties of chlorpromazine.”
In actual fact, the early
phenothiazines were all similar, but as a subgroup of the class of
antipsychotic medications: by brand name, these notably include Thorazine (the
drug at issue), Compazine (which later became used largely as an antiemetic),
and Stelazine. Haldol, whose clinical use started by the late 1960s, is a definitely different
class of chemical (and I don’t know how this drug was discovered).
By 1981, a textbook I used in a
neuropsychiatry class explained that antipsychotic drugs were discovered (in
more clinically operating [and later] ways than Deniker and Delay encountered)
by how certain new configurations of chemicals produced the side effects called
extrapyramidal effects (or “…symptoms”; abbreviation, EPS), which for decades
have been regarded as a bane of such medications. Once such side effects were
seen in the discovering studies, then the drug was tested for its clinical
value (in treating symptoms of schizophrenia). [Added 11/23/15: See this footnote, part 2, for substantiating information.]
Atypical antipsychotics ignored.
Further, given the fact that EPS (and the longer-term problem of tardive dyskinesia [TD]) were a set of side effects important to try to get rid of, a
new class of antipsychotics—commonly called the “atypical antipsychotics”—started
being discovered, tested, and marketed, of which clozapine (Clozaril) and risperidone
(Risperdal) were among the first, hailed
as producing less EPS (though the potential for developing TD from such new
meds remained). To say that later, “atypical antipsychotics” are similar
chemically to the likes of chlorpromazine is oversimplifying to the point of
being grossly misleading.
##
The rest of the Elkes obituary
on the doctor’s history and distinctions—apart from anything tied especially
closely to chlorpromazine—seems credible enough and worth noting for scholars
of this field, in this day and age where it seems there is increasing stupidity
in public discussion about psychological and psychiatric topics, not only tied
to alarming stories about mass shootings and the like.
But it would have been helped if
some key things about chlorpromazine, and others of the antipsychotics, were
discussed correctly in the obit.
