In the last post, the rant of Dr. Stephen Stahl is obviously the product of someone injured by what he sees happening around him to the world that he’s known throughout his career. He creates a "Straw Man" argument in which the heterogeneous collection of critics of the pharmaceutical industry are portrayed as if they are of one mind [a deranged mind at that] and specifically motivated to destroy access of the mentally ill to much needed future treatment. It would be equally easy to find other rants in the blogs on the other side of the issue [probably in the archives of this very blog you’re reading]. Dr. Stahl creates a group he calls Pharma-scolds who say:
"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!!!"
"…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?"
Dr Stahl sees his friends and colleagues literally out of work as part of a collapsing industry – particularly in the UK:
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.
A rant from the other side of the coin would point to the patients with diabetes, obesity, tardive dyskinesia, the SSRI withdrawal syndrome, etc. People whose lives have been altered by the side effects that were minimized or frankly hidden by the pharmaceutical industry. It would bring up the bilkoing of State and Federal programs by schemes like TMAP; the corruption of the psychiatric literature and continuing medical education; the greed of physicians participating in ghost-writing, guest-authoring, speaker’s bureaus; the stealth advertising and detailing campaigns designed to deceive [I’m on that side of the fence, so I can do that rant with more expertise]. But Straw Man arguments or Ad Hominem attacks [like Stahl makes against Carlat] are Logical Fallacies by definition. They’re the kind of arguments people make when they have some personal investment in being right. And in this case, both sides cover their arguments with the protective umbrella of passionate patient advocacy.
Psychiatry has moved in monotonous cycles where new approaches are widely embraced, over-utilized, then become the new problem rather than stay in their former role as solution. Freeing the mentally ill from prisons by creating humane mental institutions became the "snake pit" State Hospitals of later years. Then liberating the warehoused patients from hospitals became the creation of the homeless mentally ill street people. Psycho-surgery, Insulin Coma, Convulsive therapy all moved from innovation to abusive. Psychoanalysis and other "mind therapies" went from scientific breakthrough to "n=1" speculations. Now psychopharmacology and neuroscience are waning as their limitations and ill effects are more apparent. It’s in the nature of medicine to move through paradigm shifts and cycles like this, but psychiatry has less access to an anchoring basic science, and so it swings wildly compared to the rest of medicine.
Were we able to climb a tall tower where we could look over the whole forest, I expect we would see the current moment in a more balanced way. There’s a limit to what can be done by manipulating the neurotransmitters and their receptors – and we’re probably closer to the edges of that limit than we’d like to accept. The same is likely true of the dynamic psychotherapies, the behavioral therapies, and the cognitive therapies – we’re closer to their limits as well. From the tall tower perspective, the "empty pipeline" and the collapsing psychopharmacological R&D industry lamented by Dr. Stahl may have more to do with the limits of our current understanding than with all the bluster and contentious arguments that occupy the foreground.
It’s interesting to be a retired doctor practicing some in Charity Clinics in an under-served rural area. I don’t feel impotent when I see patients. There’s some crisis intervention, a rasher of social work, a bit of psycho-dynamic therapy here and there [even a dollop of CBT], plenty of Meyer’s Common Sense Psychiatry, the generic medications, and more Internal Medicine and Neurology than I would’ve guessed. And when I think about the medications I use now compared to the ones I used as a resident in the pre-DSM-III, pre-Psychiatry-as-Clinical-Neuroscience days. There are the generic SSRIs [the ones with low withdrawal potential], a few older Tricyclics, Wellbutrin, the numerous anti-psychotics have dwindled to only Haldol and Risperdal [for psychotic patients who can’t/won’t tolerate Haldol], Depakote or Lithium for Manic Depression, and some remarkably better engineered stimulants for ADD/ADHD. I only use Benzodiazepines short-term for people in crisis. It’s not that different from 1987. I can usually put together what’s needed – limited more by resources and time than by the constraints of the state of the art. There are obviously a lot of patients who want or could use a lot more than we can do, but the limitations are hardly in the failings of psychiatry, they’re in the complexities or circumstances of the patient’s lives. I end those volunteer days feeling like I’ve done my job, usually rolling around in my mind some unanswered question from a confusing case on the way home. It was like that in 1987 too. On clinic days, I rarely think of the things I write about on this blog except as an ever-present reminder to refrain from over-medicating.
What I’m aiming at is answering Dr. Stahl’s question:
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 treatment discoveries so worthless as to discard these efforts for the future?
His question itself borders on melodrama, but to take it at face value: "No, they weren’t as worthless as all of that." And at an earlier time in our history, one might have heard, "Were the last 25 years of psychoanalysis and the other psychotherapies so worthless as to discard those efforts for the future?" It’s an equally melodramatic question, but it has the same answer. Later disappointments in a paradigm when its limits are reached are no reason to discard the paradigm altogether. But if Dr. Stahl asked, "Were the last 25 years of unethical marketing strategies and active manipulation of medical information by the pharmaceutical industry so egregious as to discard those practices for the future?" The answer is an unequivocal, "Damned right they were – at any cost!" The later disappointments of formerly promising advances in medicine are just part of how things work – as predictable as the tides and the seasons. But Dr. Stahl’s question is a piece of rhetoric that completely bypasses the central ethical issue of the hour. He adds, again somewhat melodramatically:
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.
If today’s pharmaceutical industry can’t make it by playing it straight, let them go. We can wait for our kids and a "Pharma industry that is interested in mental health" instead of ill-gotten gains from panhandled blockbusters…
I greatly enjoy reading your posts and appreciate your long-term perspective over your career..
Background: single manic episode at age 42 (about 4 yrs ago) after long period of stress, sleeplessness due to an infection, had just decided to try Sam-E for my persistent blah mentally slowed down depression or pacing unable to sit down and concentrate. THEN I promptly switched into a happy state over a period of weeks. Singing TV theme songs happy. Memories rolling like movies in my head. Grass was green, I had come up from underwater, let out of prison into the sunlight. Thankful and happy, then it got weird. My counselor friend took me into the hospital before I did anything irreparably stupid.
Been on a steady dose of Depakote ER and lamotrigine since, but I’ve never been able to get better than a dullish “yeah, I guess I feel okay” (except briefly while starting lamotrigine-happy). UNTIL that is I changed my eating habits that is. (Eliminate gluten, sugar, industrial seed oils and caffeine. Add fat: eggs, half&half, coconut oil, etc. I wasn’t hungry).
Improvement in mood and a 20 lb weight loss was the result. A blog I have followed since the spring is Emily Deans MD Evolutionary Psychiatry blog, which is chock full of fascinating stuff and summaries of studies that examine the connections between brain chemistry and how we react to food. Obviously big pharma is not terribly interested in that but other psych drs might be. Hope you’ll google it. Extremely interesting writing, as is yours.
FDA approved uses of Depakote are confined to: acute mania, epilepsy, and migraine (see http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/018723s039lbl.pdf). Depakote for maintenance therapy for bipolar disorder is an off-label use of this crappy anti-manic, anti-migraine, anticonvulsant.
I’m not much in love with Depakote either. The one patient [with clear Manic Depressive Illness] I see who is on it reqularly “flunked” Lithium, and seems to be doing okay on Depakote so far. Most of the people who were already on it when I started have opted out because of weight gain or peripheral edema. It seemed like it was most popular with the “I’ve been told I was Bipolar” set whose problems in life seemed to have other determinants to me.
If Abbott Labs and its academic proxies could make a case for the use of Depakote in maintenance therapy for bipolar disorder, they would have done so. I am aware of only one RCT (Depakote vs. lithium vs. placebo):http://archpsyc.ama-assn.org/cgi/content/full/57/5/481?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=bowden&searchid=1&FIRSTINDEX=10&resourcetype=HWCIT. Neither lithium nor Depakote were superior to placebo Nevertheless, Abbott Labs does sell a lot of this poorly performing drug: http://i.bnet.com/blogs/depakote-sales-to-medicaid-alone.jpg?tag=content;drawer-container. I have to feel sorry for “ratherbedigging” – this individual is/was taking two anticonvulsants/CNS depressants! No wonder he/she felt “blah” and he/she probably couldn’t remember a damn thing either.