like old men often do…

Posted on Tuesday 20 September 2011

I am not a neuropsychopharmacologist or a even neuroscientist – certainly not a clinical neuroscientist. By my own estimate, I’m not included among Dr. Stahl’s "pharmascolds, scientologists, and antimedication crowd who believe either there is no such thing as mental illness, that medication should not be used, or both." I haven’t personally been harmed or had someone close to me harmed by taking a psychoactive medication. I am a psychoanalyst, a group that was disenfranchised with the rise of the psychopharmacological focus of modern psychiatry, but that didn’t hurt me personally, and it has been true for thirty years without getting me stirred up. So in-so-far as I can know myself, my credential for inserting myself into the public discourse is that I’m a psychiatrist, and I’m angry. Of course I’m still unhappy about being marginalized in my specialty because I still think it’s important to talk to people about how their minds work in ways that get them in trouble, and trying to help them untie those knots. But even that’s a chronic frustration – true for decades. The thing that brought me out of the woodwork is that I’m mad as hell about being being lied to. And I have been lied to, as have our patients.

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…
They go on to point out that most discoveries have been serendipitous findings by clinicians who follow patients through the course of their illnesses and who happen onto something. The fantasy that great discoveries are made by people who go back to their expensive laboratories and pursue the paths they’ve heard about at the most recent meeting just doesn’t have a very good historical precedent. They describe the anti-serendipitous forces in modern medicine – things like short sessions, farmed out clinical trials, etc. They don’t actually say it, but they sound like they might even be open to my kind of n=1 psychiatry – as a way of happening onto something. They even suggest using computerized medical records as a source for serendipity – an innovative idea if those records have enough recorded parameters. But the point is not their suggestions, it’s that they’re getting off the bus and looking over the landscape instead of pressing down on the gas. Good for them.

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.

I wrote this as a part of my recent blogging efforts towards bringing integrity back into psychiatry – academic and otherwise – particularly in the area of psychopharmacology. But to be honest, I don’t think that the crisis in drug development is a central problem in psychiatry right now. It’s just the area where the integrity issue has been a glaring problem. I really think the current crisis was caused by an unusually maladaptive solution to the last crisis – the one that was swirling around in the 1970s when I was in training. I didn’t see it clearly back then [as is often the case in hurricane], but it seems clearer now. If things go true to form, I’ll probably soon be blathering about my view of those days, like old men often do…
    September 21, 2011 | 7:54 AM

    Well and elegantly put, sir. One hopes that the very most competent journal in the sphere picks this up and publishes it in next month’s number.

    September 21, 2011 | 8:56 AM

    Please blather on . . . I’ll bet there will be a lot of wisdom in your reminiscences.

    September 21, 2011 | 10:53 AM


    From one “old man” (actually, even older) to another, an old man with a very similar background (psychiatrist, psychoanalyst, etc.), but maybe somewhat less angry for having stuck with doing mostly psychotherapy instead of writing prescriptions all these years, I’d just like to say that you really nailed it here. Thanks!

    September 21, 2011 | 10:58 AM

    From the outside looking in, I cannot begin to tell you how appreciative I am for your willingness to speak truth to “power.” Please keep up the good work; I’m sure, at times, it seems that your message falls on deaf ears. But if people like me–outsiders to medicine–can hear you . . . so can the insiders. May their numbers–and their anger–grow until inaction is no longer acceptable.

    Anne C Woodlen
    September 21, 2011 | 12:01 PM

    Old age is when we are supposed to reflect on the lessons we’ve learned from a long life, and gather the young around us to teach them. Go for it–you are absolutely right! I took antidepressants every day for 26 years because they said I had a “chemical imbalance.” I now have nephrogenic diabetes insipidus, chronic renal failure, diabetes mellitus, severe obstructive sleep apena, etc., and an indwelling catheter, power wheelchair and breathing machine. I’m the poster child for drug damage. See also

    September 21, 2011 | 5:34 PM


    September 22, 2011 | 4:19 PM

    I wish a psychiatrist would write in their blog how an ongoing patient is to discuss these issues with their doctor without making their doctor defensive? I still have severe mental illness, so I have to have a doctor even if I don’t take pills for what ails me. Are virtually ALL psychiatrists nowadays familiar with the drug company distortions? Even in recent years, it seems like psychiatrists blow off my concerns about antipsychotics and will lie to my face about side effects and risks (OK, lie is a strong word, they will heavily bias the information, that is what I should say. Feels like a lie to me when someone tells me risperdal almost for sure won’t cause weight gain, though).

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