so far off track…

Posted on Thursday 17 November 2011

I doubt that many think it strange for the American College of Neuropsychopharmacology to have a scientific session called Will We Have New Drugs or Not? Addressing the Crisis in Neuropsychiatric Drug Discovery [page 12]. After all, that’s what Neuropsychopharmacologists think about a lot. And I suppose that having the Director of the NIMH give a talk entitled Who will Develop the Next Generation of Medications for Mental Illness? The NIMH Perspective doesn’t seem unusual to most, particularly the people attending this conference. We all know that’s what Dr. Insel thinks about. And if you follow these things, you’ll remember that Dr. Stephen Stahl had an absolute meltdown about this same topic recently [Are future psychiatric treatments doomed? Be careful what you ask for…you just might get it], blaming poor Danny Carlat, an army of religious fanatics, and a group that sounds like resurrected hippies:
    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? 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?
I have no idea what Dr. Insel will say, except that he can be counted on to sound an alarm about the dire public health burden of mental illness – he always does.

Is there really a crisis? The pharmaceutical manufacturers might be seen as having a crisis, an artifact created by patent laws that limit the period of exclusive rights to produce and sell a given drug. With no new product to market when exclusivity runs out on the old ones, a company has nothing to sell so it’s dependent on new drug development. Most pharmaceutical companies deal with this by having a diverse portfolio of products to buffer a fallow period in any given area. Dr. Stahl believes that Pharma has been chased off by the ranks of the misguided and that’s why we have no new drugs …
    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…
… missing the point that this is happening because there are no new CNS drugs rather than the other way around. There’s no crisis in Pharma. They’re just doing what they do – fleeing a ghost town heading for the next gold rush.

Dr. Insel will probably see the mentally ill as having a crisis – nothing new to stem the tide of the escalating public-health-burden-of-mental-illness. That’s actually an impossible argument to justify these days. Almost everyone agrees that over the last twenty years, America has been over-medicated [inappropriately]. Recently it’s been reported that 10% of us are on antidepressants. I don’t know how many are taking atypical antipsychotics, but from the corporate profit/loss sheets, it’s no stretch to say that it’s way too many. Street traffic in benzos and pain pills is a big problem in my neck of the woods – likely yours too. So symptomatic psychoactive medication may itself be the current public health problem rather than untreated psychiatric symptoms – the chemical imbalance of today being iatrogenic.

Dr. Insel himself recently commented on our current medications:
    … the recognition that mental ill health is a complex mix of genetic and experiential factors. “This is not new,” he affirmed. “But what is new is the ability to probe the genetics of the disorder.” But whether the drug industry will take up the challenge, in the absence of plentiful molecular targets, is unclear, he suggested. “[It] has invested in me too compounds—and sometimes in compounds that are identical to someone else’s. And let’s be frank, that has worked really well for them,” he said. But he declared, “Antipsychotics and antidepressants are not very good.” Much more research into the biology of mental illness was needed, he said.
It’s kind of hard to see mentally ill patients as having a crisis because of as yet undiscovered drugs, particularly now. And the same people who were formerly touting the wonders of the last round of new [now old] drugs are the ones lamenting that there’s nothing new[er] looming on the horizon. There’s little doubt that we’d all rejoice if we had more effective and less toxic medications, but as our recent history makes very clear, new doesn’t necessarily guarantee either of those things.

If the crisis is not in the pharmaceutical industry, and it’s not with our patients, where is it? I can think of a several places. There’s a multi-billion dollar industry here and abroad that has come into being during the twenty-five years since Prozac was introduced to support the explosion in clinical trials: Clinical Research Organizations, Clinical Research Centers, Medical Writing Companies; Marketing firms, etc. They face the very real crisis of having nothing to do. Inside of psychiatry, there are a lot of practitioners who have lived out Insel’s Psychiatry-as-Clinical-Neuroscience metaphor, and only prescribe medications. I expect that the absence of new medications puts a real damper on their practices [since the Primary Care Physicians hand out the old medications like candy]. Likewise, the people who have made a career out of being on speaker’s bureaus or giving CME presentations [psychiatrists working for industry to promote new drugs] are also headed for an out-of-work crisis. More ominously, academic psychiatry has relied heavily on support from the pharmaceutical industry, and is likely to find its foundations sinking into the sand rather than resting on solid bedrock. One would predict that the city that has grown up around the boom economy of the recent past will look a lot more like a downtown Detroit in not too many years. That’s what happens when "bubbles" burst.

The 1950s ushered in a dramatic age of psychopharmacology with the introduction of Lithium, the Monoamine Oxidase Inhibitors, the Neuroleptic Antipsychotics, the Tricyclic Antidepressants, and the Benzodiazepines. The ensuing first fifty years of the American College of Neuropsychopharmacology has been an exciting time for drug research in psychiatry. The Selective Serotonin Reuptake Inhibitors came along in the late 1980s, the Atypical Antipsychotics in the 1990s; and those two classes of drugs are now near the top of the charts for pharmaceutical sales in the US today. So I expect that it does feel like generations of psychopharmaceuticals, one following the other, reaching back to the dawn of our remembered history. But Dr. Insel’s specific topic [Who will Develop the Next Generation of Medications for Mental Illness? The NIMH Perspective] seems slightly off-point to me. Dr. Nester’s Session topic is closer to the mark [Will We Have New Drugs or Not? Addressing the Crisis in Neuropsychiatric Drug Discovery]. Is the wave after wave of new pharmacologic treatments going to continue – currently simply awaiting the next breakthrough? Or is psychopharmacology entering a period of paradigm decline altogether?

As I understand the usual history of paradigms, when a new paradigm is introduced, there’s great excitement over its ability to clarify what was previously murky, or in the case of treatments, to treat formerly untreatable conditions. Next, the paradigm begins to be extended into areas beyond its original boundaries. But as time passes, the areas where the paradigm doesn’t add much begin to show. Even later, the downsides and limitations becomes increasingly apparent – eg adverse effects. In these later doldrums, when a new paradigm emerges – off we go again sailing on smooth waters. The old paradigm then slowly finds its proper, but appropriately circumscribed, place in the order of things.

There’s little question that psychopharmacology is in the doldrums right now with the dominant focus on the downside of the current medications – disappointing efficacy, adverse effects, and the disillusioning revelation that many in academic psychiatry and the pharmaceutical industry have colluded for some time in shameful and deceitful practices that discredit either as a resource for credible information. So even if there were new medications in the mythological pipeline, psychopharmacology would be in a period of paradigm decline based on the disinformation and disappointments accumulated for the last twenty-five years. I would hope some people at the ACNP conference in a few weeks understand that.

Rather than placing their emphasis on some desperate search for new and better drugs, both the NIMH and the American College of Neuropsychopharmacology might think about focusing on helping psychiatrists learn to use the drugs we already have more effectively and safely. And it wouldn’t be a bad idea for both groups to lead the way in understanding where and why things went so far off track in so many areas…
    November 17, 2011 | 2:25 PM

    There are many things in today’s society that can make one depressed. Job stress is one of the biggest. Understanding what’s making people miserable is the job of the psychiatrist; and we need to be hearing from them. A professional opinion on modifiable drivers behind misery might actually change the things making people miserable.

    As more psychiatry becomes just a question of biochemistry, the professional opinion on those things that aren’t due to “chemical imbalance” is lost. This is a loss for all of us.

    November 17, 2011 | 3:44 PM

    To Mickey and all the regulars on this fine blog:

    I pose to you an open question: Has the time come to move on? Now, I don’t mean to forget about all this corruption and toxic fraud, but to just cut off on our own and start our own society and organization of psychiatrists that think sanely and say the hell with the APA/NIMH? I think one of the biggest hurdles psychiatrists need to get over is realizing they may not need the APA/NIMH anywhere near as much as they think they do, and that at this point these entities may not be worth saving/reasoning with any more.

    Dare I say it, but I think the APA/NIMH passed the point of no return long ago. At this point the only thing propping them up may very well be the fact they’re too big to fail, especially considering all the government money they get (just like the banks)!

    And that’s not necessarily a bad thing. Instead of wasting our energies fighting these idiots, we could do what Robert Whitaker has done and start a non-profit organization like The Foundation for Excellence in Mental Health Care (link below), which seeks to promote a true recovery model of care and bring real science back to psychiatry. And NO, this is not a foundation that is anti-meds; it’s pro-science.

    And take a look at the board members! Such a varied, exciting bunch — including David Healy! And some of the members are also mental health patients, as it should be.

    I personally think this is the way of the future: physicians and patients working together to construct a new paradigm of care grounded by real science and an ability to be open to wherever the science leads them. It’s time to just let the APA/NIMH run itself into the ground while we (we being patients and responsible psychiatrists) jump ship onto something cutting edge like the Foundation. As the Foundation grows and receives more grant money for clinical trials that truly ARE useful to patients and physicians (like seeing if some patients with psychosis can recover without meds when in a structured environment) and patient outcomes improve, the APA and the NIMH will be seen to be even more irrelevant and will either be forced to change or die.

    And speaking of funding: I don’t think that’s as huge a hurdle as some may think. The Foundation recently received a $2M donation not from the government but from Don and Lisbeth Cooper, owners of a holistic healing community in North Carolina.

    I don’t know about you, but I’d much rather have the funding come from people who have experience and a passion for the matter at hand than some faceless government beaurocracy that throws our hard-earned tax dollars at corrupt scum like Madhukar Trivedi and Tom Insel.

    Look: It’s just like what’s happening in the rest of the country. People are ever so slowly realizing they can’t wait on the government because it’s hopelessly corrupt. People are realizing they need to take their survival into their own hands and they’re blogging the truth and giving tips on how to survive and thrive in this age of astonishing widespread corruption.

    Bottom line: we can’t wait any more for the APA/NIMH to get the message. At this rate, they never will. Isn’t it time to cut bait and do our own thing with the Foundation?



    November 17, 2011 | 6:40 PM

    Dr. Insel’s comment –

    … “But what is new is the ability to probe the genetics of the disorder.”

    Really, Dr. Insel?

    And the NIMH and APA wonder why many of us have reached our limit….
    It’s one giant academic/scientific myth followed by another…


    Mark Kramer
    November 17, 2011 | 7:37 PM

    Let me say that your blog is terribly misnamed.
    Your comments are certainly NOTboring!
    They are disheartening.


    November 17, 2011 | 9:03 PM

    There are doctors who are not part of the membership (APA, wow and the patients have to tolerate being called scientologists or part of a cult for speaking out yet there is an elite group who pay to join a club that harbors pharma paid doctors…think about who is in a CULT)…so one way patients can go against that current is to find a doctor not entrenched in their status within their elite old boys club or not even a member at all. The other step is to walk away from psychiatry’s set ways and medication based ‘help’ and don’t look back. There’s no way to fight the corruption it goes to the top and we don’t even know the half of it.

    The DSM5 is that groups handbook. Think about what they will use as treatment as a result…pills. That book is not the end all be all of what is wrong when someone has a mental health crisis!

    November 17, 2011 | 11:09 PM


    Well said!
    And you’re not alone in your thoughts and opinions… There’s a growing number of us out there!

    Fellow parent,


    November 18, 2011 | 2:27 PM

    To Mark: I think I recall many, many, many postings ago that Mickey shared that his blog name was selected by his grandchildren when they first helped him set it up. When he was blogging about things political more than things psychiatric. But can’t agree more: he’s NOT boring! Still every time I access his blog, the name makes me smile when I think of his grandchildren coming up with it!

    Mark Kramer
    November 18, 2011 | 8:58 PM

    Grandchildren are a blessing!

    November 25, 2011 | 8:47 PM

    Is there any way to add more syllables to neuropsychopharmacology?

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