Friday, September 10, 2010

Stephen Stahl + Lurasidone: The Hired Guns Come to Town

Just when you thought we had reached the point of antipsychotic supersaturation, yet another me-too drug is edging its way into this $20 billion market. The drug is Lurasidone, and the company is Sunovion (formerly Sepracor). FDA approval is likely by the end of this year, and in anticipation Sunovion has begun a marketing blitz, tossing so much money at hired guns that it looks like confetti. And where there is drug company money to be had, Stephen Stahl is never far behind.

Lurasidone is simply another antipsychotic—no more, no less. The two major clinical trials (Pearl 1 and Pearl 2) have shown inconsistent efficacy results, high rates of side effects such as akathisia (restlessness), parkinsonism (tremor and stiffness), and sedation, and apparent inferiority to Zyprexa. Like several of the newer antipsychotics (such as Ability, Geodon, and Fanapt), Lurasidone causes little weight gain and few metabolic abnormalities. With no clear advantages over its many competitors, Lurasidone will succeed or fail based purely on the strength of its promotional campaign.

Which is why Sunovion has hired the impresario of drug company-funded education, Stephen Stahl, as their chief hired gun.

Stahl is the driving force behind a road show of Sunovion-funded “programs” entitled “Schizophrenia: Building Awareness—Advancing Understanding.” I first started receiving flyers for these lectures in July, and I get a new one every week or so. I’ve scanned some of them into my computer and have posted them on Evernote here.

The most recent promo piece came a couple of days ago, in the form of an email from Stephen Stahl himself. It started this way:

"To my fellow Boston area Psychopharmacologists:

Just a head's up about a local educational program I hope you can attend related to schizophrenia. The content is based both upon my textbook, Stahls Essential Psychopharmacology, and two cases from my private practice.”

Obviously aware of the increasing skepticism about pharma funding of physician education, Stahl addresses the issue head on: “ Although supported by Pharma and not CME (a new company Sunovion with a drug in the pipeline is the sponsor), there is no mention of any product here, just information on disease state, what I think is a very a cool update (understandable) on genomics, neuroimaging and the prodrome related to schizophrenia, and illustrated after the first didactic lecture with two cases taken from my practice.”

While I applaud Stahl’s transparency, I think he misunderstands the problem with pharma-funded programs. Their deficiency has nothing to do with the fact that they mention their drug, or any other drug. Why would a busy psychiatrist attend a half-day program on antipsychotics in which “there is no mention of any product”? In fact, we want to hear plenty about products. We look to experts like Stahl (and others on this tour, such as Leslie Citrome, Henry Nasrallah, Andrew Cutler, and Steve Potkin) to help us navigate the increasingly confusing terrain of antipsychotics.

We want them to talk about products, and we want specific recommendations. What is their first choice of antipsychotics and why? What are their second and third choices? What do they think about the increasing popularity of conventional antipsychotics? In their heart of hearts, do they really think that Lurasidone is worth choosing over its competitors? Shouldn’t we be hesitant to try me-too medications, when others of equal efficacy have long track records and clinical experience?

I predict that none of these experts will address these painfully obvious questions. Because if they did, they might let it slip that risperidone is their drug of choice. Or Abilify. Or Trilafon. Or Some Other Drug That Is Not Lurasidone.

Instead, audience members will hear about purely hypothetical mechanisms of action, many of which will be presented in such a way that Lurasidone will appear to have a "potential" advantage over its competitors.

This, after all, is the marketing strategy that Stahl has pioneered. Keep the audience mesmerized with colorful cartoons of fancy mechanisms of action that have no proven connection to the drug’s clinical action. Then say that because of these mechanisms of action, the sponsored drug “might” or “should” or “could potentially” or “will theoretically” be the best thing since Fridays.

Yesterday, Stahl’s CME company, NEI, sent me a free booklet, “Psychosis and Schizophrenia: Thinking It Through.” Like his road show, this book is funded by Sunovion, and it contains a coyly phrased endorsement of Lurasidone that is vintage Stahl: “Actions at 5HT7 and 5HT1A receptors suggest potential antidepressant and pro-cognitive actions, but this requires confirmation in clinical trials and real world clinical experience” (page 43).

Sorry for the poor review, Steve. But as Randy Jackson says on American Idol, “I’m just tryin’ to keep it real, dog.”

46 comments:

Neuroskeptic said...

Fantastic analysis.

"We want them to talk about products, and we want specific recommendations."

This is the key, isn't it - what clinicians want is clinical recommendations based on clinical experience. But that's the one thing that Pharma-funded symposia will never provide. and it's never going to get accepted at a conference (it's "unscientific")...

Bernard Carroll said...

Well said, Danny. This is the sort of thing I call academic wallpaper or academic Muzak – it sets the ambience for the come hither message. Another apt term is meretricious.

Barney Carroll.

Anonymous said...

When will it end in your business? When is enough enough? How much more credibility does your profession have to lose before it starts prohibiting this behavior among its members and/or widely ostracizing those who engage in it? How much?

I'm coming off my medications because I have come to believe strongly that not only are your medications an expensive, side effect-ridden sham, the entire foundation of your entire profession's "evidence" base is a pharma-funded, pharma-created, pharma-marketed, disease-mongering sham. Increasingly, I feel I am not alone in my beliefs.

I mean no offense to you personally, only to your profession. It has straddled the ethical/moral line for too long and I see signs that it has overstayed its welcome. The credibility psychiatry tried to build with the medical profession by dismissing the person and focusing on drugs is beginning to crumble. Well, not beginning, but the crumbling is accelerating.

By the way, the idea that grief after the loss of a loved one is major depression is offensive to me as a patient. Just my personal opinion. Sorry to vent. I've simply had it.

pj1280 said...

Re: Anonymous

THIS THIS THIS is exactly why I dislike being a psychiatrist. Not because I disagree with your criticism, but because you are RIGHT ON and no one with an MD seems to care.

I entered psychiatry because I find the human mind to be fascinating, and psychological suffering to be profoundly disturbing but remarkably amenable to powerful interventions, both psychotherapeutic and pharmacological.

However, I absolutely HATE that I feel that I (and most of my colleagues AND patients) have been fooled into the pseudoscience that is pharma marketing. It IS a sham. Most of the patients who come to see me are indeed suffering, but more often than not, it's NOT a primary mental illness that requires drugs, it's the absence of strong coping skills, lack of resources, a phase-of-life issue, or whatever.

And those with a true biological illness often don't get miraculously better with meds. But instead of asking deeper questions about the biology of mental illness (that is what's exciting about psychiatry), big pharma just pumps out me-too drugs that give us another 3rd-line (or 4th, or 5th) agent that ends up doing exactly the same thing.

Unfortunately, most patients buy into this. They ask for the drug they just saw on TV (or know that their sister is taking, or heard about from a friend, etc), and unfortunately most psychiatrists I know are only far too happy to prescribe based on that request.

The "explanations" of drugs' "mechanisms" are laughable (and have little evidence to back them up), but again, most psychiatrists don't have the scientific background to ask more critical questions of big pharma to understand the truth. (They LOVE the pretty pictures in Stahl's book, and I have to say, they are mesmerizing and a good heuristic, but where's the evidence that that's how drugs work????)

Likewise, I absolutely agree that grief is not depression, just as irritability is not bipolar, poor attention is not ADHD, most insomnia does not require nightly narcotics-- and I could go on and on. However, patients and doctors alike (and let's not forget the insurance companies) have bought into the belief that anything "out of the ordinary" is a disease state and must be treated as such-- with a drug.

Who knows, lurasidone might turn out to be a miracle drug for the hardest-to-treat schizophrenics. I'll probably prescribe it now and then, but for the most part it'll have a very small place in my armamentarium.

The fact that these drugs are approved on a small evidence base, have little to do with the biology of the disease, and treat a "disease" state that has become so vast in its description, unfortunately distracts us from the patients' own stories, and from more effective (and safer, less costly) alternatives. It makes a mockery of this profession, and it will catch up with us.

pj1280 said...

Re: Anonymous

THIS THIS THIS is exactly why I dislike being a psychiatrist. Not because I disagree with your criticism, but because you are RIGHT ON and no one with an MD seems to care.

I entered psychiatry because I find the human mind to be fascinating, and psychological suffering to be profoundly disturbing but remarkably amenable to powerful interventions, both psychotherapeutic and pharmacological.

However, I absolutely HATE that I feel that I (and most of my colleagues AND patients) have been fooled into the pseudoscience that is pharma marketing. It IS a sham. Most of the patients who come to see me are indeed suffering, but more often than not, it's NOT a primary mental illness that requires drugs, it's the absence of strong coping skills, lack of resources, a phase-of-life issue, or whatever.

And those with a true biological illness often don't get miraculously better with meds. But instead of asking deeper questions about the biology of mental illness (that is what's exciting about psychiatry), big pharma just pumps out me-too drugs that give us another 3rd-line (or 4th, or 5th) agent that ends up doing exactly the same thing.

Unfortunately, most patients buy into this. They ask for the drug they just saw on TV (or know that their sister is taking, or heard about from a friend, etc), and unfortunately most psychiatrists I know are only far too happy to prescribe based on that request.

The "explanations" of drugs' "mechanisms" are laughable (and have little evidence to back them up), but again, most psychiatrists don't have the scientific background to ask more critical questions of big pharma to understand the truth. (They LOVE the pretty pictures in Stahl's book, and I have to say, they are mesmerizing and a good heuristic, but where's the evidence that that's how drugs work????)

Likewise, I absolutely agree that grief is not depression, just as irritability is not bipolar, poor attention is not ADHD, most insomnia does not require nightly narcotics-- and I could go on and on. However, patients and doctors alike (and let's not forget the insurance companies) have bought into the belief that anything "out of the ordinary" is a disease state and must be treated as such-- with a drug.

Who knows, lurasidone might turn out to be a miracle drug for the hardest-to-treat schizophrenics. I'll probably prescribe it now and then, but for the most part it'll have a very small place in my armamentarium.

The fact that these drugs are approved on a small evidence base, have little to do with the biology of the disease, and treat a "disease" state that has become so vast in its description, unfortunately distracts us from the patients' own stories, and from more effective (and safer, less costly) alternatives. It makes a mockery of this profession, and it will catch up with us.

Uma said...

Thank you Anon and pj1280, it's great when someone so effectively sums up the essence of why we're here reading this blog and what are the answers we're looking for.

Psychological pain is real and I always wanted answers based on functional knowledge of the brain and asked if there were not simple mental exercises I could do to cope better with my situation (I guess I equate psychological pain with neck pain. You can pop pain meds or you can do exercises to improve flexibility and stability, adopt better posture and stuff like that).

I dismissed things like the attachment theory but now I can honestly say that it held many answers for me. We sneer at the simplicity of love and kindness because they're not 'scientific' enough, we want to be completely (and measurably) cured and in the process of finding that clinically proven panacea we have forgotten many things that do help. And the thing that helps most is when a doctor can be as human as the patient.

On this particular blog, I have seen MDs talking to MDs and non-MDs talking to non-MDs. Rarely do MDs talk to non-MDs.
During my own search for answers, I wrote to many psychiatrists and psychologists. I had never been so completely ignored, except by one British psychiatrist.

She would always answer my emails, even the most dismissive ones about psychotherapy. When I knew what I was talking about she encouraged me, when I didn't seem to know, she would steer me in a better direction.
Why she let me carry on with that I don't know. But when that difference ceased to be, is when I was able to move away from my obsessive tendencies.

We are intelligent beings and we resist anything that messes with our minds because (I think) it makes us less human. To bring down that resistance is the start of the therapeutic process and the road to healing.

Mental illness runs in my family and I've seen my parents try everything. Less than two years ago, I had written down a date when I was going to kill myself if I didn't feel any better by then. That was the turning point in my life because I was serious about that date - it made me equally serious about finding other ways to end that pain and eventually I did find them. We're not completely clueless (about what heals), we just have the wrong definition of true healing.

John M. Nardo MD said...

The last two comments, one from a patient, the other from a Psychiatrist, are both bulls-eyes. I too came to Psychiatry [from Internal Medicine] "because I find the human mind to be fascinating, and psychological suffering to be profoundly disturbing but remarkably amenable to powerful interventions, both psychotherapeutic and pharmacological." And as to "The credibility psychiatry tried to build with the medical profession by dismissing the person and focusing on drugs", I'd like to add a comment. That happened around the early 1980's. It was announced as the "medicalization of Psychiatry." That's when "evidence based Psychiatry" became to growing war cry, the DSM became criteria based, and those NIMH Neuron pictures became ubiquitous. Psychodynamic thinking, psychoanalysis, crisis intervention, even the ancient "common sense psychiatry" of Adolph Meyer became targets - some deserved, but a lot of it sounded like Sarah Palin talking about "liberals" - contemptuous.

Psychiatry was fascinating because it was ambiguous - reaching in a lot of directions for tools to help the mentally ill, and as pj1280 says, they are "remarkably amenable to powerful interventions, both psychotherapeutic and pharmacological." With "medicalization," I think people hoped to make things more scientific. It feels like the opposite happened. If anything, the biologists ["Actions at 5HT7 and 5HT1A receptors suggest potential antidepressant and pro-cognitive actions ..."] sounded more like mystics than the analysts, therapists, or the existentialists. At least the latter were aware they were in the subjective realm. All the pseudo-objectivity of the latter day biological chemists is frankly embarassing.

I think this would just have been the swinging pendulum that has always been a part of mental health practice, except for the addition of pharmaceutical money - which profits so much from this "biological era" that it has held us here long past the usual time when a new paradigm wears thin and the pendulum begins its inevitable swing. That's what Carlat's blog and a lot of others are about. This is not about the predictable oscillation of paradigms in an ambiguous science. This is about corporate greed buying a paradigm and capitalizing on it - financing it's direction rather than allowing it to follow its own path. At least that's how it looks to me...

John M. Nardo MD said...

The last two comments, one from a patient, the other from a Psychiatrist, are both bulls-eyes. I too came to Psychiatry [from Internal Medicine] "because I find the human mind to be fascinating, and psychological suffering to be profoundly disturbing but remarkably amenable to powerful interventions, both psychotherapeutic and pharmacological." And as to "The credibility psychiatry tried to build with the medical profession by dismissing the person and focusing on drugs", I'd like to add a comment. That happened around the early 1980's. It was announced as the "medicalization of Psychiatry." That's when "evidence based Psychiatry" became to growing war cry, the DSM became criteria based, and those NIMH Neuron pictures became ubiquitous. Psychodynamic thinking, psychoanalysis, crisis intervention, even the ancient "common sense psychiatry" of Adolph Meyer became targets - some deserved, but a lot of it sounded like Sarah Palin talking about "liberals" - contemptuous.

Psychiatry was fascinating because it was ambiguous - reaching in a lot of directions for tools to help the mentally ill, and as pj1280 says, they are "remarkably amenable to powerful interventions, both psychotherapeutic and pharmacological." With "medicalization," I think people hoped to make things more scientific. It feels like the opposite happened. If anything, the biologists ["Actions at 5HT7 and 5HT1A receptors suggest potential antidepressant and pro-cognitive actions ..."] sounded more like mystics than the analysts, therapists, or the existentialists. At least the latter were aware they were in the subjective realm. All the pseudo-objectivity of the latter day biological chemists is frankly embarassing.

I think this would just have been the swinging pendulum that has always been a part of mental health practice, except for the addition of pharmaceutical money - which profits so much from this "biological era" that it has held us here long past the usual time when a new paradigm wears thin and the pendulum begins its inevitable swing. That's what Carlat's blog and a lot of others are about. This is not about the predictable oscillation of paradigms in an ambiguous science. This is about corporate greed buying a paradigm and capitalizing on it - financing it's direction rather than allowing it to follow its own path. At least that's how it looks to me...

John M. Nardo MD said...

The last two comments, one from a patient, the other from a Psychiatrist, are both bulls-eyes. I too came to Psychiatry [from Internal Medicine] "because I find the human mind to be fascinating, and psychological suffering to be profoundly disturbing." And as to "The credibility psychiatry tried to build with the medical profession by dismissing the person and focusing on drugs", I'd like to add a comment. That happened around the early 1980's. It was announced as the "medicalization of Psychiatry," "evidence based Psychiatry." The DSM became criteria based, and those NIMH Neuron pictures became ubiquitous. Dynamic thinking, psychoanalysis, crisis intervention, even the ancient "common sense psychiatry" of Adolph Meyer became targets - some deserved, but a lot of it sounded like Sarah Palin talking about "liberals" - contemptuous.

With "medicalization," I think people hoped to make things more scientific. It feels like the opposite happened. If anything, the biologists ["Actions at 5HT7 and 5HT1A receptors suggest potential antidepressant and pro-cognitive actions ..."] sounded more like mystics than the analysts, therapists, or the existentialists. At least the latter were aware they were being subjective. The pseudo-objectivity of the latter day biological chemists is frankly embarassing.

I think this would just have been the swinging pendulum, except for the addition of pharmaceutical money - which profits so much from this "biological era" that it has held us here long past the time when a new paradigm wears thin and the pendulum begins its inevitable swing. That's what Carlat's blog and a lot of others are about. This is not about the predictable oscillation of paradigms in an ambiguous science. This is about corporate greed buying a paradigm and capitalizing on it rather than allowing it to follow its own path.

Anonymous said...

I take lithium because I trust it. This other crap that gets shoved my way with every new psychiatrist I see, forget it.

Anonymous said...

Well said, pj1280 and Dr. Nardo. I now routinely see patients coming to me on five different agents. It is madness! And then they wonder why they can't concentrate. So they think they must have "adult onset" ADD, and want another pill! Say what you want about the limitations of psychodynamic psychiatry, but at least back then we actually THOUGHT about our patients!

Anonymous said...

Regarding grief...The Compassionate Friends, the volunteer organization supporting parents who have lost a child, considers the first two years to be FRESH grief....if you attend one of their conferences, your name tag has a special sticker on it if it's been less than two years since you lost your child as they see it as "fresh grief". And these wizards on the DSM committee have come up with two weeks??? Two weeks and it's a mental disorder?? Give me a break.

doctorLIE said...

When the evidence is presented from "my psycopharmacology textbook and 2 cases from private practice", and not from clinical trials or review of journal articles, you know what kind of "education" you can expect.

Joseph P. Arpaia, MD said...

Lots of great points here.

@Anonymous #1 - Unfortunately its not just psychiatry that spouts BS. Check out Dr. Carroll's Health Care Renewal blog for posts on other specialties that seem to be fronts for Pharma or device manufacturers.

@Dr. Nardo - I think there were several economic forces pushing the "medicalization" of psychiatry in the 80's. One was managed care which saw "medication management" as cheaper than therapy delivered by psychiatrists. Another was the RVU schedule which made it far more lucrative for psychiatrists to do "medication management" than therapy. A third was the pharmaceutical industry which saw psychotropics as a cash cow. The collusion of these three was required for us to reach our current state.

There are other forces as well. One is the expectation that some people have that they are not supposed to ever feel nervous, sad, sleepless, or in pain, and if any of those symptoms occur then they need to run for help like Chicken Little. This, of course, is fueled by marketing and disease mongering. Tell people they are sick often enough and eventually they will believe you.

And therapy isn't a cure all either. Its track record is not much better than no treatment in a lot of studies. Its not harmless either as therapists can and do damage their clients.

I think that we need to accept the fact that our current understanding of how the mind and body work is abysmally poor. We don't have a theory, there is little if any valid research, either about pharmaceuticals or therapy, and yet we are supposed to help people. Its like trying to treat disease in the Middle Ages.

I think that if we constantly remind ourselves that we are clueless, then we proceed cautiously and do much less damage, and even some good.

pj1280 said...

Here's another way to look at it.

As a psychiatrist, if you were to ask me "what would be the most helpful new development in the treatment of schizophrenia?", my answer would not be "a new atypical antipsychotic."

These "me-too" drugs are not miracle cures because we just don't know enough about the biology of the disease. (OK, lurasidone might be a BLOCKBUSTER for reasons we don't yet know, but I'm not holding my breath.)

It's the drunkard-under-the-lamppost phenomenon. Just as the drunk looks for his keys under the light, the drug companies are looking at D2, D3 and 5HT receptors when schizophrenia is just as much a psychosocial disease as a biological one.

I'll be excited when Steve Stahl comes to town with a seminar on the community-based management of severe psychotic disorders, but unfortunately there are no pretty pictures (or money) there.

Joel Hassman, MD said...

Just curious, how many of the psychiatrists commenting here lamenting the poor choices and foolish direction of our field still belong to the APA?

If you are still a member and support the organization as is, aren't you being at least a bit hypocritical? I do not see any real leadership reinforcing a return to an eclectic practice of our profession. Sorry, but the established and entrenched hierarchy is out of touch with what patients need. It is in their rhetoric and their slogans.

By the way, Dr C, sorry we could not meet in person before I left Maine, but I appreciated the effort. Personally, this is one of your best postings in a while!

David M. Allen M.D. said...

While I agree in essence with all of the comments here, I start to get concerned when I hear statements to the effect that "all" treatments and diagnoses in psychiatry are bogus.

Much of the time, it is the incompetent psychiatrist who develops a reductionistic or pharma-inspired treatment plan which is flat out inappropriate for a particular patient.

In the right hands, psychiatric treatment can be very effective, although of course not for everyone and and of course not without side effects. Black and white thinking is irrational.

I also think those of us opposed to the current direction of the APA need to stay in it, not get out of it. It needs people like us. Getting out is essentially capitulating.

Dr John said...

Several have posted in reference to the problems that psychiatrists choose to see as worthy of TX as "remarkably amenable to powerful interventions, both psychotherapeutic and pharmacological."

This just is not true certainly for the major classes of drugs that are being handed out like PEZ including antidepressants and antipsychotics.Some data may indicate that many may be better off avoiding antipsychotics(WHO) altogether or at least that they are no better than placebo (meta-analysis of SSRI's). "Psychotherapy" is useful but as a systematized intervention it's not often clearly better than just someone talking to the "sick" person who is nice and the pt likes.Most studies of psychotherapy indicate this is much more important than technical training.

To pretend otherwise would indicate we are willing to heap well deserved criticism on the Lincoln Log models of psychopharmacolgy spewed out by charlatans like Dr Stahl but we wish to hang on to the myths of efficacy of those same treatments because to do otherwise means we must look at the entire corpse of psychiatry and not just the legs protruding from the body bag.

Joel Hassman, MD said...

Dr Allen, I respectfully disagree, my perspective is when a group is hopelessly lost, and those within who possess an appropriate vision for renewal refuse to mutiny to remove inept and clueless leadership, the healthy and responsible need to "jump ship" and let those who will not change to their destiny, sink more likely than swim.

Marginalizing is powerful when done responsibly, and the APA needs to experience this now if real credibility to our PROFESSION, not an organization, can be restored. Sure, I am one opinion, but what has changed for the better in the past 10 years? I watch the same message and agenda echo with every new President, similar to what we see in our country's political system as well. Well, the independents and moderates like me are rising as a sizeable influence.

I am not interested in being assimilated. The Borg must go, and they won't without a fight!

By the way, Dr C, read James Jefferson's review of your book in the Aug Clinical Psych News, and thought it more positive than the headline hinted. But moreso, the commentary by Gurprit Lamba below on same page ended with what should resonate in our new colleagues: "Only when we reboot our approach to patients by incorporating psychosocial and behavioral interventions into our armamentarium will we be able to meet the needs of our patients."

You think APA leadership says that with a straight face!?

David M. Allen M.D. said...

Dr. Hassman,

Let the mutiny begin.

There are a lot of psychiatrists who feel the way we do, but getting them to speak up, let alone organize, is no simple task.

Dr. Carlat took a shot at the current reductionistic climate in the field with his book, and I'm taking one with my new book.

I wish I knew how to get more of us to speak up publicly rather than be like some of the ones I see who just complain to each other.

Regards,

David

SteveM said...

Re: "Only when we reboot our approach to patients by incorporating psychosocial and behavioral interventions into our armamentarium will we be able to meet the needs of our patients."

Blah, Blah, Blah... "We must do this... We must do that..." Eternally stated with transparent, feckless insincerity. The M.D. contributors to Psychiatric Times, (excepting Dr. Frances) have elevated this practice of diversionary tactical avoidance to an art form.

But talk's cheap. Those are all just gaseous pronouncements floating mindlessly in the dense, turgid atmosphere of Planet Platitude.

You restive psychiatrists are revisting the same well documented issues over and over. Dr. Carlat's blog site has become a kvetch basin of recycle that empties into nowhere.

So when are you guys going to actually step up to the plate, self organize and do something tangible and corrective rather than just bitch and moan?

Joel Hassman, MD said...

Uh, SteveM, I am advocating for something, if you would read the content! If the majority of psychiatrists, who I know is more than 50%, all leave the alleged premiere organization that supposedly represents the interests of the profession, they (as in the APA) are left with a pathetic self interest minority who's agenda is clearly exposed as what it is: improving themselves first and if fortunate, patient care second.

I am curious, what do you advocate that psychiatry can do as a majority to have a substantial positive impact on future care? Please, give us tangible examples so we can learn from your harsh rebute of what we offer now!!

Let us be honest, this site attracts its share of covert antipsychiatry commenters who only pine for the field to dissipate altogether. But please, prove me wrong with points and details we can effectively learn from.

Thoryke said...

Would anyone care to explain what "pro-cognitive" effects might be?

Heck: what counts as "anti-cognitive" in this strange definition of potential efficacy?

SteveM said...

Re: Dr. Hassman

I was not picking on you personally. I merely grabbed that convenient quote from the book you referenced.

No offense, but advocating via blog rants falls short of actually doing something. I do Decision Management for a living. And one of the paradigms of the process is called "Objectives Focused Thinking". Basically that means defining what you really want and then working back recursively through a series of "meta-objectives" that connect the dots to the desired outcome.

Objective focused thinking is valuable because it separates out activity from progress. Advocating without a specific target endpoint is only activity. Even if you somehow coaxed many members to resign from the APA, that would do little to change how psychiatry is actually practiced.

But say you contrive a limited but real objective of "Emplacing activist thinkers in APA leadership positions". Rhetorically, what would be some action items to realize that outcome? The meta-objectives may be "organizing like-minded psychiatrists", "communicating your intent to the larger psychiatric community", "recruiting energetic psychiatrists to run for the positions". Each of those objectives has an explicitly defined outcome. Hopefully, you see what I'm getting at. Activity connected to tangible progress.

Parenthetically, I think one of the biggest barriers to fundamental change that physicians face is their instinctive desire for autonomy. So engaging in the necessary coordination and collaboration activities to actually achieve political or administrative objectives is a challenge.

I like you guys. But unless some of you step up to the plate and collectively take action apart from blog posting, you'll be kvetching as kvetch kan till the kows kome home.

Anonymous said...

I want to know if anyone has done a study on just who attends these drug commercials and why. I mean anyone with half a brain realizes this is all junk. So why waste your professional time? Are attendees paid? Is the food that good? Are attendees all given promises of lucrative Dr. Drug Rep gigs? Really, I cannot fathom why these "conferences" are attended by any doctor with integrity. Maybe they have nothing else to do. I don't know.

John M. Nard MD said...

I want to know if anyone has done a study on just who attends these drug commercials and why. ... Really, I cannot fathom why these "conferences" are attended by any doctor with integrity.

At last, question with possible answers:
1. CME is required for continued licensure.
2. Physicians in general medicine see hordes of unhappy, anxious people and are looking for something to do for [or with] them.
3. Company funded CME is cheaper [sometimes free].
4. There is food...

Sara said...

"In fact, we want to hear plenty about products. We look to experts like Stahl (and others on this tour, such as Leslie Citrome, Henry Nasrallah, Andrew Cutler, and Steve Potkin) to help us navigate the increasingly confusing terrain of antipsychotics.

We want them to talk about products, and we want specific recommendations. What is their first choice of antipsychotics and why? What are their second and third choices? What do they think about the increasing popularity of conventional antipsychotics? In their heart of hearts, do they really think that Lurasidone is worth choosing over its competitors? Shouldn’t we be hesitant to try me-too medications, when others of equal efficacy have long track records and clinical experience?"


The fact this is still what you want instead of actual recovery stories from people who have either conquered or controlled their psychosis or schizophrenia and been able to move on with their lives med free, at least in some cases, indicates to me that you are not thinking anywhere near broadly enough. I also think you should be demanding some long term (and unbiased) outcome studies of people who are taking antipsychotics, either new or old ones -- it doesn't matter -- vs. those who aren't. Just read A Beautiful Mind and pay attention to the progression of John Nash's "disease." How many people realize just how little "active" treatment he really had and how much good it did him in terms of his ultimate "recovery?" Even the author Sylvia Nasar doesn't "get it," but the facts are indisputable and for those of us who understand just how toxic today's treatments are, Nash's ultimate return to reasonable "wellness" without much treatment was all too predictable.

Anonymous said...

"I am curious, what do you advocate that psychiatry can do as a majority to have a substantial positive impact on future care? Please, give us tangible examples so we can learn from your harsh rebute of what we offer now!!" (sic)

Organize. Form an alternative professional organization to the APA. Organize CME programs that openly discuss criticisms of biopsychiatry as it's practiced today, and also discuss alternate approaches. Push for election of dissidents to positions of responsibility within the APA. Write articles for publication in the mainstream press explaining your views. Make some noise. Wave your arms. Get some attention.

"Let us be honest, this site attracts its share of covert antipsychiatry commenters who only pine for the field to dissipate altogether."

Let us be honest, nobody is born into this world as an antipsychiatrist. Many of us have had bitter experiences resulting from our care under the tender mercies of psychiatry. Some of us (myself included) have had our lives blown apart by the drugs pimped by mainstream psychiatrists including (at one time) Dr. Carlat. The fact that you pull out the "antipsychiatry" epithet at the slightest hint of criticism from a non-psychiatrist leads me to question the sincerity of your desire for reform.

Joel Hassman, MD said...

To the above anonymous commentor, let me just reply with this: I have had bitter experiences with police officers, never for anything of a felony nature, but, there are obnoxious and inappropriate officers out there, and yet I would never call for the abolishment of the police force.

Yet, there are commentors out there, here included, who give these testimonials how they were mistreated, probably very true and unfortunate, and then go on to advocate the profession be hung! Maybe you yourself do not think this way, but, it gets old to read this mentality. I personally am offended that because Dr X did not practice responsibly and ethically, I am guilty because I am a psychiatrist too. This mentality is out here amongst these pages, and I will speak out if I read it at sites that are trying to instill hope, faith, and direction for improvement.

Sorry if my comment was taken as an offense to you. But, I interpret how it presents until I read otherwise. And this is a medium that gets away with too much!

By the way, your recommendations are appropriate, but, the hierarchy of this profession is entrenched with old guard patriarchial and entitled thinking that cannot be negotiated. I know this personally. So, I still think if the APA had less than 20% of active practicing psychiatrists as members, they would just be preaching to empty halls, and that has to impact on the egos that fill them already!

Dr John said...

I am not sure what a covert anti psychiatrist is. Most of what I see is not covert at all. I am a "psychiatrist" and would classify myself as very much anti psychiatry in that I believe most of what has been passed off as science or truth for the past 100 years in this field is bullshit and has almost nothing to do with actually helping anyone but the psychiatrist. If that's anti psychiatry so be it. I think it's possible for us to humanely try to help those who are suffering as could a priest or a chiropractor. That does not mean I buy into a providential god or the importance of a chiropractic sublexation.

Maybe we should listen to what these angry people are saying. I think the " anti psychiatry" crowd makes some good points. The truth can be painful but it will set you free baby.

Daniel Carlat, M.D. said...

Nicely said, Dr. John. I'm also sick and tired of being on the receiving end of this epithet. It seems that "anti-psychiatry" has devolved into a description of any dissent within the field. If I dare to say that some of our treatments don't work or that some psychiatrists are unethical, suddenly I am doing great harm to the field, presumably because I will discourage potential patients from seeing psychiatrists, and such patients will get sicker and sicker, all because of me. What a load of BS. Dissent within any profession is always triggered by a real failing that needs addressing. In the case of psychiatry, the failing is an unimpressive fund of scientific knowledge about the mechanisms underlying the disorders we treat.

Sara said...

"Antipsychiatry" is used today very much the way "Scientology" was used in the past. It's a screen for mindless, ad hominem attacks that don't bring anything useful to the table in terms of really helping either professionals or patients deal with mental health challenges and the problems of current treatment paradigms. Just because someone challenges the status quo with reasoned, well argued points does not mean they are from some lunatic fringe. This just demonstrates, I'm afraid, how fragile and defensive the mainstream practitioners of psychiatry really are.

David M. Allen M.D. said...

There are plenty of extremists on both sides of the issues we are discussing, and they tend to squawk the loudest.

It's not that hard to spot the "true believers" from the people who actually believe in honest debate and examination of ALL the evidence. The extremists are the ones who say "my mind is made up, don't confuse me with the facts."

Dr. Carlat, it is not the psychiatrists who criticize some recent trends in the field who are damaging psychiatry's reputation. The practices we criticize are doing that all by themselves!

Joel Hassman, MD said...

You did not post my last comment regarding my opinion about antipsychiatry commenting, but it does exist and to minimize or rationalize it is just aiding and abetting the behavior!

Quite frankly, I do not understand why it is underestimated. It thrived at Furious Seasons, and since he has stopped his site, these people are looking for other sites to spew their venom.

But, don't believe me. Just wait until some moments of honesty and candor are revealed.

Anonymous said...

I am anxiously waiting to try Lurasidone. I happen to be a Masters level therapist who has been living with Schizoaffective disorder, bipolar type for 17 years now. I have tried every atypical and a variety of the typical anti psychotics. I cannot handle the anti psychotics at moderate to high doses. I also have a difficult time working without a low dose of seroquel or haldol due to voices/paranoia/cognitive symptoms. The unfortunate issue happens to be that I am in pain and have mild akathisia due to the low dose of Seroquel (again I have tried every one except Clozaril).

At this point I am in need of a medication that can help my symptoms without causing me as significant of side effects. I have done research on using Luvox to assist with akathisia for Abilify due to the role it plays with sigma 1 receptors. My MD's concern is the interaction with my other medication. Again I am looking forward to trying Lurasidone but Fanapt and Saphris were both disappointing.

Anonymous said...

Dr. Joel Hassman,
Please share your definition of "anti-psychiatry." Is it anyone who has a slight problem with your profession, it's practitioners, or its generally accepted practices? Because if it is, oh baby are you ever in a world of hurt.

By the way, you seem to advocate for censorship. Nothing good ever comes of censorship.

Anonymous said...

For someone who has Schizoaffective disorder the idea of a new medication is a positive one. The newest medication (Saphris and Fanapt) are both poor choices. I have tried all atypicals and continue to search for one that I can tolerate. They allow me to feel more comfortable in my mind but cause akathisia, physical pain and somnolence. The typicals work on symptoms but the side effects are intolerable.

I happen to also be a Masters level therapist who works with people living with Schizophrenia and Bipolar Disorder. I know from the trenches that we are working harding therapeutically on symptoms and in need of more effective scientific options. Let's encourage more research on L glutamine, etc.. Let's see what Lurasidone can do too. I personally can benefit from a medication that works on cognitive symptomatology.

I would like to hear more proactive psychiatrists asking for medication that is based on new research and designed to uniquely benefit the mind. Schizophrenia is painful. It is not a business.

pj1280 said...

Anonymous wrote:

"...I personally can benefit from a medication that works on cognitive symptomatology."

And there you have it, folks. That's the marketing gimmick. All it takes is for Steve Stahl to get out there and suggest (never mind prove, we don't need proof!) that because of its "actions at 5HT7 and 5HT1A receptors," lurasidone might have "pro-cognitive" actions, and that's what doctors are going to have in mind when they prescribe this drug.

C'mon, which antipsychotic user wouldn't benefit from a drug that improves cognition, even if the benefit is only theoretical?

It's sort of like the Cymbalta-pain issue. Docs have been trained to exhibit a conditioned response to the depressed patient with "pain" (and many of them will report some sort of pain in a review of systems) and prescribe Cymbalta, even though its effects on pain are not that great.

I'm convinced, if a drug company can put its drug in a "niche" (eg, Seroquel-sleep, Cymbalta-pain, now lurasidone-cognition) they have a gold mine on their hands.

Anonymous said...

Thank you for your comment to my brief blog. I have to note that I am not stating that I want to take Lurasidone due to an advertisement. I am merely stating that disorganized symptoms would benefit from biological assistance. Evidence will need to show if Lurasidone can provide this. The fact that companies advertise and push medication for several barely research reasons makes me sick. I do not feel medication should be advertised.

Anonymous said...

I originally thought Lurasidone looked like it held some promise for the cognitive symptoms of my disease. However, the more of it I learn of, the more in common it has with other medications currently available. "Me-too" drugs such as this only serve to prove that D2 blocking agents have come as far as they're going to go. The only novel drug in the pipeline is a glycine reuptake inhibitor by Roche for negative symptoms of schizophrenia. I can't help but think that Big Pharma would hate to see an actually cure with all of the cash that antipsychotics net each year.

Adrian Newman-Tancredi said...

Those who believe that all the antipsychotics are the same can always go back to using haloperidol or chlorpromazine (never mind the dystonia and tardive dyskinesia). Or perhaps you prefer to put on 10 or 20 kg of body weight on olanzapine.
Or perhaps aripiprazole and other recent drugs really are better tolerated and more efficacious?
Please remember that the rapid advances made in pharmacotherapy over a relatively brief period (a few decades) were achieved largely thanks to the much-maligned pharma companies and receptor-based pharmacology that seems to be heavily criticised in this discussion...

Daniel Carlat, M.D. said...

Hi Dr. Newman-Tancredi,

While I cannot speak for others, my own opinion is that newer antipsychotics have represented great advances in some ways and for some patients. My problem is not with the pharmaceutical company's scientists, but rather with the tactic of exploiting the greed of doctors (for money, for fame, for publications, for the narcissistic satisfaction of rubbing shoulders with wealthy drug company executives) to incentivize them to become de facto drug reps for the companies.

If the science is legitimate, it will make its way into the medical journals and doctors will find out about the advances and will start prescribing the better drugs. Paying doctors to do promotional talks is a sleazy way to get the word out.

Occam's Tool said...

A few thoughts: Cognitive improvement---I suppose that would be improvements in executive functions, as set changing seems to be the major problem in schizophrenia.

I actually have gotten specific recommendations in the past on meds from company sponsored conferences(Geodon having a sweet spot for dosing of 120-160 mg/d, and lower doses being generally worthless). But with each turn of the screw at FDA, departure from script gets harder at drug company sponsored meetings.

Generally, I try to review the literature as best I can, and treat the symptoms as they come up. Occasionally Stahl has some good points. But part of the frustration of the literature is that I have yet, for example, to see a study that outlines the treatment of psychosis in, say, a pregnant 24 year old Native American woman who is a steady pot smoker, is a tobacco smoker with asthma, and who has hepatitris C and occasional meth use. Therefore, almost everything I do is an extrapolation from literature, not something found in literature.

Anonymous said...

There are no pure scientific pursuits in mental health. Both pharma driven endeavors and academic ones (even psychosocially/behaviorally oriented research) is polluted by self-promotion and money. The drug industry has simply refined this "sham" science into a capitalistic machine. There are tons of examples of poor psychosocial research that has gained acceptance as notable therapeutic interventions, e.g., EMDR. Mental health (not just psychiatry) needs a total renovation of its ethics and values. It needs to move more toward professions such as neuroscience and old school behavioralism (think Dr. Fox's old videos of operant conditioning). The one thing you have to applaud lurasidone for doing is it is attempting to demonstrate efficacy on a objective measures (i.e., the MATRICs battery for demonstrating pro-cognitive effects). This is a vast improvement over the clinician rating forms currently used in most registration trials in psychiatry. Mental health should find non-objective measures in this day and age as totally unacceptable. Objective endpoints (and composite endpoints when no objective end point is available) should be the gold standard.

Anonymous said...

Meh...how could anyone have lurasidone as their favorite anyway? It's just getting out.

Too, about the pharm companies not comparing drugs and acting like...companies...and typicals becoming more popular. Yeah, there is a lot of pressure to use cheap drugs, whether the patient does better on them or not. Typical vs Atypical isn't a always or never thing - it's supposed to be worked out on an individual basis. I know ppl. who do better on typical drugs, I know ppl. who do better on atypicals.

About them acting like companies - what'ja expect?

purplesque said...

Well said, Dr. Carlat. I just wanted to let you know that through your blog you are reaching a lot of minds not yet corrupted by whatever it is that corrupts us eventually. And that is good.