Monday, March 31, 2008

APA to Devise 5-Year Plan to Become Industry-Free

The incoming president of the American Psychiatric Association, Nada Stotland, M.D., is getting serious about the distorting effects of drug company money on the organization. She recently formed two new groups to scrutinize this issue.

The first is called the Committee on Commercial Support. I don't know any details about this yet, because I'm not on it. But the title pretty much speaks for itself.

I was, however, appointed to the "Ad Hoc Work Group on Adapting to Changes in Pharmaceutical Revenue." According the email inviting me to join, our mission is:

"The formation of an ad hoc work group of the Board [meaning the Board of Trustees] charged to work with the Medical Director to: identify the categories and amounts of monies received from the pharmaceutical and other industries producing products or services used in psychiatry by the APA and its subsidiaries; determine what direct and indirect financial consequences there would be from discontinuing each category; indicate how the APA could adapt to the attendant change in revenue; and to provide the Board with the elements of a 5 year plan to end or diminish the pharmaceutical revenue received by the APA. The ad hoc work group will report to the BOT with a report and recommendations by October 2008."

Thus far, the confirmed members include: the chairperson, Jeffrey Geller, MD, a public policy expert and professor of psychiatry at U Mass Worcester; the vice chairperson Dauda Griffin, MD, a psychiatrist in Cambridge MA; David Fassler, MD, the newly elected secretary-treasurer of the APA; Richard Harding, MD, APA president in 2001-2002; Carolyn Robinowitz, MD, the current APA president; and myself.

We haven't met yet, and I can't guarantee you that I'll be able to report much about the proceedings on this blog, because there are some confidentiality rules that I will have to respect in order to avoid getting kicked off. But I wanted to at least let everyone know about this extremely encouraging development.

Kudos to Dr. Stotland!


Supremacy Claus said...

Every member of the review committee is an appalling, biased, Massachusetts, America Hating, extreme, left wing ideologue, devoid of credibility. It is just a biased hate group. The group is a disgrace, and ridiculous.

I urge all psychiatrists to resign their memberships.

Anonymous said...

Congratulations on being appointed to the committee, Dr. Carlat!

I hope that APA's efforts will be informed by the following article:

Kline NS.
Relation of psychiatry to the pharmaceutical industry.
AMA Arch Neurol Psychiatry. 1957 Jun;77(6):611-615.

Anonymous said...

Regarding James La Rossa's last comments from the March 19 posting , I wholeheartedly agree with his point: the pharma industry will dump its role in CME before being embarassed or abandoned by the people who clammored for the support in the first place. This is the embarassment psychiatry as a whole has to accept and responsibly distance itself from now and not wait for a commmittee to acknowledge. No disrespect to Dr C or the colleagues in this committee, but I am convinced this is moreso a ploy to muddy the waters or just plain distract people from responsible pursuits into further exposure of irresponsible behaviors by the Pharma industry.

Unfortunately, I must say something giving some credibility to Mr S.C.: it's making this process more political than it should be. Not as a left wing process though, as I have seen more right wing or conservative behaviors by the leaders in APA, and as I said before, people who are financially benefitting from this process of "biochemical imbalance models" will not give it up without a fight. Probably not a fair one at that!

Mr S.C., I resigned my membership 13 years ago for a reason I sense is very similar to this one now: psychiatrists were at least cowards if not clueless in letting managed care get a foothold into the management of mental health care reimbursement, and the people in charge at that point would not show the guts to band together and fight for the most important cause, the patient!

Now, it is drugs. You wonder why Scientology gets the press it is able to slime itself onto by the behaviors of my profession. Silence is death. You can't be a physician and be watching your wallet as much if not more than listening to the patient.

That's what this is about for me, folks. Succumb to greed, and you are no better than those who pay you. A rant, but needed said!

James M. La Rossa Jr. said...

Dear TF: as I said to SC tonight as a follow-up to the post you refer, is that -- while what he says resonates as reasonable -- many of his assertions fly in the face of my personal experience. Almost every person I have have ever known who has suddenly found themselves in psychiatric distress, arrived at that dangerous medical fork in the road because they could no longer trust their own counsel, and had become unable to help themselves. In other words, they could not manage any constructive self-triage -- one of the hallmarks of SC's logic. Perhaps you (speaking to SC) are short- changing how very scared and irrational psychiatric patients can present. Isn't it possible that psychiatry is , quite simply, "trickier" than other branches of medicine (which may not be politically correct to admit) and that one of the byproducts of that is that the patient is profoundly confused by his/her own symptomology because it doesn't relate to their understanding of what is and is not "medical illness" and what can be done about it? The medicine of choice for depression on Cape Cod, for example, might be a stiff brandy. That kind of self-triage and OTC remedy just doesn't make the cut sometimes. Why can't you (SC) just admit that psychiatric patients are woefully inadequate at helping themselves because it is the thing they think they are doing to help themselves that is often contributing to their illness. Psychiatrists have a very hard job with very high stakes. Why not admit? Would you allow a close associate or friend to walk the isles of CVS looking to for his self-administered "cure" instead of doing everything in your professional capacity to insure that he/she received the best diagnosis and treatment possible? I don't believe that SC could.

Lastly, while you and SC have differed on many points of principle and/or medicine along the full spectrum of conversation, you both reject(ed) the APA for highly specific reasons relating directly to its politics. One would conclude that the powers that be within the APA consider seriously taking the association back to its roots. If nothing else, a medium like this very blog, which could be administered, coincidentally, by a newly appointed committee member, may very well make the difference. What we can all agree on is that what worked once won't work anymore. The influence game is changing. I look forward to your next posting. Regards, j.

Supremacy Claus said...

The APA has figurehead officers, elected yearly. It is in Washington DC. The staff runs it, especially the Executive Director. Appoint Attila the Hun, leave him in DC for 2 years, you get the same outcome. A weasel. In pursuit only of the self-interest of the agency, along the rent seeking, left wing lines of DC culture. That has happened to even the leadership of the US Chamber of Commerce.

To get the APA to represent clinicians is impossible without remaking it. Elect full time Presidents, paid $500K a year, who set policy, for terms of six years. Move the APA office to the Midwest or Southwest, and not Chicago or Cleveland. Somewhere sensible.

Anonymous said...

Thank you james for your comments and assessments. As opinionated this next comment is, I feel it is based on the history of our culture and our species: the leadership of an organization, which is usually comprised of older and conservative individuals, forgets its roots and experiences in the process of being educated and formulated. Such individuals only look out for themselves and their small circle of equals and pass laws, rules, and expectations that affect others and not themselves. Thus, the equal timeless battle between generations that rages because people in power do not appreciate what they impose on others impacts, for the most part, soley on those who must answer to those rules/laws. Animal Farm is so accurate a portrayal of how the road to hell is paved with good intentions.

God, I'm sounding like SC now!

Anyway, to bring it back to this debate, the APA has no real agenda to change, because they are addicted to the money and other perks that Pharma gives out: I'll give credit to this business, they accept the premise that you must spend money to make money. A colleague told me yesterday she estimates that about 2/3 to 3/4 of the APA conference in May is Pharma funded. You think all those APA cronies are going to give up their Spring flings each year? Come on! I just hope Dr C stays grounded in his efforts working with this committee.

One of my mentors said to me years ago when I asked if he was going to the conference, in wonderful sarcasm, "why would I go to a function full of psychiatrists!?"
Hence why he was a mentor, among important clinical training as well. The politics in my field is at times stifling. Politics=favors=money=favoritism.

Try to answer this question if you can, James: why does Psychiatry have physicians who are board certified before 1994 be exempt from the recertification process?
Does a two tiered system reflect well of the field to both non-psychiatric colleagues as much as the public? It is simple to me: these old guys and gals don't want to accept the responsible accountability in showing they are up to date with the field, and so use the younger colleagues as pawns to prop up the legitimacy of the field in this recertification process. EVERYONE SHOULD BE RECERTIFIED, and everyone every 5 years should be reviewing the oath taken in becoming a physician.

By the way, psychiatry by in large is a thankless endeavor. One of my supervisors in my training, while not someone I recall fondly now, did have true words of wisdom at the time: "everyone thinks they are a psychiatrist and will intrude into the process of treatment, until they either screw it up or realize they don't know what they are doing, and then they run and leave you, as the true expert, to be hit by the "sh*t that hits the fan" ".

70% of antidepressant RXs should NOT be written by non psychiatrists
in this country. That is an indictment to the follies that go on in mental health these days!

Again, I ranted, I'm sorry, but I like to put it out there.

Good luck, good day, good times.

James M. La Rossa Jr. said...

When I started Primary Psychiatry in 1994, its mission was to educate psychiatrists about primary care medicine and PCP's about psychiatric medicine. That year, 70% of antidepressants were prescribed in the PC setting. Today TF quotes the same figure.

When it was launched, Primary Psychiatry was a nuts & bolts type of journal -- lots of clinical educational reviews -- and the hope was that since so much of psychiatry is dealing with medical comorbidities, the journal would fill a distinct need.

Fourteen years later (my interest in the journal was sold five years ago), every clinical study about psychotropic prescribing in the PCP setting seems to make the same conclusion: Primary care doctors are still no better at prescribing psychiatric drugs than they were in 1994. (Meanwhile, 75% of Primary Psychiatry's circ was made-up of PCP docs). The journal was certified for Category 1 CME. Credits were $7.50, or $22.50 for three each issue. Today, credits are given for free since the journal is subsidized by pharma ads. Fourteen years later and the numbers remain the same. That's a lot of paper in the wind, isn't it?

Anonymous said...


I liked Primary Psychiatry in its heyday (90's to around 2000), so it is nice to know you were involved.

I always ask various physicians how they feel about psychiatrists writing somatic RXs, and most respond there is no place for it if the psychiatrist is not providing physical care to warrant the RX. Then their defense to my comeback that if they are not providing psychiatric services in their office in writing for SSRIs and the likewise, they just retort, "well the patient is coming to me with a problem I can help with".

This is the hypocrisy that is pandemic in medicine, like I said in an earlier posting: every one is a psychiatrist until they screw it up and dump it on me to fix their "well intentions". Yet I am out of line if I would start a patient on an antihypertensive.

It boggles the mind!

good times, ggod day.

James M. La Rossa Jr. said...


Thank you for the nice words about my "former life." It was a fun time. It was also an era when you heard the term "Consultation and Liaison Psychiatry" bandied about with great regularity; not so anymore. Like you say, no one cares until the matter gets botched.

OB/GYNs are very comfortable prescribing psychotropics. I know many women who think of their OBs as their PCPs. And, as we know, OBGYNs asked for and received "primary care designation" about 10-years ago.

Would you like to see the APA lobby for psychiatrists to receive the same PCP-designation? Why shouldn't you be able to prescribe an antihypertensive to a patient if you have taken a sufficient medical history? In many countries, psychs are the physicians of last resort. Would you and your colleagues welcome such a thing? Since so many of your patients present w/ comorbid illness(es), why not? Bon Weekend all.

Anonymous said...

Dr. Carlat,

Now that you are on the most important component of the APA, are you at liberty to say anything about the progress of your work group at the halfway point?