revolution II…

Posted on Monday 30 May 2011

Redefining the role of psychiatry in medicine.
by Lieberman JA and Rush AJ
Am J Psychiatry. 1996 Nov;153(11):1388-97.

OBJECTIVE: The authors evaluate the forces that are changing psychiatric practice and propose options for redefining the clinical and educational goals of psychiatry within medicine.
METHOD: An overview of current external and internal forces shaping psychiatry is provided. These forces are both social, political, and economic [external] and scientific and technological [internal].
RESULTS: The convergence of these forces leads to recommendations for redefining psychiatric practice and education.
If psychiatry fails to redefine itself on the basis of its scientific foundations, political and economic forces may lead to an untenable redefinition that could threaten the field.

CONCLUSIONS: The redefinition process may lead to altered roles and somewhat different knowledge bases for psychiatry. The profession must choose whether to be reactive or proactive given this challenge.
An excerpt from the full text:
This was the standard line in the years following the DSM-III revision of the diagnostic categories in 1980 and the resulting dramatic redefinition of psychiatry that followed. In 2000, Dr. Lieberman wrote another commentary on the subject [available on the internet in full text][editor’s note included here]:
Drugs of the Psychopharmacological Revolution in Clinical Psychiatry
by Jeffrey A. Lieberman, M.D., Robert Golden, M.D., Scott Stroup, M.D., M.P.H. and Joseph McEvoy, M.D.
Psychiatric Services 51:1254-1258,  2000

Editor’s Note: In the commentary below, Jeffrey A. Lieberman,M.D., and his colleagues discuss changes in pharmacological treatment that have occurred since 1993, when the article reprinted on page 1249 was published. That article reported one-year outcomes for patients treated with clozapine, an atypical antipsychotic approved for use in 1990. Dr. Lieberman and his colleagues describe events leading to the introduction of atypical antipsychotic drugs like clozapine and of the selective serotonin reuptake inhibitor antidepressants — second-generation drugs of the psychopharmacological revolution that began at midcentury. They review evidence of the effectiveness of these drugs and discuss the benefits of both types of medication, such as more favorable side effect profiles, as well as the drawbacks, such as greater costs for both kinds of drugs and weight gain among patients taking atypical antipsychotics. The authors point out that the second-generation drugs represent a valuable payoff from earlier investments in basic neuroscience research.
Fluoxetine [Prozac] and Clozapine were both developed before 1980, so I guess he was talking about the earlier revolution, like maybe Thorazine, Lithium, and the Tricyclics. Whatever he meant, he was certainly right that 2000 was in middle of the salad days of the psychopharmacological revolution in clinical psychiatry – the fruition of the sentiment in his 1996 comments above. Lieberman ended his commentary with, "lamenting that we are following the changes rather than being proactive":
As we move into the 21st century, the field of clinical psychiatry continues to evolve. In one sense that is good: the field is dynamically responding to the economic, scientific, and academic pressures that have an impact on it. However, in another sense it is perhaps lamentable that the field has not been more proactive in defining itself and its vision for change instead of being reactive as it is swept along by the scientific revolution occurring in medicine and neuroscience and the reform in health care financing. The effects of both are rapidly reconfiguring the health care delivery system and the roles and practice of clinical psychiatry.
A decade later, Drs. Lieberman and Rush were teamed up [in a herd of authors] for another commentary in the American Journal of Psychiatry:
Conflict of Interest— An Issue for Every Psychiatrist
by Robert Freedman, M.D., Editor-in-Chief, David A. Lewis, M.D., Deputy Editor, Robert Michels, M.D., Deputy Editor, Daniel S. Pine, M.D., Deputy Editor, Susan K. Schultz, M.D., Deputy Editor, Carol A. Tamminga, M.D., Deputy Editor, Nancy C. Andreasen, M.D., Ph.D., Kathleen T. Brady, M.D., Ph.D., David A. Brent, M.D., Linda Brzustowicz, M.D., Cameron S. Carter, M.D., Leon Eisenberg, M.D., Howard Goldman, M.D., Ph.D., Daniel C. Javitt, M.D., Ellen Leibenluft, M.D., Jeffrey A. Lieberman, M.D., Barbara Milrod, M.D., Maria A. Oquendo, M.D., Jerrold F. Rosenbaum, M.D., A. John Rush, M.D., Larry J. Siever, M.D., Patricia Suppes, M.D., Ph.D., Myrna M. Weissman, Ph.D., Michael D. Roy, Editorial Director, American Journal of Psychiatry, James H. Scully Jr., M.D., Medical Director and CEO, American Psychiatric Association, and Joel Yager, M.D., Vice-Chairperson, APA Steering Committee on Practice Guidelines
Am J Psychiatry 166:274, March 2009

To many psychiatrists’ dismay, unresolved conflicts of interest between parts of our profession and the pharmaceutical industry continue to be a focus of concern… Our standards should address not only the conduct of high-profile opinion leaders, but also our responsibility as individual physicians to deliver to our patients the highest-quality evidence-based medicine.

Conflicts arise when interests that once seemed congruent begin to diverge. For the pioneers of psychopharmacology, the pharmaceutical companies were invaluable allies. Pharmaceutical companies had the latest information on new drugs such as imipramine, chlorpromazine, and diazepam that offered unprecedented therapeutic efficacy for depression, psychosis, and anxiety… However, as psychopharmacology has matured, education about biological treatment has often narrowed to carefully orchestrated marketing of specific drugs that may have only marginal advantages over other drugs in the same class… There is no clearer example of conflict of interest than the participation of prominent psychiatrists in pharmaceutical company speakers bureaus, which supply academic opinion leaders to deliver company-approved presentations that market their drugs to their clinical colleagues in the guise of medical education.

Because development of drugs at present relies solely on the pharmaceutical industry, the American Journal of Psychiatry publishes industry-supported clinical studies of new drugs, when the reviewers and editors judge that they contribute new information that is important for clinicians to consider and that is not available from any other source… These clinical research articles are a unique part of the education of psychiatrists about new drugs. They offer readers the opportunity to make their own decisions about the merits and results of a study supporting the use of a new drug, because they can inspect the methods and data for themselves.

Many new drugs have made psychiatric and other medical treatments safer and more acceptable to patients. However, there are also unfortunate examples of prominent companies failing to report important information about drugs that is critical for their safe use…

The development of better treatments is an urgent need for our patients. Strong academic-industrial collaborations help ensure that pharmaceutical companies develop new treatments guided by the discoveries of academic researchers. There is a danger that conflict of interest concerns may discourage these collaborations, which are crucial if our field is to develop the next generation of treatments based on discoveries in genetics and neurobiology. Thus, psychiatrists who participate in the development of new treatments and in education about their use have special responsibilities to be transparent and circumspect about any conflicts of interest… The code of conduct will be more effective when it is coupled with a peer review system, similar to the ethics committees of APA district branches that help enforce ethical standards for clinical practice…

APA ethical guidelines currently take into account the considerable expense of CME and journal publication and therefore allow pharmaceutical company support for these activities. Advertising in the American Journal of Psychiatry is separated from editorial functions by a strict fire-wall to assure that it does not influence editorial decisions or intrude into our medical content, but display advertisements seem increasingly incongruous with our standards for unbiased medical information…

The subsidy that each of us has been receiving is part of what has fueled the excesses that are currently under investigation. Accordingly, in the future it may cost more to attend meetings, to earn CME credits, and to receive journals… Each of us must acknowledge—in the choices that we make—our own responsibility to limit conflicts of interest in order to preserve the integrity of the field that is so important to us all.
Speaking of being "…lamentable that the field has not been more proactive in defining itself and its vision for change instead of being reactive as it is swept along…" how is it possible that people in the thick of things didn’t know what was going on – how corrupt things had become? Dr. Rush had been in the middle of TMAP for 13 years before Grassley came along. Dr. Lieberman was in the cohort that contained Nemeroff and Schatzberg. It would’ve taken more than blinders, more than even a blindfold, to not see that academic psychiatry didn’t just have conflicts of interest problems, conflicts of interest had become something of a feature of the specialty. And speaking of blinders, NIMH Director Tom Insel’s response has no acknowledgement of his part in the problem or mention of it happening on his watch:
Psychiatrists’ Relationships With Pharmaceutical Companies
Part of the Problem or Part of the Solution?

by Thomas R. Insel, MD
JAMA. 2010; 303(12):1192-1193

Psychiatrists have rarely enjoyed a surplus of public trust. During the past 3 years, public trust in psychiatry has been further undermined with accusations that several leading academic psychiatrists failed to disclose financial conflicts of interest… As public trust in the pharmaceutical industry has plummeted, the close connection between leading psychiatrists and the pharmaceutical industry, once a sign of progress for the profession, is now cited as evidence of corrupt influence…

The bias in prescribing practices and the conspicuous tilt toward pharmacological interventions are not unique to psychiatry. But this in no way diminishes the severity of the problem in psychiatry. 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.

There is no denying the need for academic and industry scientists to collaborate. Indeed, the public health imperative for scientific collaboration is formidable… Public trust will ultimately depend on finding better treatments, but this goal can only be reached if psychiatry finds a way for academic investigators to interact with industry without real or perceived financial conflicts of interest. New NIH regulations will increase clarity and rigorous NIMH oversight can ensure better management, but academic leaders and their professional societies will need to transform what has become a culture of influence. The greatest threat to an era of improved public health stemming from the productive and ethically sound relationship among academia, industry, and practice is a defiant embrace of the status quo, in which psychiatrists are seen as a leading source of the problem rather than as leaders in finding the solution for financial conflicts of interest.
Both the AJP‘s commentary and Insel’s JAMA editorial soft-pedal the problem:
    • Strong academic-industrial collaborations help ensure that pharmaceutical companies develop new treatments guided by the discoveries of academic researchers. There is a danger that conflict of interest concerns may discourage these collaborations, which are crucial if our field is to develop the next generation of treatments based on discoveries in genetics and neurobiology.
    • There is no denying the need for academic and industry scientists to collaborate. Indeed, the public health imperative for scientific collaboration is formidable…
What has gone on with CME, speaker’s bureaus, ghost-writing, mis-represented research, unreported income, etc. is fraud. Nobody’s worried about legitimate collaboration, but that’s not what happened, what’s still happening. And there’s a solid good old boy network operating in it all, including at the NIMH. For starters, Tom Insel is an active part of the problem as in helping Nemeroff get a chairmanship, as in keeping him on NIMH committees. The APA is part of the problem as in defending Schatzberg, as in allowing the DSM-5 to continue its tradition. John Rush and Jeffery Lieberman are part of the problem as in Brain Resources, as in PsychoGenics Inc, as in STAR*D. The pharmaceutical companies are part of the problem as in almost everything. Collaboration between academic psychiatry and the pharmaceutical industry is a privilege, not a right – earned by good behavior – not by Viva Zyprexa, or ghostwriting our literature, or hiring KOLs as detail men, nor by psychiatry chairmen getting rich working for drug companies. And the move needs to come from within psychiatry because we’re the ones with an ethical code to offer guidance, not the drug companies. Thirty years ago, they emptied psychiatry of the analysts post-haste, so there’s a precedent for thorough housecleaning. Time to point the cannon in another direction and fire at will. Target #1? Tom Insel…

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