Posted on Wednesday 27 April 2011

In my last post, I was connecting several dots that I hadn’t realized were so closely related in both spirit and time – the review article in which Dr. Nemeroff favorably reviewed three new depression treatments without acknowledging his conflicts of interest and was called to task, and an early article chasing genetic markers for drug response that I had found scientifically flawed. The motivation in both cases seemed blatantly commercial rather than scientific. For completeness, I’ll reference the obvious extension of the story. Within less than two years, Dr. Nemeroff authored a Perspectives article in a journal he edited, Neuropsychopharmacology, that described yet another depression treatment he was financially connected to without disclosure.
  • by Nemeroff CB, Mayberg HS, Krahl SE, McNamara J, Frazer A, Henry TR, George MS, Charney DS, Brannan SK.
    Neuropsychopharmacology. 2006 Jul;31(7):1345-55.
      Currently available therapeutic interventions for treatment-resistant depression, including switch, combination, and augmentation strategies, are less than ideal. Observations of mood elevation during vagus nerve stimulation (VNS) therapy for pharmacoresistant epilepsy suggested a role for VNS therapy in refractory major depression and prompted clinical investigation of this neurostimulation modality…
      Mechanisms that mediate the beneficial effects of VNS therapy for treatment-resistant depression remain obscure. Suggestions for future research directions are described.

      Acknowledgements: We thank Sally Laden for editorial support in developing early drafts of this manuscript. We maintained complete control over the direction and content of the paper. Preparation of this report was supported by an unrestricted educational grant from Cyberonics Inc.
This time, the sky finally fell. In the aftermath, Nemeroff resigned as editor but it was too late. Senator Grassley got involved and began to investigate his conflicts of interest – finding that Dr. Nemeroff had conflicts in reporting conflicts not only with journals, but in his reporting outside income to Emory University where he was the Departmental Chairman. Ultimately he resigned that position as well. In someone’s future book, this will also be the time when it dawned on us all that "editorial support" meant industry-financed ghost-writing.

But I’m after another point this time through the story, a point beyond the perversion of science for profit. As tempting as it is to stack the evidence that our psychiatric literature and academic structure has become so contaminated by its marriage to the pharmaceutical industry as to be universally suspect, there are other things on the table. Back in 2002, Charlie Nemeroff wrote a review article. Independent of his motives, what he said was wrong – wrong as rain. Nobody’s running around wearing Lithium Patches. Milnacipran is hardly a household name. Mifepristone remains a failed work in progress. It’s almost a decade after his Treatment of mood disorders article, and his new, emerging, novel ideas went nowhere. And in spite of Cyberonics having the largest stable of scientific advisers ever assembled, VNS therapy hardly comes to the mind of anyone who isn’t on Cyberonics’ payroll.

It’s the reason I facetiously called this the Age of Emerging-New-Psycho-Neuro-Pharmacology. I meant that seriously [even though I’ll cop to facetiousness on the side]. Sticking for the moment with Nemeroff, recall that he testified as an expert back in the early 1990s in front of the FDA that Prozac didn’t cause suicidal thoughts. And he was instrumental in getting David Healy unhired in Toronto around that same point. He was wrong about that too. The SSRIs can evoke suicidal thoughts, particularly in adolescents.

We’ve probably spent too much time focusing on the obvious fact that many of our Key Opinion Leaders and Thought Leaders have sold their souls to the drug trade, and failed to emphasize  that what they say has turned out to be just plain wrong. And it’s not just Charlie Nemeroff, it’s everybody – singing the praises of great breakthroughs coming just around the corner – members of the choir including APA Presidents, NIMH Directors, Chairmen of many Psychiatry Departments. Psychiatry as a specialty has drowned in the rosy but non-materializing future and failed to notice that those predictions have had a dismal batting average. Right now, we’re chasing a new fantasy as unlikely as the others, urged ever forward by Dr. Nemeroff:
    Ten or 20 years from now, we will be sending our patients to the laboratory to characterize them in terms of genetic polymorphisms and/or to an imaging laboratory. Then based on those findings, and on the clinical presentation of the patient, we will be able to do what we can’t do right now, which is to answer the question—of all the treatments that are effective for depression, what is the best one for this particular patient?
Given his track record, or maybe I should say their track-record, one might say that the likelihood of it turning out as advertised here would be in the range of zero. But that isn’t even the biggest point. It’s another "Ten or 20 years from now" story – like the end of most modern articles – "directions for future research." Motives aside – futuristic review articles, APA Presidential Addresses, NIMH Director’s calls for Decades of Discovery and Translation, all focus us along a group trajectory which from any rational perspective hardly seems very exciting to anyone who isn’t on the pep squad. I guarantee that the doctors at the Internal Medicine meetings or the College of Family Medicine aren’t sitting around saying, "Boy, those Psychiatrists are really on a roll now!" or "Now that they’ve gone and gotten scientific, they’re really part of the fold!" What they’re more likely saying is, "I’m not going to get any help from making a referral, so I might as well write a prescription like they do. Where’s that brochure the detail man left in here the other day?" And in Dr. Nemeroff’s  unlikely fantasy, ‘Ten or 20 years from now,’ they’ll be saying, "Is Ms. Jones’ SMA-PSYC back yet? What does it recommend I put her on?"

I’ve got a lot more to say about this but I’m going to stop at this point, because I can feel the sarcasm welling up – meaning I’m getting angry. And the point isn’t venting my own frustration or anger, it’s about the trivialization of something that doesn’t need to get lost in all of this madness. For the moment, I’ll stop with this. They weren’t just wrong about the future of their psychopharmacologic prowess, they were wrong about what the specialty of Psychiatry is actually about – very wrong…
    Joel Hassman, MD
    April 28, 2011 | 9:38 PM

    Leadership, if that is the fair word to call what amounts to those who head the APA, KOLs, and probably a sizeable percentage of colleagues who run residency programs, have failed those of us who work in this field to practice the way we were trained that is truly ethical, responsible, and accountable. And I believe in two adages that are applicable to the deceit and irresponsibility that is metastisizing in psychiatry: “deeds, not words, are what define us”, and, “we are judged by those we associate with”.

    Strange, simple and pervasively true adages over the ages, and yet still ignored and dismissed, especially by those who fail by those terms.

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