Friday, October 10, 2008

New York Times' Judith Warner on Nemeroff

When Judith Warner, a major columnist for the New York Times, writes a piece focusing on American psychiatrists, and entitles it "Diagnosis: Greed," you know the profession is in serious trouble.

Bringing a fresh perspective to an issue that readers of this blog may be seeing as a dead horse, Warner points out that the astonishing revelations of psychiatrists earning millions from drug companies is part and parcel of the broader financial ruination that we are witnessing daily. Just as lack of government regulation and oversight allowed our economy to collapse because of the rise of subprime mortgage-backed securities, the lack of regulation of the physician/pharmaceutical relationship has led to a medical culture of greed and the collapse of confidence in our profession.

To quote Warner:

Nemeroff didn’t bring down any banks, didn’t freeze the American credit markets, hasn’t plunged the world economy into recession. But his extensive, excessive and untransparent ties to the pharmaceutical industry are all too common, unfortunately, among his cohort of “thought leaders” in psychiatry and other medical specialties. And these relationships have led to a dangerous crisis of confidence in the basic integrity and validity of America’s medical research.

The APA and other medical organizations are beginning the process of reforming themselves. I think we need to speed things up. There isn't a moment to lose.

10 comments:

therapyfirst said...

It's like when you read about how a police officer is found committing crimes; it only tarnishes the rest of his profession. The problem here is it is not just about one psychiatrist being greedy and selfish, it is about several to many who not only have positions in academia, but also of political influence in some instances.

Nemeroff is just one lame-o of many; what disturbs me greatly is that Schatzberg is going to be the APA President in 2009. If he assumes this position, our profession is beyond redemption. And I am not even a member of the APA!

People get annoyed with my analogies to the Holocaust, but it applies to me. This field is just walking itself to the gas chamber. Does anyone give a damn anymore? I practice psychiatry because I like helping people, and this field has applications I feel have that impact. But it is not just about medications. Anyone want to weigh in on this!?!?

Gina Pera said...

Maybe for the intelligentsia, the crisis of confidence comes from researchers having close ties with pharma.

But for Joe Six-pack, the crisis comes more from lack of education (especially science education) and perhaps weak circuitry in the pre-frontal cortex.

After all, knee-jerk fear of new things that aren't immediately understood seems more of a limbic-system-run-amok problem. But it's surely not helped by the "mental health" profession being largely unclear that neuroscience must inform clinical practice.

fatosphere said...

Good luck. There's two decades of research out there that's been contaminated by industry money. And two decade of clinicians whose training has been dominated by industry-influenced curricula. I don't know how anyone can sort the problem out.

Paul Feeney said...

There is another big elephant in the room besides egregious conflict of interest: psychiatric forced medication and commitment. I think without these two "weapons" psychiatry would find its societal impact curbed in a meaningful and beneficial manner. Psychiatry is getting away with "Nemeroffing" because the pseudo-legal foothold established has detrimentally legitimized this discipline. I have an increasing difficulty attaching the practice of medicine to psychiatry anymore. This is unfortunate because people need help coping with trauma and crisis.

Lastly, off-label use of psychotropics should be regulated and controlled under the same rules as Pharma does in Phase 2/3. It's now longer a professional courtesy - psychiatry has more than proven itself unable to police itself for such privileges. Secondly, the theoretical underpinnings of these treatments (nevermind the "disease") are far too weak or plain false as to allow a lesser burden for conducting experimentation on humans.

I truly wish the APA had the guts to do what's needed here. I don't think the rank and file get either though. It's easy to throw tomatoes at Chucky, but he's an emblem - not the real problem, imo.

How do you overcome the will of money, prestige, power, and professional legitimacy?

Anonymous said...

Ms. Pera:
I think we are all for neuroscience informing clinical practice. The problem is this: As long as Big Pharma makes the rules, buys researchers, and decides what "findings" are significant (even if "research" has to be falsified so profit is ensured), there is very little "science" in neuroscience. Me thinks that "weak circuitry in the pre-frontal cortex" is wreaking havoc on the superegos of those psychiatric researchers (like Nemeroff, Biederman, Keller, and many more), resulting in a crisis of credibility about psychiatric reasearch as a whole. And this is not a good thing!

Gina Pera said...

I'm sure you're right, Anonymous, about the superegos with pointy elbows. It's always the people with the strongest certitude who rise above those who are more circumspect and cautious.

But I still maintain that these medications would simply fade away if they weren't actually helping people.

The biggest problem is training rank and file physicians to use these meds properly. And if pharma can't/won't do it, who will?

In my experience, problems in psychiatry go so much farther and deeper than pharma ties. In fact, that seems inconsequential in comparison.

Paul Feeney said...

Gina,

It's not all that hard to understand why psychotropics, as a class, haven't faded away. Enough people need to believe they do work and do so believe. Notice the the departure of serotonin for dopamine: less pushing of SSRI/SNRIs on to neuroleptics... No "oops, sorry, got that one wrong, will do better next time"? Just lock-step-march into the sea.

The disparity between real and apparent efficacy of psychotropics has been in print for a while now, but I believe the answer is in following the money.

There will be some die hard, meaning vested Numeroff/Biederman types) but we should all be able to recognize them as in the pocket of commerce and self promotion.

What's the other alternative that pays? I'm not convinced psychiatrists would remain so wedded to the belief in psychotropic efficacy (nevermind safety) if existing treatment alternatives were as easily reimbursed by payors. The problem is in what get reimbursed. This has been effectively circumscribed by the DSM - a major roadblock to fixing the problem, imo.

Psychiatrists have the power and incentive to change this around. A little mea culpa goes a long way as would ferreting out those seeking to pathologize behaviour in the form of the ever expanding DSM - it should be tossed in the bin heap.

I know it's hard to stick your neck out. David Healy's experience probably hasn't gone completely unnoticed nor is it easily to look back upon one's own education, peers, and experiences as indoctrination...

Gina Pera said...

Paul wrote: "Enough people need to believe they do work and do so believe. Notice the the departure of serotonin for dopamine: less pushing of SSRI/SNRIs on to neuroleptics.."

------
Paul, it is a GREAT THING that we've expanded our neurotransmitter repertoire to include dopamine. Do you know why? Because millions of people have been treated for "serotonin issues" when in fact they have "dopamine issues"!

Right off the bat, I can think of 20 people with late-diagnosis ADHD I know who were treated -- sometimes for decades with both antidepressants and therapy. And they never...got....better. They grieve at their wasted years. And, it especially didn't help them to be called Treatment Failures.

You're just not carrying on a just cause if you don't learn about the people you might be harming railing against these medications as being all profit-driven. It is not smart. It is not compassionate. I don't know what it is, but it's not those things.

therapyfirst said...

I really do not understand Ms Pera's last comment about the role of dopamine, because if it is offered as a reason to justify the use of antipsychotics like Seroquel, Abilify, and even Zyprexa as potential legitimate meds to treat Unipolar Depression and, sadly to offer, anxiety disorders, sites like Dr C's and others hopefully will expose the folly of such pursuits.

If your point revolves around the biological principles to ADD, then I see your point to a degree. However, even the biology to ADD is not pure for just that chemical, so I hope you are not selling medication as a "cure all" for this or any other psychiatric disorder. It is about biopsychosocial philosophies from my experience, and thus a profound reason why this biological model being inappropriately sold by so many alleged "leaders" in my profession is now being exposed for the fraud both the model and the salesmen they really are.

The whole point, from my perspective, in seeing people like Charles Nemeroff be exposed for what their true intentions are, is we as doctors better realize there is little transparency at hand when our alleged colleagues are just shilling products to fatten their wallets and not truly represent a medication for what it really offers. And, in many cases these past 10 to 15 years, is as much toxicity as potential gain.

And that is a shame, as responsible psychiatrists know and practice better. What worries me, since I have spent some time on the internet in the past year, is some sites only use these limited, but poor examples of psychiatry gone bad, as opportunities to hoist effigies of these rogues as commonplace examples of my profession as "evil" and pervasive, and that is just wrong. As I said in my first comment at this posting, use a bad example to tarnish the whole field is just fostering a mob mentality, and I will do what I can to dispell such erroneous thinking.

Dr Nemeroff and others who are now being exposed for their selfish greed better realize that those of us who became MDs will not support them based on some lame fraternity principle of "be there for the brothers" attitude. First do not harm, Dr Nemeroff, remember that if you have attended any medical school graduations of late at Emory?

And, in the end, I feel good mental health care starts with a sound and well trained backround in philosophies of diagnosis and treatment. Pills do not give you skills, whether it is a mood or cognitive disorder. So, let's not get wrapped up about whether it is about neurotransmitter X or Y. It's the whole alphabet.

Your book sells a multidimensional approach, Ms Pera? I hope so.

therapyfirst (BC psychiatrist)

Gina Pera said...

Sorry, I've just now seen this question directed to me by Therapy First.

My book (Is It You, Me, or Adult A.D.D.?) doesn't "sell" anything. It reports the best information on the subject from leading experts and includes dozens of first-person stories.

I devoted an entire chapter to explaining why Bad Therapy is Worse than No Therapy (bad therapy being therapy that takes no account of ADHD's neurogenetic foundation and neurobehaviors, not to mention frequently coexisting low insight).

And there are two more chapters explaining what type of therapy is helpful for ADHD, including CBT specifically geared for ADHD along with compassionate help in addressing late-diagnosis issues, not to mention emotional scars from woefully misguided therapy and psychiatric treatment.

I hope that answers your question. But it sure sounded more like a demand -- or a threat. Sorry, I've learned enough about psychiatrists to never be intimidated by one again. :-)