not much more to say than that…

Posted on Sunday 26 June 2011

eth·ics [eth-iks]
  1. [used with a singular or plural verb] a system of moral principles: the ethics of a culture.
  2. the rules of conduct recognized in respect to a particular class of human actions or a particular group, culture, etc.: medical ethics; Christian ethics.
  3. moral principles, as of an individual: His ethics forbade betrayal of a confidence.
ethos [ˈiːθÉ’s]
— noun
    the distinctive character, spirit, and attitudes of a people, culture, era, etc: the revolutionary ethos.

It is the ethos or culture of medicine that defines us [primum non nocere – "first, do no harm"], and it is that very culture that has been under particular assault during the recent decades. And while psychiatry is not uniquely vulnerable among the medical specialties, it has been a place where the traditional ethos of medicine has faced some of its most difficult challenges. Last year, I reviewed some of the seemingly desperate treatments in the past [for review…] – things like Insulin Coma Therapy, Leucotomy, and Shock Therapies. They were all over-utilized, examples of one of the dangers to the medical ethic called therapeutic zeal. Since many of the illnesses treated by psychiatrists are desperate by themselves, when something comes along that works, it’s almost universally over-used – then the other side of the coin becomes apparent.

Another force in the ethos of medicine is a conflict that physicians of all ilks deal with every day. When any person develops a symptom, the felt experience in the face of an unexplained symptom is anxiety. So there’s a conflict between the physician and the afflicted patient. The patient’s goal is clear: they want someone to take their symptom seriously, they want it to have no consequences, and they want it to go away. The physician is by definition interested in knowing the cause, and is asking lots of questions and doing lots of poking, looking in places that aren’t often looked into, and maybe ordering lots of tests. So, number one is find the cause, later comes symptomatic treatment. It is the skilled doctor who negotiates that conflict easily. But in the ethos of medicine, that conflict is always alive and well. The patients want to feel better. Doctors want them to be patient. And in psychiatry as I know it, the term cause can mean anything from biology to psychology to relationships to poverty to anything else to ‘who knows?’ The patients still want to feel better, no matter the cause.

Medicine separated itself from the other healing arts based on primum non nocere – doctors didn’t drill holes in peoples heads anymore to treat headaches [except in ORs after an MRI showed something in there]. Our problem in psychiatry may have something to do with therapeutic zeal or patient’s wishes to feel better, but that’s not the center ring right now. It’s greed – just plain old, garden variety, human greed. It’s always been there. Why would anyone ever open a pharmaceutical manufacturing business except to make a profit? That’s not greed. That’s enterprise. Why wouldn’t a pharmaceutical manufacturer want to beat the competition? That’s not greed. That’s business. But when a drug company pays a medical writing company to ghost-write favorable scientific articles, and pays psychiatrists to sign on as authors, and they do it; or when that campaign results in harmfully medicating patients; or when side effects are hidden on purpose in the process; that’s greed – and the basic ethos of medicine has been violated and changed. Who is at fault? The whole culture that allowed such things to happen is at fault. And, as we are increasingly finding out, it happened a lot.

I think my own opinion about why this happened may be a minority view, because I personally think it happened beginning in 1980 with the coming of the DSM-III and as a corollary to the changes that were introduced with it. I didn’t then, nor do I now, believe that what we knew as Manic-Depressive Illness before was a mistake and that we were missing vast numbers of cases of Bipolar Illness as it’s now described and diagnosed. I didn’t believe then or now that there was a unitary category of Major Depression that consumed all the previous depressive diagnoses. I still see the claim that our diagnostic scheme is indicative of unique disorders [that multiply like rabbits with each revision] is built on fallacy. And I still believe that major psychiatric dis-ease can result from problems in the mind. In my opinion, the wish to "medicalize" psychiatry was little more than that – a wish. But that’s what we did – psychiatry became clinical neuroscience, almost overnight.

My problem is that unlike many of my psychoanalytic and psychotherapy-oriented colleagues, I think and always did think that neuroscience is pretty fascinating. I never met a data table or a graph I didn’t like. But when I look at the sea of Clinical Trials that now fill our journals, I don’t see much in the way of neuroscience. I see pseudoscience – maybe marketing research. The graphs, and tables, and statistics are there, but there’s so much obfuscation and manipulation that it’s hard for me to see the net culture as scientific. So we seem to have an ethos problem in our literature too – an all too regular betrayal of the scientific method. If you look at studies from over four or five years ago, there regularly aren’t honest statements about who wrote them, who actually did them, who had a conflict of interest, or many times, what the findings really were. This blog is filled with reviewed studies – many of which shouldn’t have been published, maybe shouldn’t have even been done. Now we’re getting to read some of the back-stories, about the ghost-writing, about the conflicts of interest, about the guest authors, about the spin, and one is left wondering at times if it’s just some kind of mass charade.

How would the change in 1980 lead us to this sorry state of affairs? Part of it came from the drug companies who jumped at the chance to throw money at a starving academic psychiatry. Part of it was the pressure from the pharmaceutical companies and 3rd party carriers for us to get medical. Part of it was a reaction against the era of the mind doctors [psychoanalysts, psychotherapsts] and the experientialists of the 60s and 70s. But we can’t get around the fact that a lot of people were literally "bought." There are just too many instances of Departmental Chairmen, APA officials, practicing psychiatrists, "kols," who made a lot of personal money by participating in some pretty shady dealings – things they couldn’t possibly have thought were on the up and up. I can’t see how anyone can be on a speaker’s bureau, using company slides, and trained in the company line, without knowing that they were not respecting the basic tenets of the ethos they were trained to practice in. To me, they were bought men and women, going over to the dark side. There’s really no other way to interpret the speaker’s bureaus or a lot of the industry funded CME presentations. And there’s absolutely no other way to explain the epidemic of jury-rigged studies in our journals.

How does one change a culture? I never thought about that much before, but I think I knew the answer as soon as I asked the question. You tear down the Iron Curtain. A corrupt culture can’t maintain itself without secrecy. There’s really not much more to say than that…
    June 26, 2011 | 5:58 PM

    Dr. Mickey, it’s all true. But here’s what I see, as a patient grievously injured by willful ignorance in psychiatry: Psychiatrists now know that much of the research, even the medical textbooks, that they’ve relied on to inform their practices are faulty. They never had time to keep up, and now they’re not going to go back and critically look at what they’ve been taking for granted. They know it’s garbage in, but they avoid acknowledging that it’s garbage out — of their mouths that is, and into their practices.

    They insist that good intentions are enough. They’ve too much invested in practicing as they do and they are not about to change. So even though they know there’s no scientific justification for anything they do, they continue to prescribe, overprescribe, increase dosages, experiment with polypharmacy, etc. — and ignore side effects and clear lack of efficacy.

    You can see this dichotomy even in Daniel Carlat’s work — and he’s a reformer! Clearly, transparency about pharma bribery is not going to be enough. What is the answer???

    Joel Hassman, MD
    June 27, 2011 | 12:27 PM

    Personally, I find the pattern of pathological patriarchial attitudes among older colleagues to be a factor to the decline of psychiatry. I just turned 50 this month, but I still do not get the mentality of colleagues over 65 who are still practicing as a whole. Frankly, arrogance and false omnipotence that has been directed to me only strokes the fires of antipsychiatry zealots that pervade this medium these days. I never had any real interest to learn and practice psychodynamic therapy, because, as a psychologist colleague so wisely pointed out to clarify my disenchantment, many Freudian supporters end up acting like a cult, which only turns off those who do not embrace their philosophies and agendas with the extremist zeal demanded by Freudians I have witnessed over my years since residency.

    Don’t get me wrong, I do not indict an entire generation or paradigm, but, when this generation of psychiatrists saw where psychiatry was turning in the 1980’s, their reactions and choices as a whole did not help reel in responsible and appropriate challenges to defend the profession. So, those who were actively promoting greed and those who just sat silent and would not challenge collleagues run amok are equally guilty in the slow death of psychiatry.

    And watch, DSM5 will be such a daming nail in our coffin, it may just be the final one. Just one man’s opinion !

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