In this segment, Dr. Gillman tells us about his professional background and what makes him an expert on the subjects of depression and their most appropriate treatments.
Dr. Gillman is an internationally well-known and well-recognized expert on diagnosing biologic depression and using MAOIs, a class of antidepressants widely used in the 1960s and 1970s but rarely used today, and is also one of, if not THE, leading expert on serotonin toxicity (improperly referred to as 'serotonin syndrome' by non-experts) and runs a website called psychotropical.com trying to shed light on these issues, as well as the historical and current problems with psychiatric and medical research.
Ethan: To get started, I wanna introduce Dr. Ken Gilman.
Ken: Thank you very much for asking me to join you and your listeners in talking about these interesting things and let's hope we can produce a little clarification and edification.
Ethan: Dr. Ken Gilman is the chairman of the International MAOI Expert Group. He is a self-described neuropharmacologist, retired psychiatrist, and your LinkedIn profile describes your focus, especially over the last decade, has been in the fields of drug effectiveness, dishonesty, and bias in pharma-funded studies, side effects and toxicity with particular expertise in serotonin toxicity, neuroleptic malignant syndrome, and drug toxicity in general. You have, according to ResearchGate, 170 publications with over 4,000 citations. Tell us about Psychotropical, but also, over the course of your career, how do you maintain resiliency?
Ken: Goodness me, where to start? The substantive part of my training career I was involved quite a lot in research. In those days, I don't suppose things were quite so cutthroat. The pressure to pass exams or publish papers was nowhere near as great. So we cruised along doing different things. I probably have the most extraordinary dichotomy in terms of the type of psychiatric practice that I had. At one stage in the earlier part of my training career, a day in my week, I worked on the Jeffrey Knight Psycho-Surgical Unit, where we did stereotactic tractotomies, where we implanted yttrium seeds for people with very severe treatment-resistant depression. I hate that phrase, treatment-resistant depression. We haven't found the right treatment yet-Depression, it should be called. A lot of people might see that as being a fairly extreme biological intervention for depression; it was actually a jolly good operation. And it was very safe. We had very few significant problems or serious side effects from the operation. And I did that in the morning. And then in the afternoon, I worked in the sex therapy clinic, where my co-therapist was the professor's wife. Christine and I used to have wonderful fun doing our sex therapy. We both agreed with the notion that if people couldn't laugh about it, then there probably wasn't much hope for them. I don't believe there'd be anybody else anywhere in the western world who's done brain surgery in the morning and sex therapy in the afternoon. Isn't that a wonderful juxtaposition?
Working in that unit, I got a very great deal of experience of very difficult cases of depression because, of course, we took, referrals from teaching hospitals all over the country, and, of course, referrals from abroad as well. We treated patients from various different countries. Very early in my career I was exposed to an unusually large percentage of patients with very severe depression. So that meant that by the time I started practicing outside of that area, I was much more ready to use MAOIs than almost anybody else. I was blase about them right from the beginning and I used to use Clomipramine all the time because all the decent psychopharmacologists that we were aware of and who used to refer to us in the seventies all immediately came to the conclusion that Clomipramine was clearly the most potent of all of the tricyclic antidepressants. It was only about that time that the better neuropharmacology data was coming out that made it very clear that the difference was that it was a potent serotonin and noradrenaline reuptake inhibitor and none of the other tricyclics fitted that bill. I think that's something that even now, is not understood or insufficiently understood. And as I'm sure many of the analyses of this question of whether SSRIs are as good as tricyclics or not, compare them to Amitriptyline and state that amitriptyline is a dual action serotonin and noradrenalin reuptake inhibitor, which is clearly not true. So the knowledge of connecting what we know about neuropharmacology to what we know about how drugs work in real patients is just not happening. Most psychiatrists don't understand neuropharmacology. It's quite frightening and I speak to famous professors at various institutions in North America and Europe, especially in relation to things like serotonin toxicity, and it becomes apparent very quickly that they actually don't what they're talking about.
Ethan: The problem is not so much that they don't know; the problem is that they think they know, and they don't know.
Ken: Yes, George Bernard Shaw.
Ethan: I don't know nearly enough, but I know what I don't know, and I know when I need to refresh and find good sources.
Ken: Yep. You made me think of my George Bernard Shaw quotation. Beware of false knowledge; it is even more dangerous than ignorance. There's a psychological phenomena that describes this, isn't it? That people don't know enough to know how much they don't know. Can you think of what it is?
Ethan: The Dunning Krueger Effect?
Ken: I think that's it. Yes. Well done.
Ethan: The curve of, once you realize that you really don't know anything, that's when you know the most. One thing that I really am coming to appreciate about you, Ken, is you appreciate nuance and you're comfortable with uncertainty. Part of our problem in America, and maybe worldwide, is this drive and desire for certainty and order, but when you're talking about a human being, we're so complex neurobiologically that we can't ever have certainty. Doctors and providers and patients have to come to grips with the fact that we are messing with systems that, yes we have a lot more knowledge about them than the general public, but we still don't know so much about our field and what causes our illnesses.
Ken: Sometimes we haven't even got to the stage where we know enough to understand how much we don't know. Anyway, I never really liked London. I'm a country boy at heart, so as soon as I'd got enough runs on the board to have a good chance of getting a job where I wanted one rather than where I was forced to go, I moved and I went to the professorial unit down at Southampton, which was delightful. Way back in the early ‘80s, I started using sodium valproate for mania way before anybody else, when I was just looking for any excuse to treat any patient with bipolar disorder with whatever antiepileptic I could get my hands on. Because it seemed to me perfectly clear that exploring the effect of different antiepileptics on bipolar disorder was absolutely the way to go. It was soon apparent that it was so extraordinarily effective that I remember ringing up Gordon Parker, who's just about the only professor in Australia or psychiatrist in Australia that I would have respect for. In my opinion, Gordon's done some of the best work anywhere in re-establishing the concept of melancholic depression, joining people like Barney Carroll and various other people in America, and arguing that DSMs been a complete disaster and has turned all sorts of depression just into a meaningless spectrum. It's done a great deal of harm to research over this last, well, the whole of my professional lifetime, basically the last 40 years. So Gordon would be one of the people I'd have some respect for. So I rang Gordon to say, ‘Look I've treated half a dozen or 10 patients with sodium valproate for mania now, and it's been so extraordinarily effective; I'm worrying that somehow I'm seeing things through rose-colored glasses, so I thought I better ring you guys and see what you were doing with it and how successful you were.’ Gordon said, ‘We've only treated 3 or 4 patients, Ken, so you tell me what you think.’
We had a house on the river not far from Southampton. It was rather a nice little spot. So I lived at the house there and worked at Southampton, and I rapidly got promoted to be the acting consultant there when somebody left. But at that stage, I had already decided that I wanted to go and live somewhere nice and warm. And I was thinking of tropical North Queensland. I wanted somewhere politically, socially, and economically stable, English-speaking, and where I wouldn't have to do any more damned exams. I hated exams. They simply filtered out the people who could rote learn, but couldn't actually think for themselves. And as soon as I got promoted to be a consultant there, I realized that my previous thinking about the system over there, the National Health Service, was that, what did George Bernard Shaw say, ‘Those who can do and those who can't, teach?’ It's a little bit unfair to teach us, but there is a kernel of truth in it.
Ethan: And those who can't teach administrate.
Ken: Yep. In the research coffee room, we did a whole hierarchy that went about 4 or 5 stages further than that. Those who can't teach, write book chapters. Those who can't write book chapters, do epidemiology, and those who can't do that do drug trials or something. I realized that the more competent you were, the more of the actual work you did, and the less competent you were, the more you sat on committees telling the people doing the work how they ought to do it. And within a matter of weeks, I was called in front of one of these committees to explain something about what I was doing, and after half an hour of being told I must do this or I should do that, or whatever, I said, ‘Look, I'm doing the work. You don't have the authority to tell me how to do it, so if you want to go on discussing it, please continue. But I've got to go and do some more work.’ And I just got up and walked out. I think I'd already made my decision to come to Australia. But when that happened, I thought, yes. It would be completely impossible to go on working in the National Health Service because I just wanted to get on with what I wanted to do and not spend half my time sitting in committees discussing how it ought to be done. Yes.
And then I almost got persuaded to stay because of a couple of research papers I was writing. They were just starting a new research place outside London. I think it was financed to the extent of 500 million back then in 1980, and they offered me a job there. But I decided to come to Australia instead. In my first 10 years in Australia, of course, I couldn't really publish or do any research. I was too busy establishing my private practice. I worked a little bit in the public hospital to support the public system and had my own private practice, but a significant part of the time, I was the only psychiatrist here in Mackay, which is about a thousand kilometers north of Brisbane. For any Americans listening, you may need to look at a map. And then, of course, the Internet came along and it wasn't long before we were computerizing our practice and using the Internet and everything else. And then of course it became possible for me to sort of re-engage in the research community. But obviously as a full-time practicing clinician I didn't have much time to do it, but I kept up with reading the stuff that interested me and stuff like that.
And then of course I had to retire early because of my neck and back trouble. I simply couldn't use my arm to write anymore. And that forced me to give up clinical practice. We were very fortunate in that our circumstances were such that we were financially okay. And so since then, that was 2006, I've been retired. In the very early part of my retirement, I decided I really ought to put my money where my mouth was and publish in proper journals 1 or 2 papers about things that I'd been rabbiting on about for a long time, most of which were, going against the tide of opinion. That's fairly characteristic of my career, going against the tide of the opinion. Those first two papers were the paper on Mirtazapine, explaining that it wasn't a drug that increased serotonin; it actually decreased serotonin. I was astonished how the profession accepted what I would call essentially fraudulent and deceitful data that was produced about Mirtazapine. Those who are interested need to read that peer reviewed paper and look at what I've written on the website as well (https://pubmed.ncbi.nlm.nih.gov/16342227/). But I was flabbergasted how easy it seemed to be for the drug companies to pull the wool over the eyes of psychiatrists. Quite extraordinary.
Ethan: It's a wild field that we work in, especially in America and the land of the free market.
Ken: It is a little bit of a problem, isn't it? It's degraded science to a very substantial degree. I'm sure that many of my colleagues, our colleagues, don't really appreciate what a big problem it is. They convince themselves that they can go out to dinner with drug reps and not be influenced by it. And it's so naive, isn't it? The easiest people to con are people who think they can't be conned. Of course, David Healy has been active in that sphere and has uncovered a lot of the evidence of the perfidy of the pharmaceutical companies in relation to fudging data and all of that sort of thing.
As I think you realize my mission, since I essentially stopped publishing scientific papers - that's changed now - but before I had any help I just decided I'd published enough papers to have the cred that most people would listen to me and publishing papers is basically a waste of time. Nobody reads them. Even if they do, they don't get cited properly. It's just a joke that the medical literature has become a complete farce. So I decided the best thing I could do with the rest of my energies was to educate the public because if we're gonna get MAOIs used more, it's gonna be consumer demand that does it. Educating doctors takes decades, not years. So you've gotta create the demand. And then, if doctors are poked in the ass by the demand, then they'll get their act together and start doing something.
Ethan: The problem in America is direct to consumer advertising. You and I are gonna do direct to consumer education.
Ken: I've been very much focused in this last five years on getting information to the public and trying to educate younger doctors. So we're absolutely on the same page there