1 Boring Old Man

As strange as it might sound, all that testimony of the Janssen Sales Reps at last week’s Texas trial transported me directly back to the mid 1980s when we got a new chairman for our psychiatry department. He was a nice enough guy, but whenever I met with him, casually or officially, I left feeling oddly. It took me a while to figure out why that was. He was a strategizer. Instead of saying what he wanted, he spoke indirectly and the things he said were strategic. He would "open" with something. I would respond. But it didn’t flow like a conversation. I almost always felt, where are we going here? – but I never found out. I now know that what he was strategizing towards back then was psychiatry as it is now – doing drug research, writing prescriptions, talking DSM-III talk, becoming Key Opinion Leaders. It was the talk of a salesman – openings, talking points, closings. Meetings were brief but confusing for the same reason. I left frustrated and he seemed frustrated too. At the time, all I knew was that I felt vaguely crazy much of the time.

What I would say now is that he knew which way things were going to go – into the world of pharmacology, neuroscience, evidence-based medicine, and that psychiatrists like me were going to go some other place. I think he was trying to strategize those of us from before into fitting into the new order. Had he said that outright, my life would’ve been much easier. I’d have said "no thanks" and moved on. But that’s not how it was back then, and that’s not the central point of this post. It’s the way of talking, the music – talking to someone who is trying to manipulate the direction of a conversation [and hoping you don’t notice]. In the years that followed, I was still on the faculty "across the street" at the Psychoanalytic Institute, though my contact with the residents dwindled quickly. In the few times I was around Dr. Nemeroff who came a few years later, I had the same feeling – the feeling of being sold something.

I haven’t been around salesmen like that in years until last week in that trial. It seems like a stinging indictment to say that the new psychiatrists that came into the department were salesmen, but that’s what it felt like. I had the same problem with the literature which I essentially stopped reading. It felt "promotional." There would be an opening, setting up some line of reasoning.  That would be followed by the study with lots of graphs and tables. The graphs broke many of what I had been taught to be rules – scales that didn’t start with zero, using the standard error of the mean [that minimizes variations], showing nothing of the raw data, using statistical tests that wouldn’t pass muster in a statistics class, having increasingly long conflict of interest declarations, all with a rise in studies with industry funding. The closing would be a conclusion that felt overstated.

There was one point in the trial where I felt like getting up and leaving the courtroom. It was during the cross examination of Dr. Bruce Perry. He was there to testify about the efficacy and safety studies on Risperidal, and I think he planned to discuss Janssen’s seeding of the literature with articles. His testimony was interrupted by almost constant objections of one kind or another. When it came time for the cross-examination, The Janssen lawyer essentially testified himself – pausing to ask questions of Dr. Perry that could only be answered in one way. He essentially went through a litany of selling points that sounded like the promotional literature used to sell Risperdal when it first came out. Dr. Perry was reduced to monosyllabic answers. The Judge even commented, "How about throwing in a few more questions." He then cherry picked obscure sentences in C.A.T.I.E. that offhandedly mentioned SGAs strengths. I know the lawyer was just doing his job, but the "sales pitch" to the jury grated on me every time he opened his mouth.

There is a tremendous irony in what’s happened in psychiatry in the last quarter century. It has been an era of "hard science" – evidence-based, measurement-based biological science – replacing the more ethereal models of the mind. But a lot of it has been bad science at best. It’s as if the trappings of science – studies, statistics, biological references – have passed for the real thing. So the irony is that in an era of scientific revolution, we’ve had a preponderance of pseudoscience used as a marketing tool by Sales Reps like the ones we heard testify in Texas, the Speaker Bureau KOLs out selling psychiatry to the Primary Care Physicians, and Dr. Shon barnstorming the various States to sell TMAP. Janssen threw in the towel in Texas when  Dr. Glennmullen began to talk about the studies that were hidden – the ones that showed the real incidence of weight gain and the metabolic syndrome early on.