Stahl’s first question…

Posted on Wednesday 31 August 2011

In my last post, a minimalistic formulary of generic medications rolled off my tongue. A friend read it and asked, "Do you keep score?" No, I don’t keep score, but I do keep up. In the adult clinic, we see only indigent and uninsured people. We have a pharmacy with donated drugs, a few purchased, and the capacity to apply for drugs through companies’ hardship programs. In the Child and Adolescent Clinic, most of the kids are on Medicade, meaning their medications [generics if available] are covered. For some drugs [left above] the medications are available as $4.00/month or $10.00/3·month prescriptions in local pharmacies [Kroger shown]. On the right are the prices for other generics. We do stock Depakote 250MG [Divalproex] and Risperidone 0.5MG and 1MG [Risperdal] when we can. But, there are a very small number of people on either of one of those medications. But I keep up because cost, for these patients, is a limiting factor.

When I watch the direct-to-consumer ads on television or see the glossy displays in the Journals for the more recent versions of these medications, I sometimes wonder if the people taking them are any better served and have better results than the patients I see in our little rural clinic. I don’t really know the answer – having little experience with those drugs that we hear so much about. That list up there is only a baker’s dozen [2 anti-anxiety agents, 2 "mood stabilizers," 2 anti-psychotics, 6 anti-depressants, and 1 stimulant]. If we added in all the in-patent non-generic drugs available in psychiatry, the count in each category would rise, but the number of categories would be close to the same.

I’m rambling on about this because Dr. Stahl’s question haunts me: "Were the last 25 years of mental health treatment discoveries so worthless as to discard these efforts for the future?" The two groups of drugs on the list not yet in use back in 1987 were the SSRIs [introduced that year] and the Atypical Anti-psychotics [derivatives of Clozaril, introduced in the 1970s]. Most of the changes in the last 25 years weren’t exactly "mental health treatment discoveries" in the meaning of the word dis·cover – to find something new. They were more like re·fine·ments – variations on known themes. While that’s a perfectly legitimate direction for the pharmaceutical R&D departments to take, certainly not "worthless," Stahl’s question implies something that’s not quite right. He’s what the Red Guard under Mao called a "roader" – going down a different road. He’s mostly talking about the fate of the US and UK CNS pharmaceutical industry which is apparently not faring very well at the moment [in spite of big numbers on their quarterly reports – even with their settlement losses and lawyer’s fees in the debit column].

Rereading his polemic, it’s largely about pharmaceutical industry. In fact, Stahl’s first question is spoken from an industrial point of view, "If you were in the Pharma business, would you work with psychiatry anymore?" I guess I misread it the first time through. I took "psychiatry" to mean something like "the domain Psychiatry" – the medical specialty. That didn’t make any sense to me at all. My perception is that the field of psychiatry has embraced psychopharmacology with a passion, almost merging at times with the pharmaceutical industry. But I think he meant "the domain Mental Illness" – the area of medicine where psychiatrists spend their time [the drug companies call it CNS medicine]. And why wouldn’t the Pharma business want to work in this area anymore? He thinks it’s because of the people he thinks are hell-bent on destroying them, are suing them all the time, are bad-mouthing them:

    "the anti-psychiatry community"
    "the antipsychiatry blogs [e.g., Carlat]"
    "antimedication crowd"
    "there is no such thing as mental illness"
    "make mental illness go away by legislation and committee!"
    "treat human mental suffering with love and peace"

liberals? religious nuts? hippies? Whoever they are, they are specifically motivated to destroy Pharma, and they are naive foolish people. According to Dr. Stahl, these forces are succeeding as evidenced by the closure of the R&D facilities in Europe and the US. Stahl’s lament is that the businesses will move overseas, that his colleague’s are out of work, that once "shut down" the R&D facilities will take years to rebuild, that there will be no new treatments developed for the future. It’s interesting that he doesn’t mention government interference, usually a part of the rant made by the business guys when they’re under the microscope [my guess is that government’s been left out because Stahl sees government as part of his solution].

There really are people who oppose the pharmaceutical industry categorically as greedy capitalists without compassion for the mental suffering of the afflicted. I’ve certainly met such people through the years who see psychiatrists in the same way – just making a buck off of suffering people. But it’s a heterogeneous lot. Among the people I’ve met who are opposing the CNS pharmaceutical industry, many are people who were harmed or who have seen others harmed by the medications. Some are bothered that the primacy of psychopharmocology has eclipsed or replaced other ways of looking at mental pain and other forms of treatment. Most are mad about the deceptive advertising, the withholding of information about adverse effects, about dissemination of misinformation to physicians, and about the stealthy invasion of the psychiatric literature with some powerfully slanted or fraudulent science. Some are angry that the psychopharmacologists have unilaterally declared that psychiatry is clinical neuroscience, as Dr. Insel, chief at the NIMH puts it – essentially sending everyone else to time out. I’ve felt each of those things at some point along the way.

But right this minute, I’m stahled. It feels like everything that brought me to this table is in that post he wrote. It’s not fair to him, because it was the day I read about Senator Grassley’s investigation of Charlie Nemeroff that my sleeping giant woke up. After all the years of ignoring the signs that he was just a crook, there it was in black and white – on the Pharma payroll in more ways than I could’ve imagined. And it wasn’t just him. It was a whole culture [or subculture] of psychiatry in that game at various levels of immersion. Before that, I thought he was in the pocket of Pharma, but I guess I thought it was something benign like doing drug studies to get grant money – things like that. I hadn’t paid attention, read the papers [journal articles]. I knew from my friends that he was never around, off being important. I just didn’t know what he was off doing or what he was writing [or at least signing off on]. I don’t know if Dr. Stahl is like that. I doubt it. Charlie set a one of a kind line in the sand, unlikely to be crossed. But when I read Dr. Stahl’s rant, I feel those same juices begin to flow.

Dr. Stahl contends that the Pharmaceutical companies are closing their R&D facilities because a group of lunatics is trying to destroy the industry by blogging and suing them. I’ve read all of those suits. The successful suits have been brought by people who have been harmed by the medications because the companies consciously withheld information about side effects that they knew about in advance. There’s a whistle-blower suit coming up about an industry financed, academic psychiatrist run, program that bilkoed the State of Texas and others out of millions of dollars based on Pharma-biased opinions. There have been a number of government fines for illegal business schemes and practices. These aren’t suits from hippies, or religious nuts, or wide-eyed naive liberals. They’re from people who’ve been betrayed by medicine, and their individual payouts haven’t approximated the extent of the damage.

Dr. Stahl would have us believe that their CNS R&D labs are closing down because of a lack of hospitality by the patients who desperately need their products – present and future. Thus Stahl’s second question, "Were the last 25 years of mental health treatment discoveries so worthless as to discard these efforts for the future?" What discoveries? They brought us variations on the theme of SSRIs – already around in 1987. They made our best anti-psychotic, Clozaril, into some detoxified non-fatal drugs – unfortunately not quite detoxified enough. But discoveries? Not so much. It’s not their fault. There apparently wasn’t anything that wanted to be discovered just yet. Science is like that. The pharmaceutical companies are shutting down their R&D labs because those labs haven’t produced or found anything for them to sell. Their marketing departments have done a yeoman’s job of way overselling the drugs they did come up with [and now they’re paying the price in the courtroom]. That’s why I posted my meager formulary at the beginning of this post. I get by with the oldies. There’s no recent discovery from the last 25 years on that list – just a couple of refinements. If there were something out there that really changed people’s lives in a positive way, I’d be going to the kind people who founded and run our clinic and asking them to get it for our patients. I’m sure they’d find a way. They always do.

So why do I feel the Nemeroff juices flow when I read Stahl? It’s that argument again, the public health argument. Charlie started his papers and talks with the dire statistics on the public health burden of depression – ergo his vagus nerve zapper, or his approach du jour for treatment-resistant-depression, were matters of vital importance for the future mental health of group unspecified. Stahl’s making the same plea, sarcastically. Once the hippies shut down CNS Pharma, it’ll be gone to China. Americans will lose a vital industry. The Mentally Ill people of the future will suffer needlessly. It’s the Public Health argument with variations – like economic collapse. Well, he’s kind of right about that last part. If big Pharma exits CNS Medicine, their marketers and R&D people will be out of jobs; their pill-makers around the world will suffer; their KOLs will lose the gravy train; the Clinical Research Organizations that grew to meet Pharma’s needs will have no more CNS customers. There’s a whole CNS Medical Industrial Complex that’s going to take a hit. No question about it. And Stahl sees the hippies and religious nuts doing cartwheels as these dominoes fall.

Dr. Stahl’s public health argument is gratuitous. Twenty-five years ago, he was a younger man co-chairing a meeting in London with Paul Janssen, the father of Janssen Pharmaceuticals, "the prize winning inventor of Haldol, Risperdal, Fentanyl, Lomotil, and more." In that meeting, Stahl said that the "the future could not be more promising." He was right, the future of the CNS Medicine arm of the Pharmaceutical Industry was a bright shining star. Janssen’s company and Dr. Stahl were part of the realization of that promise over the ensuing two decades as the alliance of Pharma and Psychiatry’s academy forged a mutually lucrative symbiotic march ever upward and onward. Of late, this over-sold enterprise began to crack. Paul Janssen’s company is right in the middle of the storm having lost in the courts already, and facing the courtroom again for masterminding the huge TMAP scam. Dr. Stahl sees a house of cards falling and blames it on a pseudo-community of ingrates and whack-jobs instead of getting honest and looking at how he and his associates participated in a collusion between psychiatry and industry that is eerily like that of the oversold housing market – with about as much corruption. In his rant, he’s singing songs of public health while writing a fictionalized account of what’s happening. One of his solutions is to keep the flame alive by protecting the carriers of truth from their litigious enemies:
    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.
Dr. Stahl and his cohorts were betting on "25 years of mental health treatment discoveries" that just never materialized. They participated in creating an illusion of success, even as things didn’t work out as well as they hoped. They succeeded in keeping people focused on "the future" that "could not be more promising" and away from the often disappointing and sometimes toxic present. And they overlooked the perversion of science and integrity that’s now blatantly apparent. As the bubble Dr. Stahl apparently believed in is bursting, he’s looking for someone [else] to blame instead of the mirror…

Postscript: As I’ve been writing this in dribbles throughout the day, I’ve been checking in on Dr. Stahl’s blog where a brisk debate has been going on in the comments between Dr. Stahl’s medical writer, other Pharma defenders, and some people from the other side of the coin who are anything but hippies or religious nuts. Drs. Danny Carlat and Bernard Carroll, well-known and well-respected psychiatrists who have been pointing out this Emperor’s state of undress for years are commenting. Allen Jones who discovered the TMAP debacle and got fired for investigating it is there as well. It’s a powerful read [comments here]. The discussion has spread to Dr. Carlat’s blog [here]. These men hardly fit Dr. Stahl’s enemy roster:
    …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?
    Daniel Carlat
    August 31, 2011 | 8:40 PM

    Thanks for this post–it’s particularly eloquent and actually quite moving. My favorite and most quotable line is “The pharmaceutical companies are shutting down their R&D labs because those labs haven’t produced or found anything for them to sell.” It really is that simple. It always is in business.

    August 31, 2011 | 9:41 PM

    My favorite line was “But right this minute, I am stahled.” LOL. Cute.

    September 1, 2011 | 4:42 PM

    I am not a medical professional, but I also am not a hippie, a religious nut or even a liberal. As 1boringoldman says, I am simply someone who saw her daughter not helped and perhaps harmed by psychiatric medication. A troubled 14 year old, put on Abilify AND Lexapro AND Naltrezone and Zonisamide. Did we see ANY improvement in mood or behavior? No. None. Nada. Did we see evidence of side effects? You betcha. But it was not until we hired a different psychologist with a different point of view who simply said, “You do know that your daughter is way over-medicated, don’t you?” Well, no, I didn’t know. How could I know? Everything prescribed to her was done so by board certified psychiatrists. How was I supposed to know? But then I started learning. I read The Truth About the Drug Companies by Marcia Angell. I read Side Effects by Alison Bass. I read Our Daily Meds by Melody Peterson. I read Overtreated by Shannon Brownley. Then I read Comfortably Numb by Charles Barber. Followed by Anatomy of an Epidemic by Robert Whitaker. Then The Emperor’s New Drugs by Kirsch and Manufacturing Depression by Greenberg. And I learned about Nemeroff and Biedermann and Keller. I now hesitate to take an asperin. And get some “respected” “revered” psychiatrist like Stahl is going to claim that it’s nuts and religious fanatics who don’t believe that suffering exists? Oh, come on….obviously this is someone who sees his gravy train drying up. A hit bird flutters. I just wish I understood why these guys aren’t in jail! And it took a Senator to draw attention to all this? It’s just shameful, imho. And my daughter? She’s in her second year of college and works hard at staying in a relationship with us that is respectful and appropriate. Is she perfect? No, she still has struggles and maybe always will have to face challenges that others don’t. But I shudder to think where she would be if we had not stopped all that medication five years ago. It hasn’t been easy….the line of “mental health professionals” who continued to suggest she’d be aided by meds is a very long line, some of them imposing a fair amount of pressure. But whenever one would bring it up again, my daughter would say, “You don’t know my mother.”

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