Monday, December 1, 2008

Biederman, Goodwin, Greed, Arrogance

Thanksgiving week was a busy one for revelations of greed among two of our top academics in psychiatry: Dr. Joseph Biederman and Dr. Frederick Goodwin.

Apparently, in 2002 Dr. Biederman solicited hundreds of thousands of dollars for a "Johnson & Johnson Center for the study of pediatric psychopathology." One of the publically stated goals of the center was to “move forward the commercial goals of J.& J.” I'm shocked, just shocked. Actually, this is not really as horrendous as it seems. Researchers like Biederman are always on the hunt for research funding. They prefer NIH funding, but that is increasingly scarce, so they hold out their hats to industry.

When you take research money from industry you are always making a deal with the devil. Your intentions are to produce serious research, but you know that your funders are not in the business of charity. They want to "move forward the commercial goals" of their companies, and you know that going in. Ideally, this represents a "confluence of interests," using buzz-phrase popular among advocates of academic-industry collaboration.

In theory, there's nothing inherently wrong with such collaborations, as long as the nature of the relationship is disclosed, and as long as the principal investigator takes great care to play by all the rules, both legal and ethical. Unfortunately, the New York Times article and a follow-up posting in Pharmalot imply that Biederman did not play by the rules. For example, Harvard and MGH rules stipulated that researchers doing company-funded trials are not allowed to get paid more than $10,000 in consulting or speaking income from the funding company. Biederman made much more than this and did not disclose it.

Basic ethical guidelines dictate that if a company doesn't pay you a requested grant, you should not respond by pressuring colleagues not to use that company's drug. But e-mails unearthed in court documents imply that Biederman did just that:

Mr. Bruins wrote that Dr. Biederman was furious after Johnson & Johnson rejected a request that Dr. Biederman had made for a $280,000 research grant. “I have never seen someone so angry,” Mr. Bruins wrote. “Since that time, our business became non-existant (sic) within his area of control.” Mr. Bruins concluded that unless Dr. Biederman received a check soon, “I am truly afraid of the consequences.”

Dr. Biederman comes across as petty and retaliatory. Is he also a brilliant, productive researcher who cares about children? Of course. But there is no excuse for this level of arrogance and greed.

Next up: Frederick Goodwin. Another brilliant, smart researcher who cares deeply about people with mental illness. He is former chief of NIMH, and co-writer of the major textbook on bipolar disorder.

He is also a passionate defender of the free enterprise system and an enemy of those who criticize the pharmaceutical industry. For example, he is on the board of directors of the rabidly pro-pharma organization, Center for Medicine in the Public Interest (CMPI), and has teamed up with its Vice President Robert Goldberg (not one to be tangled with--see this earlier slimefest on my blog) on articles such as this diatribe against Marcia Angell and Arnold Relman which is posted on the website of the conservative Manhattan Institute.

Okay, but so what? He's a conservative, I'm a liberal, this tent is big enough for both of us.

My main beef with Goodwin stems from his participation in a May 2007 symposium at the annual meeting of the American Psychiatric Association. The symposium was organized by my friend and colleague Nassir Ghaemi, and was entitled "Uneasy Partners: The Pharmaceutical Industry and the Psychiatric Profession." There were five speakers. Dr. Ghaemi reviewed the landscape of the controversies, I did a talk showing that 46/46 industry-sponsored symposia at the the 2006 meeting promoted a drug made by the sponsoring companies, David Healey discussed disease mongering, and both Howard Kushner and David Osser talked about the need for evidence-based medicine. Finally, Dr. Goodwin came to the podium as the "discussant," presumably to comment on our presentations.

But instead of discussing our talks, Goodwin decided to use Marcia Angell's book, The Truth about Drug Companies, as target practice. Angell was not on the program, and her book was only mentioned in passing by one of the presenters. But Goodwin seemed to despise her and her book. He went through her main points, rebutting them systematically, arguing that pharmaceutical companies are wonderful, that medications are very helpful, that there is nothing wrong with making money, and that drug companies are not as profitable as everybody thinks. Then, he went on a bizarre tangent about how one of the major networks is filled with scientologists.

I must say, I was amazed, dumbfounded, and profoundly embarrased for my profession. I had never met Goodwin before, but, like other psychiatrists, I revered him as a legend in the field. That all came crashing down as I watched him make a series of strident statements that were largely irrelevant to any of the points made during the symposium. He entertained the audience by being charismatic and at one point got a very cheap laugh by ridiculing the non-industry sponsored symposia at the meeting.

So when I heard about Goodwin's lack of disclosure regarding The Infinite Mind, I was not surprised--only saddened. He, and Biederman, and Nemeroff, and many other less well known hired guns are bringing the profession of psychiatry to its knees.


Supremacy Claus said...

Dan: Where is the evidence that psychiatry is on its knees? And if it is, how did these speakers do it to psychiatry?

The Parity Act passed. Today's meds are wonderful for most patients. More applications are helping people. Psychiatrists are very busy, being recession proof. They are working harder, helping ever more people. The fraction of patients going untreated has dropped.

The left wing attacks on psychiatry are a tiny nuisance. The profession is driven by patient outcomes, and is endorsed by the overwhelming fraction of people doing better.

Which decade would you like psychiatry to return to?

The biggest beef? Things are too slow. Not enough new meds. Not enough off label effective applications of old meds. Not enough funding for research. Too much left wing obstruction of research careers of young psychiatrist (insane to go into research while left wing ideologues are permitted to rampage against research, as promoted by insurance companies). Not enough hitting back against the enemies of clinical care such as left wing dominated governments, insurance companies, and media.

Anonymous said...

Dan: Things that are left out of most of these stories are key truths. In context asking for fee for services rendered is not wrong, exploited in this fashion it takes on a whole other appearance. Also, Harvard/MGH did not have the 10k rule until recently- you can't apply a rule historically. In all, reporters and bloggers seem to forget the advances in care these clinicians have made- thousands of lives are better for their work. I am all for calling out the offenders, but if you are not part of the solution, you are part of the problem. Finding a way to get physicians quality practice-based education in compliance w/o bias is what we need to be focusing on here- constantly nailing the same people to the wall gets your agenda across, but does nothing for practicing clinicians. Biederman can say he has helped, can you?

therapyfirst said...

You are the mench, I do note that.

At the end of the day though, this is a culture that has become so much more narcissistic and entitled, it is really hard to differentiate what is the fault of the doctor versus the patient. I really believe that the boomer generation plays a big role in this behavior, fostering the quick fix mentality and "greed is good" that really took hold in the 1980's. And now the next generation has been corrupted as a group and taking the low ground to new depths. Hey, I see it every day in community settings as much as in private practice, so it is not just a socioeconomic process.

Yeah, I'm embarassed, ashamed, and mad as hell, as these are our alleged mentors and leaders. So, what is the message for doctors who have gotten their degrees in the past 10 to 20 years? Let people screw with your training and disciplines, and then just screw someone else back? No, no one is above the law, or the process is doomed. I am tired of seeing older colleagues, who, while rightfully pissed they have been told what they can do and moreso what they can't do, they then stood silently while third party organizations raped the process of mental health care and then such docs just added insult to injury by getting in the proverbial beds with the assailants. Harsh analogy, but it is what I have seen up close and too personal.

When Obi Wan says to Anakin at the end of Revenge of the Sith, that "I have failed you", the difference here is the mentors failed us because they not only did not stand their ground to refute evil of managed care and pharma gone wild, they rationalized it as "it is the only way"

Well, in every Star Wars movie is the line "I've got a bad feeling about this", and 2009 isn't looking too good if no person or organization of substance and respectability steps up and says "ENOUGH"!

Where is the accountability in this culture? Oh, I forgot, you need to have a soul to be accountable. It is just evil. Souless, rational, and without empathy. Did I miss this in residency? Thankfully, yes.


skpsycho said...

The above comments are ridiculous. Standard pro-psychiatric rhetoric, I get it a lot. These people talk about "helping even more people" (while "being recession-proof", of course), but they base their definitions of help on ephemeral artifacts: statistical outcomes, cost-effectiveness and measurement scales. They have forgotten when they connected with another person for real - not necessarily a patient, just anyone at all. They have forgotten when they lay on green grass and stared in the sky for the last time, or felt genuine joy or sadness themselves. Arguing with them is useless - the communication between different paradigms is rarely possible - but you must not be discouraged.

Supremacy Claus said...

TF and skpsycho, tell us how you would manage a depressed patient differently from Dr. Fred Goodwin.

A 50 year old woman comes to you, with a sad mood for months, and low energy. She struggles to get her work done. Her sleep and appetite are poor. She has fleeting suicidal ideas. She uses no illegal drugs or alcohol. A couple of relatives had the same symptoms.

Go. What else do you want to know about her? How long will your assessment take, days, weeks, months? Dr. Goodwin might start her on an SSRI. You do what instead.

therapyfirst said...

It is not the only reason, but if you as a patient or non clinician want to understand at least a bit why psychiatrists have prostituted themselves to big pharma, seek out the column by Glenn Treisman, MD, at titled "Two for me, None for you" that offers a wonderful yet painful assessment of what managed care has done to mental health interventions.

This is why too many doctors have sold out, because we were sold out by managed care and no one, NO ONE, not physicians, patients, regulatory bodies in government or citizen watch dog groups, did anything to stop this disgusting intrusion into health care.

In the end, what doctors like Goodwin or Biederman are doing is an acceptable alternative, but, I just want to ask people who cry out how unfair doctors are, what do you offer as fair and reasonable alternatives to make a living after one has spent 12 or more years after HIGH SCHOOL getting an education and training to take care of people? I can't wait to hear replies that are genuinely intended to provide alternatives for someone like me who has worked damn hard to provide a service that only about 50,000 people practicing active clinical care psychiatry in a country of over 300 million are responsibly trained to provide. Do the math: that is about 1 in about 6,000. Simple expertise anyone can master going to an equivalent trade school? I think not.

Supremacy Claus, I honestly do not understand what your true agenda is by commenting at this site. I can only speak for myself, but an evaluation takes a lot more time than 60 minutes, so your question cannot be answered with a simple number. You meet with the patient, formulate a provisional diagnosis, apply a standard treatment intervention to the diagnosis you sense applies, and then follow up and see how time, energy, and commitment to the treatment process by the patient proceeds. Biggest point: is the patient willing to change? Take a med, be in therapy, reframe issues or perspectives, change psychosocial stressors as able, ALL OF THE ABOVE.

The retort to you, is, can you accept that the answer is vague and nondescript?

DR C: do you have to retype the word verification twice for submission? I lost what I thought was a better comment than what I resubmitted later yesterday at this post after typing in correctly the first WV, and then hit the Red X, and realized later the green heading at the top did not appear before I left the site, as I learned the second time.


skpsycho said...

Well, if you pose the question in this way, I don't know what to answer. This is part of the reason why I quit psychiatry and became a bioinformatician. Apparently, you feel that by providing a few pieces of dry clinical and demographic data, you gave us enough information to be able to help this particular person of flesh and blood, with her unique life story. Well, if you believe so, then, really, the only thing you can do is give her a pill. And if I didn't have the time or desire to go into the details, I would also go for a pill - the problem, however, is that I don't think of a pill as help.

And of course it's always more complicated too. A pill is never just a pill. It comes with "counseling", perhaps involuntary hospitalization, permanent record and stigma of mental illness, and of course the side effects.

And why is it that you want to "do" something anyway? What is the reason why you so desperately want to get involved with this woman's life and take responsibility for changing it? Why not simply leave her alone? Okay, okay, she might commit suicide, - but lots of people around you die every day and you couldn't care less. You don't go around at night persuading all the drunk drivers to abstain from driving. I'm not even mentioning the homeless and hungry people. Why go out of your way to help this particular person, sometimes against her will? Well, the answer is simple - this is the task you are being paid for, and you can't afford to fail.

Daniel Carlat, M.D. said...

TP--no you don't have to type in the word twice. But if you are leaving a long comment, I suggest typing it in MS Word than copying and pasting it into the comment section. Then you definitely won't lose it.

Aussie Psychiatrist said...

I think Supremacy Claus is using irony guys. Perhaps easier for me to recognise as we use a lot of irony in Australia, too much maybe.

Without any irony whatsoever though I would like to say Biederman's promotion of pre-pubertal bipolar disorder has done enourmous harm.

therapyfirst said...

My apologies for not rereading my last submission above before sending it, as I got hung up on the Word Verif issue and just forwarded it.

the third paragraph should read:
'..what goodwin and biederman are doing is an UNacceptable alternative..."

Sorry, I will not make this mistake again.

Still hate word verif though!


Supremacy Claus said...

TF: The agenda? Freedom. Stop tyrannizing the most over-regulated service in the nation. Stop the pretextual oppression of clinical care or get a bloody nose.

I strongly urge Dr. Goodwin to get an appointment with a top Washington DC litigator and to sue everyone, every publisher, every republisher, every radio station, every dirtbag government official, every low life regulator, every staff of every Senator, every Senator, just everybody attacking clinical care, and their employers, supervisors, ISP carriers. Do total e-discovery on the enemies of clinical care, and use every gotcha to take them out.

To deter.

What is the bill for your idealized total workup and therapy of a bread and butter patient, the most common type, the modal presentation, even to primary care? Does the cost have 3, 4, or 5 numbers a year? People who bash HMO's should view the autobiographical girl interrupted to see the abuses the HMO's ended. Girl annoyed the parents. Hospitalize for 2 years for a personality makeover at the cost of $1 million in 1970's dollars. Those with filthy hands should not point fingers. The psychiatrists did it to themselves.

Aren't both exploiting a patient of ordinary means with gold plated, voodoo, garbage science cult lies? If you do lay down with her on the grass and stare at the sky, is there a $300 an hour charge? If you charge, you need to be arrested for consumer fraud. If you do not plan to charge her anything, that is the precise value of that type of service, nothing. Laying on the grass together, staring at the sky is called friendship. People who charge money per hour for friendship are called whores.

Anonymous said...

And, in some circles, people who charge money for drugs are called dealers or pushers. LOL. Your arguements are very funny! And illogical!