Conversation with Malcolm H. Lader


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In this occasional series we record the views and personal experience of people who have specially contributed to the evolution of ideas in the journal's field of interest. Malcolm Lader is a British psychopharmacologist who, from 1966 to 2001, directed an MRC-funded research group at the Institute of Psychiatry. He has made fundamental contributions to understanding of benzodiazepine dependence and his work gives salience to the problem. From 1983 to 1993 he was President of the Society for the Study of Addiction.

EARLY EXPERIENCES AND MEDICAL TRAINING

Addiction (A): It is often useful to start off an Addiction interview with some information on our subject's personal background.

Malcolm Lader (ML): My family was, I suppose, very poor working class. My father's family were from Leeds. My grandfather was an agricultural labourer who came off the land into a clothing factory. My mother's family came from Liverpool, again quite poor. My father was, however, professional—he won a scholarship to Leeds Grammar School and then obtained a university degree, but in the wrong subject. My grandfather wanted him to do medicine on the basis that you could always make a living in medicine, but my father refused. He went into industrial chemistry—dye stuff chemistry. Just as he was about to graduate in 1926, the German dye industry got back on its feet again so he never worked in industrial chemistry until the outbreak of the Second World War. He had short-term jobs and he always told me that his greatest ambition was to be working-class and not unemployed. He was in a reserved occupation during the war making poison gas. He got a reasonably well-paid job after that, but of course he only had half the pension years. Because he had to save hard, I was probably the poorest medical student in my year. My father seemed better off in later years and we had a car by then, but there still was not much money to spend. It is one of the reasons why I was not able to go to Oxford and settled for the local university, Liverpool.

A: What sort of experience was life at medical school like?

ML: Liverpool medical school was very orientated towards becoming a doctor—a tremendous amount of practical work. The medical students were relied upon to help run the medical services in Liverpool, which were very run down and vastly under-funded. I saw real poverty. When I was doing obstetrics in the 1950s, the most common cause for an elective caesarean was pelvic distortion due to rickets. People talk about poverty now, but they have no idea what poverty was really like then in northern industrial cities. The day I qualified I left Liverpool and came down to London.

‘in the 1950s, the most common cause for an elective caesarean was pelvic distortion due to rickets. People talk about poverty now, but they have no idea what poverty was really like then in northern industrial cities.’

A: Did medical school provide a stimulating peer group?

ML: Well, it might have done, but I had to come home for my evening meal and get down to studying. I suppose that is why I sailed through exams.

A: Well, you won almost every prize in sight, didn’t you?

ML: Almost! and I got the first Distinction in Medicine for 10 years. But I did not have much of a social life. It was a very one-dimensional training that one received.

POSTGRADUATE EXPERIENCES

A: But when you qualified you knew that you wanted to go on and study in London?

ML: What had happened was that I got a distinction in physiology and the professor of physiology wanted me to do a BSc in physiology: I wanted to try. I had won enough prizes to pay for that. I did the BSc and among the many books I read there was one edited by S. S. Stevens on experimental psychology (Stevens 1951). I suddenly realized that psychology was not just lying on a couch and speculating. It could actually be an experimental subject and that started my interest in that area, but I put it on hold while I went into clinical medical training. The next thing that shaped the rest of my career was that I came down to London and got house jobs (internships), despite not having trained at a London teaching hospital. Then while wondering what to do, my fiancé Susan (now my wife) showed me an advertisement in the BMJ for research in psychopharmacology. I was also interested in pharmacology, but they were looking for people with experience that I did not have—I had just finished my house job. Susan told me that the person advertising, Professor Schild, was her tutor—she was doing medicine—and she had a word with him. He remembered me, having been my examiner in pharmacology in Liverpool and he had awarded me a distinction. So I applied. He managed to stretch the grant from NIMH to cover me as well: that is how I got into psychopharmacology. Professor Schild was at University College, a refugee from Nazi Germany.

A: So you started there in 1960, and you did your PhD at University College?

ML: Yes I did my PhD at University College London and I was using the same techniques there as at the Maudsley where I was under the supervision of Michael Shepherd. I also had contact with a psychopharmacologist called Hannah Steinberg and I worked with Lorna Wing conducting research that got me an MD as well as my PhD. Then I decided that I had to get a formal psychiatric training and Michael Shepherd encouraged me in that ambition. I did my psychiatric training between 1963 and 1966 and I believe that I was Aubrey Lewis's last registrar.

A: Am I right in thinking that although you were training as a psychiatrist and you had at that stage firmly set your mind on a research career?

ML: Yes, that is right. I think the clinical side was something that I knew I had to have in order to be able to understand what I was doing in the laboratory. But I did enjoy the clinical work.

A: But somewhere you had been bitten by the bug of science?

ML: That was when I was doing the BSc in Physiology, under Professor Gregory. He was actually a gastroenterologist, but he just fired me with enthusiasm for the experimental method. However, I think one can overplay the experimental method. Flashes of insight are also important and the experimental method tells you how to look; the two are complementary, but there have been a lot of futile experiments done. When I was chairman of the Ethics Committee at the Institute of Psychiatry, one of the things to focus on was whether the studies really needed to be conducted.

A: So by the time you had completed your 3-year Maudsley training, you have already got your PhD and your MD; an unusual qualification for a registrar?

ML: Well, I am not so sure. When I think of the people that I trained with, many of them had some other interesting qualification: psychology, anthropology, history, law. It was full of interesting people who had diverse strings to their bows.

A: So what was the work that you did with Lorna Wing?

ML: It was on human and clinical psychopharmacology—barbiturates and benzodiazepines. We were looking at normal subjects and trying to develop methods of quantifying the drug effects other than relying only on the subjective reports.

A: So that 3-year training, was it time-out, a diversion that had got to be done or what?

ML: I thoroughly enjoyed it; I found I really had an interest in people, not just as butterflies pinned out on a board, but as human beings with their own values, their own problems, their own strengths. One of the things that I was taught—Michael Shepherd was good at this—was that normality is actually much wider than one thinks. There are some unusual people around and it is too facile to say they are all mentally ill—they are not mentally ill, they are unusual, but they really do contribute to life. I found it fascinating to spend time talking to these people.

A: Who were your important clinical teachers?

ML: Oh, Aubrey Lewis—he is a legend; he had a depth of knowledge and erudition that was quite outstanding. Some people found him formidable but I never did; I always found him very sympathetic. Once we met him on holiday and we spent a quite delightful day on Lake Garda, with him acting as an unofficial guide. One of the first times I met him I chanced my arm. We were having the Admissions and Discharge Conference and I had admitted my first patient. He said to me, ‘how long is the patient going to stay in?’ I said ‘6 weeks’ and he asked why. I said, ‘well, this is the first patient I have admitted and I have no idea what the factors are which govern duration of stay. But I have looked up in the hospital records that the mean duration of stay is 6 weeks and that is the best estimate I can give.’ He roared with laughter and said something about, ‘well, I think that is a very logical approach’. He was not overpowering. He could set you many intellectual problems, but if you were honest with him and if you did the work, you got on well with him. I thought he was so erudite. When I came to read his paper on, for example, health and ill health that was a real revelation (Lewis 1953).

A: Anyone else exert an important influence at that stage of your career?

ML: Michael Shepherd was another such person, in an unusual way. Some people found Michael very disconcerting and thought he was a very difficult person to cope with. He was certainly a shy man, but in a way he had a breadth of knowledge that was even greater than Aubrey Lewis’s, but without necessarily the depth. He was one of the most well-read people I have ever come across—philosophy and so on; and this quirky psychiatry that he taught. So he was a second major influence. I did work with Gerald Russell on the metabolic ward. I think as far as research was concerned, Michael Rutter was a great influence, but he was in epidemiological research rather than  laboratory  research.  But  to  see  him  in  action  when I was involved in the Isle of Wight survey was just extraordinary.

TOWARD AN INTEREST IN BENZODIAZEPINES

A: I am well aware that this is an interview with a scientist who has contributed enormously widely to his science of psychopharmacology; I notice 630 publications, 20 authored and 50 edited books listed in your CV. You have practically stocked a library single-handed. But we are focusing here on just one slice of your work—that part which deals with addictions. Tell me how you became interested in addiction?

ML: When I qualified I went into clinical psychopharmacology and worked with psychotropic drugs, I was thus sometimes working with drugs of addiction such as the amphetamines. But in the late 1960s there still was not a great deal known about the pharmacology of addiction. What really worried me was that the use of drugs illicitly was at doses that were outside normal clinical experience and the actual substance itself was not necessarily well defined. I felt that the whole of addiction was tilted towards the non-pharmacological factors so I wanted to keep well away from it. Then of course I got involved in the benzodiazepine withdrawal problem and was sucked into addictions, initially with a little reluctance, but then more enthusiastically.

A: Tell me a little about that work on benzodiazepines which was to prove so seminal?

ML: Essentially it was looking at the benzodiazepines and whether they were associated with dependence. The epidemiological interest that I had had came in because it appeared to me and one or two of my contemporaries such as Peter Tyrer, who was working with me, that there was an excessive use of benzodiazepines long-term, but at normal dose. That was, I think, the factor which was unexpected because it was a given at the time that dependence was associated with escalation of dose. We had patients who were taking benzodiazepines but still on a therapeutic dose of no more than, for instance, 30 mg a day of diazepam, and yet when they tried to stop they got withdrawal symptoms and found they were unable to stop. One of our first studies showed that a few people who had escalated would get a withdrawal reaction, but then so would the people who had not escalated the dose. We had to say essentially the textbooks are wrong: one can get a physical dependence at normal dosage. When we looked around it seemed to me that there were people taking lower doses of alcohol who also had some problems or were getting physical withdrawal. I never thought that this was an unique phenomenon. I thought it was only unique in that the extent of the problem was enormous with benzos. We went on and did many studies using, I think, a reasonable experimental method; we published a Maudsley Monograph (Petursson & Lader 1984). We overcame a great deal of resistance among general practitioners, other psychiatrists and so on, until the day when they all said, ‘Oh, we always knew that you had problems with the benzos’. But they did not always know!

‘We had patients who were taking benzodiazepines but still on a therapeutic dose of no more than, for instance, 30 mg a day of diazepam, and yet when they tried to stop they got withdrawal symptoms and found they were unable to stop.’

A: There were people writing who were very sanguine?

ML: Yes, they were trying to minimize the problem. In fact, in the United States there was never quite the concern there was in the United Kingdom. My allies were the media, people such as Ester Rantzen, for example—I appeared on her programme a couple of times. The first time her programme dealt with the issue they had more letters concerning this problem than they had ever had on any other topic; and then we saw all the tranquillizer groups set up. There was some exaggeration—that everybody is going to get withdrawal. But there were many practical problems and I think what has happened is that there has been a complete change in prescription practices on this class of drugs. These followed the Committee on Review of Medicines report (1980), the Committee on Safety of Medicines (1988), but what probably most influenced developments was the legal profession. Patients were starting to bring in class actions that were ultimately unsuccessful, but it got the general practitioners to think again.

THE UK AND INSTITUTE OF PSYCHIATRY AS WORK BASE

A: You remained at the Maudsley Hospital and Institute of Psychiatry for your working life—you got to this campus and are here to this day?

ML: I am refusing to leave even in retirement!

A: I was talking to someone from a developing country the other day who reminded me of how difficult it often is to do science as a sole operator—you may be the only person in your speciality and you always had the lure of America. Do you think Britain over your decades of highly active work, has been a developing country where the research base is small, or do you think this country overall provided you with a good environment in which to work? Were you envious of people working in America?

ML: I never got round to working in America; I think I would have liked a few years in the United States, but there were factors that kept me in this country—partly my wife's career, partly that I was able to do what I wanted to do here. I was lucky that I was taken on by the Medical Research Council on its External Staff, and I always had enough money to do the research I wanted and enough people who would come either as staff, on an MRC Fellowship, or just attached from the Institute. I would like to have gone to somewhere such as NIMH for a time because I think it would have been a rigorous training. In a way the sort of researches I did was almost a form of self-training, because my original supervisors at UCL were animal pharmacologists rather than clinical pharmacologists. The Institute is research-orientated and so is the Maudsley, so I could recruit patients to our studies rather easily. In the United States a great deal of the money goes on clinical facilities and although huge grants are made, the hospital is being run on them.

A: So it was not a positive disadvantage to work in the United Kingdom?

ML: No; and when I was starting out—we are talking now of the 1960s—the psychoanalytical model dominated US psychiatry. Then, rather than move onto the biological and pharmacological models, they went to the social model. So it was only probably by the 1980s that the Americans were beginning to get their act together on psychopharmacology. Of course since then they have dominated the field.

A: Is there an obverse equivalent to yourself in the United States; is there a Professor Malcolm Lader clone there?

ML: No, it is just so much bigger in America. When I was starting here I was the first Professor of Psychopharmacology, the first of this and that. In this country now there are plenty of active people in this subject—I do not feel that it is going to wither just because I am less active; and also in this country psychopharmacology is an intrinsic part of the training of any psychiatrist and now is similarly very important in the United States. The subject is well established as pharmacology in psychiatry, like any other branch of clinical pharmacology. It also has the advantage that it is a bridge between psychiatry, which is still looked at askance by many other specialists, and general medicine and general science.

A: SoPetursson & Lader (1984), how did that come to be written?

ML: Hannes Petursson was among the best PhD students I ever had. He came on a scholarship from Iceland to train in psychiatry and then he wanted to do research. He worked with me because it just so happened that my work was what he was interested in. He was brilliant conducting the research. Also he was one of these people who sets up collaborative projects with all sorts of people who it would have never have occurred to me to approach. We then had a group of about 20–25 people from different backgrounds and orientations—I think at one time I had someone from each continent. My regret is that I could not find a post to keep Hannes in this country. He went to back to Iceland and he is professor in Reykjavik, and we keep in contact. I think that the monograph has been quite influential to show how you can go about looking at an addiction problem (Petursson & Lader 1984).

A: Were you always funded by a 5-year renewable MRC Programme Grant?

ML: Yes, I sometimes joke that I never had a permanent job. I had hoped that they would set up a unit but there were reasons why they backed off from that. I had my own salary and 5-year research funds. The advantage about that system was that I needed, say, only 9 months every 5 years when we all had to sit down and work out what we were going to do next. I would get the money, usually with a bit of trimming or negotiation, and then I could carry out 4 years or more of research without having to think about the next grant. Not only that, but I would actually have a little bit of extra money which I could use to pilot other studies.

A: Although you were a university teacher you were not burdened with a large teaching programme, were you?

ML: I do not think anyone in the Institute was. That is one of the advantages. You could concentrate on the laboratory research. I served on many committees that I could not have done if I had been overwhelmed by teaching.

PRESIDENCY OF THE SSA

A: You became president of the Society for the Study of Addiction (SSA) in 1983–93 and you are now an Honorary Fellow. Can you tell us what that experience meant for you?

ML: I think when I took over the Society it was limping along. However, the one asset it had was a viable journal with an excellent editor. But aside from the scientific worth of that journal—and it has gone from strength to strength—it generated money. That was important for what I could do. I had always felt that a society needs a base and it needs an administrator who has a responsibility to that society; it should not move around when the president changes. In the event I was president for longer than almost anybody. We were based at the Institute of Psychiatry and I was very grateful to Mrs Lily Hughes, who was a superb administrator. I started to draw the threads together—again, able to do that because of the financing. It seemed to me that, first, the Society should have an annual meeting and that I instituted. It had to be at a fixed time of the year. I did not want it to be London-based. The second thing was that we had a couple of endowed lectures that few people attended, and obviously it was logical to fit those into the annual meeting—we had a ready-made audience; and there were various other organizational aspects. I was particularly keen that we tried to get some educational programmes going and I think I was successful. It was slow work. It was not that there was any antagonism to what I was doing, but each initiative took time to set up and we would have to monitor it and make it viable; and during that time the journal continued to go from strength to strength, generating substantial sums of money.

A: So although you were not identified in totality with addiction you were recruited to come in and take the presidency of what might at the time have been a rather run-down entity, but was potentially a central institution on the British addiction scene.

ML: It was advantageous to have someone coming in and taking a disinterested, dispassionate view of SSA's strengths and weaknesses. If you have no axe to grind you can go ahead and do what you think is right. and I think that was really my role; I just came in—I did not know anything about the subject or its organization, and I drove a coach and horses through the whole topic to try to get the Society better established.

‘It was advantageous to have someone coming in and taking a disinterested, dispassionate view of SSA's strengths and weaknesses.’

A: Let us go back to the generalist issue here in another way. My calculation is that you have at various times been a member of the editorial board of no less than 42 learned journals, so you were bringing to SSA an extraordinarily broad experience of journals and of learned societies—international as well as national experience.

ML: That is right. I was founding editor, with Peter Venables, of Biological Psychology that was slightly to the side of my main interest. It was very interesting, to set up a journal. I did it for about 15 years and then handed it on. But with regard to Societies, I could see some disasters—in fact, there was very nearly a disaster with one society that tried to run big international meetings without proper  support  and  had  to  be  rescued.  But  I  think  there is a difference between international societies which these days survive because the e-mail keeps societies together—and national societies which are much more homogeneous, they have common purposes, and they are affected by the same medical, scientific and legal system.

A: So you also gave the SSA a new constitution that took a great deal of negotiation?

ML: Yes, I think so. It seemed to me that we had to update it; the old one was not very comprehensive.

A: And you set up annual meetings that continue today. Tell me this, what is your idea of what a scientific journal can achieve, what is your message to anyone taking over a journal, how do you do it? You have such broad experience—what do you expect of journals?

ML: It depends on the level. If you run a flagship journal then you do not want to overload it with turgid data papers; you need some data papers, hopefully not turgid. It should also be the forum for a debate and such a journal should publish review articles. I have never regarded review articles as just fillers. I think they are very important, because over my career the amount of published material has multiplied enormously; you cannot keep up with that material except in your core subject. A flagship journal should have a correspondence column, news and notes—the sort of thing one finds in Addiction. Below that level, I think it is important that the journal has a high impact factor, and these days, of course, it will be published on the web and that gets the papers very quickly to the readership. The data journals may have a problem finding and keeping competent referees. As many referees as possible should be used to lighten the load and deal with submissions sympathetically. At the moment journals have gone to online refereeing and online  processing,  and  it  can  take  you  as  long  to  get onto the website for the journal and get the paper downloaded to actually referee it. Some journals are not referee-friendly.

ADVISORY RESPONSIBILITIES

A: Then you entered into the addictions world again very importantly as a member of the Advisory Council on the Misuse of Drugs. A lot of people will no know what ACMD is; can you explain what your role was?

ML: ACMD is a statutory committee, which means that it is set up by an Act of Parliament to advise the government on aspects of addiction. It has a strong advisory role, but of course it does not have any executive power. I found that a fascinating experience. I chaired the Technical Committee because I could understand the pharmacology. But I would sit with some of the leading people in the UK addictions field and also very intelligent and well-informed lay people in order to influence policy. For example, I was at the debates that with the advent of HIV-Aids: the important thing was harm minimization and not some monolithic moral crusade.

A: You were there from 1981 to 2001–20 and for 17 years you were chairman of the Technical Committee. Can you tell us what your responsibilities were as chairman?

ML: The Technical Committee is a Standing Committee of the ACMD which is charged with the responsibility of looking into technical matters, but in particular we would advise as to whether a class or an individual drug should be scheduled in a particular way. For example, the anabolic steroid question came to us, and khat came to us. We were given a lot of technical material, and had to come up with a recommendation which went to the ACMD. I flatter myself that most of the recommendations we came up with went through without major modifications, and were then sent off to Ministers to act as they saw fit.

A: Who were the chairmen you worked with, who did you find most impressive?

ML: The first person I worked with was a dentist—Sir Robert Bradshaw. He was a superb chairman. Then we had the late Philip Connell, an avuncular, affable person: and then David Grahame Smith who was a clinical pharmacologist who started off in cardiac pharmacology. He also was very avuncular. He was a very good chairman as well.

A: Your skills as an adviser have been widely used in this and other countries. I see, for instance, that you did a 14-year stint for the Committee of Review on Medicines, and for the last 15 years you have been advising the Ministry of Defence. Is that work you have enjoyed?

ML: Once you learn the basic principle which is that you advise and that if the ministers or the civil service do not want to take your advice, that is their business. Within that kind of framework the work is enjoyable. I have felt that whatever advice I have given has never been dismissed out of hand even if it was not acted upon—it has always been looked at sympathetically; and I think that is a reflection of the high quality of our civil servants in this country. They basically have the tradition that they are not serving the party that is in government, but they are there to serve the British public as administrators and I think by and large they do that very well.

A: You have advised the pharmaceutical industry on many occasions, but what is your view on that industry?

ML: They have changed over the years. You have to realize that they are not charitable institutions, they are there to make profits for their shareholders and to do that they need to have a good reputation. The pharmaceutical industry does not want to be known as a hard-nosed, ‘cutting-corners’ type of organization. The change has been that it is getting more and more difficult to produce worthwhile drugs—you are getting more minor variations. For example, the number of drugs that the FDA in the United States is licensing each year has halved over the last 10 years or so. It costs something like $500–700 million to develop a new drug and you can understand how the pharmaceutical industry—at least some of the companies—are pushed to the edge. Sometimes they overstep the mark, and they have to be brought back into line. I was a ‘game-keeper’ for 14 years when I was on the CRM (Committee on Review of Medicines), which was essentially a regulatory role, and then a ‘poacher’ as that experience was regarded as invaluable by the pharmaceutical industry, as well as my background scientific and psychiatric experience. The companies vary—there are some companies I have not done much advising for, or much consulting as I have felt they were too commercial. There are others that I really enjoy helping. But I have always said that if they want my opinion it is going to cost them a fair amount of money—if they want to hear their own opinion echoed back at them it is going cost them twice as much!

A: You are a famous academic traveller—one day you are along the Great Wall of China, the next down the Camberwell Road.

ML: I have been to 70 countries, but there are almost 200 in the world. Part of that is through the pharmaceutical industry who ask me to do lecture tours. Then you haggle over how much of it is going to be basic medicine and science, and how much of it is going to be their product; they know they cannot put too much in about the product. As long as it is clear upfront I can live with it. What I do not like is when you go to an international meeting to a symposium, and you suddenly realize it has all been put together by a pharmaceutical company and not acknowledged on the programme. That used to happen at times, but it is much tougher now that the FDA woke up to it.

A: You advised WHO on many occasions?

ML: Not many—there were several occasions, particularly to do with benzodiazepines. I am not entirely sure it was a satisfactory experience. There was one 5-day meeting I remember vividly where I went along to give advice—it was apparent in the first hour that our report has been stitched up in advance and that left a nasty taste in my mouth. I hope things have got better and certainly my more recent encounters with WHO have been much more satisfactory.

A: Malcolm, you are now looking back on a long professional life. The play continues. Looked at in the round what do you feel have been your major achievements, or your major disappointments?

ML: I think the major achievement has been to give emphasis to the need that if a doctor prescribes medication, he or she must have to think their way right through to the end and how they are going to discontinue it. It does not sound like a major achievement, but I think it is. It means that we will not be overtaken again by a benzodiazepine-type disaster that gives a great deal of symptomatic distress to a large number of patients world-wide. Safeguards are now in place, for example, if a compound today is developing a new psychotropic drug, they have to spend quite a deal of effort on showing what happens when you try to stop. That, in terms of number of people times symptomatic distress, is the most important thing that I have done.

‘the major achievement has been to give emphasis to the need that if a doctor prescribes medication, he or she must have to think their way right through to the end and how they are going to discontinue it’.

A: Because you describe a very hardworking boyhood, studentship, no privilege, and no money, you might become just a hard-working scientist. But you shame me with your breadth of reading. Did you purposely set yourself a programme of reading or did it just happen?

ML: Well, remember that for my generation there was no television; wartime was very drab and quite dangerous. You had to make your own entertainment. When I was a child I had seven jigsaw puzzles and I got so bored with doing them that I used to turn them over and do them on the blank side. But my main diversion was reading. I would visit the local library and take out a book to read and then go back the same day because I had finished it. You were not supposed to take out two books on the same day. I learnt to read in air-raid shelters. It was always one of my main passions. I went to school when I was 5 and when my mother told the head teacher I could read, she just sniffed and assumed it was children's books. My mother said, No, he can read the newspaper, which I did. There really was not much else to do. But then I so much enjoyed it; it was a relaxation. When I was doing my second MB examination I had set out my programme of revision which I finished with 2 or 3 days to spare. Someone had told me, do not revise during the last 3 days because it just interferes with what you have learnt before. So I read War and Peace and I could not put it down, it was such a fascinating book. I have read all the great classics of that sort at various times, and all the travel, of course—I always take a nice fat novel with me and read that.

WIDER INTERESTS

A: Other reading?

ML: I have always been fascinated by the English language. It is an extraordinary language. Currently I am reading Melvin Bragg's The Adventure of English (Bragg 2003). I have always been able to write fairly well and I won English essay competitions at school.

A: And recently you have been working for an Open University degree in law?

ML: Yes, a subject that is different philosophically and conceptually from medicine and science, and I have thoroughly enjoyed it. Once you pick up the basic assumptions of precedent and authority, it is a fascinating topic and also comes in quite useful at times.

A: You are a substantial medico-legal adviser and expert and you have advised the Court on many occasions?

ML: It is something which, when I was very active academically, I did little of. I always took on cases that were interesting and there are some fascinating cases. For example, I became very interested in one topic, lithium neurotoxicity. By the time I had written a paper on it (Kores & Lader 1997) I had more cases than anyone else in the world. That was something that fascinated me.

A: As well as your science and your reading, you have had some propensities as a collector: would that be true?

ML: I have always found works of art and antique furniture much more interesting that unit trusts which diminish in value. I had quite a good collection of water colours which we sold because when we moved house recently there was too much light; some pleasant antique furniture which we use; and then most recently I have become interested in medieval herbals. Through the internet I have put together quite quickly all sorts of herbals from 1450 to the present day. Some of the older ones are written in Latin and I think I will have to go back and revise my Latin!

A: You moved through a very changing English society. Early on it was perhaps a rather class-bound society. Are you aware of it being a more open society now? Were you ever handicapped by not having been to Winchester or Eton?

ML: I do not know—you cannot do a double-blind controlled cross-over trial on yourself. I sometimes wonder if I had had a different background whether things would have been easier. I think it does not really matter that much. I think a good school will help you to make your way by hard work and I went to the famed Liverpool Institute. But the thing you then have to learn is how to work co-operatively with people. It is much easier for young people to make their way now because we are so short of doctors. One only has to look at senior doctors to see how multi-ethnic a group they are today. But I think there are still pockets of resistance.

A: Do you think your life has been guided by any personal, ethical or value system, or a general humane Greco Roman Judaic belief in justice and truth?

ML: I have always felt sympathy for the underdog and I saw deprivation in the Liverpool slums; and then I always feel that the politicians do not really care about the poor and that they are in politics for their own benefit. Therefore it is up to non-political organizations to try to redress the balance without necessarily taking to the barricades. I have always wanted to leave the world a bit better than when I entered it, which is not very difficult because we have had the Second World War, the Holocaust, all those kinds of things.

A: You have referred several times to the Second World War—this was frightening for you as a child?

ML: It was frightening. I was 3 when it broke out. I think my earliest memory is probably about the age of 4 in 1940, holding onto my mother's hand as she chatted with the neighbours wondering when the Germans were going to invade. That was all very unpleasant; and then the whole drabness of life. I do not think people realize how different the world is; now people complain if they have not got two cars. The diet we had was monotonous, but I suspect very healthy. Now of course we have got 20–30% of the population with body mass indexes over 30. But for those who lived through the Second World War, it was a very, very major life influence—and one you never shake off.

A: If today a young person were to come along and say, Professor Lader, I’m thinking of a career in addictions. I have got a good BSc, I have got a clinical training—is it a sensible thing to do? How would you answer?

ML: Well, it is not the top of the grant-givers’ priorities. When I was a trustee of the Mental Health Foundation, I actually managed to establish a little committee that had ring-fenced funding for addiction, but as soon as I left it just disappeared. It is like pushing at a door with a large spring on it. I think that someone with that background going into addiction has to accept that they are not going to get the grant support that they would in schizophrenia, molecular biology—that is, in Britain. I think in the United States it is different because there is more ring-fencing of money for addiction. My advice would be for them to go to the best research centre to do a PhD there, and then think again just to confirm that they are still interested and whether the career prospects are still there. The clinical side is difficult because we know the type of client, the type of user involved. They are not the easiest people to treat so you do not necessarily get the satisfaction of treating a depressed patient who is going to get better, or control the symptoms of the schizophrenic patient. I think probably the important thing is to seize the opportunities that come your way. As I said, my whole career getting into psychopharmacology was accelerated by this NIMH grant which came through to me. I probably would have ended up in psychopharmacology anyway because I was so interested in it, but it would have been more difficult. The danger was that I would be viewed merely as a professor of psychiatry with an interest in psychopharmacology, so it was a privilege to become a psychopharmacology professor and not be ambushed by teaching and heavy clinical commitments. I understand what the academic professors of psychiatry have to do trying to raise the funds for research to keep the university department going and all the clinical work and administration to cope with as well.

A: The importance of marriage?

ML: One of the most sensible things I ever did was to persuade my wife to marry me. I first met Susan when I was 22 and we married when I was 25. I was a PhD student and she was a medical student. Happily we have been a very solid couple ever since. I rely on her totally for providing support and sympathy, and sheer commonsense. My three daughters are a delight, but none of them are in medicine. One is a statistical sociologist, one is a psychologist in health education and the youngest has a PhD in molecular biology. There are also my seven grandchildren. Friendship is important, but family support transcends friendship. With family you have a common heritage, a common experience and the friendship.

A: If you had not been a medical scientist, what sort of career do you think you would have followed—would you have been a lawyer, a Law Lord?

ML: I have no idea. One always has fantasies about what one would have done, but I do not think I would have been an antique dealer. I could have done law, but it was always a question of what branch of medicine I would go into rather than would I do something different.

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