1 Boring Old Man

Are future psychiatric treatments doomed?
^{Be careful what you ask for…you just might get it.}
NEI Blog
Neuroscience Education Institute
by Stephen Stahl
August 23, 2011

^{Nobody likes drug companies these days. Worse than tobacco companies and big oil companies! Supposedly they have ruined CME and have corrupted psychiatric experts as consultants, lecturers and research grant recipients! Drug companies only engage in expensive patent extension gimmickry and offer no true innovations! Let’s criminalize the marketing of psychiatric drugs, levy billions in fines to Pharma, force out their CEOs and even make them and their Pharma collaborators take the “perp walk” on their way to court in chains and orange jumpsuits and in front of the cameras! Get out of our professional societies! Get out of our journals! Get out of our medical centers! Good riddance!!!}

^{Well, if that is what we have been asking for, we are now getting it. Drug companies have already largely pulled out of our meetings, our live CME and our medical centers. Next, the Pharma-scolds want Pharma to stop doing even legally sanctioned FDA activities such as peer-to-peer dinner meetings (many academic faculties now banned by their medical schools from participating), sampling by sales reps (many clinical centers ban reps), and legal freebies (no coffee or bottled water even allowed in Massachusetts let alone a book). If these Pharma nay-sayers and payors had their say, the new “American Textbook of Psychiatry” would be the Physicians Desk Reference with religious adherence to following the label. This in a field where over half of legitimate practice is off label! And this is progress?}

^{Pharma have heard these protests loud and clear and are now pulling out of psychiatric research. Two of the biggest defectors are the two British companies Astra Zeneca and GSK, who have shuttered all their laboratories for mental health research for good, closing facilities all over the world including those the US, UK and Italy and elsewhere. Also, Pfizer bought Pharmacia/Upjohn and closed their CNS research center in Kalamazoo, Michigan; bought Parke Davis and closed their CNS research center in Ann Arbor, Michigan; bought Wyeth and closed their CNS research center in Princeton, NJ; and then for good measure closed their own CNS research center in the UK. Merck closed their CNS research center in the UK where I worked in the 1980s, then bought Organon/Schering Plough and closed their CNS research center in the UK/Scotland for good measure. I could go on and on. This has had a devastating impact especially on the US and the UK. In fact, the UK has gone from a leader in CNS Pharma Research Centers, to having no big Pharma CNS research at all, with thousands of unemployed R and D scientists there and no prospect of CNS therapeutic innovation coming from their shores in the foreseeable future.}

^{Undoubtedly this is to the great delight of the anti-psychiatry community, lights up the antipsychiatry blogs [e.g., Carlat] who attract the Pharmascolds, scientologists and antimedication crowd who believe either there is no such thing as mental illness, that medication should not be used, or both. Did you know that psychiatric illnesses are pure inventions of Pharma and their experts to treat patients that do not exist with drugs that are dangerous and do not work with the purpose only of profiting themselves? Stop the profits! Make mental illness go away by legislation and committee! Treat human mental suffering with love and peace and all will be well! Who needs mental health professionals and their diabolical drugs anyway?}

^{If you were in the Pharma business, would you work with psychiatry anymore? So, we have gotten what many of us have asked for. No Pharma. But that also means no new drugs. This has sparked a crisis in mental health therapeutic research worldwide but especially in the UK and US. The UK in fact is having a crisis meeting at the Royal Society of Medicine in August, where I am attending with about a dozen others, including the head of the NIMH from the US, the head of the MRC from the UK, and various UK and US academic and industry leaders to discuss what we should do about this. The last time I went to such a meeting was in 1987, where I co-chaired a meeting on this same topic with the famous Paul Janssen (now deceased), the prize winning inventor of Haldol, Risperdal, Fentanyl, Lomotil, and more. At that time I stated that the future could not be more promising. What a difference 25 years makes! Returning now to the same Royal Society of Medicine with others, but now with our collective tail between our legs, we are stating that “things could not be worse.” Were the last 25 years of mental health treatments discoveries so worthless as to discard these efforts for the future? Once you stop things, it takes a long time to start it up again. David Nutt, UK psychiatrist extraordinaire and a good friend who will be at the meeting at the RSM, is recently quoted in the UK press as saying, "What we have forgotten, and must not forget, is if we stop this research we will have a dead space of 20 to 30 years before we can re-tool again.”}

^{If we shut down, then we and our patients with depression, schizophrenia and other mental illnesses lose hope for any improvement in their situation in our lifetimes. I still think we can innovate, but we need a new model and I will get back to you with suggestions from the Royal Society of Medicine meeting when I return. Some good ideas are coming mostly from Europe as the US is still intent on shutting down Pharma. As a former Lilly president told me recently, “We will someday be a great Chinese drug company.” To reverse this trend and keep this industry in the US, we can try to support innovation through the NIH, and I have volunteered to serve on advisory committees on new drug development if that ever gets off the ground; but this NIH drug development effort is now threatened by the current US budget austerity. We can try to do it though academia, or small companies. The ECNP (European College of Neuropsychopharmacology) of which I am a member has some creative ideas which I strongly support such as trying to persuade drug companies to share the information they already have, putting details of their research and unused potential drug discoveries into a "medicines chest" that outside organizations can exploit, with the ECNP providing insurance against any potential litigation. Medicines for brain disorders take longer to develop than for other conditions – on average, 13 years – and there is a high failure rate. It looks like the UK and the Europeans are much more active in trying to resuscitate mental health therapeutics, while we in the US remain hell bent on destroying what is left of it. We can join the British and the Europeans and move forward, or we can completely kill this industry and wait a decade or two, while experiencing no progress and thus leave a legacy of no innovation and no apparatus to innovate. We will have to see if our children or grandchildren who become mental health professionals want to rebuild a Pharma industry that is interested in mental health or if yet another industry leaves the US for good.}

^{Be careful what you ask for. You might just get it.}

Psychiatrists have always been an easy target. As a young Internal Medicine resident, I thought the same thing. The psychiatry residents didn’t seem to have to live the insane lives of we other house officers. They hung out together and didn’t mix with the rest of us. I had little notion of what they were talking about or how they spent their time. At a later time when I was a psychiatric house officer, that view changed as I realized that my second residency was perhaps more draining than the first, just in a different way. That was the mid 1970s, the era of the anti-psychiatrists like Thomas Szaz and The Myth of Mental Illness. In 1980, Robert Spitzer and his cohorts from Washington University brought us the DSM-III, revolutionizing psychiatry with a call to return to the white-coated world of mainstream medicine – leaving the mind behind and embracing the brain. But those were the prequels. 1987 stands out as the opening parentheses of this as-yet-unamed era that seems to be currently on the wane – the year that Eli Lilly’s PROZAC was approved.

I have no idea if the meeting that Dr. Stahl refers to of the Royal Society of Medicine has anything to do with the coming of Prozac, but I know that year sticks in my mind as the time when psychiatry became largely the practice of psychopharmacology. The multiple determinants behind that change have been documented throughout the blogosphere, in numerous books, and await only the sands of time to gain the clarity that detached history can bring [neither Dr. Stahl nor I will be the authors of that future historical treatise]. But I would love to read the proceedings of that 1987 meeting ["At that time I stated that the future could not be more promising"]. I hope that Dr. Stahl will be moved to tell us more about the 1987 meeting – why it was called? what did they talk about? who attended? what did it have to do with what followed in the last 25 years?

One crisis I know about from my own life in the years leading up to 1987 was the increasing difficulty funding psychiatric training and research. I was directing a residency training program at that point, and we were starving. Funded resident placements were disappearing as the private mental hospitals felt the pinch of plummeting insurance coverage. Likewise, State Mental Hospitals were shutting down at an equally precipitous rate. Federal funding had been slashed again and again. In all quarters, academic psychiatry was hanging on by a thread. My job was education, and that was an increasingly difficult task. I certainly saw the furrowed brow of our aging chairman as he watched the Psychiatry Department he had built over twenty-five years eroding in front of his eyes – including our Biological Research laboratories. Our new chairman arrived preaching the gospel of research – drug research – and the Department changed radically. That was when I left for private practice. I didn’t understand what was happening. All I knew was that I didn’t need to be involved in whatever it was. Then, in 1991, Dr. Charles Nemeroff arrived as chairman at Emory and the rest is a history you already know. The crisis of funding, of course, disappeared.

In 1987, Dr. Stahl speaks of a crisis meeting at the Royal Society of Medicine ["The last time I went to such a meeting was in 1987, where I co-chaired a meeting on this same topic with the famous Paul Janssen (now deceased), the prize winning inventor of Haldol, Risperdal, Fentanyl, Lomotil, and more…"]. At the time, Paul Janssen was the leader of Janssen Pharmaceuticals, so it’s obvious that PHARMA was well represented there. Is that where academic psychiatry and the pharmaceutical industry forged their alliance? I know that I often speak of the invasion of psychiatry by industry, but that’s not really fair. From what I saw at Emory in those days, their coming was hardly an invasion, it was more like accepting a warm invitation. So I wonder if the crisis addressed by that meeting was funding psychiatric research and education – just my speculations from afar.

^{Pharma have heard these protests loud and clear and are now pulling out of psychiatric research. Two of the biggest defectors are the two British companies Astra Zeneca and GSK, who have shuttered all their laboratories for mental health research for good, closing facilities all over the world including those the US, UK and Italy and elsewhere. Also, Pfizer bought Pharmacia/Upjohn and closed their CNS research center in Kalamazoo, Michigan; bought Parke Davis and closed their CNS research center in Ann Arbor, Michigan; bought Wyeth and closed their CNS research center in Princeton, NJ; and then for good measure closed their own CNS research center in the UK. Merck closed their CNS research center in the UK where I worked in the 1980s, then bought Organon/Schering Plough and closed their CNS research center in the UK/Scotland for good measure. I could go on and on. This has had a devastating impact especially on the US and the UK. In fact, the UK has gone from a leader in CNS Pharma Research Centers, to having no big Pharma CNS research at all, with thousands of unemployed R and D scientists there and no prospect of CNS therapeutic innovation coming from their shores in the foreseeable future.}

As any number of people try to tell Dr. Stahl in the comments to his post, his premise that the mythical Pharma-scolds have run off the Pharmaceutical Companies is not only sarcastic, it’s at the least naive, and more likely in the "damned silly" category. Pharma-scolds aren’t that powerful. Back then, psychiatry opened the door, and the drug companies rushed through ushering in an era that was doomed from the outset, an era of ethical decline and corruption that no-one could have even imagined back in the salad days of 1987. Dr. Stahl laments the current state of things and the projected long road back, without acknowledging how those earlier solutions have created an even bigger problem in the present. So twenty-five years later, Dr. Stahl is returning to the Royal Society of Medicine where he "…stated that the future could not be more promising," to blame the unintended consequences [surely unintended, but actually inevitable consequences] of those days on this straw man group – the Pharma-scolds.

I’d like to say that I hope this crisis meeting Stahl was off to was less myopic than the one long ago, but I frankly doubt that happened. I came into psychoanalysis around the time that organized paychoanalysis was in the same boat Dr. Stahl finds himself today. It’s a funny thing about power. Once people have it, they think it will endure, and adapting to a changing fate rarely goes well or quickly. It took the psychoanalysts decades to make the changes needed and adapt to the new reality after the coming of Managed Care, the DSM-III, the primacy of Neuroscience, and Prozac – to stop talking about "them" and start looking at "us." That process is still ongoing.

^{This has sparked a crisis in mental health therapeutic research worldwide but especially in the UK and US. The UK in fact is having a crisis meeting at the Royal Society of Medicine in August, where I am attending with about a dozen others, including the head of the NIMH from the US, the head of the MRC from the UK, and various UK and US academic and industry leaders to discuss what we should do about this.}