Posted on Wednesday 16 June 2010

No, it’s not just another rant about Dr. Nemeroff. There are others…
A Leader of Ethics Reform at NIH Seems to Think the Rules Don’t Apply to Him
Project on Government Oversight

by Ned Feder
June 09, 2010

Now in the news is a controversial decision by Dr. Thomas Insel, a top official at the National Institutes of Health [NIH], to help Dr. Charles Nemeroff get a new job and a new NIH grant. Dr. Nemeroff, while at Emory University, was one of the most blatant violators of the NIH‘s financial conflict-of-interest [COI] policies…

And now we arrive at another incident that occurred while Insel was Director of NIMH—one involving a different perpetrator, a medical researcher in the NIH‘s intramural program. Dr. P. Trey Sunderland was the head of an NIMH research group that studied Alzheimer’s disease. In December 2006 he pleaded guilty in a federal court to a criminal conflict of interest created by payments to him of almost $300,000 from a drug company for work related to his NIMH research. In his opening statement at a House hearing in September 2006, Representative Joe Barton noted that Dr. Insel, as the Director of NIMH, had recommended a $15,000 retention bonus for Sunderland in January 2006, at a time when Sunderland’s COI violation was already well known [The retention bonus is an optional government payment whose purpose at NIH is to attract and retain physicians]. Representative Barton mentioned additional optional benefits provided by the NIMH to Dr. Sunderland after his violations of the NIH‘s COI rules were discovered and confirmed.

The NIH is trying to improve its ethical standards—and repair its damaged public image—by tightening the rules on financial conflicts of interest. POGO asks: Is it appropriate for Dr. Insel to lead this effort? NIH Director Francis Collins should deal with this question promptly and publicly. It’s a problem that should be easy to fix.
I really don’t have any beef with Dr. Insel, Chief of the NIMH, but his sensor for misbehavior is either set turned way down or maybe even turned off. Here’s another case, Dr. Trey Sunderland, where the infractions were well known but Insel just kept on as if things were fine.
Sunderland pleads guilty to the charge under a plea agreement in which he admits to taking "unauthorized" payments from Pfizer, agrees to pay the government around $300,000, and serve two years’ probation. For its part, Pfizer maintains that it broke no laws and breached no ethics.
But back to Psychiatry as a whole…
The trouble with psychiatry: One shrink’s view
Increased focus on drugs shifts focus from profession’s roots in psychology

May 25, 2010

NEW YORK – Psychiatry has lost its soul.

That’s how grimly Dr. Daniel Carlat, a psychiatrist in private practice outside of Boston, characterizes the state of his profession. "Over the last 20 to 30 years, psychiatry has really transformed itself from a profession in which we try to understand people and understand their psychology – and talk to them and help them that way – into a profession in which we diagnose diseases, and we medicate those diseases," says Carlat…

The slide started, says Carlat, when psychiatric blockbusters like Prozac, a so-called selective serotonin reuptake inhibitor, or SSRI, was approved in 1988. Thanks to Prozac and its cousins such as Zoloft and Paxil, and their relatively limited side effects, prescriptions grew to the millions. Borrowing the words of late Harvard psychiatrist Dr. Leon Eisenberg, psychiatry went from being "brainless" to being "mindless," Carlat says. Today, psychiatrists spend 20 minutes with a patient every few months, in essence adjusting medications, compared to an hour or more each week trying to understand what was wrong…

While no one completely understands what’s going on in the brain of a depressed person, drug makers have been quick to take advantage of the medical model of mental illness, pushing their own expensive medicines in dubious ways, Carlat says. And he would know. In 2001, he was contacted by the pharmaceutical giant Wyeth, which offered him $750 to have a short lunch with primary care doctors. The basic idea: to tout the company’s psychiatric drugs, such as Effexor. Wyeth, later bought by Pfizer, gave him slides and took him to expensive conferences, where key opinion leaders in the field would lecture on the newest drug trials. And each time he did his talks, drug reps would listen in.

"I knew that if I wanted to get another gig, and another phone call, another invitation for another $750 check, I was going to have to say some pretty positive things about their drug, and I was going to have to downplay some of the negative side effects," Carlat says. Finally, after having made $30,000 and realizing he was just a hired gun, he started talking frankly about the side effects. The next day, he said, a drug rep came by his office and asked him if he’d been sick, as if that was the only logical explanation for such behavior.

"Doctors usually are going to think that other doctors aren’t going to try to deceive them about things, but unfortunately, that’s not true," says Carlat, who later wrote about the experience in The New York Times Magazine. "Doctors are just as vulnerable to the allure of money, marketing and financial incentives as anybody else."

For example, in 2006, one prominent psychiatrist, senior National Institutes of Medical Health scientist Pearson "Trey" Sunderland, was sentenced to two years’ probation for accepting about $300,000 in consulting fees from Pfizer without first obtaining approval and disclosing the funding. In response to this and other incidents, just last week, National Institutes of Health director Dr. Francis Collins proposed new, more stringent rules about how to manage researchers’ financial interests in companies whose work is related to their own. As part of the new proposal, NIH-funded institutions would be required to post conflicts of interest on a public website…
Today, a friend said after reading my flurry of posts about Dr. Nemeroff, "I think Dr. Nemeroff really hurt you."  I personally had very little dealing with Dr. Nemeroff. I don’t know if he could pick me out of a line-up, even though he always greeted me with my first name. But my friend is right. Dr. Nemeroff and his sort really did hurt me. They took over a profession that I loved and turned it into a commodity. I was extremely lucky to have garnered my reputation and referral sources before he came to town, so I had the opportunity to practice Psychiatry in the way I think it should be practiced. But it did hurt to see the field as a whole "lose its soul." It still hurts.

Practicing as I do now for free at several charity clinics is still exciting and interesting. I write a lot of prescriptions [I hope rationally]. But I do a lot of talking and listening too – just like I was taught to do in the good old days. I work with some psychologists, social workers, and licensed counselors, and we have a fine time trying to figure out the best course of action for the often thorny problems that walk in our doors.

The thought of doing rapid sessions prescribing drugs based on reported symptoms and not really getting to know the people with those symptoms makes me cringe. Dr. Insel has an important duty at the NIMH, but it’s not to promote the likes of Sunderland and Nemeroff, it’s to help us out here practice good medical mental health care [again]…
    June 16, 2010 | 10:22 PM

    Some years back, a young psychiatrist just trying to get his practice started had a job working for one of the HMO’s. He was supposed to see a patient every 20 minutes, no matter how complicated the history or the current problems. How long does it take to write a couple of prescriptions, after all?

    My young friend quit the job when they decided to make it more efficient. Now in that 20 min time slot he was to see 2 patients — in the room at the same time. You could write the Rx for one while listening to the other one. Of course that did simplify things. It puts a damper on that time-consumer — talking. Who’s going to want to talk about their problems with someone else sitting there waiting their turn?

    June 17, 2010 | 6:55 AM

    I can understand the distinction between Nemeroff’s actions hurting your profession as opposed to hurting you personally. One of the most unusual things about your blog is the utterly dispassionate and, yes, disinterested scalpel you employ in your dissection of all things relevant (and occasionally joyously irrelevant) covered therein. Anyone can see that you have high standards for others. But you also have even higher ones for yourself. Do you have any idea how rare a thing that is? It keeps me reading, every day. Thanks, and keep it up.

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