1 Boring Old Man

There’s nothing wrong with having drugs to use that are symptomatic rather than curative, weaker than we’d prefer, or more toxic than we’d choose. That’s true of medicine no matter what the specialty. It’s why medical training goes on so long [like a lifetime] – learning to get the most out of what’s available without hurting people. It’s the state of the art as they say. But as a doctor seeing patients, to do that, I have to have access to accurate information about medications. I recently listed the thirteen generic drugs I primarily use in a practice in a charity clinic. Only three of them were in use when I finished training [Lithium, Haldol, and Elavil]. Like doctors since the beginning of time, I relied on accurate information to learn about the other drugs on that list [and a whole lot of others that aren’t on that list because they are prohibitively expensive where I now work]. When I returned to a situation where I needed to know about medications after years of a psychotherapy practice away from the medication world and went to "bone up," what I found was just not credible. In fact, a lot of it was just plain lies.

The antidepressants sometimes cause akisthisia and suicidal ideation; regularly produce dreadful withdrawal symptoms; aren’t useful in kids; and are nowhere near as effective as advertised. I’m not mad about that. The drugs are what they are. I’m mad that I had to find out those things by myself. My colleagues in high places and the companies making the drugs knew about all of that, and they didn’t tell me. In many cases, they tried to keep me and my patients from knowing. I’m not mad that the Atypical Antipsychotics aren’t as good as we’d hoped. They’re no more efficacious than our older drugs; cause obesity and sometimes diabetes; have neurotoxicity not too different from the older neuroleptics; and produce withdrawal syndromes just like the antidepressants. I had to find out about those things all by myself. Same complaint – betrayed by formerly trusted resources, on purpose. That’s not a complaint about neuropsychopharmacologists or neuroscientists. It’s not a complaint about the pharmaceutical industry or even capitalism. It’s a complaint about people betraying the the only standard that separates medicine from the fantastic. It’s a complaint about lying in a situation where the truth is vital.

Since becoming publicly angry, I’ve met some very interesting like-minded people with differing perspectives and backgrounds, gotten to read a lot of interesting things that I would never have run across otherwise. Recently, I’ve read some of the reactions of the neuropsychopharmacologists about the fact that their moment in the sun seems on the wane. There’s not much on the horizon, and they’re hearing a lot of disillusionment and frustration about the past. They’re taking a hit from people like me who are furious at the subset among them who have gone over to the dark side [paid KOLs, guest authors, overly-educated detail-men, entrepreneurs, liars with white coats, etc.].

Some have lashed out like Dr. Stahl – flailing about blaming windmills and demons. Others have climbed even higher in an evangelical pulpit, like Dr. Insel – lost in the clouds. Some are clicking along as if it’s business as usual, like Dr. Trivedi – in denial. A few are even on the lam, like Dr. John Rush. They’re reminding us of the many ways people react in times of emotional crisis – times when an important life pathway becomes blocked or threatened. Back in the day when we taught Crisis Intervention, their reactions would have made a great set of examples. Crisis theory states that an emotional crisis is a time when lasting changes occur – either for the better or the worse. They are times when emotions that are supposed to be a warning system become the problem – a source of pain – and the actions that follow are often focused on short term fixes of emotions instead of long term solutions to problems. The result is that the last misguided solution becomes the cause of the next crisis.

Emotional crises can also lead to a period of reflection  that may result in a much needed change in direction. I’m not sure that this editorial [below] is exactly there yet, but it’s a fine example of the kind of thinking that I’m talking about. It’s staying focused on the problem and feeling around for new directions [or rediscovering old ones]:

Central Nervous System Drug Development, Basic, and Clinical Research
^{Thinking Outside the Box
by Donald F. Klein, Ira D. Glick, and Richard I. Shader}
Journal of Clinical Psychopharmacology 2011 31(5):553-554.

^{At the 2010 American College of Neuropsychopharmacology [ACNP] annual meeting, a study group entitled, ‘‘Has drug development in psychiatry hit a road block?’’ elicited spirited debate. Many participants felt disappointed with a perceived lack of scientific progress and dismayed by the industry dropping development of psychiatric medications as unprofitable. Others asked, ‘‘What alternative road is there to pursuing what some have called ‘our astounding’ biological advances?’’}

^{This apparently reduced emphasis on drug discovery for central nervous system [CNS] afflictions is substantiated by a recent report from the Tufts Center for the Study of Drug Development [CSDD] in Boston. ‘‘Big Pharma’’ considers psychiatric and neurodegenerative conditions too complex for profitable drug development. The CSDD team states it this way: ‘‘…many big drug companies are pulling the plug on R&D for neuropsychiatric medicines’’ …}

^{Our response is, ‘‘Maybe it’s the wrong road. It is still premature to search deductively for psychiatric medications.’’ The field has forgotten about the serendipitous history of psychiatric drug development, which, remarkably, worked well despite our vast ignorance. We still lack adequate knowledge about the multiple disease mechanisms underlying most of our heterogeneous CNS syndromes. Therefore, medications based on simple models [typically derived from animals that do not suffer from the same disorders as humans] having at best only the most minor, tangential relationship to any causal cascade will continue to be expensive failures. That correlates are not causes has not stopped the National Institute of Mental Health supported exclusive emphasis on ‘‘biomarkers’’ as the royal road to therapeutics. The fact is that this approach has largely failed for almost a century.}

^{Whenever a new, fascinating technology appears [eg, neuroendocrinology, genomics, imaging, proteomics, epigenetics], hope springs eternal. To admit to our lack of etiological and pathophysiological knowledge is harmful to the self-esteem of our field. In addition, it becomes hard to justify the poor return on our extensive investments…}

Crises aren’t just a time for growth or a change in direction. They’re a time for correcting what’s been wrong. As the egregious scandals have swept through psychiatry and psychopharmacology, our organizations have been way too passive, way too defensive, way too uninvolved and slow to embrace much needed reform. The known sinners in high places are still there. There’s a big difference between protecting one’s own kind and colluding with misbehavior that needs to be addressed decisively. Universities, Medical Schools, Professional Organizations, Scientific Colleges, even Governmental Agencies have ignored loud symptoms of ongoing disease during a time of epidemic. It looks from the outside like they’ve been bought out. I hope that’s not true, but whatever the case, the ball’s in their court now. No matter the cause for their failures in enforcement of ethical standards, this growing crisis is a time for new directions there too. We don’t need much reflection to know what needs changing in that department. We can’t move forward without acknowledging and addressing the failures of the recent past. There’s just no room for liars and entrepreneurs in a healthy psychiatry.