Wednesday, March 24, 2010

Dr. Tom Insel, NIMH Chief, Scolds Psychiatry

In the latest issue of JAMA (the Journal of the American Medical Association), Dr. Thomas Insel, the chief of NIMH (National Institute of Mental Health) accuses academic medicine of having become a "culture of influence," in which drug industry marketing goals have pervaded the practice of psychiatry.

Insel's commentary is entitled "Psychiatrists' Relationships with Pharmaceutical Companies: Part of the Problem or Part of the Solution?" While acknowledging (as we all should) that some collaboration between physicians and pharma is a good thing, he concludes that industry influence has radically skewed psychiatric practice in favor of the most expensive drugs, even when evidence shows that cheaper generics work as effectively. He also bemoans the fact that effective psychotherapeutic techniques are "woefully underused and frequently not reimbursed."

In what I believe is an oblique endorsement of an APA Work Group's report on the relationships between psychiatrists and industry, Insel calls on organized psychiatry to lead the way to reform:

"The focus on financial conflicts of interest in psychiatry is an opportunity to take the lead in setting new standards for interactions between all medical disciplines and industry. Academic leaders, professional societies, and patient advocacy groups could turn the tables of public trust by developing a culture of transparency for psychiatry's collaborations with industry, including the clear separation of academic-clinical missions from industry marketing."

Not all wags see Insel's commentary as optimistically as I do, of course. Bernard Carroll, over at Health Care Renewal, believes that Insel went soft on some of the poster boys of corruption, such as Charles Nemeroff, who resigned his chairmanship of Emory after it became clear he deceived the university regarding his promotional work with industry. Carroll points out that Insel might have considered disclosing his history of close ties with Nemeroff:

"Though Dr. Insel spoke in platitudes about the need for transparency as a solution, the spirit of transparency did not move him to disclose that Nemeroff is his former boss at Emory; that Nemeroff found a position for him when Insel was departing the intramural research program at NIMH; that Nemeroff lobbied for Insel’s appointment as NIMH Director; and that Insel appointed Nemeroff as an advisor soon after he moved to NIMH. These are pertinent conflicts of interest that readers of JAMA deserve to know about."

If this is true, this is interesting information that is new to me. Nonetheless, in my opinion it does little to detract from the power (and courage) of the country's chief psychiatrist calling his own profession out on the carpet for bad behavior. Bravo to Dr. Insel!


Unknown said...

I appreciate your support on my suggestion that psychiatry take the lead in addressing financial conflicts of interest, as published in JAMA this week. Your quote from Bernard Carroll amazes me as actually each point is factually incorrect. I was one of the Deans and Directors at Emory University until 2002. While I had a nominal academic appointment in the Dept of Psychiatry of the Medical School as well as the Dept of Psychology in the College, I reported to the VP for Health Affairs not to Dr. Nemeroff. To suggest that Dr. Nemeroff had a role in my recruitment to NIH may be equally inaccurate. I was appointed by Dr. Elias Zerhouni, then NIH Director, who talked to my Emory boss (Dr. Michael Johns) and my post-docs, but would have been unlikely to consult Dr. Nemeroff. And finally Dr. Nemeroff was appointed to the National Mental Health Advisory Council by Dr. Steven Hyman, my predecessor at NIMH. He rotated off our Council after my arrival at the end of 2002. Carroll's interest in "transparency" might be aided by a dose of reality.
Tom Insel

FunPsych said...

The bigger problem is not even that psychiatrists favor expensive drugs over generics, but that the culture of psychiatry has become so drug-first that we're even trying to treat psychopaths with meds. There really needs to be a cultural paradigm shift in psychiatry away from its emphasis on psychopharmacology to a more integrated approach. Fortunately, most of the psychiatry residents I meet today are equally interested in learning psychotherapy and psychopharmacology, so the pendulum is swinging, but it'll be another couple of decades before the leaders of psychiatry see things this way.

Debra said...

Ho hum.
It gets tiring and boring to hear the same, woefully inadequate "solutions" proposed to problems which go way beyond psychiatry at this time, problems that are SOCIETAL ones.
Transparency ? How long have we been hearing this one ? Just how transparent are we going to get (like running around with our thoughts pasted to our foreheads, perhaps ?) before we realize that this is not the answer ?
We have become a collectively lazy society that wants quick fixes for everything.
We want drugs that are going to cure us with a snap of the fingers (doctors and patients want these drugs...)
We want to point our fingers at everyone in our fits of self righteousness. (Whoops, almost forgot, we itch to punish the "bad guys" too..)
We are... a society of material abundance and spiritual dearth.
A society whose people in power know little about suffering, and do everything to avoid it, even dulling themselves down to avoid experiencing pain AND pleasure.
A society where people are afraid of having to make do with less.
While we're at it...
Last time I checked it was a substantive.
A DISINCARNATED substantive.
Now... there are psychiatrists, who are working in different ways.
And is there ONE "academic psychiatry" ?
Geez, the U.S. has become more "socialist" than I thought... even WITHOUT the healthcare issue...

Daniel Carlat said...

Dr. Insel,

Thanks for correcting the record.

As a member of the APA's assembly I will be in New Orleans trying to convince the assembly to adopt the Appelbaum report. It will be an uphill battle. I hope you'll consider officially endorsing it.

Thanks so much,

Danny Carlat

Dr John said...

This is about as impressive as the Pope calling on priests to be ashamed of all the abusing of young boys all these long years. I am supposed to be inspired by this? If he had stood up there and castigated the group for producing junk science perpetuating the myth that marginally effective drugs work better than placebos and drug companies in collusion with these researchers had in fact collectively robbed US citizens of billions of dollars with no real benefit to them I would have been impressed. Psychiatry leadership will do only what it is forced to do in the face of mounting negative public and political criticism which is exactly what is going on here. Zzzzz

Bernard Carroll said...

Danny, thanks for the mention of my different take on Dr. Insel’s Commentary in JAMA. I respect your view and would just say things are not always what they seem to be. There have been others weighing in today in agreement with me. Like, here:

In reply to Thomas Insel: Please do not be disingenuous. Dr. Nemeroff was your primary department chair and he played an essential role in bringing you to Emory University. You do not dispute that Dr. Nemeroff lobbied for your appointment as Director of NIMH. And I do recall seeing an announcement or press release about Dr. Nemeroff’s advisory role soon after your tenure began as Director of NIMH. Perhaps your aides can surface it.

Bernard Carroll.

Anonymous said...

It is no secret in the pyschiatric community that Bernie Carroll and Bob Rubin have had personal axes to grind against Nemeroff and Schatzberg for years. They have chosen to take their personal vendettas public. These public attacks have become boring and irrelevant. If both of them were to be transparent they would disclose the fact that they were admonished by the ACNP a few years ago for inappropriate and unprofessional behavior. Nemeroff and Schatzberg have taken the high road and chosen not to engage in this purile mudslinging.

Let's see, who are we going to believe, Tom Insell or Bernie Caroll? Duh.

As an APA Assembly member myself I will be vigorously working to defeat the Appelbaum report. When Appelbaum brought the report to an Assembly Reference Committee last year, he requested that the Committee support it so it could be brought to the Assembly floor for an up or down vote. The Committee appropriately rejected the report and it was then mysteriously yanked from the full Assembly agenda.

I believe the report will be voted down as it should at the next Assembly meeting in May. It does not reflect the will of the grassroots membership. You and Appelbaum appeared in a videotaped interview together a year ago to prematurely laud the APA's approval of the report (when you both believed erroneously that Stotland and her minions would make sure that it got pushed through). The Appelbaum report is dead in the water.

Bernard Carroll said...

Well, well, well. Now an anonymous crony crawls from under a rock to spread smears on behalf of Nemeroff and Insel. This is standard modus operandi for sleazebags. All three should be ashamed.

For the record, the admonishment determined by ACNP was for pointing out the undisclosed financial conflicts of interest alongside the exaggerated claims made by Schatzberg and Nemeroff, among others, for Schatzberg’s drug Corlux. That was not ACNP’s finest hour. Dr. Rubin and I are proud to have made a principled stand for transparency in ACNP business. We have not discussed this matter in public before out of respect for a directive from ACNP council.

I can think of nothing done by Nemeroff or Schatzberg that would give cause for a personal vendetta. The charge is a longstanding smear, with no substance. No prizes for guessing where it originated. I challenge the anonymous sleaze to put up or shut up.

InformaticsMD said...

Re: Anonymous March 24, 2010 11:06 PM

Ad hominem attacks are a logical fallacy:

An Ad Hominem is a general category of fallacies in which a claim or argument is rejected on the basis of some irrelevant fact about the author of or the person presenting the claim or argument.

Typically, this fallacy involves two steps. First, an attack against the character of person making the claim, her circumstances, or her actions is made (or the character, circumstances, or actions of the person reporting the claim). S

Second, this attack is taken to be evidence against the claim or argument the person in question is making (or presenting).

Debra said...

Geez, I guess I was wrong.
I thought that this blog was about discussion, the issues, what we could be doing to make things better for INDIVIDUAL FLESH AND BLOOD PATIENTS.
Like.. our mission as people trying to alleviate suffering among our patients WHILE putting meat and potatoes on the table (for some of us).
I know, I've always been really idealistic... Utopian.
It's really too bad.
I see this all over.
The house is on fire, and people are quarreling over who gets to drive in the fire truck, or hold the hose.
This kind of talk really doesn't interest me.
It SHOULD go on in back rooms.
Because the profession doesn't come out in honors.
(I know, I know, we are all men and women, we have our weaknesses... but do we have to air our dirty laundry in public ? Everybody knows we have dirty laundry (or they should know, at any rate...). Why advertise it ?)
I'll come back when there's something more interesting.

InformaticsMD said...


Without honesty, there can be no truth.

Without truth, there can be no trust.

Without trust, there can be no meaningful discourse.

Without meaningful discourse, there can be no society.

The push for honesty underlies all that is apparently of meaning to you.

Anonymous said...

Let's see, who are we going to believe, Tom Insell or Bernie Caroll? Duh.

To Anonymous: If we are voting, I will believe Dr. Carroll any and all times over the likes of Nemeroff, Schatzberg, Keller, Biederman, and the rest of Psychiatry's corrupt circle.

Debra said...

You have just got sucked into the "truth" vortex.
You can keep opening those doors that you have just opened.
Every time you open a door, there is yet ANOTHER one.
And what you call "the truth" keeps receding.
The BIG question ?
HOW do you determine whether someone is honest or not ?
By writing down the definition of "honest" on a piece of (legal) paper, and saying that everyone who does not fit that definition of honest is dishonest ?
That is rather limited, and a close examination of "justice" AS IT PLAYS OUT ON THE COURTS will show you that there is a world of difference between human justice in the courts and "THE LAW". And we don't live in the world of the law. We live in the world of.. the courts.
The doors that you just opened are metaphysical ones.
And, unfortunately you don't have the necessary tools to be able to analyze this problem.

Anonymous said...

Does it matter what the Assembly does? How many psychiatrists read about or even care what the Assembly approves? They approve various reports, then do not follow through to see that anything actually happens in the real world. Big waste of my APA dues money