the … era (1987-2011)

Posted on Friday 31 December 2010

It’s been a long holiday, frozen here in the Georgia Mountains. Today, there’s a blue sky and balmy weather. I think people around here have had their life-time White Christmas and are ready to put it behind us. I’ve spent my cooped up time with David Healy’s Let Them Eat Prozac, Alison Bass’ Side Effects, Astrazeneca’s $eroquel Study 15, and the blogs Healthcare Renewal, Furious Seasons, Carlat, Soulful Sepulcher, Pharmalot, and countless others. I guess I felt like a late comer to the PHARMA Wars, and I needed to catch up [I’m plenty caught up now]. Probably the most instructive thing I’ve read in all of it is the Introduction to Dr. Healy’s book entitled Introduction: Before Prozac. If you haven’t read it or don’t recall it, read it [again]. It’s an insightful narrative in its own right, but it was personally relevant for my life because I left academic medicine in the same year Prozac was put on the market. In many ways, I missed the brunt of what came after. I didn’t go to many Psychiatry meetings after that – too boring and too confusing. I stayed in a cocoon of Object Relations and Trauma theory, things that pertained to the patients I treated and I was blissfully isolated from the DSM/Psychopharm/PHARMA cosmos that so changed the world that I was avoiding. I learned a ton in the post-Prozac years, but it was from reading, my patients, and my colleagues – not from the "scene" of Academic Medicine or Organized Psychiatry [which I increasingly no longer recognized].

I’ve been surprised at my internal reaction to all of this stuff I’ve been reading. It’s a deep anger, in the general vicinity of rage. It’s not primarily focused on the immorality of it all – the buying of Psychiatry by Industry, the deceit in the studies and ad campaigns, the Doctors getting rich selling out. I sure feel plenty of that, but that’s not the rage part. It’s about having been left in the wilderness all alone and having to figure everything out by myself. I got most of it on my own, but it was hard work. I had to learn to start people low on SSRIs and tiptoe up. I had to learn to warn them about agitation early on. I never heard of akathisia in this context until this week reading these books. I had to learn that the Atypical Antipsychotics made people gain a ton of weight and that they were weak sisters in treating Psychosis. I also had to learn by trying that they didn’t do much for severe depression, much less the "blues." I had to figure out that my 1980s view of Bipolar Disorder was right after all, and that much of the "new stuff" was made up [I’m still waiting for a Depakote cure]. That’s where my rage lies. I "kept up" but didn’t learn much from it. I had to figure it out myself. And I would’ve loved to know that starting people on Benzodiazepines or Inderal with the SSRI to manage the initial akasthisia would’ve helped. Nobody told me that. Being a reasonably contientious Psychiatrist wasn’t enough.

That’s why Healy’s Introduction was so helpful. He is quite good at summarizing the essence of things and is a keen historian [I suspect him of a literary undergraduate degree]. Alison Bass is equally facile at giving out the pertinent facts that allow one to feel confident of her conclusions. There’s a "believability" factor in their writing that’s refreshing – after becoming so paranoid about anything I read that has to do with psychopharmacology. Medications are a tool in the practice of Psychiatry, and every single drug is a double edged sword. My own approach was to stay way back on the trailing edge of things, and to not try anything until my partners or friends had already tested the waters – and even then to move slowly and carefully. But even that wasn’t slow enough and I did some harm along the way – nothing fatal, but more than I would’ve liked.

Academic Medicine and our professional organizations let us down. The FDA and the people formulating the Diagnostic and Statistical Manual let us down. The Insurance Industry and the Pharmaceutical Industry let us down. And we let ourselves down, because we passed on some fuzzy medicine to our patients. I feel rage at being let down, but some of that might be a cover for that last part. Most of us that weren’t in "the game" just didn’t pay attention and were complicit and apathetic, rather than raising holy hell. I think I feel ashamed that I stayed in my psychoanalytic cocoon. I have enormous respect for people like Dr. Carlat, Dr. Carroll, Dr. Healy, Dr. Poses – the people who’ve been fighting the good fight for a long time now.

I’m encouraged by how much attention the PHARMA Wars have gotten lately, and feel some reform in the winds. But some in the face of the magnitude of the problem just isn’t enough. The tide doesn’t seem to have turned sufficiently quite yet. I don’t know what to call this era, but 2011 needs to be the final date on its tombstone…
It’s not psychopharmacology that needs to die. It’s the shameful mockery many have made of their own rallying cry – "evidence based medicine"…
    January 1, 2011 | 9:16 AM

    Give yourself credit, Mickey, for at least realizing it now and putting all this work in to educate the rest of us. I too was hiding in a psychoanalytic cocoon and essentially just opted out to do my own thing.

    I was at the point of resigning my membership in the American Psychiatric Association, but apathy made me delay just long enough that I received notice from them that I was now a Life Member with no dues to pay — so I did the passive thing and just let it be — instead of either resigning in protest at what psychiatry had become or taking up the fight inside.

    It’s this kind of passivity that allowed them to take over our profession in the first place; but I never really identified so much as a psychiatrist but went on to adopt “psychoanalyst” as my identify and its organizations as my professional home.

    It’s regretable that we good guys didn’t stay around to resist — perhaps we would have if there had been any organized effort to join. I think we all felt like individuals fighting the system and its determined forces of marketing and controlling the message of the future.

    It’s sad. I hope 2011 is indeed the final year engraved on the tombstone.

    January 1, 2011 | 9:51 AM

    “I never really identified so much as a psychiatrist but went on to adopt ‘psychoanalyst’ as my identify and its organizations as my professional home.”

    I think we all did that. In part, it was because we were under attack. And that atack was partially justified in that Psychoanalysts had dominated Psychiatry for decades. I was directing the Residency at the time all of this was happening. At that time, I was a candidate and actively tried to stay in the ‘Psychiatrist’ identity, but it didn’t matter. I saw it as a sign of the times and left peacefully.

    I don’t think my anger is related to that – paradigm shifts are the stuff of science [as are ‘fads’]. But I do think we all ‘wilted’ in part because the challenge was justified. There is a potential for arrogance in Analysis, something of a “we know”-ness that doesn’t play well. I think my anger came later when it became apparent that the “evidence based” metaphor was such a sham – particularly with the likes of our Chairmanboy. Right now, I’m sort of obsessed with a 1996 clinical trial [“Study-15”] that compared Haldol to Seroquel. The results are clear as a bell. Seroquel is a lousy antipsychotic. It’s better that peanuts, but barely, compared to Haldol. Astrazeneca danced all night to dismiss this study in their race to get Seroquel through the FDA in spite of the “evidence

    Seroquel is the best-selling drug in the best-selling class of drugs now – bringing in 4-5 Billion dollars a year in spite of some serious side effects. We should’ve noticed that. What we would have gotten in response was something I heard in those later Emory years over and over, “You’re just saying that because you’re still hung up on Freud.” In spite of the fact that ad hominem arguments were declared logical fallacy in ancient history, people still use them because they work. They sure shut us up.

    What’s interesting to me is that they shouted down their own colleagues who balked at the pseudo-science – Barney Carroll, David Healy, etc. – bilological Psychiatrists who said that a lot of the emperors had no clothes. So I wonder if the rest of us had joined in the fray if it would’ve made a difference. As much as I would like to think it would’ve – I kind of doubt it. Such things usually have to play themselves out, but it leaves me wondering what Psychiatry will become if biological psychiatry takes the turn away from the industry marketeers.

    January 1, 2011 | 11:00 AM

    I think we analyst types were intimidated by “evidence based” because we didn’t have hard evidence, in the sense of controlled studies, to back up our methods. Single case, anecdotal illustrations were no match for their numbers/stats “evidence,” never mind that the results weren’t all that good. But they impressed those who were looking for “science.”

    So we just shut up and let them have the day. It would have taken too much time and energy and interest that I lacked for me to learn enough to argue with them. Medicines really didn’t interest me; I wanted to work in therapeutic encounters. So I just more or less left psychiatry for psychotherapy — or maybe it’s equally true to say psychiatry left psychotherapy.

    January 1, 2011 | 11:24 AM

    When I think about my own career, I feel exactly the same way. I enjoyed the world where “(n = 1)” better that the statistical world I left when I changed specialties. But there is another piece that kind of haunts me. In earlier times, the plight of the severely mentally ill – chronic psychotic people – was seen as society’s problem. State Hospitals, the Community Mental Health Movement, etc. are long gone. With our world of private psychotherapy patients and Psychiatry in the world of paying customers, the chronically impaired got lost. The biggest mental hospital in America is the L.A. County Jail right now. We pretended that psychopharmacology would take care of that part of things, and it just hasn’t panned out. I’m not sure what ought to be, but I do think it’s something organized Psychiatry and Academic Psychiatry ought to be thinking about, planning for. That’s not happening anymore. One thing for sure, Schizophrenia is not a “neuroleptic deficiency” and those “forgotten people” are way more “forgotten” today than they were in 1987…

    January 1, 2011 | 3:54 PM

    We all were wandering in the wilderness once. It took me a long time to figure out the fraction of the picture I now somewhat understand.

    I got kicked into action a little earlier because one of the worst scandals of suppression of medical research of the 1990s happened right down the hall from me, and resulted in my boss, a decent, honorable, honest, smart, responsible doctor, David Kern, losing his job for trying to do the right thing. The case never got the attention it should have received (like many others), never resulted in any kind of investigation, and still is not a subject for polite conversation at Brown.
    (See these posts:

    I still feel bad for not marching on University Hall at the time. (Even so, I still lost my full-time faculty position at Brown a few years later.)

    So to atone, I started trying to figure it out. And after a while I discovered that the case was not a local anomaly, but part of a system-wide problem. And after Lehman Brothers’ bankruptcy in 2008, I discovered it was part of a global problem.

    So we have a lot of work to do, but welcome to the fray.

    And thanks for keeping an eye on Health Care Renewal (

    January 1, 2011 | 4:07 PM

    By the way, re your concluding remarks – Dr Wally Smith came up with the term “pseudo-evidence based medicine,” which seems apt:

    January 1, 2011 | 8:27 PM

    And after Lehman Brothers’ bankruptcy in 2008, I discovered it was part of a global problem.

    Sometimes, when I have this thought, I think I’m getting paranoid. Then I wake up and realize it’s not a dream but a grim reality…

    January 1, 2011 | 8:53 PM

    Honored to be in that reading list, thank you. I do recommend reading Robert Whitaker’s recent book “Anatomy of an Epidemic”. This book will sum it all up for you and everyone else…the psychiatric paradigm…all of it.

    Happy New Year, keep up the great posts here.

    January 1, 2011 | 9:00 PM

    Your an excellent writer, and get some fairly complex issues across in ways the layman can understand….How about publishing a book…I would say you have half of it written here on your blog already.

    January 1, 2011 | 9:01 PM

    Poignant after thought—how you felt/feel about being alone to navigate it all—imagine the countless people on psych meds who took meds, suffered withdrawals and scraped by for info on safe and low dose titration to decrease withdrawal symptoms. Or, being a mother (me) doing all of this calculating and research while watching a child suffer on the drugs, the decreases, withdrawals and ultimately now having to relearn how to do basic care, read, write, talk….after a decade of antipsychotics on the growing brain.

    This is why what you write even with retrospect–here–is important. The more we know, the truth and transparency in the end is what will truly help people navigate the waters once entrenched in the muddy psychiatric system and its drugs we call treatment that are merely patent extensions and pharma profits before patients. Sad, but true. It’s not a mystery why meds don’t work, or always need to be adjusted….

    January 1, 2011 | 9:40 PM

    At it states:

    On the face of it, the investigation of possible hazards posed by SSRIs does not seem to have followed the conventional dynamics of science, where anomalies in the data are supposed to spur further investigation. In this case, debate has been closed down rather than opened up. Journals that might have been thought to be independent of pharmaceutical company influence have “managed” not to publish articles and the appropriate scientific forums have “managed” not to debate the issues.

    This sounds eerily familiar with regard to another domain in medicine.

    Allow me to substitute a few words:

    On the face of it, the investigation of possible hazards posed by Electronic Medical Records does not seem to have followed the conventional dynamics of science, where anomalies in the data are supposed to spur further investigation. In this case, debate has been closed down rather than opened up. Journals that might have been thought to be independent of Information Technology company influence have “managed” not to publish articles and the appropriate scientific forums have “managed” not to debate the issues.

    January 1, 2011 | 10:30 PM

    I’m in the same camp as WriteWithStan and Soulful Sepulcher. They have taught me so much, along with Alison Bass, Carlat Blog, Pharmalot, & Pharmagossip. As a solo psychiatrist in a remote region of Northern Minnesota the past 25 years, I have given up on the APA, my statel medical society,& , of course, WebMD & Medscape to stay “informed” in psychopharmacology. Like Doug Bremner & Dan Carlat, I would encourage you to publish a book. Your recent Blog hit home hard for me…

    Nancy Wilson
    January 2, 2011 | 3:09 AM

    I appreciate your insights. I had similar feelings – disbelief and dismay – when I was introduced to the Academic Psychiatry scene in 2005. Some faculty did not want to follow the rules, which were designed to safeguard patients and research participants. I raised holy hell to no avail, and then I left the institution. Afterwards, I found solace in the sources you referenced in your post. The tide may be turning here in Dallas: Dr. Carlat’s book Unhinged has captured the attention of local psychoanalysts.

    January 2, 2011 | 4:37 AM

    One needs to be careful & not fall into the trap of misrepresenting Dr David Healy’s words. The Evidence however is clear that here is a man who is a fairly mainstream psychiatrist that is in favour of E.C.T
    Check out
    A History of Electroconvulsive Treatment in Mental Illness
    Authors: Edward Shorter and David Healy

    January 2, 2011 | 12:37 PM

    This is a great post and certainly sums up how many psychiatrists and other health professionals feel about how the drug companies interact with the rest of us.

    I’ve been bipolar for 12 years or so and started off in the dark places spoken of. I started off believing doctors and taking what they gave me, trusting that they knew what they were doing and believing that ignoring the side effects were the right thing to do because the “doctor said so”.

    I don’t feel this way any more.

    I’ve spent many years studying psychopharmacology and other treatments for mental illness. I have also tried almost every one of them because I’ve had to. I’m one of those patients that exists on a cliff somewhere never sure whether she’ll fall over the edge.

    And I fear that in all this anti-pharma talk people like me get left behind. I know how devastating drugs are. Antipsychotics, in my opinion, are some of the worst, but what else are we to use to treat people with a mental illness?

    Due to my own knowledge and the amount of time I’ve spent talking to doctors I don’t bother with a doctor I don’t think has a grasp of things. And so the ones I talk to admit that clinical experience and judgement guides their treatments more than studies. Studies are limited. Studies don’t even bother with certain patient populations. You have to use your best judgement. But this judgement, however flawed, is certainly better than not treating these people at all.

    I see anti-pharma people all the time and all they want to do is throw the baby out with the bathwater – all psychopharmacology is evil. It simply isn’t that simple. These medications _do_ work for people. Not as many as we would like. Not necessarily as cleanly as we would like, but they do work.

    And anyone who has a job, for which they are paid, has a vested interest in keeping it that way. Drug companies are in no way unique.

    I’m glad when doctors wake up and start being honest with themselves and their patients. It’s the best thing that can happen for both. But we still need psychiatrists and we still need treatments.

    – Natasha

    Catherine Creel
    January 2, 2011 | 2:47 PM

    I can really appreciate the clarity of your comments. Your dismay at the direction psychiatry has taken is also clear. But what puzzles me is why you let yourself off the hook so easily for sticking your head in the sand and not speaking out. There are physicians, Peter Breggin for one, and lay people who have fought for years to have the misrepresentations (aka lies) of psychotropic drugs revealed. Some headway has been made but just barely. It will not happen as long as people who can see it or are bothered by it do nothing. Do you really believe your voice doesn’t help at all? I’ve spent the last 20 years assisting people whose psychiatrists placed them on these drugs. These doctors far and wide don’t believe people when they speak of how the drugs make them feel. Worse yet, most are ignored or accused of malingering or when they tried to discontinue them using the ambitious schedule the physician swore by because the [drug] company said so and become so ill they can barely function. For many, a rapid or abrupt withdrawal is the beginning of the road to disability.

    The first ten years I tried to talk to physicians about the true nature of these drugs. I can literally count on one hand the number of people who checked into it any further. They did this by calling the drug companies and asking specific questions about withdrawal syndrome only to be told there have never been any reports of their drugs causing this (I wonder if these doctors heard the part when I talked about how drug companies don’t need to document feedback they receive if they “believe” their drug was not responsible). But I digress.

    Here’s my point — your voice counts. Everybody’s voice counts. Don’t think for one moment that yours wouldn’t have been of any help all these years past. But the road to fixing this problem still lies ahead. You can join us now. Frankly, I find it frustrating that you’re getting kudos for reading a few books and blogs and blogging your thoughts on it..

    But you can still help. The possibilities are limitless. Become a thought leader for others who are lost in the ‘wilderness’. Utilize your blog to make your voice heard. Write to colleagues, meet with them, provide information to politicians who have been working for years to expose the true nature of the pharmaceutical industry (Sen. Charles Grassley, et al).

    But please, stop trying to convince yourself and us that your voice and actions would have been meaningless. That’s exactly what’s been missing — the numbers of physicians who vocally refused to buy in to the lies. If you do it for no other reason, please do it for all the people who have suffered (and died) from these drugs.

    This is a comment for Natasha — there are alternatives to drugs for people. I’ve worked with people in these ways for over 20 years. Most could not have previously imagined themselves surviving without the drugs. But they did and continue to do so. For a better understanding about the lack of efficacy of these drugs I recommend The Myth of the Chemical Cure by Joanna Moncrieff.


    January 3, 2011 | 5:16 AM

    Again, I implore those reading here to read Robert Whitaker’s newest book ‘Anatomy of an Epidemic’. Evidence based and astonishing stats on the rise of disability in America and the connection to psych med use and increase in psych diagnosis.

    Also, phrasing people who are interested in truth and ethical data that back the drugs that are created for treatment as ‘anti pharma’ or anti psychiatry’ is getting OLD.

    Anyone taking psychiatric medications should be well-rounded and versed in the goings on of how the pills got to your pill boxes.

    The dangers of Seroquel and Zyprexa for example might not have happened to ppl (diabetes,weight gain, metabolic syndrome, death) if the drugs were not approved in the first place. The drugs were approved by the FDA based on lies from the drug companies AstraZeneca and Lilly. The data was cooked, buried and skewed to make their drug pass the FDA process and both drugs have injured and killed innocent people.

    I am witness to over a decade of watching a child grow up on antipsychotics and mood stabilizers and now watch her in her 20’s struggle to think, speak and write. The drugs caused brain damage.

    The person who questioned the validity of this blog author’s voice being one that counts due to ‘reading a few blogs and books’–no one can choose another person’s path of journey or judge why or when they stood up, spoke out or remained silent. This blog IS a voice and its one that has risen to the top of my reading list. There are FEW doctors/psychiatrists who write this way, actually NONE.

    Bremner writes sporadically and Carlat still reads as a passage from having to save his arse to his profession and job.

    Great blog here, keep it up!

    January 3, 2011 | 9:23 AM

    Very interesting post. I’m commenting here, as a layperson, without a medical education. It’s good to see some professionals admit that their “head in the sand” approach may have been good for their patients, but not for their profession. And I would like to add that what you have revealed here is not isolated to the world of psychological ills.
    My husband (a 53+year Type 1 diabetic) experienced the same treatment by conventional practitioners when rDNA insulin was “discovered.” The breakthrough in rDNA technology was not greeted by patients with laurels, but BigPharma manufacturered the need and the marketing strategy that has–over 3 decades–seen insulin-dependent diabetics become little more than consumer units for whatever latest-greatest concoctions are created by the insulin cartel. Gone is access to natural animal insulins; instead patients are constantly in flux as new treatments, new insulin-like analogs are put forth as the best treatment. As patents begin to lapse, the former ‘latest-greatest” gives way to yet another concoction.
    Many practitioners were so busy “practicing” and listening to the learned pharma reps that they didn’t have time to listen to patients, or to advocate (or demand) a continued supply of needed, proven medication. Perhaps years down the road, some of these practitioners, too, will feel they have been sold a bill of goods by BigPharma and the medical organizations that pander to them. Perhaps someday, a few of these endocrinologists/diabetologists will shake their collective heads, and ask why they didn’t listen to patients and question the “science” that drove diabusiness. Or maybe it’s just too comfortable or too profitable to go along with the current pharma-driven recommendations and never look in the mirror . . . or at the obituaries of patients who died before their time.
    I appreciate your contributions, and wish you the best of luck disseminating the information. I know there are some of you who are fighting the good fight, and hope your message spread across specialties. Recognizing that antipsychotics and mood stabilizers are probably the easiest to abuse because results are often subjective, nevertheless other drugs–even those as basic and life-sustaining and OBJECTIVELY measurable as insulin–are foisted on trusting patients. Practitioners continue to profit while patients struggle to merely maintain life, believing that a cure is being sought when the ONLY thing being sought is maintenance of the status quo.

    David Hager, M.D.
    January 3, 2011 | 3:11 PM

    I find the model of hypertensi­on to fit depression­/anxiety well.
    * Heritable vulnerabil­ity
    * Variable phenotypic expression – usually dependent upon lifestyle factors
    * Both somatic and cognitive-­behavioral interventi­ons work. For many, the latter obviates the former, but is less utilized because more effort is required from the patient (and doctor.)

    In contemplat­ing lifestyle factors, and evolutiona­ry variables, I’ve come to conclude that much morbidity is fundamenta­lly related to a mismatch between atavistic wiring and the qualities of our modern lifestyles that we’ve accepted as “normal” through recent generation­al habituatio­n. Trouble is, our wiring didn’t change to match our lifestyles­.

    Thus, the recently evolving “discoveri­es” that social connectivi­ty, purpose and regular exercise mitigate depression and anxiety! Once upon a time, we spent our days in tribes with generation­al histories and stories, scouring the land for our next meals (while avoiding becoming a meal ourselves.­) For that we are still wired, for better and for worse.

    We are not wired to sit at keyboards in grey cubicles for 40.0 hours a week, stuffing our insatiable bellies with candy bars and sodas, and then hiding in our houses, where we hold down couches that we might spend hours staring at TVs. And from the resulting angst emerges a hope that the good doctor will restore happiness … with a pill, just like the TV says.”

    More from my private practice experience:
    In my own experience, there are a few “real rules” that influence psychiatric private practice.

    1. If I don’t diagnose, I don’t get paid. Thus, everybody gets a diagnosis. (Was taught this as early as my residency in the ’80′s)
    2. The less time I spend with someone, the more money I make. Once upon a time I had a spreadsheet that calculated $$/minute based on CPT codes and their assigned reimbursements. This is a main reason why psychiatrists are choosing to see over 20 patients a day now.
    3. I have one string on my guitar any more – medication. I (my profession) helped to create that, and now that’s what patients expect me to play. Wave the magic wand (prescribing pen) and make me happy, doc! So, if I want that patient to keep coming back (especially if reimbursement is good), what will I do?

    March 23, 2011 | 2:26 PM

    Hello admin, thanks for posting and link back to my site.

    July 14, 2011 | 12:57 PM

    […] Boring Old Man blog, “Mickey,” the anonymous blogger, a retired academic psychiatrist, posted about how he figured out the extent that health care dysfunction affected psychiatry while […]

    August 17, 2011 | 6:12 AM

    […] Boring Old Man blog, “Mickey,” the anonymous blogger, a retired academic psychiatrist, posted about how he figured out the extent that health care dysfunction affected psychiatry while […]

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