1 Boring Old Man

To see a world in a grain of sand,
And a heaven in a wild flower,
Hold infinity in the palm of your hand,
And eternity in an hour…
        ^{Auguries of Innocence 1803
        William Blake}

Watching Dr. Healy last night [david healy and robert whitaker…], I was awed by his encyclopedic grasp of the topic of suicidality with the antidepressant drugs – seemingly one topic, but it moved among the world of advertising, cartoons, media reports, psychiatry, academic medicine, the pharmaceutical industry, the medical literature, history of medicine, and myth – painting a collage of something very large hidden in plain sight. It gives the impression that it’s all linked by some sinister intelligence pulling the puppet strings. While not denying that there are unsavory motives peppered throughout the various elements in this story, I expect that most of the people involved are just looking at their particular corner of the world, and failing to connect all the pieces that reveal the whole picture.

These days, it’s not fashionable to quote Freud [primarily based on what he too didn’t see], but in this case his vision was clear [if not clearly stated] – the thing that maintains unconsciousness is not that the various elements of a story are hidden, but the linkages between them just aren’t seen [The Unconscious, 1915]. So The Unconscious is not a place in the mind like in the movies, guarded by a vicious beast. It’s simply not seeing how all the pieces fit together, not looking at the whole story – often because to do so would be painful, disruptive, lead to an uncomfortable change of direction, throw a monkey wrench into the system. Both David Healy and Robert Whitaker have stories to tell, but ones unfortunately usually only heard by sympathetic audiences. In the case of the Casper Conference in New Zealand where they spoke, the audience was  people whose lives have been turned upside-down by irreversible medication side effects – things like like suicide. Ten years ago, David Healy gave a similar talk to the horror of Charles Nemeroff, who essentially got Healy fired from a new job [in that case, maybe there was a vicious beast at the gate after all].

^{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?}

^{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?}

^{My Ph.D. thesis was on the seratonin re-uptake system and I’ve been, I was one of the people when the S.S.R.I.’s came out first who would have been much quicker than most of the rest of my colleagues to use this new group of drugs. I continue to put a very large number of people that I see on the drugs. And I believe as the research that we’ve done indicates that if you’re really going to use the drugs properly and I’m in the business of using these drugs to treat people, is you’re really going to find out who does well on these drugs, what you find out at the same time is who does poorly.}

The Journal
^{The report is of using Risperidone in refractory depression, a psychiatric topic yet it’s published in the Annals of Internal Medicine instead of a psychopharmacology or psychiatric journal. Why? That one’s easy. There is/was a big push to get primary care doctors prescribing meds for depressed people. There are a lot more of them than psychiatrists. The most overt example was Lilly’s Viva Zyprexa campaign, but most of them are into that marketing scheme.}

The Authors
^{The authors are all Janssen employees instead of the usual academic psychiatrists, like the article a year earlier in Neuropharmacology where they were joined by Mark Rapaport, Martin Keller, and Charles Nemeroff. Why? Dr. Nemeroff had just been dethroned as editor of Neuropharmacology for conflict of interest and "guest authoring." The previous Risperidone augmentation article was also implicated in Nemeroff’s using his editorship to advertise, including an after the fact addition of coi declarations. So this time, Janssen was playing it very, very straight. There’s never been an article with as many declarations of industry ties as this one. Why are they shouting?}

Guest authoring
^{As mentioned, there was plenty of evidence that the earlier article was one of those industry generated articles that was "guest authored" [authors invited to sign on after the fact]. This article has a long list of declarations detailing the exact contributions of each of the listed authors to prove beyond a shadow of a doubt their participation [see this]. They were a very busy bunch. The one thing they forgot to mention was who wrote the article.}

Ghost Writing
^{Oh look! in the Acknowledgements there’s a tell-tale comment, "Editorial assistance was provided by Susan Ruffalo, PharmD, MedWrite, Newport Coast, California." If you take a look at MedWrite, [President: Susan Ruffalo] there’s little question what they do for a living.}

Enhancing the Data

Minimizing the Adverse Reactions
^{Oh look again! There’s a comment on this article in a later issue of the Annals listed down at the bottom. It’s from Drs. Koek and Carroll [here]. It takes the data apart showing any number of stealthy ways the data has been enhanced, obfuscated, and the side effects minimized. The drug effect wasn’t very impressive to start with. This reanalysis makes this study look trivial indeed.}

FDA Approval
^{"ClinicalTrials.gov registration number: NCT00095134." If you look at the Clinical Trial for this study and go to the history of changes, this is a "phase 3" trial – that’s the kind of trial you use when you apply for FDA Approval. Clearly, Janssen had hopes of getting Risperidone approved for augmentation in treatment resistant depression so they could advertise it "on label." They didn’t succeed, but their latter day saints did succeed with later  atypicals.}